Protrusive Dental Podcast

Protrusive Dental Podcast


Dental Suturing Tutorial – PDP114

April 25, 2022

Virtual Hands-On Suturing Masterclass enrolment ends 2nd May 2022 – click here to get your hands-on kit + video instructions


Your suture is the signature you leave on your surgery. I actually suck at suturing, and so does my handwriting, so I’m really not winning at signatures! This was a really selfish episode because I really wanted to improve my suturing skills – I enrolled on the Suturing Masterclass with Dr Cajee and brought him on to level up our sutures! In this episode, Dr. Nabeel Cajee will help you break down the basics of different suture techniques and share some tips for use in practice. 



https://youtu.be/37rY0q6v2cg
Check out this full episode on YouTube

Need to Read it? Check out the Full Episode Transcript below!


Protrusive Dental Pearl: Use the power of video messages to communicate with patients (think post-op instructions) or your lab technician (they love the detail). Currently I am using LOOM which allows me to seamlessly record my screen and my voice/video and creates a sharable link.


“Excelling at suturing does three things, it helps patients heal better, less complications, eliminate dry socket. With good suturing, it allows you to grow as a clinician and take on more surgery cases” Dr. Nabeel Cajee


In this episode we discussed:


  • Dr. Cajee’s pathway to Implant Dentistry 4:03
  • Types of suturing materials 11:03
  • Types of Sutures for specific cases 17:33
  • Different Techniques of Suturing 19:04
  • Vertical vs Horizontal Mattress Suture and when to use them 24:05
  • Guidelines in tying the knot 26:21
  • How to Improve Suturing skills 30:00
  • Best type of Suture for a Functional Crown Lengthening 33:00

Check out the SUTURING MASTERCLASS (scroll all the way down the page) to gain confidence in your overall surgical skills with a hands-on kit to get stuck in! $70 OFF with code ‘Protrusive’


All of the Protruserati clan get $70 OFF the SUTURING MASTERCLASS with the code ‘PROTRUSIVE‘!



Click below for full episode transcript:
Opening Snippet: What was your first experience of suturing like? If you're like, my guest, Nabeel Cajee, then it was probably like, you know what, I got this, he had a background in embroidery

Jaz’s Introduction
But for me, I was absolutely hopeless. And to be fair, I’ve improved a lot since the first days in dental school, but there’s so much I still need to improve on, which is why I found you one of the best people to teach on sutures. This guy is brilliant. He’s got a whole online portfolio of videos to watch. And it is something that’s really helped me and I’m continuing through his course. And I want to bring him on to share with you some nuggets of inspiration to improve your suturing come Monday morning. We covered this episode. But no, there are two types of courses, there are courses that you do, which will ultimately, it may not be the main goal, but ultimately it will improve your return on investment, or it will give you a return on investment. So I know that if I start placing implants, and I got an implant year long course, it might cost me a lot of money on this one year long course. But I know that there’ll be a return on investment, I can offer my patients implants. And that should reflect my bottom line. That shouldn’t be the reason I do the course, ideally, but it will have an ROI. There are other courses that you do, and other things that we’ve purchased like microscopes for example, or suturing, for example that you do because you know that you can give the highest quality of your care to that patient. One of the things that Nabeel says that when you place a suture, that is your signature of the surgery. I love that saying, right? And to be fair, from my experiences with suturing, I can definitely do with a helping hand hence why I’ve come to this sort of episode, I think I can share this with everyone to help you all. In this episode, we’re going to cover what are the types of sutures available. If there was one suture, you had to stock in the practice, which one would it be and why you might need to venture into different types of knots and different types of sutures.


The Protrusive Dental Pearl I have for you is something that we practice where I work in Reading. And every time we do an extraction, as well as giving the verbal post operative instructions, we’ll also give written post op instructions. But one thing we did around about 18 months ago is we recorded a video, it was one of my colleagues, Susie in the practice, she has just explained to the camera, what you need to do exactly the same kind of stuff that we were giving verbally. But now through a video format. And after analyzing the stats after about a year, a lot of our patients are clicking on this. So even though they’ve been told verbally, even though they have the sheet, a lot of our patients end up clicking on this YouTube link. So essentially, after the extraction, the nurse knows to just go in the templates automatically send this email because they’ve had an extraction. And that’s got like all the reminders for them. And a lot of our patients benefit from this. So the pearl here is consider any procedure for which you give a post operative instruction, and you want to go really a level beyond then I think if you can record a video, whether it’s on YouTube, or one of my favorite programs now loom, you can visit loom.dental to learn how that works. So you make a loom video of you just speaking to the camera, it will be you in the corner, and some or you can make some big as well. And you just explaining the instructions, you can communicate whatever you want through a video message to a patient, I think it really adds to the level of care that you’re giving. I think it’s something that’s quite innovative. And this is 2022. So this is the future, I think this future is video communication, and being able to reinforce what you’re saying in the surgery through video. And I think that there’s an opportunity here for marketing when the patients, watch your video. And if you make it public, then anyone on the internet can gain some advice after extractions. And that can help you with search engine optimization. Or your patients once they watch the video that you know what my dentist is awesome. I’m going to share this link with anyone who needs it. Or the next time they need to give a dentist recommendation. They will, Oh you know what I’m going to recommend Jaz or Susie or whatever. Because after I had my extraction, they even sent me a video of them explaining everything I felt really well looked after. So Pearl is to think about, could you implement a video letter to your patient as part of post operative advice or any message that you want to send to them after the appointment? Let’s improve your sutures with Nabeel Cajee. I’ll catch you in the outro.


Main Interview:


[Jaz]
What was your, what’s the pathway into implant dentistry in the US? I’m sure there’s many pathways, but what was your pathway?


[Nabeel]
Yeah, my pathway was really the year after I graduated at dental school. In dental school, I didn’t place a single implant or restore single implant. It was really right after I finished dental school, I found myself as a resident in a trauma center. And I was an advanced general resident and part of our charge was to restore all of the implants that the Oral Surgery residents placed and those were just tons of trauma cases. So my very first case, the day after dental school or mean starting in my residency was an all on four quad zygomatic. Honestly, that was my very first case.


[Jaz]
That’s the craziest first case I’ve ever heard of.


[Nabeel]
Yeah, it was. It was like Welcome to dentistry quad zygomatic and I just loved it. I just loved, you know, everything about like the implant prosth side. And then part of that year, I got to spend about four months just on oral surgery service. And I picked up a lot of like the base surgery skills that way. And at the end of that year, I said, you know, it wouldn’t take too much more for me to be at the point where I could take my patients just start to finish, I want to place the implants right where I want them. I want to restore the cases as I want to. And that really got my journey started.


[Jaz]
It’s fascinating, you know, I mean, as Steve, Steve Jobs said something I mentioned in the podcast and I’m speaking to a guest like to understand the journey. And since we have already hit the record button, you mentioned something really cool about your journey. Dr. Nabeel Cajee, welcome to the Protrusive Dental Podcast. It’s great to have you it’s late night in California. It’s early morning and Reading and I really appreciate you, you making time you’re a father of an eight month old girl, I love your Instagram, I love you sharing everything. And it just makes sense. So on that point of, you know, connecting the dots, it makes sense, your journey, your evolution, where it started in your residency. And there’s always in everyone’s journey, an element of luck and timing involved, like had you been in a residency where the direction and the mentorship and the cases and your first case was in a quad zygomatic, right? You may have been into a different niche within dentistry. But it’s amazing how that blossomed. And then now it makes sense with the suturing masterclass. We’ll talk about that later. But it kind of when you look back, does it make sense now how you have evolved in this direction in your career?


[Nabeel]
Well, honestly, and if I were to even dig further back, as a child, my mom would embroider. And she didn’t have any daughters. So she’d actually asked me to help her. So I think those base skills as a child, embroidering with my mom, later on, when given the opportunity and residency, it was just fun. It was just fun to jump into those surgery cases, and then build from there.


[Jaz]
And well, you’d like good at suturing straightaway, because of the hand skills that you had from embroidery?


Unknown Speaker
I think that may have played a role just feeling very comfortable with needle and thread. But honestly, like starting right out of dental school, I didn’t know a lot of surgery techniques, I mean, suturing techniques, I think very few people leave dental school with this whole arsenal of suturing techniques ready to apply in various clinical scenarios. So I think I was inclined toward it. And then given the mentorship specifically of a doctor, Dr. Gaffapour for me, he really built my suturing skills as a resident and gave me a foundation to springboard from and you know, that’s where then I was able to build from there and just grow, grow, grow. And I just love sharing it at this point.


[Jaz]
It’s interesting though, that because when I think back to my learning of sutures, I remember being I think it’s like, second or third year dental school. And it’s a five week course in the UK. And we get to like, it’s like foam, we’re practicing on foam. And I mean, this one guy, says a group of eight, I mean, this one guy will just completely hopeless, right? And the reason what prompted me to reach out with the suturing masterclass and speak to Rex and doing the course and I’ve got the models here, and I’m going to show them in a moment. So I love it. But the reason I got into it is because I had this incident where I was tutoring and things weren’t going so great. And at the end, my nurse, the way nurses communicate to us, or DA’s for you guys, where they communicate to us in a very subtle and beautiful way that maybe you should do some see. And this is Oh, you know, the implantologist? He does it differently. When they say he does it differently, that’s when you know that, okay, I think I need to revisit?


Unknown Speaker
You know, and I think that’s it you know, you seem like many GPs, you know, at some point you don’t stay a basic restorative GP. At some point, interest grows. Some people it might be orthodontics, but some people are surgically inclined, and they want to build in that direction. So I think if you want to build in that direction, all of a sudden, you’re going to start doing more surgical extractions, you know, get into implants, get into these surgical scenarios where you’re looking at tissue that you want to bring together. And you say, Wait, if I want to bring that tissue more coronal, how would I do? If I want to bring it down, how would I do? If I want to close with tension? You know, reading those scenarios, how would I do it? And that’s all of a sudden where you’re like, Okay, I know that single interrupted, but dropping the single interrupt is just art. It’s just not getting you where I want to go. So what could I do to actually get there? And you’re so right, you’re out there to do that.


[Jaz]
You’re so right. With that question that how would I do that? And that’s the question I asked all the time. So in my three years, obviously, you’re in the implant field and you’re niching and your surgical background has influenced you further to go deeper into that field. For me. I’m very much a general dentist. I like treating all sorts of cases and I’m ortho restorative, but in the last three years, I mean, in the last few years I did my first like, full canine to canine palatal functional Crown Lengthening case, that was my first thing that I did in a way, that was a big feat for me. So then I remember revising, like, okay, and then one of the question was, okay, my sequencing writing everything down my protocol, you know what I’m doing something for the first time a bigger case like that, which is a step beyond for me, a step above for me. And one of the question was, how am I going to switch, this is my single interrupted going to be enough kind of thing, right? So I lost the end. Okay, how would you close such a case? And we’ll talk about what type of sutures will be interesting to know from you. But that was one and then doing more wisdom teeth, from my experiences in Singapore and being influenced by someone called Nekky Jamal in Canada and his course and stuff. So yeah, definitely, I’ve seen the evolution of surgery. And that’s why I think I recognize that okay, I need to up my skills here with suturing and you’re the man to help me Nabeel, I can see that already. So let’s dive in with the first question, man. I was taught Vicryl, and Vicryl is a brand, right? Vicryl is a brand, it’s a PGA, polyglycolic acid. Right? So that was the first suture that was taught to us as students, and the sizes, which I think will really go down back to basics, just explain a moment about sizes and what it actually means for the newbie dentist listening. And that’s the first sort of suture that we learned, is that the universal suture? Is that a, if you only had one, would it be that one?


[Nabeel]
Great question. I’ll go back to what are the sizes of sutures. So there’s something called the US Pharmacopoeia system, and that’s what designates the sizes. So it goes, it starts off as 00. And that’s actually the biggest suture you can get. We will not be using that in dentistry that will be to like, pull muscles and big structures in the body together. And then it goes, you know, it just goes further and further up. So, you know, then so then it goes 1-0, 2-0 It’s all these O’s. But, you know, generally in dentistry, we use between 3-0, and about 5-0, 6-0. If you get into more micro surgery techniques, and that’s say periodontist, that are now using ophthalmic grade sutures for really like Target papilla gently together, they’ll go even further to like 7-0, 8-0 using microscopes and all of that, but let’s keep it basic, right? For the surgically minded GP, I would say stick to a range between 4-0 and 6-0 right? 3-0 is a good one, a 3-0 Vicryl but what you’ll see is the larger the suture is the thread just your tear the tissue more, you actually want a smaller suture. So 3-0 Vicryl is a good one. My one of my personal favorites is the 4-0 PGA, I won’t use the brand name because you can get any of them. That is a favorite of mine. However, you know, when we look at sutures, you know, we look at different categories so that you’ll see, you know, absorbability would be one, knot retention would be another, how long does it hold under tension, let’s see here. A price, you know, the economy of sutures. And unfortunately, when you take all of those different categories, and you stack it against sutures, there isn’t one suture that has it all. There’s some that come close,


[Jaz]
I wouldn’t think so just like in restorative dentist. And there’s no one matrix system is best for us to restorations and I was definitely expecting you to say that. Can you give us like a one minute guideline as to the Nabeel’s recipe book in terms of the single interupted in a normal case, would you use 4-0 vicryl? And then in for surgical cases, have you heard you or is every case so unique, depending on the tissues that you actually might change even between certain type of surgeries?


[Nabeel]
Yeah. So I would say this is with a caveat that in the right clinicians hand, the suture choice doesn’t actually matter. Okay? However, there are sutures that are better for certain clinical scenarios than others. So to close some grafts, there are some periodontist that will use Chromic Gut.


[Jaz]
Yeah, what does that with that name like Chromic Gut? It just sounds like the, what was that name derived from just sounds horrible.


[Nabeel]
Yeah, it’s just you know, in the gut being like the cat gut intestines, you know, in chromic formulation to make it last longer.


[Jaz]
So it’s actually made from the intestines of a cat?


[Nabeel]
Maybe originally, but I think now there might be a little bit more synthetic material use in them. But you know, those materials are more natural materials. And for me, I wouldn’t think about using a chromic gut in a grafted site because you do have more of an inflammatory response from the breakdown of the suture, but you know, that’s me. I want something that’s like inert to the tissue. I would probably use a monofilament synthetic, which won’t trap bacteria, which won’t trap the plaque on the threads as well as wick bacteria onto the threads, you know, things like that. But in the right clinicians hand it works, right? However, when we’re looking at cases, say, as a surgical GP, you know, as a GP, you can do all the surgery cases, you want to as long as you’re doing them to a high level of care. And I think that’s where the suturing choice then does make a difference. Where if you were to be in a scenario, and you have to explain your work, and someone’s like, why are you using, you know, this sutures, that the best suture for the job, you know, I don’t want to be the scenario I’m saying. It’s a great suture, it works in some people’s hands, but…


[Jaz]
I just use the same one for everything. It works.


[Nabeel]
I just use the same one for everything, you know, I want to be in a position saying I use the best material for the job. And in that case, you have the different categories, which would be braided sutures, non braided sutures, which is kind of like a twined rope, or fishing line, you know, the difference in how the threads are laid out. The synthetic and natural sutures, and then the variances between them. So vicryl is a braided, synthetic, you know, it has the advantage of not having a strong of like an immune response or inflammatory response as it breaks down. But it does wick stuff into it. It does wick debris into the suture.


[Jaz]
Oh, it’s covered in black usually in my hands.


[Nabeel]
Yeah, it wouldn’t. I mean, sometimes when I’ve used it, patients look back and they say I have something growing and infection, you’re like, No, no, no, you don’t. Just run the course, you know.


[Jaz]
But the difference between your sutures and my sutures that when they come back to you, you’ve actually got a suture to cut, but by time they come and see me after about a week, you know, the patient may think, Thankfully that oh, this tissue absorbed but from doing your course already I know that actually absorbability can take up to 60 days, I was like, What? Okay. So obviously my sutures are falling out and not absorbing. So that’s the difference between your sutures and my sutures, you’ve probably seen a lot of yours come back, or as mine has just gone ingestive


[Nabeel]
Well, we could change that. You know, I think some of that might come into a knot time. You know?


[Jaz]
Yeah, exactly that. If I was to break down exactly the stage, I think my choices stuff is okay. It’s when it comes down to the knot. I’m sure we can explore a few tips there. Anything else that any sort obviously, it’s a podcast episode down day, it’s to entertain, it’s to educate the people driving and stuff. Any key point you want to call for we got the next question in terms of the wide sort of range of different sutures, even in terms of stalking them as a practice. But how crazy do you want to go like having different types? Is there a more economical way to do it?


[Nabeel]
Yeah. And you know, I think you don’t need to have tons of types. I think vicryl 4-0, or PG 4-0 is a great one for like, your everyday extraction, things like that. And then having one like one other or two other synthetic monofilament say for more delicate positioning of soft tissue, you know, a nylon 5-0 or polypropylene 5-0, those two sutures, kid, you know, a nylon or polypropylene 5-0, and a 4-0 vicryl that can carry you.


[Jaz]
I mean, if you speak to a dentist to let’s say works in an emergency clinic, and all they do is extractions. And that’s it. They don’t do any fine soft tissue work and they just get people out of pain, then the only one they probably need to stock to keep, you know, in terms of law and economics would probably be a 4-0 vicryl, is that fair to say?


[Nabeel]
Yeah, I’d say a 4-0 vicryl. It’s a great suture for extractions. I’m not a big fan of the gut sutures for extractions, especially sometimes in wisdom teeth, especially if there was muscle pull, it just breaks them apart. So the vicryl can actually have some strength and fall out if the patient doesn’t come back for a follow up.


[Jaz]
Yes, I can vouch for that one. Nabeel, what are the most essential types of sutures now. What I mean is you know I can do a single interrupted, I can do a horizontal mattress and for coming to your course. That’s all I know. Okay? So what are, sort of like as a young dentist newly qualified, which ones do you absolutely need to know and then as you evolve your interest, what are the kind of sutures that you think that we should know as a clinician?


[Nabeel]
Good question. You know, I think everything starts with the single interrupted, but and I think it’s good to practice anytime you get a chance to suture just drop that single interrupted, but at some point, you realize that doesn’t carry you far enough. So a suture that I think every dentist should know. And one that I want you to place tomorrow is the laurell suture, okay? Once you, it combined, it’s a twist of the horizontal mattress that you know, and it’s one step above that. Right? Once you place the Laurell suture, you’re gonna get hooked on suturing. Because you’re gonna look at your flaps come together beautifully. And you’re gonna say this one simple variation of something I was doing all of a sudden lead to a big difference. And so that’s going to be the next step. And then from there, you know, there’s all the continuous ones. And I think it’s just gonna instill a fire in you to learn more and more.


[Jaz]
I think the continuous ones is something I’m looking forward to learn from the course. Because at the moment, I’m on like decision making, the kit and stuff. The kit just arrived two days ago, which I’m just showing this now.


[Nabeel]
It just cleared customs.


[Jaz]
Yes, so it cleared customs. So this is cool. Because speaking to Rex, I was like, Look, I wanna do this course. But I don’t want to do just the lectures only I want to experience the hands on like, Well, we haven’t really shipped out before. And I was like, listen, make it happen. Let’s see if we can make this international now. And I can, these blades made it through Man, these blades made it through..


[Nabeel]
Amazing


[Jaz]
Yeah, I know, right? So you got all the different types in here. But these models are something else. And they’re the same ones. What I love is that the same ones that you use in the videos that you show, and the different angles that you show is going to be make it really good and amenable for me to practice those. So I’ll practice laurell, and the continuous. I think I know what to do, but I can see in the video, and then the pace that you go out was just perfect. But also there’s the ability to pause, and watch again and once again, which for me when I was previously looking at textbooks, and even online, looking at diagrams, or drawings and stuff, illustrations, I just can’t learn that like that I actually see someone to do it. And I think your point is great that you must implement, like you said, do the layout and do it straight away. And when you do it tomorrow, when you I’ve learned sutures in the past, I’ve learned you know, some way of you know on the extraction course and maybe just a little bit thrown in there, I do the suture, if I don’t do an extraction soon, I don’t practice that specific type of knot technique, you know you forget, you forget exactly that, oh, is it this way? Is it that way? And then in the you know, I’m already running late, and the pressure is on and my nurses looking at me like Hurry up. At that point, you’re like, Okay, single interrupted, the one that will pull out in a week. So I think it’s great to have that kind of resource to look back on. So I mean, amazing. So with those different techniques that you show, I’m looking forward to practice them on the models. One other suture that I uses the horizontal mattress and whatnot. So it’s particularly after an extraction like a purse string, grow everything together. And a variant of that which I learned when I was in Singapore is the cross stitch. So instead of going like as a square, you’re just going diagonally one across, it just makes like an X sign. And that’s something that I uses, a similar variant. When, Is that the main indication for a horizontal? And when would you actually use a vertical mattress suture?


[Nabeel]
Good question. So what you’re talking about is what we call the figure of eight suture where you form an X across. And that suture is actually ideally used during socket grafting, because you can play something in the socket, and it’ll form an X or almost like a net on top of it. It’s a great suture. One of the issues I think you may have with those sutures, is when you tie your knot, it bounces up. Do you find it hard to get the knot flat against the tissue?


[Jaz]
Yes, yes, I know what you mean


[Nabeel]
I know. Okay, so that’s a tricky thing. And in the course, there’s something I called the modified surgeon’s knot. It’s where you do three forward throws, two reverse, one forward. And that’ll help you get those knot tighter, just a little tidbit. But that’s a great suture to close an extraction site. But I want you to try the Laurell. The Laurell is going to change how you see extractions, completely change


[Jaz]
I love doing so much more sectioning and elevating. So the need to suture here and obviously, with my evolution, I wanna be able to help my, I’m referring more to implantologist and you know, I like to help him with the grafting. So I think that’s where it’s gonna come in. And yes, excited to learn the Laurell technique. When would you use a vertical? I’ve never had to use, probably because of lack of knowledge or experience. But what is the indication for vertical?


[Nabeel]
What’s the difference between the vertical and the horizontal mattress?


[Jaz]
And when would you use the Yeah, exactly.


[Nabeel]
So the difference between the two and when you think about it, the horizontal mattress has two entry points which are basic, same mesial and distal, right? When you close and say you’re trying to bring together the tissues with a little tension, if you pull too tight on the knot, you choke the tissue, because it’s the knot is horizontal across. So the horizontal mattress can actually be used. I’m just going to give a clinical example. Say if you’re biopsied something, you can actually place a horizontal mattress at the base of it and cut your leash and out and it holds hemostasis, right? Think about that. But is that necessarily what you want when you’re grafting a site to choke the blood supply, that’s what you do


[Jaz]
I love the way of saying it choking, it just, it’s a perfect term to use.


[Nabeel]
So the vertical mattress takes the horizontal mattress and because now you’re looking at a more apical and coronal entry point, it does the same thing but doesn’t choke the blood supply. And that the, so you’re trying to be really delicate and bring a papilla up together. The last thing you want to do is choke the blood supply. You could use a vertical mattress to bring the papilla up.


[Jaz]
Got it. Very good. I think as a GP doing more and more surgery, do you think a vertical is something that is a natural evolution sort of technique to learn beyond horizontal mattresses? Do you think it’s essential in surgery?


[Nabeel]
I think it’ll have its advantages, say bringing tissue up and not choking the blood supply very delicately like say bringing a papilla up, It does, however, for closing it, then you may want to look into you know what we would you know, there’s suture techniques named after different surgeons for different scenarios. So we go over a lot of them, the the Laurell, the Biddle stone, the, you know, the Ford, a lot of these ones meant for the scenarios of grafting and others


[Jaz]
Very good. And when we come to tying the knot, I mean, you mentioned already make sure that we don’t choke it, tension free. Is there a description or a guideline in terms of you know, tomorrow morning, when we maybe the suturing, How tight do you want to go? Is there a guideline? Is there a test and have you if you’ve choked it? How do you know you choked it? How do you know you’re too loose, like a lot of mine, guilty of being too loose, and I justify it in my head like yeah, you know what, I’m not choking the tissues, I’m not choking, but is there a guideline as to how how tight they should be?


[Nabeel]
Blanched after you’ve tied down, what you want to see. And when you throw your knots down there, there’s various types of surgery knots. And, you know, so there’s the common, the most common surgical knot is two forward throws, one reverse throw, right? So two times clockwise, counterclockwise, then you reverse it. And then there’s what we do that the modified surgeon’s knot, which is three throws, and it has its advantages and disadvantages, but what you want to see is when you do your first throw, you want to see those threads lay down nice and flat against the tissue, not with a lot of tension, because you don’t need a lot of tension. But you want to see that that first throw lay down flat. And then when the second throw comes down, you want to see it lay neatly on top of the first throw, that just locks it in. And then you add on a couple extra just to secure the knot. But it doesn’t have to close with a lot of tension. The knot doesn’t, you know, it just has to lay down flat against the tissues.


[Jaz]
So lay it flat, but no blanching. And previously, we’re not we know now that we’re talking numbers and throws and stuff. From a background I come from the way I was taught was two in one direction, one in the other direction, and then one again, in the opposite direction, is that acceptable? Because I know there’s so many variations. Is that okay?


[Nabeel]
Yeah, that’s fine. You know, sometimes,


[Jaz]
But is that the Nabeel Cajee way? It wasn’t it?


[Nabeel]
You saw by it was like, Yeah, you can do that, you know, when part of my training was seeing special needs, individuals with special needs in the operating room. And one of our rules was that not better not come loose. Because if those stitches came loose, that patient has to go back to the operating room because you can’t see them otherwise. So and these aren’t patients that are compliant, they’re going to intervene, and they’re gonna want to play with their sutures.


[Jaz]
So this is under general anesthetic or sedation?


[Nabeel]
Yeah, under general anesthesia. So, if those sutures weren’t tight, we were had to, we had to cut them and tie them again, if they weren’t secure. So we would do two forward, one reverse, two forward, one reverse, two forward, one reverse. Six throws


[Jaz]
Is that many times? Okay.


[Nabeel]
Whacking it that many times. I think that, in a general practice, you don’t have to do it that many times. But at this stage, I generally go 2-1-2-1. And the reason for it is if you see when you look at your knot, the two forward throws, it’s like 2-1-2-1, the knot just locks on itself, what do we you know, and there’s something called the square knot, which is generally one forward throw, one reverse throw, but when you look at it two single throws can actually unravel on itself a bit, but not but when you but technically we’re stacking the actual surgeon’s knot. And that’s just so much more secure.


[Jaz]
Amazing. Well, you’ve answered my main questions I want to know about about suturing and I think there’s a lot of nuggets there for everyone to go away with and when they place in the next suture to realize about okay, putting too much tension, the different ones available, but I think maybe inspired people for those who are thinking okay, I need to improve my suturing skills. What’s the next step? I think your course is the answer for that. Tell us about the making of this course. What is the mission statement, and how you think that this is changing the sort of way that we can learn sutures?


[Nabeel]
Who I had in mind when we made this course is essentially the surgically minded GP, you know, someone who has been wanting to get into implants, or have been placing them for some time. And now see some of the challenges. You know, someone who sees, you know, wants to jump into some soft tissue grafting, someone who wants to do some wisdom teeth, but there’s essentially a rule that I live by, which is only open what you can close. And so you’re seeing these scenarios, and you want to close them right. You know, and essentially, it’s three things, you know, you want to close these right, because suturing, excelling at suturing does three things, it helps patients heal better, less complications, you know, eliminate dry socket from your practice with good suturing essentially, it allows you to grow as a clinician and take on more surgery cases. Because if you find that fun, well, why not have fun every day. And the other part to it is, I really believe suturing is the signature you leave on your surgery cases.


[Nabeel]
Wow, I love that.


[Nabeel]
I really believe that. I love it. And I take great pride in this work. When I’ve done with a wisdom tooth case, I had my patient a mouth mirror and I say look inside, I want them to see the suturing work. And when they’re like wow, I’m not even bleeding, it’s clean, you know, it’s just it helps everything. Suturing is not one of those skills you leave dental school and you have all of them. And my goal is just to give that dentist who really wants to get into these cases and do that type of work, you know, as much as I can give them from my experiences, my training and and understanding to be able to read scenarios on a clinical side and then apply you know, if we want to move tissue in, you know, up down, you know, as well as a good understanding of the fundamentals, which would be you know, what types of threads are out there? What are their pros and cons you know, though these are the lectures of their own


[Jaz]
That’s why videos are just so clear in demonstrating in terms of clarity of the lessons, the pace and the ability to rewatch again and again and again, because my evolution and it just came at a perfect time for me as I’m venturing more into Perio-Prostho, I’m actually going on in 15th July I’m going on, there’s a chap at dental school, Billy Asha’s in the UK. He’s a fantastic clinician and he’s doing a Perio-Prostho course. And I could see myself getting more into more Crown Lengthening case in the future, so I going on myself so get back on that question I was asked you, Crown Lengthening, functional Crown Lengthening on the palatal side of the upper canine to canine and you’ve removed some bone and then now you’re and obviously cut some gum away. And now you’re approximating the tissues back. Obviously, cases vary, but what is the kind of suture that you would use for that kind of case? If you were to visualize that case now?


[Nabeel]
So you straight across canine to canine?


[Jaz]
Yes I scalloped I removed about two millimeters of gingiva, scalloped palatal side, I did not raise any flap labially just palatally and then just approximate the tissue. So why did I just did because it was what I knew I did between each papilla. I did a single interrupted. Okay. Is that okay? And then is there something else that could be a bit better than I probably use 4-0 vicryl? So again, the result healed fine. He’s now in full mouth rehab , he’s now into crowns. And I managed to gain the ferulle that I wanted. But that signature that I leave on my patients at the moment, I feel as though it’s going to be better now that I found you. But it’s something I’m working on. So is there any way that you would approach this kind of scenario?


[Nabeel]
Generally, whenever I’m laying flat, you know, tissue back against the teeth, you know, and you want to, and you want to especially moving the papilla exactly where you want them to go. And that type of approximation. I look to the sling suture or the continuous sling. That’s, it’s just you have so much control over how the papilla get laid down. It’s amazing.


[Jaz]
And you covered on the course right?


[Nabeel]
It’s yeah, it’s definitely in the course. I had, you know, it’s a great suture. It is a little tricky. I mean, I love that you jump straight into, like I’m not even going labial, I’m going palatal you know I admire your..


[Jaz]
I had a good mentorship, Nabeel, there’s a periodontist, Amit Patel, really sat with me and said okay, this is the game plan and he drew the diagram to me, and I had a little bit of experience, and I was doing more surgery in the last three years more than I ever had before, so and the case went brilliantly. I was really proud and really hard on patients. It was at the right time for me, but I know I’ll be doing more this next three to five years. So it was, your course came at the right time for me in terms of my learning needs.


[Nabeel]
Yeah. I mean, for a lot of those, for me, it’s the as I said, the continuous sling, I would probably have gone for a 5-0 polypropylene suture, or a 5-0 PTFE suture. I think for these cases, that the vicryl is a great suture. But when you see how, when you jumped to the 5-0 suture, the needle also changes, you probably have, you know, what was used an FS2 needle, which is a little bigger, and the ability just to slide through these tissues and control them. And you’ll just see how gentle the sutures are then to the actual tissue. You know, you fell in love when you got married. And when you had your child you’re gonna fall in love again.


[Jaz]
Absolutely, absolutely. I love that. Buddy, thank you so much for giving up your time. And there’s a little discount code that implant ninja team have given us. I’ll share that in the outro with everyone so that they can check out your course, I’m excited to learn the Laurell. I’m excited to go back and see what I should have done with that crown lengthening case. But you know, one thing I wasn’t saying in the intro as well is there are two types of courses, maybe right there, these courses, which do have some degree of return on investment, like if you go on a certain type of, if you’ve got an implant course learn how to place implants, then you hope that in five years time, you’re going to make a return on investment on the implant course. With suturing, I agree with that may reduce dry socket. It may reduce post operative complications, but it’s difficult to assign a bottom line to better suturing. But there’s nothing better than having the confidence that, you know what my suture is going to stay. This is my signature, just like you said, I love that and having the knowledge and the feeling that you’re giving the best surgical care to a patient, you combo price on that, right? There’s no ROI needed. That is the ROI right there. So that’s the category that your course comes in, in how I feel. So I’m excited to really practice, practice, practice. And we’ll all. In crown lengthening in case I do. I will DM you on Instagram, share your Instagram in the moment, my suturing obviously and I cannot wait to do that, my friend. Tell us your Instagram handle, my friend.


[Nabeel]
It’s @drcajee


[Nabeel]
@drcajee. Amazing. Everyone check out Nabeel and his work and his journey as a new parent, relatively new parent and all the implant stuff that he does. Any final words while you have the microphone to the world of dentists, mostly UK, Europe and now US, Canada, Australia and New Zealand. What do you want to say to everyone on this topic?


[Nabeel]
Well, first of all, Jaz, I just want to thank you for having me tonight or this morning on your side. And you know, to the world of dentists, I think dentistry is just such a beautiful field, that we have the opportunity to grow, to grow on a daily basis, to grow on a yearly a career path, you know, where your skills are today, and where you’ll be in a year or two years, may be completely different. And I really want to see our generation of dentists you know, really defining something new for the field, bringing new technology, new techniques to the forefront, I really want to see us practicing like we’re in 2022 later on, you know, like we’re in the future. And I just really hope that you know, what you experienced with us during this podcast was valuable. And if you choose to take the course that it really benefits you


[Jaz]
It certainly will, my friend. Thanks so much for giving up your time.


Jaz’s Outro: Well, there we have it guys some great inspiration there for suturing. If you’re on that journey, like I am sometimes little things that we take for granted like suturing is exactly the kind of thing that you need to do to feel more confident about your overall surgical skills. So you’ve got to level up your suturing, head to protrusive.co.uk/suture. And it will take you straight to where you want to be to enroll in the class. And as part of the Protrusive discount that famous ‘PROTRUSIVE’ discount code. If you use it on there, you will get $70 off. Now, if you’re international people ie if you’re outside the US, you will get $70 off and that will be reflected on the shipping because shipping is quite dear. It’s about $100. So if we can knock off $70 shipping, that makes it a bit more palatable. Then it makes sense why the shipping is so much because it’s the medical equipment being sent to you and the models and stuff which you get to keep obviously so that will take care of the most of the shipping for you. But if you’re in the US, then you can knock off $70 off the overall price of the course. So check out protrusive.co.uk/suture and we’ll take you straight to the implant ninja school where you can enroll to level up your game in suturing. Thanks so much for joining me and I’ll catch you in the next one