259. Pascal Magne, DMD, PhD, MSc - Immediate Dentin Sealing

使用IDS时需要注意的一个问题是，当你做临时修复体时，任何树脂类材料都会粘在IDS上。

One of the problem with the IDS that you have to be careful about is that when you provisionalize, any resin based material will stick to IDS.

所以你必须避免这种情况，否则当你把临时修复体撕下来时，可能会连带把粘接层甚至IDS层一起扯掉。

So you have to prevent that to happen because if you don't, when you tear off your provisional from the tooth, you might rip off your adhesive layer, damage the IDS layer.

因此，把临时修复体和IDS隔离开，是这里最重要的第一个原则。

So isolation from the provisional is the first very important principle here.

欢迎收听《牙科快讯》。

Welcome to Dental Digest.

这是一档专注于循证牙科文献的播客。

This is a podcast devoted to following evidence based dental literature.

接下来是您的主持人，医生。

Here's your host, Doctor.

梅丽莎·塞伯特。

Melissa Seibert.

她目前在空军从事牙科临床工作。

She's a dentist currently practicing in the Air Force.

话虽如此，本播客中的所有内容均不代表美国空军的立场或官方认可。

With that being said, nothing contained within this podcast is intended to be reflective or endorsed by the US Air Force.

我可以问你几个关于IDS的技术问题吗？

Would you mind if I ask you a few technical questions about IDS?

我完全理解。

I completely understand that.

天哪。

Good grief.

你总是聊这个话题，我能理解你可能听腻了。

You talk about this topic all the time, so I can understand if you're kind of tired of it.

当然。

Absolutely.

不，不，不。

No, no, no.

我永远不嫌多谈IDS。

I'm never tired to speak about IDS.

上世纪90年代最了不起的突破之一就是IDS，那时候我和朋友迪迪埃·迪特施基在日内瓦做牙医，他还是我的论文导师，我那时候还是个新手，我们一直在研究陶瓷修复体的粘接，但怎么也粘不住牙本质。

It's one of the most amazing thing that came out during the 90s, you know, is IDS and because we were struggling so much with this Bonded Dentin with my friend Didier Dietschy, you know, when Didier Dietschy was my thesis director and when I was a super baby dentist in Geneva, we were looking at bonding ceramic restorations and we could not bond ceramic restorations to dentin.

当时用的粘接剂，比如Scotchbond多用途胶，其实已经算不错了，可一到粘接非直接修复体的时候，就是粘不牢。

We had the right adhesives like Scotchbond multipurpose was a very decent adhesive back in those days, and we could not make it bond to dentin when cementing a nonlay anne.

如果是直接做树脂充填，效果还行，可一到粘接环节就出问题。

It would work pretty decently when doing a direct composite, but not during a cementation.

我们用扫描电镜拍到的照片清楚显示，只要粘接剂没处理好，牙本质形成的混合层就会被压碎，跟粘接的水门汀分离开，中间出现缝隙。

We had those amazing scanning electron microscope pictures showing that if the adhesive is not procured, so on the dentin, the hybrid layer was crushed and would separate from the luting composite and create a gap.

那时候我们真是束手无策，完全搞不懂问题出在哪。

And so we were really powerless and we were wondering what's wrong.

后来，我们听说德国牙医斯特凡·保尔——他在瑞士工作，之前跟帕斯卡尔一起做过研究——回来跟我们说，可以在取模前先涂一遍粘接剂，粘接时再涂一遍，这样粘接成功率会高很多。这事儿发生在1995年，真是关键转折点。

Then suddenly we heard Stefan Paul who was a German dentist who works in Switzerland, but he had been working with Pascal back then and he came back from this research time with Pascal and he told us about dual bonding and said, you know, if you apply the adhesive before impression and then you apply it again during cementation, you have a better chance of bonding and that really was the trigger in 1995.

他后来和同事贝希inger一起发表了这种双层粘接技术。

And he published that with a colleague called Berchinger, the dual bonding technique.

但再往后我们才知道，其实日本人早就搞定了，他们管这叫树脂涂层，只是论文只用日语发表的。

But later we found out that actually the Japanese were the first one to have nailed it under the name resin coating, they published it only in Japanese.

所以当时根本没人知道这件事。

So nobody really knew about it.

是东京大学的nikaido toru在1992年做的。

And it was Toru Nikaido at the Tokyo University, 1992.

他们当时叫它树脂涂层，或者树脂牙本质封闭，后来stefan paul称之为双固化粘接，而我们则提出了IDS这个说法——因为我们觉得，这本质上就是一次性、直接地把牙本质封住，用的是一个能保证厚度均匀的粘接系统。

But basically they call it resin coating, pashlet resin dentin sealing, then Stefan Paul dual bonding and then we came up with the word IDS because I think that it's basically bonding to dentin straight away and once for all, that's our concept using a field adhesive system, using a field adhesive system that is giving you a consistent thickness.

如果你用的是未填料的树脂，IDS的操作会困难得多，因为它们太薄，固化效果差，这一点已经有大量科学证据支持。

So IDS is much more challenging to do if you use unfilled resins because of their insufficient thickness, they don't polymerize well in thin layers and, all this is scientific evidence.

后来我们做了大量研究，发现只要在取模前先对牙本质做树脂涂层，这些问题就全解决了。

Of course, we did lots of research since and basically resin coating the dentin before the impression has resolved all those problems.

现在已经有临床研究数据了。

And now we have clinical studies.

我的朋友，荷兰的marco gresnik，做了非常出色的贴面研究，证明只要牙齿暴露的牙本质超过百分之五十，使用IDS的成功率几乎是百分之百。

My friend, Marco Gresnikt in The Netherlands came up with excellent veneer studies showing that with teeth with more than fifty percent of exposed dentin, you know, the success rate is absolute with IDS.

所以今天，我们已经很清楚：只要正确操作IDS，效果就非常好——当然，我们待会儿会聊到，因为很多人其实并没有做对。

So basically we are to a point today that where we know that if you do IDS correctly, I know that we'll talk about that because there's lots of people who don't do IDS correctly.

不幸的是，就连在研究领域，梅丽莎，我就不点名了，但确实有项研究声称IDS根本没什么效果。

Unfortunately, even in research, Melissa, even in research, I'm not going to speak names, but there was a research done where they said, oh, ideas doesn't really make a difference.

但如果你仔细看那篇论文，他们会用粘接剂，然后用气流吹薄，甚至在粘固修复体之前就把粘接剂吹掉了。

Well, if you look at the paper, they use the adhesive, they air thinned it, they air braided away the adhesive when they cemented the restoration.

结果他们就说IDS没用，可实际上他们根本做错了。

And then they said the IDS is not working because it was done completely wrong.

他们甚至贴出了IDS之后暴露的牙本质小管的照片。

They even posted, they even show picture of the exposed dentin tubules after IDS.

你看了能不惊讶吗？

You are like, what?

根本就没有树脂留在牙齿上。

Okay, there is no resin left on the tooth.

明白吗？

Okay?

所以你看，读摘要的时候一定要小心，得去翻全文，把整篇论文看完。

So you see, you have to be very careful when you read an abstract, go to the article, read the entire article.

每当摘要说IDS无效时，一定要仔细查看材料与方法部分，弄清楚他们到底是怎么操作的。

Whenever an abstract is telling you IDS is not working, grid the material and method and log how they did.

如果他们把粘接剂吹薄了，或者没用对粘接剂，那当然会出问题。

If they air thin the adhesive, they didn't air block the adhesive, they used the wrong adhesive.

这些做法当然会对结果产生巨大影响。

Of course, all those things are going to make a huge difference.

但如果你去看高质量的研究，根本找不到多少反对IDS的论文。

But if you read the good research, you will not find many papers against IDS.

现在IDS已经是公认的做法，适用于牙冠、嵌体、高嵌体和贴面。

It's now a universal concept and it works for crowns, inlays, onlays, veneers.

这已经是一个普遍接受的理念。

It's a universal concept.

这里有很多问题值得探讨。

There's a lot of questions there.

其中一个问题是，首先，做IDS时到底该用哪种粘接剂？

And so one of them is, first of all, what adhesive do you have to use for IDS?

有些人会用通用型粘接剂来实施即刻牙体密封技术。

Some people will use perhaps a universal adhesive for their immediate dent and sealing technique.

我知道你非常注重客观性，不会偏向任何特定品牌，这一点我很清楚。

And, you know, I know that it's very important to you that you keep things very objective and that you don't align with a particular manufacturer.

但说实话，我确实知道，你的操作流程里用的是OPPO-one FL。

But I know, I'll just be honest, I know for a fact, perhaps that in your protocol, you use OPPO-one FL.

这是第四代的黄金标准粘接剂，性能非常出色。

It's a fourth generation gold standard, very well filled adhesive.

所以我想问你，从理论上讲，要正确实施这项技术并充分发挥其优势，是不是必须用特定的粘接剂？

So let me ask you, in order to, in theory, properly do the technique and really harness the benefits, does it have to be certain adhesives?

如果是的话，是哪些？

If so, which ones?

当然，直接回答就是：没有专门为IDS设计的粘接剂，这本来就是一个通用方法。

Of course, the raw answer would be no, there's no specific adhesive for IDS, it's a universal approach.

实际上，IDS能让几乎任何粘接剂的表现都更好。

So IDS will make pretty much any adhesive better.

这是最直接的回答。

That's the raw answer.

但有些粘接剂，操作方式得不一样。

Now, with some adhesives, you have to do it in a different way.

比如那些需要吹气薄化的粘接剂——因为里面含有溶剂，像Prime & Bond这类全合一型或通用粘接剂。

For instance, all adhesives that have to be air thinned because there is solvent in the adhesive resin, I'm talking about the prime and bond style of products, all in one style of products, universal adhesive style of products.

如果粘接剂需要吹气薄化，那只有在上面再加一层流动型复合树脂，IDS才有效。

When the adhesive has to be air thinned, then IDS will work only if you cover it with an additive, an additional layer of flowable composite.

那些研究粘接剂和IDS效果的实验里，他们有这么做吗？

Are they doing that in those studies where they test those adhesive with ideas and it doesn't work?

答案是没有，不是系统性地这么做。

The answer is no, not systematically.

所以才会出现那些有争议的研究，根本原因是实验操作不规范。

And so that's why you will have those studies that are controversial, but the reason is they are not done correctly.

因此，加一层流动型树脂非常关键。

So the addition of a flowable layer is very important.

即使你用SC Bond，我们也知道SC Bond和全酸蚀、自酸蚀这些体系，我个人觉得都没问题，但你必须在SC Bond上面再盖一层流动树脂，效果才会更好。

Even if you use SC Bond, we know SC Bond and the total etchers, the self etchers group there, well, fine with me, but you have to cover SC bond with the flowable layer and it will work better.

如果你不这么做，就得涂更厚的一层，但那样就不再透X光了。

If you don't, you have to place a thicker layer, then it's not radiopaque.

这样一来，你的修复体下面就会出现黑线。

So you will have black lines under your restorations.

你希望这样吗？

Do you want that?

不希望。

No.

如果你打算一步完成，又不想用流动树脂，那Optibond FL几乎是唯一的选择，当然你也可以用Ormond Three，那是另一种场粘接剂。

So if you want to do it in one step and without having to use the flow, Optibond FL is your basically not only options because you could use Ormond three, which is another field adhesive.

我觉得还有PQ1之类的产品。

I think there is also PQ1, something like that.

市面上有几种粘接剂是透X光的。

There's a few adhesive that are a radio opaque.

Optibond FL 显然是最主流的选择。

Optibond FFEL is obviously the most prominent.

我特别喜欢这款粘接剂具有放射不透性这一点。

And I love the fact that the adhesive is radio opaque.

这个优势太明显了，亲爱的梅丽莎，我觉得根本不用犹豫。

It's a huge plus, my dear Melissa, to me, it's like, it's a no brainer.

你必须用放射不透的粘接剂，因为做树脂充填或粘接时，经常会有大量多余粘接剂溢出。

You have to have a radiopaque adhesive because many times you do composites, you cement, there is excess of adhesive all over the place.

有些多余粘接剂会跑到牙龈下面，肉眼看不见，但拍个X光片，Optibond FL 就会清晰可见。

They could be excess subgingivally that you don't see, but if you take an x-ray, Optimal Dialyphale is extremely visible on an x-ray.

对我来说，这绝对是必须的。

To me, that's a must.

你提到的另一个问题是，有些人用得不好，可能是因为他们在处理IDS时操作不当。

One other point that you brought up is that perhaps some people are not getting the idealized outcome with it because they're post treatment of IDS, they're doing it improperly.

比如在安放最终修复体之前，或者取下临时冠之后，他们直接用喷砂把粘接层全给磨掉了。

So whether it's right before they deliver the restoration, right after they take off the temporary, they're completely perhaps removing the layer with air abrasion.

那在那之后，你是怎么处理牙齿的？

How do you treat the tooth after?

你做了即刻牙本质封闭后，再精细调整一下牙釉质边缘。

So, you know, you do the immediate dent sealing, then you refine your enamel margins.

如果要让患者离开，你就先做个临时修复体；如果是即刻修复，可能就不需要临时修复体了。

You provisionalize it if you're going to send them away or if you're doing same day dentistry, perhaps you're not going to provisionalize it.

但在正式粘接之前，你怎么处理那层IDS呢？

But then how do you post treat the IDS layer right before you're about to deliver?

你会用喷砂吗？

Are you using air abrasion?

在酸蚀牙釉质的时候，你是只蚀刻牙釉质，还是连同IDS层一起蚀刻？

And when you're etching the enamel, are you etching the enamel itself and the IDS layer or just the enamel?

IDS的一个关键问题在于，做临时修复体时，任何树脂类材料都会粘在IDS上。

So obviously the one of the problem with the IDS that you have to be careful about is that when you provisionalize, any resin based material would stick to IDS.

所以你得避免这种情况，不然取下临时修复体时，可能会把粘接层甚至IDS层一起撕掉。

So you have to prevent that to happen because if you don't, when you tear off your provisional from the tooth, you might rip off your adhesive layer, damage the IDS layer.

所以，把临时修复体和牙体隔离开，这是最关键的第一步。

So isolation from the provisional is the first very important principle here.

以前Bisco出过一款叫Pro V Coat的产品，但后来下架了，对吧？

There was a product by Bisco called Pro V Coat that they removed, right?

现在这产品已经没了。

And it's gone.

这真挺遗憾的，因为Bisco是少数几家真正把IDS当作临床操作来对待的公司之一。

So this is very sad because Bisco was one of the only company that recognized IDS as a clinical procedure.

他们当初介绍Pro V Coat的时候，明确说过这产品主要是为IDS设计的。

Know, they mentioned when they talked about Pro V Coat, they mentioned IDS being the primary reason for this product.

我当时特别兴奋，甚至还记得为他们拍过一段相关视频。

So I was super excited and I even I remember doing a video for them about that.

不过，你其实用很简单的办法也能达到同样效果——比如在牙面上涂一层凡士林。

But you can also achieve that goal very efficiently with simple petroleum jelly Vaseline on the tooth.

我平时做树脂固化前，或者做PMMA临时贴面、牙冠之前，都会这么处理。

I do that all the time before placing firm it or before doing my PMMA provisional veneers and stuff like that or crowns.

第二点是防止粘连。

Second thing is so prevent adherences.

也就是说，当你回来取下临时修复体时，避免损伤IDS层。

That means preventing damaging the IDS layer when you come back and remove your provisional.

其次，清洁表面。

Secondly, cleaning the surface.

在临时修复期间，通常会有大量凡士林之类的物质被冲掉。

Most of the time, you know, with the times during provisionalization, a lot of the Vaseline and stuff washes out there.

表面会残留碎屑，可能还有细菌。

You will have debris, you will have maybe bacteria.

所以把表面擦干净非常重要。

So it's very important to wipe off the surface.

可以用氯己定或者酒精清洁牙齿，最后再进行喷砂处理。

Use, you you can use chlorhexidine, you can use alcohol to clean the tooth, and then ultimately you are going to air abrade.

用30微米的氧化铝或CoJet喷砂都可以，压力调到30psi，喷几秒钟，直到表面完全变得哑光、干净，不能有任何白色残留或不平整，看起来要像酸蚀过的牙釉质一样。

So air abrasion with 30 micron aluminum oxide or co jet doesn't matter, you know, at 30 PSI, few seconds until your surface looks totally dull clean, you should not see any whitish residue, any irregularities, it has to be looking like basically etched enamel.

然后你要对整个预备表面进行酸蚀，包括IDS区域，这不会造成伤害，反而能清除残留物，酸蚀后冲洗干净并吹干。

And then you are going to etch the entire preparation surface, including your IDS, it's not going to hurt, it's going to clean debris away anyway, etch, rinse, and dry.

理论上，现在你甚至可以用酒精吹干，因为没有牙本质暴露出来，对吧？

And now in theory, you can dry even with alcohol because there is no dentin exposed, right?

如果你在放大状态下把IDS做得非常到位，放大其实也很关键。

So if your IDS was absolutely well done under magnification, you know, magnification is another thing.

看得越清楚，操作就越精准，放大八倍时，你的分辨率能达到大约25微米。

The more you see, the more precise, you know, your resolution will be about 25 microns with magnification eight times.

所以我把八倍放大当作一个门槛，只有到这个程度，你才能真正看清细节。

So I like to put this as a threshold, you know, eight zero is when you can start really seeing things.

说到牙本质，我之前忘了提一点：做IDS之前，你必须清楚牙本质的位置。

And when you deal with dentin, so another thing that I forgot to mention is that to do IDS, you need to know where the dentin is.

在第一阶段，当你完成牙体预备、准备做IDS时，一定要确保粘接剂准确覆盖到牙本质，不能漏掉任何牙本质区域——书里就有一个漂亮的案例，是我做的一个贴面。

And at stage one, when you prep the tooth, you are done and you want to do IDS, you have to make sure you place the adhesive on dentin and you don't miss Dentin because in the book, have a beautiful example of a veneer that I cemented.

贴面的近中一半是用IDS粘接的，远中一半则没有用IDS，你猜怎么着，梅丽莎？

The mesial half of the veneer was cemented with IDS, the distal half of the veneer was cemented without IDS and guess what, Melissa?

五年后，远中部分掉了。

After five years, the distal part broke off.

好消息是，我们把它重新粘回去了，二十年过去了，修复体还在嘴里，修过之后照样用。

The good news is we bonded it back and the restoration is still in the mouth after, I don't know, twenty years later, it's still there, repaired.

所以这算是最坏的情况了。

So that's the worst case scenario.

其实也没那么糟。

It's not so bad.

不过，你回来处理时，得用喷砂清理IDS层，但一定要仔细检查，这次有没有把牙本质暴露出来，或者之前有没有漏掉牙本质。

But anyway, when you come back, you air abrade the IDS, but you have to look carefully if you re exposed dentin during that stage or if you missed dentin before.

如果漏掉的牙本质面积很小，就一平方毫米左右，我倒不怎么担心，蚀刻完直接在那块地方再涂一遍底剂就行。

If the missed dentin is a very small tiny surface, one millimeter square, something like that, I would not worry that much and just reapply the primer on that area after etching.

底剂可能会污染到其他IDS层，但问题不大。

The primer might contaminate the rest of the IDS layer but it's not a big deal.

我们其实做过研究，就算用Optibond FL的底剂污染了IDS层，也不会影响树脂和IDS层之间的粘接强度。

We actually have a study that showed that if you contaminate the IDS layer with primer of Optibond FL, it's not going to affect the resin to resin bond to the IDS layer.

然后涂上粘接剂，但先不要光照固化。

And then you apply your adhesive and of course without curing.

这一点非常重要。

So it's very important.

很多人出问题，是因为没注意到牙本质暴露，之后又没做任何处理。

I think a lot of people get in trouble because of they miss Dentin and then don't do anything about it.

很多人出问题，是因为IDS层太薄，被空气吹干了，没用空气隔绝。

A lot of people get in trouble because the IDS layer is too thin, has been air thin, not air blocked.

第一次操作时，在IDS层上涂甘油非常关键。

It's very important to apply glycerin to the IDS layer when you do it first.

如果不这么做，光是没用空气隔绝，你的粘接层厚度就可能损失近一半。用Optibond FL时，单层涂在平面上大约是80微米。

And otherwise you lose almost half of the thickness of your adhesive already by not applying the air block actually with Optipond FF, you know, adhesive is about 80 micron when you apply it to one layer on a flat surface.

如果不做处理，IDS层的氧抑制效应可能高达40微米。

If you don't, IDS oxygen inhibition can be up to 40 microns.

所以你想啊，如果不涂甘油，80微米里一下子就没了40微米，对吧？

So imagine you lose 40 microns out of 80 already if you don't do the glycerin, right?

所以这些细节，我总说，魔鬼藏在细节里。

So all these things, I always say, with ideas, the devil is in the detail.

你必须得应对这些问题。

You are going to have to deal with that.

但对我来说，做这些步骤已经成了习惯，Optibond FL 用起来特别合适，操作起来轻松多了。

But, you know, for me, it becomes such a routine to do ideas and Optibond FL is so appropriate that it makes it very much easier to apply.

毫无疑问，它正变得越来越重要。

There is no doubt it's becoming.

所以我猜其中一个答案是：一定要彻底熟悉你的粘接剂。

So I'm guessing one of the answer is, you know, be extremely familiar with your adhesive.

我不喜欢有人用好几种粘接剂。

And I don't like, you know, that people use multiple adhesives.

一种用于这里，一种用于浅牙本质，一种用于深牙本质？别这样，就用一种，但得把它摸透。

One adhesive for this, one adhesive for superficial dentin, one adhesive for deep dentin, one adhesive for No, use one adhesive but know it.

好好研究它，如果你打算用自酸蚀型，那就用自酸蚀型，但得按我们之前说的那些步骤来，比如特别小心，别让粘接剂太薄，或者在上面再涂一层流动树脂。

Know it well, study it well And okay, if you wanna use self etch, do self etch, but then you have to do some specific steps that we talked about, like being extremely careful, having the adhesive to thin or applying the flowable on top.

我觉得，丹尼斯那边最大的障碍，也是我经常被问到的问题，这正是我想请教你的地方。

I think just again, one of the big hangups with Dennis and a question that I get asked all the time, and this is why I'm asking you one of the big hangups.

我们来简单回顾一下，完成IDS治疗后、正式粘接前的步骤。

So let's just recap here is just the post treatment of IDS right before you submit it.

简单说，先取下临时冠，然后把隔离剂擦干净。

So just to recap, you take off the provisional, you go ahead and wipe off the separating medium.

这里说的隔离剂是凡士林，接着用气枪吹干，再做全酸蚀。

We're talking about petroleum in this case, and then you're going to air braid and then you're going to total etch.

也就是蚀刻牙釉质和IDS层，冲洗干净后，在牙釉质上涂底漆和粘接剂，对吧？

So you're gonna etch the enamel itself and your IDS layer, go ahead and rinse that off and then apply the prime and adhesive to the enamel, correct?

没错。

Right.

我之前说过，如果粘接的是完全非牙本质的表面，甚至可以在涂粘接剂前用酒精擦干。

And as I said, when you bond to totally non dentin surface, then you can even dry with alcohol before applying the adhesive.

这步不是必须的，但我做瓷贴面时喜欢这么做，为了确保绝对干燥。只要滴一滴酒精，用气枪吹一下，连周围残留的水分都会被蒸发掉。

Not necessary, but I like to do it on porcelain veneers to really have a dry field and when you drop, you apply one drop of alcohol and you air blow it, it evaporates all the water even around you.

吹干挺麻烦的，因为你吹气把水分赶走了，可一停吹，水又会绕回牙齿周围。

And drying is tricky because when you air blow to dry the prep, the water is pushed away and then you stop blowing, it comes back around the tooth.

所以得特别小心。

So you have to be very careful.

酒精能稍微缓解这个问题。

The alcohol prevents that to happen a little bit.

很多人反对IDS，尤其是在现在这个时代，我们已经能很方便地做即刻修复了。

One of the big oppositions against IDS, particularly we have a day and age where we can now fortunately do a lot of same day dentistry.

你备完牙，一小时左右就能戴上嵌体或牙冠了。

You can prepare the tooth and then within an hour or so you can deliver the onlay, the crown, etcetera.

所以这背后有两个主要的顾虑。

So kind of two of the big hang ups against it.

其中一个就是，既然我做的是即刻修复，就没必要担心和新鲜切割的牙本质粘接的问题。

One of them is I don't need to worry about bonding to freshly cut Dentin because I'm doing same day dentistry.

另外，有人说IDS能减轻术后敏感，但我得承认，有些临床研究显示，这其实并不成立。

And then also a purported advantage of IDS is that it decreases post sensitivity, but I will admit I have seen clinical trials in which this is demonstrated to not be the case.

那你怎么回应这个观点？

So what would you say to that?

第一个问题是，你直接在新切的牙本质上操作，所以觉得没必要做IDS。

The first question is about, oh, you work on freshly cut dentin, you don't need to do IDS.

但那样你只得到一个短暂的峰值。

Well, that gives you only one little peak.

就这些了。

That's it.

但你得不到我之前说的那些其他好处。

But you don't get the rest that I told you about.

再说，就算你不是当天完成治疗，而是过两周再粘接嵌体，其实也没区别——你只要用低速车针把预备体内部再稍微磨一下，就能重新获得新鲜的牙本质。

Anyway, even if you were not doing same day dentistry, even if you would do dentistry two weeks, you would bond the inlay two weeks later, it doesn't make a difference because you could take the bur at extra low speed and roughen the inside of your prep again and you have a freshly cut dentin too.

所以，当天做还是隔天做，本质上没什么不同。

So it doesn't make a difference whether you do it same day or not same day.

你随时都可以用金刚石车针，配合大量水和气，把牙本质重新处理成新鲜状态，两种情况都能做到。

You could always re fresh the dentin with the diamond bur, lots of air and water, and you have a freshly cut dentin in both cases.

那做IDS的好处到底在哪呢？

So then what's the advantage of doing IDS?

剩下的那十八个好处啊，比如更好的骨强度、让备牙更方便扫描、减少术后敏感、更保守的治疗因为骨强度高、减少牙冠覆盖范围等等。

Well, all the other 18 advantages that are left, which is the better bone strength, making your preparation softer for scanning, preventing post operative sensitivity, being more conservative because you have better bone strength, you will do less calspal coverage, etcetera.

你去看看我书里列出的二十一条做IDS的理由，把那些跟新鲜牙本质有关的去掉，还剩下将近二十条呢。

Look at the 21 reasons to do the ideas in my book and then remove those that are related to the freshly cut dentin and then you still have 19 left or something like that.

你明白我的意思吧？

You know what I mean?

再说另一个情况，延迟粘接，也是一样的道理。

So now the other thing is the delayed, you say the delayed bonding, same thing.

延迟粘接能让粘接剂有时间充分固化。

The delayed bonding gives you time for the bond to mature.

但这只是其中一个好处。

Well, that's only one advantage.

其他的好处还多着呢。

You still have all the others.

你看，梅丽莎，如果你不做IDS，哪怕是在即刻修复里，粘接效果也不会好。因为我们的所有研究都显示，用的是新鲜切割的牙本质。

See, the thing is, Melissa, if you don't do ideas, even in same day dentistry, your bond will not be good Because in all our studies, Melissa, we have freshly cut dentin.

就算你做DDS，用的还是新鲜切割的牙本质。

Even when you do DDS, we have freshly cut dentin.

我们总是重新打磨牙本质，结果粘接强度就上不去。

We always refresh the dentin and the bond is weak.

所以你看我们所有的研究，当我们做所谓的DDS——也就是延迟牙本质粘接时，其实是在戴冠的时候才粘接。但即便如此，我们还是会用车针重新处理一下牙本质。

So you look at all our studies, when we do what we call DDS, it's called delayed dentin bonding, When you bond to dentin during the delivery of the restoration instead, even when you do that, when we do that, we refresh the dentin with a burr.

所以我们始终面对的都是新鲜切割的牙本质。

So we are always in the situation of freshly cut dentin.

这根本不重要。

Doesn't matter.

粘接剂还是没完全固化。如果有人跟你说：‘不对不对，我早就光固化过粘接剂了’，那我问你，粘接剂那么厚，你怎么固化它，又怎么把修复体戴上去？

The adhesive will still be unpolymerized and if people tell you, Oh, no, no, no, no, I polymerized the adhesive before, I said, Well, how do you polymerize the adhesive if it's thick and then seat the restoration?

他们就会说：‘哦，但我把它吹得特别薄，厚度根本不是问题。’

And they will say, Oh, but I air thin it so much that the thickness doesn't matter.

没错，亲爱的，你说得对，如果你吹得那么薄，它比氧抑制层还薄，根本没法固化，你的混合层也会被压坏。

Yes, very good my dear because if you air thin it so much, it's thinner than the oxygen inhibition layer is not going to polymerize anyway and your hybrid layer will be crushed by this.

这其实是我们1992年最初的研究，跟那个ADHD研究是一回事。

And that's our original works in 1992 with the ADHD that's back to that study.

未固化的粘接剂根本无法牢固结合混合层。

Unpolymerized adhesive will not secure the hybrid layer.

这确实非常重要。

And so, I mean, this is something that's really important.

你在书里，尤其是前半部分，就详细讲过IDS的种种优势。

This is something that you talk about in your book, really in the first part of your book, all about the advantages of IDS.

好吧，行吧。

And so, okay, fine.

就算你对新鲜切割的牙本质不感兴趣，也还有好多别的理由支持这样做。

If perhaps the freshly cut dentin that's not of interest to you, there's really kind of a whole number of reasons to do it.

我个人支持这么做，正是因为这样能给粘接剂足够的时间充分形成结合。

And personally, the reason I'm a proponent of doing it is exactly you're giving your bond time to develop.

你刚才简单提了一下，但能不能再详细说说？这个点我特别关注，也最感兴趣。

So you've kind of briefly touched on this, but would you talk about I mean, again, this is the area that I really lock into and hone in on.

为什么粘接需要时间来形成呢？

Why does the bond need time to develop?

因为树脂是会聚合的，对吧？

Well, because resin polymerize, right?

聚合是需要时间的。

So polymerize with time.

举个例子，做微拉伸强度测试的时候，如果你当天测和第二天测，结果会不一样，对吧？

So I think the time we know that, for instance, when you do a micro tensile bone strength, if you measure the same day or the next day, you will have two different number, right?

所以通常在微拉伸强度实验里，大家都会等24小时，等粘接完全固化。

So usually in micro tensile bone strength studies, you wait twenty four hours for the bond to be fully developed.

这其实就是我们说的树脂的暗固化过程。

So it's the time for what we call the dark polymerization of the resin.

等这一步完成之后，粘接层才开始慢慢老化。

And after that, the bone starts its degradation.

所以情况正好相反，对吧？

So it's the opposite, right?

但有意思的是，我们用Optibond做实验时，《修复牙科学杂志》上有一篇论文，叫《即刻牙本质封闭有助于延迟修复体就位》，你可以去看看。

But it's interesting because when we did with Optibond, there's a study in the Journal of Prosthetic Dentistry that you can read, it's called Immediate Dentin Sealing Supports Delayed Restoration Placement, right?

在这项研究里，我们在最终粘接修复体之前，分别让临时修复体保持了两周、七周和十二周。

So in this study, we waited two weeks, seven weeks and twelve weeks of temporization before the delivery of the restoration.

使用Optibond时，他们发现七周后的效果最好。

And with Optibond, they felt the best result was after seven weeks.

也就是说，七周后的粘接强度比两周时更强。

So the bond got better after seven weeks compared to two weeks.

而用SC粘接剂的话，粘接强度从一开始就下降了。

With the SC bond, the bond started to decrease immediately.

所以两周时效果最好，到了七周和十二周，强度明显降低。

So the result at two weeks is the best and then seven weeks and twelve weeks is getting significantly lower.

这就是实验结果。

That's the results.

有意思的是，我兄弟那时候跟我说，帕斯卡尔，做这种贴面时，你得给实验室留七周时间。

So it's funny because my brother back then told me, Hey, Pascal, when we do veneers in these cases, you have to give me seven weeks of lab work.

我就说，米歇尔，这理由不成立，因为病人得戴着临时冠七周啊。

So I said, No, Michel, that's not a good reason because then, you know, patients have to stay in provisions for seven weeks.

事情没那么简单。

It's more complicated than that.

但这项研究的目的，是想证明即使已经放了十二周的IDS层，依然能成功粘接，因为很多人对此很担心。

But the goal of the study was to show that even an old, a twelve week old IDS layer can be bonded to, because lots of people were worried about that.

他们说，哦，延迟确实有好处，就像你提到的那样。

They said, Oh, delay is good, like you said.

我们喜欢延迟，是因为粘接强度会随时间提升。

So we love the delay because the bond matures.

但另一方面，长时间暴露在湿气和污染中，这个IDS层还能不能保持良好的粘接性呢？

But on the other side, the time spent in moisture and contamination, does this IDS layer remain bondable with time?

而这项研究的答案是：可以。

And the answer from this study was yes.

十二周后依然能很好地粘接。

It remains bondable after twelve weeks.

Optibond的测试结果不错，虽然不是C级粘接，但表现得很理想。

The result for Optibond, they felt not a C bond, but for Optibond, felt as good.

它的数值和两天前、两周前的测量结果，以及即刻修复的对照组数据在统计上完全一致。

It was the same statistically identical to the day, to the two week measurement and to the direct control measurements, which means restoring the same day.

所以说，粘接修复这门技术，简直像走钢丝，而Optibond恰恰是越等越出色。

So basically an adhesive dentistry, it's almost like fine line and it just gets better with time or well specifically Optibond.

顺便说一下，如果有人在听，听到SE时有点困惑，我说的是Clearfil SE Bond第六代产品。

And by the way, if anybody's listening to this and they're when you say SE and they're kind of confused, you're talking about Clearfield SE Bonded sixth generation.

是的。

Oh, yes.

不好意思。

Sorry.

抱歉。

Excuse me.

Clearfield SE 自酸蚀粘接剂

Clearfield SE self etch SE Bond.

对

Yes.

没错

Yes.

我问你一个问题。

And so let me ask you this.

我很想听听你的看法。

I would love to hear your commentary on this.

说到即刻牙本质封闭，目前我们已经有将近四十项实验室研究证实了它的效果。

Really, when it comes to immediate dentin sealing, we have almost, I think, over 40 lab studies now that demonstrate its efficacy.

一些系统性综述也指出，基于大量证据，这种方法非常有效。

We've had some systematic reviews come out and say that, based on the preponderance of evidence, it's very effective.

我们还知道，GRAND NEXT研究是一项为期十二年的观察研究，结果表明——尤其是在贴面预备且牙本质暴露达百分之五十的情况下，即刻牙本质封闭确实有效。

And, you know, we know with GRESNEXT study, it was a twelve year perspective study that demonstrated, and again, these were with veneer preps and in the cases where there's fifty percent exposure of Dentin, IDS was effective.

但还有一项临床研究。

But then we do have another clinical study.

这项研究持续了三年，结果表明它并不有效。

It's three years long and it demonstrated that it wasn't effective.

我很想听听你对这个怎么看？

I'd love to hear, what are your thoughts on that?

医生。

Doctor.

我的看法是，这项研究里的IDS是怎么操作的？因为我们都知道，IDS的做法是有讲究的。

Well, my thought is how was IDS made, this study, because we all learned, you know, with IDS.

我1995年刚起步时的做法，和我现在用的方法早就不同了，因为我在不断改进。

We all, so if you take my ideas that I was doing when I started, you know, in 1995 is not the same ideas I do today because I learned from my mistakes.

如果你拿上世纪90年代的研究来跟现在的比，当然结果不一样，像Gresnyk那项研究从一开始就是规范操作的。

So if you take a study that started in the 90s, of course, you are not going to have the same result as a study like the Gresnyk study who started the right way.

他起步的时候就有清晰的思路，背后还有大量数据支持。

Know, he started with the oral idea, a lot of data behind him, you know.

所以，当你做一项更近期的研究，能利用最新的数据，受益于那些对IDS不断优化改进的原始研究时，结果自然会不一样，这很合理。

So when you do a more recent study that benefits from more recent data, from the actually a more recent study that benefits from the original studies where IDS was refined, optimized, that changes the results, of course, that makes sense.

再说一遍，我会去仔细看材料与方法部分，确认具体是怎么操作的。因为我发现，大多数效果不好的研究，问题都出在粘接剂上——肯定不是用的C Bond或者OptiMon FL。

And again, as I told you, I would go in the material and method and look exactly at what was done because most of studies that I found where ideas didn't work was using the wrong adhesive, for sure not a C Bond or OptiMon FL.

有时候粘接剂被过度吹干，而不是适当吹薄，还被 aggressively 吹散了，结果牙本质又暴露了，这样一来，IDS的效果自然就被破坏了。

The adhesive was sometimes air thinned, not air blocked, aggressively air braided without, you know, and then you re expose the dentin and then of course you compromise the IDS.

对我来说，只要IDS操作得当，研究结果就一定会更好，这一点毫无疑问。

So to me, there is no doubt that the studies where IDS is made the right way, they always show an improvement.

这样的研究太多了。

There are so many.

你说40项，我觉得远不止这个数。你要是翻翻那本书，第四章末尾的参考文献列表，全是关于IDS的，数量大得惊人。

And when you say 40, I think it's much more than that because I mean, if you look at the book, the chapter four, at the end of chapter four, I have the literature list for IDS, it's enormous.

还有研究显示，就连通常本身就很强的E-max全瓷冠，也受益于IDS。

There are studies showing that even Emax crowns that are normally strong.

所以我觉得，在E-max冠上用IDS，可能看不出明显差别，因为冠本身太坚固了，反而会掩盖掉骨组织层面的影响。

So I would expect not to see a difference with IDS on an Emax crown because the Emax crown is so strong that it would mask the effect of the bone.

但即使在这些研究中，IDS也让它们变得更坚固了。

But even in those studies, IDS made them even stronger.

有一项负载至断裂的实验，你知道吗，原本要1200牛顿才能把牙冠压碎，结果提升到了1500牛顿。

They were like, there was a study of a load to failure, you know, it went from 1,200 Newton to break those crowns, 1,200 Newton.

用了IDS之后，断裂所需的力直接升到了1500牛顿。

It went up to 1,500 Newton with IDS.

但同一项研究中，当他们用SE粘接剂做IDS时，操作方法错了。

And the same study when they did IDS with SE Bond, a clear fill SE Bond, they did it the wrong way.

那样做根本没让牙冠变得更坚固。

It didn't affect, it didn't make them stronger.

可后来他们又在SE粘接剂上面加了一层Majestic Flow，这时候IDS才真正起到了增强作用。

But then when they had added clear fill majestic on the flowable on top of SE Bond, suddenly the IDS contributed to strengthening those crowns.

我记得这好像是巴西SPORE团队做的研究。

I think it was a study by SPORE in Brazil.

很有意思，他们甚至证明了：做IDS有错误的方式，也有正确的方式，用SC粘接剂时尤其如此。

So interesting, they even proved that the wrong way to do it and there is a bad way, there's a good way to do it and a wrong way to do it with SC Bonds.

这会影响牙冠的强度。

And that affects the strength of the crown.

所以，梅丽莎，当你有五十、六十项研究证明它有效，而只有大概十项研究说它没用的时候。

So, you know, Melissa, when you have fifty, sixty studies showing you it works and then you have maybe 10 studies showing you it doesn't work.

我还是觉得，多数研究的结果更有说服力。

I still believe that the number prevails here.

但当然，总有人用错方法，然后得出完全相反的结论。

But of course, you will always have people doing it the wrong way and then proclaiming a different message.

这就是现实，对吧？

That's life, right?

是的，医生。

Well, Doctor.

马尼，这真是一次精彩的分享。

Mani, this has been incredible.

最后一个问题，你一直都在参与研究。

Just as a final question, you're always involved in research.

你一直在做这么多不同的事情。

You're doing so many different things.

我很好奇，最近在研究方面有什么新进展吗？

And I'm just curious, is there anything new that you're up to with research?

有什么让人兴奋的发现可以跟我们分享吗？

Is there anything exciting to share with us?

当然，我们之前聊过IDS，但那只是你研究兴趣中的一小部分。

I mean, of course, we've talked about IDS, but that's really just a drop in the bucket in some of your research interests.

医生。

Doctor.

是的，我们现在正在研究纤维增强材料。

Yeah, I think that one of the thing that we are looking at right now is fiber reinforcement.

我觉得纤维在复合树脂中的应用很有前景。

So I think that fibers is, you know, composite resins are amazing.

复合树脂能很好地模拟牙齿的釉质和牙本质这两种特性。

Composite resins, they have those two properties of the teeth together that enamel and dentin have, you know.

复合树脂兼具牙本质的柔韧性和牙釉质的耐磨性。

Composite resin has the flexibility of dentin, but the wear behavior of enamel.

所以如果你现在问我，哪种仿生材料最出色，我会说是复合树脂，甚至可能特别提到CAD/CAM复合树脂，因为它们最接近同时具备牙本质的柔韧和牙釉质的耐磨特性。

So if you ask me nowadays exactly who is the best biomimetic material, I would tell you a composite resin and I would even say maybe a CADCAM composite resin because those would be the closest you can have to have both dentin and enamel properties together speaking about flexibility for the dentin and wear resistance for the enamel.

陶瓷没有这种柔韧性。

So ceramic doesn't have this flexibility.

陶瓷的磨损特性会对健康的牙釉质造成强烈磨损。

The wear behavior of ceramic is aggressive to the intact enamel.

这一点我们很清楚。

We know that.

所以我认为复合树脂是最具仿生性的材料。

So that's why I would say composite is the most biomimetic material.

现在我们有了像Enamic这样的材料。

Now we have material like enamic.

它真的很有趣。

It's really interesting.

这是一种介于牙本质和复合树脂之间的完美混合材料。

It's a perfect hybrid between dentin and composite.

虽然仍需要像陶瓷那样酸蚀并使用硅烷处理，但它的弹性模量处于中间水平。

Still requires etching like a ceramic and silane, but has an elastic modulus that is intermediate.

所以我觉得这种材料非常有意思。

So I think that's a very interesting material.

最后是纤维，因为牙本质本身就是纤维增强的，它的抗断裂能力来自胶原纤维。

And finally, the fibers, because we know dentin is fiber reinforced and the fracture toughness of Dentin is due to the collagen fiber.

因此，使用纤维增强的复合材料是有道理的，但必须简单才行。

So having a fiber reinforced composite makes sense, but it has to be simple.

必须非常直接明了。

It has to be very straightforward.

我不太喜欢那种在备牙时还得额外贴上去的纤维片。

And I'm not a big fan of those band aids of fibers that have to be applied, you know, in the prep.

我更倾向于短切纤维，顺便说一下，我八月，大概是8月9号，会和Pekka Valitu进行一场Instagram直播。

I like the idea of chopped fibers and by the way, I will have an Instagram live soon with in August, I think it's August 9 with PekkaValitu.

我和PekkaValitu聊聊这个，因为他对Ever X系列产品了解很深，科学依据也很扎实。

With PekkaValitu about that because I think he has a lot of knowledge and science behind the Ever X products, line products.

我觉得他们的方向是对的。

And I think they are going in the right direction.

我们现在正在探索让纤维在材料中更好发挥作用的新方法。

We are looking at new ways of making the fibers work in this material.

对我来说，这真的非常令人兴奋。

So I think this is really exciting for me.

如果你以前用过Ever X，应该会觉得挺有意思的。

I think that if you've worked with Everex before, you know, it's quite interesting.

他们最早在欧洲推出了Ever X后牙材料。

They started with Everex posterior in Europe.

但从来没在美国市场推广过。

They never marketed it in The US.

Ever X后牙材料的问题在于厚度和美观性，颜色太深，偏灰。

The problem of Everex posterior was the thickness and the aesthetic properties, very dark, very grayish.

粘度很高，非常难操作。

The viscosity, very difficult to apply.

所以他们在美国推出了Evorex Flow，用来弥补这些缺陷。

So they came with Evorex flow in The US to compensate for those problems.

不过，Flow的代价是纤维变小了，虽然断裂韧性依然很好，但收缩率更高了。转眼三十年过去了，我把所有的精力和知识都倾注在这本书里，希望能传递给好几代人。

But flow came at a cost of smaller fibers, still a very good fracture toughness, but more shrinkage So it is thirty years today and I put all my energy and my knowledge in this book in order to convey that message, I hope to several generations.

我不知道之后会不会再出另一本书，但这确实是一项巨大的工程。

I don't know if there will be another book after that but this was a big, big, big endeavor.

我还要感谢所有帮助过我、为此作出贡献的人，包括生物模拟团队的各位，还有那位博士，

And I want to thank all those who helped me and contributed, the people from the bioemulation group, you know, Doctor.

范·海伍德博士，他也参与了漂白相关的工作，还有另一位博士，

Van Haywood, also about the bleaching and Doctor.

还有巴索斯医生。

Basos, Doctor.

哈维尔·瓜迪格斯塔皮亚，当然还有我的兄弟米歇尔，你们也知道，他是一位非常出色的陶艺家。

Javier Guadigstapia and of course, my brother, Michel, who is, as you know, the most amazing ceramist.

他很早就跟我分享了他的热情与热爱，我觉得他感染我感染得特别成功。

He shared with me his passion and love early on, and I think he contaminated me very efficiently.

谢谢你，米歇尔，去看看这本书吧，别忘了读第八章，那可是我所谓的彩蛋章节。

So thank you, Michel, and look at the book and don't forget to read chapter eight because that's the, I call it the bonus chapter.

上帝爱每一个人，不管你是谁，是好是坏，无论你怎么看待自己，上帝都爱你。

God loves every one of us, whoever you are, good or bad, however you consider yourself, God loves you.

朋友们，上帝正在敲你的门。

God is knocking at your door, my friends.

他想亲自见你，但正如我所说，他是个绅士。

He wants to meet you personally but as I said, he's a gentleman.

上帝是个绅士。

God is a gentleman.

他绝不会不经过你的允许就推门而入，你知道的。

He's never going to go through the door without your authorization, you know.

在这个我们谈论尊重与多元的世界里，上帝是个绅士。

In a world where we speak about respect and diversity, God is a gentleman.

他尊重每一个人，不管你的肤色或性取向如何，都欢迎你。

He respects everyone and he welcomes everyone regardless of your skin color, sexual orientation.

他想亲自见你，而且正在敲你的门。

He wants to meet you personally and He's knocking at your door.

我喜欢圣经里描述的场景，耶稣为那些不认识他的人洗脚，甚至为罪人洗脚。

And you know, I like the idea of, you know, actually what is described in the Bible, Jesus washing the feet of the people who didn't know him, washing the feet of the sinners.

这正是我们该做的事。

And that's what we have to do.

当耶稣被犹太学者问到，什么是最重要的诫命时，他是怎么说的？

We have to love, you know, when Jesus was asked, he the Jewish scholars, they asked him, but what is the most important commandment?

你知道吗？

You know?

他说，首先要爱上帝。

And he said, well, first, love God.

那位唯一的真神，然后要爱你的邻舍。

The one and only God, and then love your neighbor.

你的邻居就是所有人。

And your neighbor is everybody.

你的邻居就是每个人，就像我说的，不管肤色或其他任何区别。

Your neighbor is everybody, regardless, as I said, of skin color and others.

爱你的邻居，欢迎每一个人，这正是他所做的。

Love your neighbor and welcome everybody and that's what he does.

他欢迎每一个人，只要你开门，他就会进来和你一起吃饭，和你开始交谈。

He welcomes everybody and he will enter, have a meal with you if you open the door and he will start the conversation with you.

如果你的心真诚而真实，你的生活就会发生转变。

And if your heart authentic and sincere, you will have a transformation in your life.

这是一次改变人生的体验。

It's a transforming experience.

它不会让你变得完美。

It doesn't make you perfect.

我依然在很多事上挣扎，但我明白有解决的办法，我也知道，最终上帝会为我预备那最完美、最终的归宿。

I still struggle a lot with many things, but I know there is a solution and I know God at the end is going to provide the perfect, ultimate place for me.