3toIXLl5RFm9rW83iwsy Back To The Suture

Back to the SUTURE – Your Roadmap to Understanding & Mastering Suturing
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D
id you ever feel something was impossible to achieve?
I sure did (and many many times over) and I’m not here to tell you that
everything is possible in life. It isn’t.
On the other hand, there are just as many things that feel insurmountable but are
achieved once you commit and finally tackle them.
It’s not that things are impossible.
It’s your mind telling you: “It’s Impossible.
Why?
Our brain is programed to be in pure survival mode. In that sense, the brain can
be our worst enemy. It will “tell us” that certain things are impossible in order to
protect us from harm and to avoid risks and failures. And therefore, we are often
hesitant to try new things, explore uncharted territories and go on adventures
that can be beneficial to our future. The brain is also where our fears live, which
again are meant to serve one purpose- protect us from harm and give us a better
chance to survive.
In our current world, existential fear is rare. We live in safe and mostly prosperous
societies, but the primitive emotions like fear, hesitation and self-doubt have
been there for millions of years before we were civilized.
Nowadays, pure survival is easy but not a good enough goal for you and me. We
all want to expand, grow and prosper and implementing surgery is on of the ways
to do that. The sad reality is that many dentists live in “survival mode”, with
hesitations and self-doubt because they were told they couldn’t do it. Some of
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these discouraging voices are external but more often internal, coming from the
primitive part of the brain. So you are led to believe things are hard and
impossible.
So let’s go back to word “Impossible”.
Very few things truly are “impossible” in life. You see people do the “impossible”
every day. Break records, accumulate wealth, reach mega success and even sleep-
train a baby in 3 days (I thought this was “impossible” until I actually did that).
So here are the first tips of this book
and the your keys to success:
If you see at least one person achieve something that you consider “impossible”,
then this is irrefutable proof that your assumption is wrong.
Rather than thinking something is impossible you need to switch you mindset to:
“There is something I don’t know and this person does”.
The step after that is figure out what did person do to overcome the
“impossibility”.
Here’s another mind trick: From now on use invisible quotations with the word
“impossible” or any other self-defeating term. Very few things are, dentists just
like you are doing it and so can you.
I hope you’re cool with these concepts because if not, it’ll be a bit more difficult
for you to move forward fast with suturing
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Now let’s take a step farther.
Would you be able to learn a critical surgical skill in 7 days?
Would you do it in 7 hours?
I’m not just talking about any skill.
I’m referring to the critical skill you can’t do without and that every surgeon must
master.
I’m talking about the pinnacle of surgery. A skill that you may be struggling with
now and desire to master to finally feel like a complete surgeon.
SUTURING: Your ability, with

your bare hands, to connect
living structures with a needle
and a thread and close a surgical
wound. It’s one of the most
important skills a surgeon must have (and who doesn’t want to be and operate
like a top surgeon).
Mastering suturing may feel “impossible” for you today.
You love surgery and know how important it is for your succes and feel insecure
about your suturing skills. The same principle applies here.
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Countless dentists already mastered the suturing game.This is your irrefutable

proof that it’s not “impossible” because it was done by dentists just like you.
These dentists don’t have any extraordinary talent or even spent years in learning
and practicing. They simply followed a well-paved path that led them to where
they are today.
Here’s my second and third advice in this book:
Don’t judge how far you can go, based on where you are today, and
don’t let self-doubt stop you from achieving what you want.
Here’s my promise:
By reading this book you are starting your first step in your roadmap to master
suturing.
It will change your mindset and make you ready to acquire some serious suturing
skills, eliminate previous dogma and misconceptions and will allow to translate
the knowledge you gain into practical actions in your practice.
Even if:
• You don’t have much experience

• Hate suturing and…
• …are frustrated with your current skills (or lack of).
This is what it will take from you
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Simply follow the instructions, my friend.
What do I mean by that?
I’ve taught thousands of dentists over the years

and most did great with suturing. However, in
every group of doctors there are some that try to
re-invent the wheel, improvise or go out of
sequence with regards to the steps.
I tell them the same: “Follow the instructions, my

friends”.
Once you get the hang of it… cool! Start modifying and trying out things.
Come up with your own way to do things and who knows? You may be on to
something new and better (yes, you have the capability to improve upon what
you learn and invent your own, don’t let anyone discourage you).
But first – In order to master suturing, you must follow the instructions to acquire
the basics that are proven to work. This is your safety net to fall back to and have
predictable success. Don’t invent your own techniques while you are training!
You must follow the instructions, step-by-step. No deviations.
Do as I do initially to create effective and predictable knots and surgical wound

closure.
Don’t deviate and don’t trust your intuition. This comes later. You don’t have
surgical intuition yet. It’ll come later.
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This approach sounds a bit military but that’s what works. When you’re in basic
training, you follow the leader and follow the instructions. This way it’ll a bit
difficult for you in training but “easier in battle” during surgery.
WHAT’S HOLDING YOU BACK?
First, you need to be stripped from common

misconceptions and dogma that are holding you
back.
This is the first step in turning you into a suturing

master.
Second, I show you what works in my hands in most cases, I give you the tools to
do it on your own and the resources to practice and gain clarity and confidence.
Here’s my plan for your growing your suturing skills:
I put everything you need to know in front of you and what to do with all that. On
your end, follow the instructions. Simple.
Can we shake hands on that?
Now that we have a basic agreement. Let’s get rid of some of that things you
were “hypnotized” to believe in.
Suturing is not what you were indoctrinated to believe it is.
It’s not a secret skill reserved to specialists or to uber-talented dentists.
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It doesn’t take decades of practice or using instruments and materials available to

only few.
It is not as complex as you may think it is and doesn’t require talent or even
previous experience.
The 3 Pillars of suturing
Suturing is only about 3 things that once you get exposed to, will unleash the hidden
power of suturing mastery that is within you.
Here’s the SECRET #1:
Out of all the suturing techniques I use, 95%

are simple. Specifically, simple interrupted
technique.
Yes. Just one entry and one exit point and tying
one knot. Basic stuff.
So obviously, the technique is not the most important factor in mastering the suturing
process.
The “secret sauce” is understanding and implementing safety principles, choosing the
right materials and applying the right mechanics all of which are beyond technical skill.
If you’re like most dentists – Suturing is a struggle.
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Tears, entanglement, knots opening, flap cut-outs, sutures that “poke” the
patient and more
unpleasant suture problems and complications.
You may even shy away from surgery all together because you lack the confidence in
suturing.
Well, confidence can be acquired. Clarity can be created.
In this book, I’m going to start our suturing teaching and coaching journey.
Here’s what not to do:
• Don’t give up or get discouraged by anyone.

• Don’t underestimate what you can achieve with the right tools, guidance and a shift
in your mindset.
• Don’t feel bad if you never took the time to properly learn suturing and didn’t
maximize your potential.
We always operate at 100% potential based on the mindset we have at the time. Our
mindset is technically our ceiling. And this is how we grow. We changed our mindset.
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I know you can master this suturing thing.
No matter if you are just starting out or if you have

been practicing for ten, twenty or thirty years. You
probably noticed there are not too many resources
to learn from.
Suturing dead-end
It feels like there is nowhere to turn to if you desire to learn suturing.
I couldn’t find good resources for my own education. I looked everywhere, online and
offline, and had to go through years of challenges.
There are only a few outdated books and courses which was a surprising fact to me.
There could be only 3 explanations:
(1) Your surgery teachers take it for granted that you already know how to suture and
don’t focus on that. They teach you the steps of the surgery but glance over
suturing.
(2) Your teachers know how to suture but don’t know how to teach it.
(3) The suturing knowledge is being hoarded. It is not shared intentionally because
everybody knows it’s the “secret sauce” for successful surgeries. No transparency
in education. Wow.
IT’S TIME for more transparency in surgical training.
In this book, I’m opening the curtains and starting to reveal the most effective suturing
secrets that the top surgeons in the world are using.
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Howard Farran, founder of DentalTown, told me the following during an interview:
“You suture at the FREAK level. You’re like Picasso when you saw”
Howard meant to give me a compliment but he was wrong (he looked kind of shocked
when I showed him the zPAD…).
I don’t have any special talents or magic skills and I use simple suturing techniques. I’ve
done a lot of suturing for the past 20 years and have clarity.
Suturing is all based on the 3 principles that we’ll explore together in the teaching system
I developed 4 years. It makes suturing simple and shows you how to suture like a
periodontist.
I created this system when I got frustrated with the fact that dentists are intimidated by
suturing. I was looking to find a solution to create a transformation in surgical training
and FAST.
There was no time to waste.
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In this system, I want every dentist to
• go back to the sound surgical principles,

• go back to optimizing safety, with clarity and confidence in
suturing.
Therefore, I called this book BACK TO THE SUTURE.

It’s tribute to the 80’s movie with a similar name. Sometimes we need to go back to the
basics, fix some things there so we can have a better future. This was the essence of the
movie and that is the essence of this book. I will take you back into the core elements of
suturing so you can grow from there in a simple and predictable way (simple beats
complex any day as far as I’m concerned).
The new suturing system has already been tested live on real dentists and works like
magic. Dentists who went through this training keep telling me the following (or a
variation of it):
“I finally GET suturing!”

It even worked on a non-dentist (a “normal” person) that was disabled in one hand at the
time of training. Even so, some of his suturing results were better than trained dentists.
If this works on a person with no dental knowledge
and with a physical disability,
Do you think it’ll work for you?
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So, let's get right to it because I value your time and we got some work to do together.
Thank you for the gift of your time to read this. The roadmap to suturing success starts
here.
Everyone operates at 100% capacity of their current mindset ceiling
So how would you increase your potential if you’re already at 100%?
By changing mindsets.
This way you can reach higher and higher levels

of success. The concept means that you are
doing well now, within your current knowledge
and state of mind.
You must keep changing and transforming to get to where you want to get (this applies
for almost anything in life).
So let’s change some mindsets.

This is your first mindset shift about suturing:
Suturing begins before you make the first incision
Naturally, it’s important to design your incisions and flap to achieve the surgical goal you
have planned.
Here is the twist.
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As I plan my flap and incisions, I am consciously thinking: “How am I going to close this
up?”
This mindset keeps me conservative and allows me to create a better flap design which
naturally enhances healing. It also keeps me calm during the procedure because I know I’ll
have good closure at end.
One of my surgical success secrets is that I’m able to visualize a procedure from start to
finish and that includes suturing. I want that ability for you as well.
Don’t let your fear of suturing dictate the surgery. I’ve seen so many dentists place
implants in a flapless approach simply because they lack clarity about suturing.
This first mindset shift is going to change things for you.
By consciously thinking about the suturing before making your first incision, will make
your mind think bigger, eliminate fear, make smarter decisions and create openness for
growth.
Here’s the next step in growing your suturing skills:
Be your own true critic.
Immediately post-op 1 week post-op
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Take photo at the end of the procedure (showing the flap) and then a photo at the 1 week
post-operative visit (most dentists don’t take follow up photos).
Place the photos side by side and compare with 100% honesty. You must also take 100%
ownership for the results. I don’t mean to say that you have control over the patient’s
individual healing. You can’t control that but you are 100% responsible. You own the case
and that is true for success and failure.
When you compare the immediate post-op photo with one week post-op, something
magical happens.
The learning and growth are just in front of your eyes.
Compare the knots and the short suture ends: How different do they look a week later?
Are they still there? Are they loose or open?
How do the flap positions compare? Are the incisions open?
Are the flaps loose? Do you see sloughing?
How does the color of the tissue compare? What is the status of inflammation?
By doing this for every surgery, you will start detecting your true points of
strength and weakness.
Don’t worry. You will not have to do this forever.
What I’m trying to teach here is to be honest and realistic with yourself and develop
unbiased judgement.
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It also teaches you accountability and ownership. We are always responsible for the
outcome, good or bad. That how a top surgeon operates.
The principle of unbiased self-analysis is critical!
You can’t improve without bringing the pain points into your conscious mind. Once you
know you own shortcomings, we have a chance to find a solution.
This process will also allow you to communicate with me in an efficient way. This way
you’ll be very specific about the things that you need help with and we are going to save
you a lot of time.
You see, when an athlete trains for the Olympics, their coach gets rids of problems and
bad practices first. A good coach change your mindset (remember, your potential is
bound by your mindset ceiling). He or she will help you get rid of self-doubt and internal
limitations that are holding you back. You need to perfect what you’re good at and that’s
again the job of a good coach, to enhance your strengths.
I want you to be an Olympic level surgeon.
My goal is to not just teach you techniques and strategies like everybody else.
I can teach you all that you need to know, but if you are holding to a misconception or
have self-doubt, you will not learn and excel. Although you may fell you need and want to
learn, the dogmas and misconceptions engraved in your mind, will make you resist my
teaching and prevent you from implementing and improving.
So we have to get rid of those first.
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Keep in mind that, learning something new is supposed to feel

uncomfortable and awkward.
It’s the key to progress and growth.
So… when I show you how to hold the instruments, needles and sutures and how to
create twists, wraps, locks etc, it is supposed to feel unnatural at first.
If it feels natural and organic, you didn’t go anywhere. You’re the old-self with the old
mindset.
Some dentists complain about certain suturing movement that “they feel weird…”.
My response: “CONGRATULATIOLNS, you’re on the right track!”.
I physically held the hands of dentists and oral surgeons to demonstrate how to do things.
It made many of them cringe. But after a few practices, it became second nature. What
felt weird now feels very natural.
Remember, we will be practicing at the Olympic level.
We are going to win Wimbledon with an amazing serve. To be at that level we have to get
out of our comfort zone, change your mindset and get rid of self-limiting beliefs and some
myths.
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Here’s the first myth to eliminate:
Myth #1
“Only surgical specialists can suture at the high level”
Dr. Howard Farran, founder of DentalTown, believes that there is some type of magic in
the ability to suture at a high level.
So let’s dispel this. There's no magic, I don’t have secrets or rare talent.
There are no special skills needed
nor do you need talent or
spending years in practice to master suturing.
Dentists can suture at a high level if they know the principles and the rules and follow a
well-paved roadmap (it’s my job to give you this roadmap).
If you graduated dental school, you therefore have sufficient manual dexterity and hand-
eye coordination. That’s all the talent you need to reach suturing mastery.
The second myth to eliminate.
Myth #2
“I need to know all the different suturing techniques

perfectly to be good”
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Here’s reality:
You need 2 suturing techniques that are performed about 90% of all times. And here’s
the breakdown:
80%: Simple interrupted
10%: X suture
10%: all the rest
In our training, I focus on the commonly used techniques so you can tackle most if not all
clinical situations.
Why waste brain power on things that are theoretical and you don’t need to use?
Let’s focus on what will get us to a great clinical outcome).
This what you know so far:
• “Impossible” is nothing
• Suturing begins before you make incisions (visualization)
• Follow the instructions, my friend
• Document, compare and learn your weak points and strengths (compare
immediate post-op to 1 week post-op)
• There is no need for talent or special skills to master suturing
Here’s something that changed my own mindset as an educator:
The sutures need to be loose and the knots need to be tight
Not the opposite!
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I heard Dr. Markus Hurtzler, master surgeon from Germany, say that at the USC
periodontal symposium Wow!
I kind of knew that for a long time from my clinical experience but when I heard Markus
say that, something clicked.
It’s the essence of suturing distilled in one sentence.
Many dentists create real tight sutures with loose knots that open prematurely. Once the
knots open, the wound is unstable and flaps are mobile leading to compromised healing.
This is important to know:
The tissues we suture in the oral cavity are fragile and require low forces for
approximation.
If you release flaps properly, contour bone anatomically when needed and create a
passive flap, then
there is no need to over tighten the sutures.
The sutures will be kind of loose. The tissue will lay almost passively with little tension and
the tight knots will stabilize all of that.
That’s all you need.
I will teach you this concept as part of the 9 LAWS OF SUTURING (coming later).
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What’s the best way to learn suturing?
I have tried it all on myself and on the dentists, I mentor

for the past 20 years. From pig mandibles, fruit, plastics,
egg yolk and realistic models. You name it.
As much as you try to simulate how it feels in reality, it

is always different. So figured out that if you can’t
simulate it, what is the point to keep doing the same thing over and over again and
expect different results. It needed to be something completely different.
I needed a system that would teach the principles of suturing techniques and creating
clarity on the exact entry and exist points, the direction of the needle and thread.
I needed a system that teaches the mechanics: how tissues get approximate and how
they get pulled and pushed to achieve the specific goal of the surgery. This is why I create
a physical model that enabled all of that. I called it the zPAD.
I incorporated common clinical situations that require suturing in this physical device.
Then came simple suturing exercises accompanied with video tutorials any dentist could
understand and practice based in my instructions (remember “follow the instructions, my
friend”?).
In this method, you can learn how to suture in a pure schematic environment. Each
exercise is meant to train your hand-eye coordination and create muscle memory for
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suturing. Each exercise is meant to leave an imprint

in your memory, so when you get to suturing during
a surgery, those principles will now be used in real
life and it would feel like you’ve done it many times
before.
Yes. It works just like that.
The teaching on the zPAD is based on the 3

principles for suturing success:
Safety: The basic principles that keep you, your assistant and the patient safe. If you think
that has nothing to do with mastering suturing – think again.
Material: You don’t need to understand complex concepts that relate to tensile strength,
chemistry and the exact composition of each suture. It’s confusing and not so clinically
relevant. What you need to know is which material and needle to choose for which
situation.
Mechanics: How many twists and in which direction,

how to wrap, lock, release, twist and tie so your
sutures a loose and knots are tight. It’s real simple if
you have the clarity and have a roadmap on
achieving it.
All these principles are incorporated and explained

in the NINE LAWS OF SUTURING and the video
tutorials that come with it.
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SUTURE ANATOMY
The basic anatomy hasn’t changed in decades. You have a thread connecting to a needle
in area that is called the swaged part. The swaged part is the one we typically hold when
we handle suturing (part of your safety rules the make sure you don’t get poked).
To simplify things and crate clarity in your mind, you need to know that each component
can be different based on various factors:
The thread factors are: Material (gut, silk, Gortex, Prolene) and thickness (3-0, 4-0, 5-0, 6-
0 the more O’s the thinner the thread). Naturally the thicker the stronger but certain
materials are inherently stronger than others (don’t worry, we’ll explore that point).
That’s all that’s important
The needle factors: Length, cross section (we only used cross cutting), curvature (radius)
and circle fraction (½, ¾, 7/8). The choice of a needle has to do with the tissues you are
suturing and the location in the mouth.
Don’t focus so much on the specifications of each thread and needle. You can literally go
crazy looking at catalog and what the different options you have. The “power of choice”
will play against you and you’ll get even more confused. I’ll show you the exact sutures
I’m using and save you time.
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However, if you like to get into the details, understand everything and do your research
on each material before you make a decision then you’ll find yourself over-analyzing.
This will distract you from what’s important and you will not make progress because…
…Over analysis leads to paralysis
I need to teach you how to master suturing and get excellent in surgery, not get a PhD in
SUTUROLOGY!
So let’s focus on what’s important and here’s where you start:
KNOW YOUR PACKAGE
Everything on the package describes what’s inside.
For example: C6. Huhh?
That “C6” doesn’t mean anything to you and me.
“C6” is a code word that a company assigned to a specific suture. (like R2D2 – why?
Because that’s his name).
This is a code by a certain company that includes the following: A needle that is X mm
long, of particular X curvature, with X mm long thread, X cross section, X material,
number of O’s etc.
All is on the package and you need to study it.
Needle code
Curvature Material
Diameter
Cross section
Thread length
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What is the best suture?
There is no such thing as the best suture. You can achieve the same results with
completely different types of sutures. Don’t fall into the old DOGMA (“you must you use
that, and you mustn’t use that”). It all depends on what you are trying to achieve and I
will give you advice as well as tips to be able to decide. Often there are several options
and you will train your eye and mind to see what I’m seeing.
Here is my first tip:
Suture tip #1:
Narrow down to five kinds of sutures
All you need is 5 different suture types. Don’t exceed that or you and your staff will be
confused and have lots of sutures go to waste (a box of 12 sutures can cost up to $180!).
I use the exact same suture 80% of the time and in the remaining 20% I use the other
four.
The brand doesn’t make a difference but don’t stock up on cheap sutures. They expire
and when they do, they lose their physical properties.
I did the research for you already.
I can save you some time experimenting by following what works. Keep it simple as this
table is your starting point.
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GUT
If I told that in my practice, a busy surgical practice, about 80-90% of all sutures material
are gut. What would that tell you?
It means that you can achieve great results with gut. Does that mean you need to do the
same? Not at all but let’s get rid of previous “brain-washing” against gut.
It’s the one of the best suture materials you can use and I use it as much as possible and
as much as applicable (you’ll see a law dedicated to that in the 9 LAWS OF SUTURING).
Gut is an absorbable suture material that

takes about 3-5 days to start breaking down.
They resorb by the enzymatic activity of the
body. They resorbed inside the tissue and the knots will easily pull off (or “fall off” during
the healing period per your patients).
The breakdown varies between patients and also depends on their diet (increased acidity
with citrus drinks will expedite the resorption). However, gut sutures keep their tensile
strength for about seven days and have excellent knot stability. They hydrate in the
mouth and practically “swell” thereby tightening knots (remember, the sutures should be
loose but the knots tight).
Don’t use gut when you are expecting extensive swelling and tissue pull or with a
coronally advanced flap. it’s inappropriate to use gut suture in these situations.
However, often in soft tissue grafting, we need to suture grafts that we will not have
access to later. Gut is excellent for that.
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I know you and many other doctors have had a

possible bias against gut as a suture material. May
not like the “memory” of the suture when it
comes out of the package (mostly true for
chromic gut). Some dentists don’t have faith that
gut sutures will hold up and that the flaps will
open. That is only true for large augmentations and coronally positioned flaps. For most
procedures, it performs very well and actually forces you to suture properly on all levels.
Once you learn to overcome the characteristics in gut sutures you don’t like, you start
benefitting.
I’m sharing this with you with only one goal – To help you understand and master
suturing and there are different way to do that.
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So it’s totally fine if you’re not ready for gut yet. All will happen at the right time.
Q: I don’t like the “memory” of gut, can I put it in water to get rid of the
memory?
A: Yes. It’ll get rid of the memory but the thread become more stretchable
and loses its properties. It may affect knot stability.
Remember that you need to get out of your comfort zone to master suturing. Getting
frustrated with gut if you’re not used to it is part of it.
Turn your frustration into
an advantage.
I believe this is one of the keys to success.
Q: When to use chromic gut ??
A: It doesn’t make a difference. It’ll last a bit longer than plain gut because of
the chromic salts. Sometimes I see more inflammation around chromic gut.
Q: What to do I do when they get stuck locked prematurely?
A: They absorb blood that clots on the suture and that can interfere. The
threads will not slide well one on top of the other which causes this problem.
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Solution: Wipe them with a moist gauze. That’s especially critical in

continuous interlocking.
Here are the exact two gut sutures that I use:
Q: Is there much difference in resorption rate depending on the diameter of

the suture, whether it's 3-0, 4-0, 5-0?
A: No, it’s the same. The enzymatic activity which is resorbing the suture is
the same regardless of the thickness.
Common use in periodontal surgery and suturing a graft that will be covered by a flap.
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PROLENE
When it comes to withstanding forces, Prolene sutures work well.
They have combination of being gentle and kind
to tissues but also strong enough to keep flaps
stable under pressure.
I love using Prolene polymer sutures for soft tissue grafting when I need to coronally
advance flaps and keep them in for a few weeks (there is virtually no inflammation
around them).
One major disadvantage is knot stability. You need to

know how to handle Prolene to create a stable knot.
They technically slip on one another and you need to
change the knot twisting routine. You need to twist
more times and in a certain way (see SUTURE LAW #9).
One other problem with Prolene is that they “poke”.
The short ends are very rigid and often patients will tell you that what bothered them the
most is a huge aphtous ulcer from the suture.
How to solve that?
KEEP ‘EM LONG
Keep the ends long (~15mm) and they will be flexible and problem solved.
They will act like a flag and patients may occasionally bite on them but the
poking problem is resolved.
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Here are the exact Prolene sutures that I use:
When not to use Prolene?
Don’t use them suturing mucosa to mucosa. An example is a vertical release that extends
into the mucosa. They get embedded and hard to remove. For these situations, I like to
use gut 5/0.
Q: Can you stabilize sutures to composite, to create an

anchor for a pedicle or a coronally advanced flap?
A: YES. However, it’s not practical. It’s a terrible plaque

trap and compromises the esthetic. At the follow up,
you’ll find the patient’s meals under the sutures. Learn
the continuous sling in suturing made simple training to solve these problems.
31 | P a g e
GORTEX
Gortex is the brand name for a synthetic ePTFE suture
that is excellent for procedures that cause significant
swelling like augmentations. It is easy to handle and
has quite good knot stability.
The reason I like to use it in ridge augmentation is due

to its high tensile strength. The sutures are almost
always there holding the soft tissues at the 1 week post-operative.
Gortex has its own nomenclature that is different than other sutures. For example: Gortex
5-0 is equal to a 4-0.
To save you time and confusion, here’s the conversion:
Here is the exact Gortex suture that I use:
32 | P a g e
The companies “want” to confuse you. Remember the needle nomenclature is just an
arbitrary code.
Here is the comparison between the different needles:
Using Gortex is recommended for large flaps and augmentations, where swelling is
expected to occur.
33 | P a g e
Where to start?
“…Ziv, Show me your suturing techniques so I can copy you…”
I get this all the time and copying is great. Actually, I want you to “steal” everything that
you see working from me and others (like the saying “Good artists copy, great artists
steal”).
Here’s the catch:
If I just show you the techniques when we train together, you will never be able to
master suturing.
Why not?
Because suturing is not only about technique. Being a suturing robot in suture doesn’t
work. You will get frustrated.
Each clinical situation each different and you need to understand general suturing
principles first.
It’s like I would be your driving instructor and teach you how to turn left, how to turn
right and how to make a U-turns but…. I didn’t tell you about the recommended speed.
Can you imagine making a U-Turn at 65 MPH?
You need to know some rules that will put all the techniques in perspective to keep you
safe and make you successful.
The rules and laws of suturing will teach how to be mindful of the tissues you are
suturing, how to choose the right materials and how to apply the right mechanics.
34 | P a g e
THE 9 LAWS OF SUTURING
The nine laws of suturing give you the frameworks and principles of suturing. My goal in
creating them was to constantly remind you to focus on safety, materials and mechanics.
These laws are meant to act as silent voices in your head when you are suturing and even
if you just think about suturing.
Remember that thinking about suturing starts before you make even one incision. I
taught that you need to take suturing in consideration when you create a flap design.
Now I’m adding another layer (actually nine layers in the 9 laws).
So let’s get started.
LAW 1 -
You shall always suture SLOWLY
Slow down everything. Don’t rush.
I often observe dentist trying to suture at light speed. Their fingers, hands, needle and
thread look like a big tornado and the results are mediocre at best.
These “fast-suturing” doctors fail because they eventually harm themselves, their
assistant and patient. They also harm the tissues and outcomes by not being meticulous
with the entry and exit points and technique, thus the creating wrong mechanics.
35 | P a g e
When you drive your car at 100 MPH all the time you are guaranteed a crash. Slow it
down.
This is how I look at speed:
Suturing is like giving an injection or making an incision.
You don't do those fast, do you?
The fast cutting and chopping is for butchers. We are not.
If you want to be accurate and precise with your suturing - S L O W D O W N.
“…but Ziv, I can do it fast and get good results, what’s the problem?”
Awesome! good for you!
There is a juggling school in town that will take you and maybe you’ll even be able to get
into a circus as a performer.
I don’t believe in surgical acrobatics, speed and trying to impress with speed.
If you rush, you will make mistakes.
When you rush, you will poke yourself, your assistant or patient, you’ll get more
entanglement, wrong tissue engagements wrong mechanics.
Use these weapons of mass destruction carefully: Cotton pliers, scissors, needles.
“There is more to life than speed” (Mahatma Ghandi)
36 | P a g e
LAW 2 -
You shall always RESPECT your flaps
Consider the tissues you are suturing as sacred. Do no harm to the soft tissues so they
stay intact and respond well to your suturing.
Remember that: ”You can’t suture hamburger meat”
A big problem you may have seen are tears in the flap.
You pass the needle through one flap, then the other, tie a knot only to see how the
suture cuts through the flap. OOOPS.
You just created a tear or a “Cut-out” which is a suturing complication. The suture didn’t
work out and you can’t suture the same spot again.
37 | P a g e
First, why do cut-outs happen?
There are 3 main reasons:
1. Friable tissue: Red and swolling gingival margins usually indicate friable tissue. Pre-
diagnose this. As you apply normal forces with the your suture, the tissue cuts-out.
2. Too much force: Any tissue will tear with significant force. Remember that we only
want the knots to be tight. The sutures need to be loose.
3. Too close to the edge
When you see friable tissue, don’t engage it. Create an entry point that is more apical and
in good tissue. Take a bigger “bite” when engaging the flap to bypass tissue that has poor
quality. Don’t apply extensive force. The oral soft tissues are thin and delicate. Only light
forces are needed for successful suturing.
As a general rule:
Don’t get too close to the edge.
The entry is 2 to 3 mm from the flap edge.
38 | P a g e
Q: How about the papilla? Does

the 2-3 mm from the edge still
apply?
A: Yes. The rule still applies.

You need the check the
direction of the force which will
be applied by the suture. You
can be less than 2-3mm from
the side of the papilla but 2-
3mm from the tip because that is the direction of the force.
THE TWIST WRIST
Needles are curved and therefore your entry into the tissue needs to be in a curved
motion. If you enter in a straight line, you are using a “stabbing” motion.
A curved cutting instrument (needle) going in a straight line creates damage.
How do you generate a curved motion?
It’s all coming from the wrist. The wrist with the needle-holder can be twisted to generate
this motion with the needle. The needle needs to be perpendicular to the needle holder.
Now, go and watch the wrist-twist video in the online course.
39 | P a g e
Q: What is the deal number of sutures?
A: The ideal number of suture is the least number of sutures to achieve
Hemostasis, approximation, and stability.
I used to be very generous in suturing, meaning I used to place too many sutures. Each
entry and exist point in the flap is trauma that creates inflammation and compromises the
blood supply.
Therefore, each additional suture that is not really needed compromises your surgical
outcome. With more sutures, there is a higher risk for cut-outs.
Here is advice on minimizing the number of sutures:
Stop at the point where you think you are half way through your suturing process (It’s
arbitrary at this point but I’m trying to help you. Give this a try).
In most cases, you’ll notice that you are actually more than half way done. That will teach
you to be conscious about the number of sutures placed and encourages you to minimize
them.
Less is more
40 | P a g e
LAW 3 -
You shall always CONTROL your needle and thread
This is another safety law.
Being always in control of the needle and thread, control

of the suture material prevents injuries and minimizes
entanglements and pre-mature locking of the knots.
From the moment, you take the suture out of the package,
until you discard of it at the end, you need to be in control
of it. That means holding it in a safe way, keeping it away
from unwanted areas and surfaces and discarding it in a safe way.
Know where you needle and threads are at any time.
You need to hold it at the swaged part to avoid

“poking” yourself.
Remove the needle from the package with an

instrument and place it in a perpendicular position to
the needle holder. That’s a starting point for 80% of
cases. Occasionally, we will need a different angle when
suturing in the distal regions.
41 | P a g e
What to do with all this excess thread material?
When the suture is new out of the package you have a lot suture material (a very long
thread). That is tricky to manage and sometimes blocks the surgical field or creates
entanglements.
Here are 2 tricks to prevent that:
The “pinky hold”: Lock the thread material

between finger 5 (pinky) and the palm. That
will hold it away from the surgical site and
will allow you to control it at all times. Now,
watch the tutorial video on the Pinky hold.
The “wrap around”: This helps when are

ready to tie a know and have a lot of thread
material. Hold the needle at the swaged part
between finger 1 and finger 2. Now wrap the
excess suture material around fingers 3, 4
and 5. Now you have less free thread
material and the suturing is simplified. Go ahead and watch the video tutorial in your
online course.
42 | P a g e
Finish strong and safe
When you are finished with your procedure, place the

sharp part of the needle inside the needle holder and
place it on the tray.
Your assistant will thank you for that. Don’t forget to

share these laws with your supporting staff.
We can all benefit from refreshing safety precautions. The first 3 laws are dedicated for
that. Know them well (1. Suture slowly, 2. Respect your flaps, 3. Control your needle and
thread).
We have 6 more to go. Hand in there!
LAW 4 -
Go with your GUT
In my opinion the more gut sutures, you use the better
you’ll do.
Using gut teaches you the appropriate force but still

relatively forgiving even if you didn’t use a perfect
technique. It resorbs at the right time from within the tissue and has good knot stability.
Patients prefer that as well because gut sutures are perceived as advantageous by our
patients and their perception of us is important (I wouldn’t recommend gut if I didn’t
think it was advantageous myself, so this is a double win).
43 | P a g e
You can use gut in areas you can’t visit again like underneath a flap or a bridge. Don’t feel
pressure to use gut if you’re not ready yet. You can certainly achieve great outcomes with
different materials.
I know you may be concerned with the “memory” of the suture and it getting stuck when
the blood clots on it. I’m with you on that and there are good solutions for that.
When you’re ready to tackle gut, I’m here for you to tackle these probems and start
benefiting from gut sutures offer us.
LAW 5 -
Go MICRO with delicate tissues

tissues
The idea behind this law is to adjust the size of the thread and the needle to the structure
you are suturing.
If you are suturing a large maxillary flap, the sheer size and
density of it can tolerate large needles and requires a
relatively thick thread (4/0) to position it. On the contrary,
when suturing in the esthetic zone, aligning papillae,
friable tissues, lower incisors flaps you need to “go
smaller” (or “go MICRO”).
When you use 5-0, 6-0 you will have less tissue trauma and cut-outs.
44 | P a g e
Here’s a technique a I call the “Prayer technique”. It allows me to create primary closure
with my suturing using 5-0 gut sutures. Pay attention to the diagonal incisions that help
me create mini-flaps that will cover the extraction sockets after the teeth have been
extracted and the sockets grafted. It will take you 10-15 minutes of your time to suture
properly but the outcome and satisfaction is certainly worth it.
Extraction of all lower incisors leaves abundance of tissue behind that if not managed will delay healing and
create a sub-optimal ridge for implants.
The key here, is to create diagonal incision through the papillae, mobilize them and rotate them on top of the
extraction sockets (following bone grafting).
Once rotated, on top of the sockets, create multiple X sutures with simple interrupted, using Gut 5-0 for primary
closure and expedited healing.
45 | P a g e
LAW 6 -
It’s the strength & slippage KNOT the material
The material doesn’t make a difference. Again: The material doesn’t make a difference.
This may come as a surprise to you and is a major dogma (you probably heard: ”You must
use this material and you mustn’t use that one”).
The actual chemical composition of the suture doesn’t make a difference and in most
cases, you can use anything to achieve a good surgical outcome.
Silk is not the devil and it’s totally fine to use it. It’s not the actual material, but how
strong it is and how it ties (suture strength & knot slippage).
What is tensile strength really (in a super simple way)
Without complicated you with physics, tensile strength is

resistance of a material to breaking under tension. It’s like
taking a rubber band and starting to stretch it. You can
stretch and stretch and at some point, it’ll tear. The longer
it lasts before it tears, the more tensile strength a material
has.
Now, imagine the forces that you applied to stretch a rubber band until it breaks, are the
same forces applied on 2 sutured flaps. These forces happen when the tissues swell and
the 2 flaps can start separating.
46 | P a g e
If you had control over the suture, holding both flaps, would you choose one with high
tensile strength or low tensile strength?
Naturally, you want a suture with high tensile strength to withstand the forces caused by
swelling. I simply call them strong sutures like Gortex and Prolene (the strength of the
material matters here).
Knot slippage
Certain suture threads easily slip on one another. An

example is Prolene sutures.
What does it mean?
If the threads easily slip and slide on one another, you

will have less pre-mature tightening and
entanglements. On the flip side, you will have less stable knots, because they tend to slide
on one another (there is no traction between them, so to speak).
With the Prolene material, you benefit from good tensile strength but will have to tackle
high knot slippage with a special way to suture (see Law 9).
So when choosing a suture material consider the strength (or tensile strength) and knot
slippage, not the material per se. Choose a material that handles well in your hands and
that is convenient for tying knots. When you expect swelling, and stretch of the tissue, go
with a suture that is strong enough to withstand it.
47 | P a g e
LAW 7 -
TEST your suture
This law is applied just before typing a knot.
You completed the entry and exit points based on

the suturing you are trying to achieve. You
envisioned how you want the wound to close and
the flaps to move. This is when you can test your
suture.
Testing the suture involves applying forces on both ends of the suture as if you are tying a
knot but without actually doing it. Observe the mobilization of your flaps and see how the
surgical wound closes. You are basically testing if the mechanics you envisioned.
are happening).
If you don’t like what you see, take it all out and re-do the suture.
If all looks good, tie a knot.
Law 7 is all about making sure the mechanics of the suture are working well before you tie
the knot. At some point, you will not have to test all of your sutures (especially the simple
ones) but keep in mind that it’s always good to check.
48 | P a g e
LAW 8 -
DON’T PULL AWAY
This law addresses the problem of “Air knots”.
“Air knots” happen when a knot gets locked

prematurely away from the tissue. As such it’s
completely useless and needs to be removed.
“Air knot” = “Premature locking” : How to

prevent that?
What we need to do is control the

entanglement so it happens close to the tissue. One of the keys of making it happen is by
not pulling away from the tissue.
If you pull away from the tissue, your knot will lock prematurely and you’ll get an “Air
knot”. Make both long and short end almost equal utilizing the wrap around technique
from Law #3 and tighten parallel and close to the tissue.
You can also tighten the short end in a “back and forth” motion, after you made you first
two throws, which creates some knot stability. When your first 2 throws are reasonably
stable, STOP BREATHING, NOBODY MOVES A MUSCLE, and complete the throws in the
opposite direction.
49 | P a g e
If you don’t pull away and stay parallel and close to the tissue, you will get a perfectly
stable knot. How will learn how these throws work in the next suturing law.
LAW 9 -
#Os = #THROWs
Last but not least!
So many dentist are wondering about how many throws? In which direction to start?
Clockwise? Counter clockwise?
Here is a general rule that will help you:
The number of the Os (how many? 3-0, 4-0, 6-0?) is the number of the throws
Example: 4-0 suture
2 in one direction
1 in the opposite direction
1 in the original direction
2 + 1 + 1 = 4  4-0 suture
Example: 5-0 suture
2 in one direction
50 | P a g e
1 in the original direction
2 + 1 + 1 + 1 = 5  5-0 suture
Q: Where to start clockwise? Or counter clockwise?
A: It doesn’t matter mechanically and it’s more about convenience. I

personally don’t look at it as clockwise or counter clockwise. I look at it as
“away from me” and “towards me”.
Let’s repeat one of the previous examples:
Example: 4-0 suture
2 Away from me
1 Towards me
1 Away from me
2 + 1 + 1 = 4  4-0 suture
Q: What if I want to do extra throws?
A: Enjoy! It doesn’t hurt but you are wasting suture material and your knots
will be bigger.
51 | P a g e
Q: I noticed that this rule is not ideal for Prolene?
A: That is correct for Prolene I add 1 and the sequence is different. The 9 th
rule becomes #Os+1=#THROWs (see example below).
Example: Prolene 5-0 suture
3 Away from me
2 Towards me
1 Away from me
3 + 2 + 1 = 6  4-0 suture
PUTTING ALL THE 9 LAWS TOGETHER
Many dentists have challenging suturing large flaps. The most predictable strategy is to first align the flap
starting from the mesial. The create interrupted horizontal mattress with Gortex 5-0 and overlay with
continuous interlocking gut 4-0.
52 | P a g e
Here is the summary of the 9 LAWS OF SUTURING. Recite them before you practice
suturing with your zPAD.
THE 9 LAWS OF SUTURING
1. You shall always suture SLOWLY
2. You shall always RESPECT your flaps
3. You shall always CONTROL your needle & thread
4. Go with your GUT
5. Go MICRO with delicate tissues
6. It’s the strength & slippage KNOT the material
7. TEST your suture
8. DON’T PULL away
9. #Os = #THROWs
Don’t be a technician dentist.
The techniques are important and you can practice them after watching the video
tutorials. The 9 LAWS OF SUTURING are your 9 layers of confidence that help you with
safety, choice of materials and the mechanics of suturing.
53 | P a g e
Now that you that have framework and a roadmap to mastering suturing, it’s time to get
to work! Watch the videos tutorials, review the suturing techniques manual and practice
on your zPAD.
Many dentists before you started exactly where are at today. The road to mastering
suturing is already paved for you and I closely mentor the dentists that not only need but
also want to be excellent in suturing.
You will master suturing.
Ziv.
P.S.
If you followed the framework of this book, you now have the
mindset to suture with clarity and confidence. You next step in
the roadmap is to practice the actual techniques and correlate
them to different types of surgical procedures.
Watch the video tutorials, study the suturing technique step-by-

step manual, draw, illustrate and practice on your zPAD.
Mastering suturing is within reach and I am here to coach and

mentor you through this process.
54 | P a g e

3toIXLl5RFm9rW83iwsy Back To The Suture

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3toIXLl5RFm9rW83iwsy Back To The Suture

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Back to the SUTURE – Your Roadmap to Understanding & Mastering Suturing

It’s not that things are impossible.

It’s your mind telling you: “It’s Impossible.

So let’s go back to word “Impossible”.

So here are the first tips of this book

and the your keys to success:

Now let’s take a step farther.

Would you be able to learn a critical surgical skill in 7 days?

Would you do it in 7 hours?

I’m not just talking about any skill.

SUTURING: Your ability, with

Mastering suturing may feel “impossible” for you today.

Countless dentists already mastered the suturing game.This is your irrefutable

Here’s my second and third advice in this book:

• You don’t have much experience

This is what it will take from you

Simply follow the instructions, my friend.

What do I mean by that?

I’ve taught thousands of dentists over the years

I tell them the same: “Follow the instructions, my

You must follow the instructions, step-by-step. No deviations.

Do as I do initially to create effective and predictable knots and surgical wound

WHAT’S HOLDING YOU BACK?

First, you need to be stripped from common

This is the first step in turning you into a suturing

Here’s my plan for your growing your suturing skills:

Can we shake hands on that?

Suturing is not what you were indoctrinated to believe it is.

It’s not a secret skill reserved to specialists or to uber-talented dentists.

It doesn’t take decades of practice or using instruments and materials available to

The 3 Pillars of suturing

Here’s the SECRET #1:

Out of all the suturing techniques I use, 95%

If you’re like most dentists – Suturing is a struggle.

unpleasant suture problems and complications.

Well, confidence can be acquired. Clarity can be created.

Here’s what not to do:

• Don’t give up or get discouraged by anyone.

I know you can master this suturing thing.

No matter if you are just starting out or if you have

It feels like there is nowhere to turn to if you desire to learn suturing.

There could be only 3 explanations:

Howard Farran, founder of DentalTown, told me the following during an interview:

There was no time to waste.

In this system, I want every dentist to

• go back to the sound surgical principles,

Therefore, I called this book BACK TO THE SUTURE.

“I finally GET suturing!”

If this works on a person with no dental knowledge

and with a physical disability,

Do you think it’ll work for you?

Everyone operates at 100% capacity of their current mindset ceiling

So how would you increase your potential if you’re already at 100%?

This way you can reach higher and higher levels

So let’s change some mindsets.

Suturing begins before you make the first incision

Here is the twist.

This first mindset shift is going to change things for you.

Here’s the next step in growing your suturing skills:

Be your own true critic.

Immediately post-op 1 week post-op

The learning and growth are just in front of your eyes.

Are they still there? Are they loose or open?