44. 与帕斯卡尔·马格纳的访谈

欢迎收听《牙科前沿》。

Welcome to Dental Digest.

这是一档专注于解读循证牙科文献的播客。

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

接下来，有请我们的主持人，西伯特医生。

Here's your host, Doctor.

梅丽莎·西伯特。

Melissa Seibert.

她目前在空军担任牙科医生。

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

不过需要说明的是，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.

今晚，我有幸采访了马涅医生。

Tonight, I had the distinct privilege of getting to interview Doctor.

帕斯卡尔·马涅。

Pascal Magne.

很多人称他为微创牙科之父，我个人觉得，他是21世纪的G.V.布莱克。

He has been described by many as the father of biomimetic dentistry and I would personally describe him as the GV Black of the twenty first century.

他是南加州大学的全职教授，著有广受欢迎的教材《前牙粘接瓷修复：微创方法》。

He is a full time professor at the University of Southern California and he authored the popular textbook Bonded Porcelain Restorations in the Anterior Dentition, a Vibrametic Approach.

这次访谈我们会聊很多内容，但说实话，一集播客能讲的终究有限。

There's a lot that we are going to delve into in this interview, but honestly, there is only so much that you can cover in a podcast episode.

如果你想听更多，我强烈推荐你去参加生物仿生牙科学会12月11日的网络研讨会。

If you want to hear more, I would highly recommend that you go to his webinar on the December 11, which is offered by the Academy of Biomimetic Dentistry.

你只要登录生物仿生牙科学会的官网，就能轻松报名。

You can easily sign up there at their homepage at the Academy of Biomimetic Dentistry.

好了。

Alright.

那我们开始这段访谈吧。

So let's roll out that interview.

这个播客是基于循证医学的，对吧？

So the podcast is evidence based, right?

我想提一下这一点，因为你知道，你可能会对科学着迷，对吧？

And there is something I like to mention about that because, you know, you can be obsessed with science, right?

科学当然重要，但科学是人做出来的。

Science is important, but science is made by human.

所以严格来说，科学并不总是百分之百确定的，你经常能看到这种情况：一个团队做了实验得出某种结果，另一个团队重复同样的实验却得到不同的结论，对吧？

So by definition science is not always you know 100% and you have many many examples of experiments that are driven by a team here, they get those results, same experiment by another research team there get different results, right?

对。

Yeah.

科学当然很棒，但它不是终点，也不是说我们所有事情都得先讲科学依据。再举个例子，我职业生涯里在学术出版方面遇到过很多这样的事。

So science is great but it's not the end, it's not the, you know, not everything we do is science based first of Another example, through my career I've had so many experiences in the publishing, in scientific publishing.

有些期刊会直接拒稿，理由居然是你用的产品没按照厂家说明书来操作。

There are some journals that will reject paper just because the products you use are not used according to the instructions of the manufacturers.

我们当时有篇论文数据非常扎实，但用的是那种修复性复合树脂来做粘接，结果就被拒了。

So we had great papers but we used for instance a looting composite, we used the composite that was a restorative composite.

那篇论文被一个重要期刊退了，但数据其实很有价值。现在我们知道，用修复性复合树脂来粘接嵌体、高嵌体和贴面，其实是非常靠谱的做法。

It was rejected by a very important journal but the data was very important and nowadays we know that looting or cementing inlays, onlays, veneers with a restorative composite is really proven to be a very good idea.

我们刚开始投稿的时候，没人愿意接收这些文章，因为这不符合厂家的使用说明，你知道吧？

When we started publishing, nobody would take those articles because it's out of the instructions for use of the manufacturer, know?

有时候，厂家单方面决定产品怎么用，但他们给出的使用指南也未必正确。

And so since when manufacturers only decide how you can use their product, sometimes the manufacturers also give you wrong guidelines on how to use their product.

有趣的是，有些科学期刊居然听厂家的，而不是听科学家的实证。

So it's interesting how some scientific publishers go by the manufacturers, not by the scientists' IDs.

这确实有时候让人挺失望的。

And that's a little bit disappointing sometimes.

但再举个科学界更让人失望的例子：有些期刊不得不撤稿，因为发现数据根本是凭空捏造的。

But let me give you another example in science that is so disappointing is that there are some journals that had to retract an article because they found that the data was actually never generated at all.

完全是编出来的数据。

It was just invented data.

所以你想想，看到一篇文章时，我就明白为什么我发论文时总要拍大量标本照片了。

And so imagine you look at an article and you know that's why when I publish I take a lot of pictures of specimens.

每次实验都一定要有标本图像，就是为了证明：没错，这个实验确实在我们实验室做出来了。

Always want to have images of specimens of the experiment, know, really to back up that yes, this experiment was really made in our lab.

我跟你说，梅丽莎，在二十多年的研究生涯里，从来没人来过我的实验室，要求看看我们研究的样本。

And let me tell you Melissa, in twenty plus years of research, I have never had one time someone come to my lab and ask me to show them the specimen of our research.

这意味着，我完全可以凭空编造所有这些实验。

That means I could have invented all those experiments.

根本没人会来问我。

Nobody would ever ask me.

你明白我的意思吧？

You understand my point?

所以这些例子都说明，证据固然很好，也很重要，但并不是总能拿到确凿的证据。

So all those stories tell you, yes, evidence base is very nice, it's very important, but we don't have always the evidence.

那我们还有什么别的呢？

But what do we have else?

我们有扎实的科学证据，但也有常识和经验，对吧？

We have evidence science good, but we have common sense and we have experience, right?

常识和经验，本身就是证据的一部分。

Common sense and experience is part of the evidence.

对很多人来说，循证医学、循证牙科就等于科学证据。

For so many people, evidence based medicine, evidence based dentistry is just scientific evidence.

我想说的是，不对，它不只是科学证据，还包括经验与常识。

What I want to tell you here, no, it's not only scientific evidence, it's also experienced and it's also common sense.

这些部分你也得用上。

You have to use those parts too.

还有第四点，就是患者本身。想象一下，根据科学证据、你的经验、你的常识，患者需要一套五万美元的全口修复，但他只有五千块。

And there is number four and number four is is the patient Because imagine that according to scientific evidence, according to your experience, according to your common sense, the patient needs a $50,000 full mouth rehabilitation and he has only 5,000.

那你怎么办？

What do you do?

你是死守证据，干脆放弃患者，觉得别无选择？还是另想办法，找折中方案？比如不用昂贵的瓷贴面，改用大块的直接树脂充填，对吧？

You stick to the evidence and you dismiss the patient because there is nothing else you want to do or you find a new approach, you find a compromise, you might not choose ultra expensive ceramic veneers but you will do much more big large direct composites, right?

我们知道，带即刻牙本质封闭的间接瓷修复效果非常好，但你可能做不了，只能选大块树脂，虽然寿命短点、维护多点，但这是患者能负担的唯一选择。

We know that indirect ceramic bonded restoration with immediate dentin sealing is a fantastic restoration but you might not be able to do that and you might have to choose large composites that will maybe last less, require more maintenance, but that's all the patient can afford.

而我觉得，这种做法依然属于循证的范畴。

And that I would still consider that based on evidence.

证据就在于，我们必须帮助所有类型的患者，而不仅仅是那些有钱人。

The evidence being we have to help all the types of patients, not only the wealthy and the rich.

这话说得太好了。

That's beautiful.

你写过一篇叫《复合树脂与粘接瓷：后银汞时代》的文章，那是我最喜欢的文章之一。

So you wrote the article entitled Composite Resinant and Bonded Porcelain, The Post Amalgam Era, which is one of my favorite articles.

我很想听听你的看法，因为银汞合金到现在还是用得这么普遍。

I'd love to know your thoughts because amalgam is still so widely used.

牙科学校里教的依然是它。

It's still what's taught in dental school.

考虑到我们现在有这么多新材料，还有没有哪种情况适合继续用银汞合金来做修复呢？

Considering the materials we have today, is there ever a time when it's appropriate to still restore with amalgam?

银汞合金的争议有时候真让人吃惊。

Well, the amalgam controversy is sometimes a little bit shocking you know.

说实话，看到银汞合金还被当作首选标准治疗来教，我觉得很震惊，因为我们现在很清楚，粘接修复和复合树脂比它好得多。

It is shocking to me to see that amalgam is still taught as the first choice of standard of care honestly because we now know clearly that there is better than amalgam and it is through adhesive dentistry and composite resins.

我知道要积累这些证据花了很长时间，但现在我觉得我们已经拥有了所有需要的证据，其中最出色的一份是尼克·奥德姆在2010年发表的论文，他把复合材料和银汞合金的对比推到了我原本认为超出直接复合树脂适用范围的领域。

I know it took a long time to develop the evidence but now I think we have all the evidence we need and one of the most beautiful piece of evidence is paper written by Nick Opdam in 2010 where he pushed really the comparison of composite and amalgam into indications that are what I would have considered crossing boundaries of what I consider application and indication for direct composites.

他们做了大量的三面、四面甚至五面的银汞合金修复和复合树脂修复。

They did large MOD, three surface, four surfaces and even five surfaces amalgam restorations and composite restorations.

所以在荷兰的私人诊所里，你知道为什么吗？

So basically in a private practice setting in The Netherlands, you know why?

因为荷兰的社会医疗体系只报销直接修复，不覆盖间接粘接修复。

Because in The Netherlands, the social system would not cover for an indirect bonded restoration but only for direct ones.

于是他们就把适应症扩展到了大范围的直接复合和银汞合金修复上。

And so they pushed the indication to large direct restorations in composite and amalgam.

结果发现，银汞合金根本没有优势，甚至复合材料的表现更好。

And what happened is they found basically no advantages of the amalgam, no superiority of the amalgam and even you know better performance for the composites.

在低龋齿风险的患者群体中，这个差距更加明显。

The difference was even more when looking at low caries risk patients.

虽然在高龋齿风险患者中，银汞合金和复合材料的差异没那么大，但复合材料依然更胜一筹。

The difference between amalgam composite was less visible in high caries risk patients but it was still the composite was still superior.

对于低龋齿风险的患者，复合材料远优于银汞合金，最令人震惊的是，牙齿和充填体的开裂和断裂率，银汞合金是复合材料的六到七倍。

So in low caries risk patients the composite was way superior to the amalgam and what is the most shocking is the cracking fracture of the tooth and fracture of the restoration which was six or seven times higher for the amalgam compared to the composite one.

这些数据非常明确：牙齿开裂、充填体断裂或开裂的风险，银汞合金要高得多。

So those numbers were very clear that the chances for the tooth to fracture, for the restoration to fracture or to crack is much higher for the amalgam.

十二年后的累积数据显示，牙齿、充填体开裂或断裂的发生率，复合材料大约是2.2%，而银汞合金高达11.9%。

Actually after twelve years I think the cumulative rate of fracture of the tooth, the restoration and cracking of the tooth was like something like two point two percent for composites versus like eleven point nine percent for amalgam.

光是这一点，就足以让我下结论：够了，别再用银汞合金了。

And so that in itself is enough for me to say you know what that's it.

银汞合金不能被称为仿生材料，因为它不与牙齿粘接，而仿生的核心就是粘接。

Amalgam cannot be considered a biomimetic material because it is not bonded to the tooth and biomimetics involves bonding.

当有人问我什么是仿生时，我要说，仿生牙科的基石就是粘接技术，你必须模拟牙本质-釉质交界处。

When people ask me what means biomimetics, you know, cornerstone of biomimetics is adhesive dentistry and you have to emulate the dentinoenamel junction.

我们通过牙本质粘接、即刻牙本质封闭，以及使用性能最佳的粘接剂来实现这一点。

That's what we do through dentin bonding, immediate dentin sealing, use of the correct and the best performance adhesives.

现在，我们终于真正进入了仿生牙科的领域。

And now we are entering the biomimetic arena.

对吧？

Right?

银汞合金根本做不到这一点。

Amalgam has been unable to do that.

让我真正醒悟的，是我们谈证据的时候，对吧？

For me, the eye opener, because we want to speak about evidence, right?

真正让我醒悟的是上世纪80年代明尼苏达州做的那些研究，所以我才决定去那里读博士，因为他们的实验室比谁都早开始研究用银汞合金修复后的牙尖形变，他们发现，当你在一颗有大范围MOD洞型的牙齿上，用加载设备弯曲牙尖，测量对侧牙尖之间的距离时，未充填的开放洞型和用银汞合金充填后的牙尖形变程度几乎是一样的。

The eye opener were studies in the 80s made in Minnesota and that's why I decided to go do my PhD there because in their labs they were before everybody else to look at the cuspal flexure of teeth restored with amalgam and they noticed that you know when you have a large MOD preparation on a tooth and you bend the cusp using a loading machine and you measure the intercuspal distance when you bend the cusp of an open MOD tooth, the cuspal flexure will be similar to that when it's filled with an amalgam.

换句话说，用银汞合金补牙，并不能恢复牙尖原本的刚性，对吧？

In other words, filling the tooth with amalgam does not restore the original cuspal rigidity, right?

用银汞合金修复牙齿，并没有真正解决牙齿的生物力学问题，这就是为什么会出现这么多裂纹、断裂，以及典型的牙裂综合征。

You don't actually address the biomechanical problem of a tooth when you restore it with amalgam and that's why we have all those cracks, fractures and typical crack tooth syndrome.

我本人也想分享一个个人经历。

I had myself, I'm going to reveal a personal information here.

我自己的两颗上颌第一磨牙都做过大面积银汞充填，结果都出现了牙裂综合征。

I had myself both of my first maxillary molar with large amalgams and that had cracked tooth syndrome.

我敢打赌你牙齿状态很好，可能没经历过这种事，但牙齿隐裂综合征真的特别遭罪。

I'm sure you have beautifully tucked teeth so maybe you haven't had a chance to experience that but crack tooth syndrome is horrible.

你想想，连呼吸都疼，一咬东西就钻心地痛，尤其是松开咬合的瞬间，冷热刺激更是受不了。我当时想，算了，再忍忍吧，拖了几周、几个月，疼是缓了点，可后来又回来了，而且更厉害，最后实在扛不住了。

You know, just the fact to breathe, doing this, the air makes an absolutely horrible pain, biting and of course the pain on especially on the release of the force when biting and cold, hot, everything hurt and you know I thought okay, I resisting resistance, I waited for a few weeks, a few months, it went away and then came back and even worse to the point that I said, now I can't stand it anymore.

于是我们把旧的银汞填充物取了，我一位同事重新备牙，取了模型，做了个复合树脂嵌体。

So we removed the amalgam, a colleague of mine prepped the tooth, we took an impression and we did a composite resin inlay.

第一个牙是差不多二十五年前做的。

That was the first one was basically about twenty five years ago.

第二个牙，另一边，是十七年前做的，两个都是用粘接的复合树脂嵌体修复的，到现在牙神经都还活着。

The second one, the other side was, you know, about seventeen years ago and both of them were restored with a bonded composite resin inlay and both teeth are still vital.

从那以后，我再也没疼过。

Today, I've never experienced any pain ever after that.

当时我真以为这牙得做根管治疗了。

And I tell you when it happened, I thought, you know, I may need endo.

我还以为这牙非得做根管不可，结果没有，牙神经好好的，嵌体也一直稳稳的。

I may need a root canal to count that tooth, but no, it's still vital and my inlays are there.

我在讲课和做讲座时，都会展示这些案例的照片，因为我真的特别自豪。

I show even pictures of them when my lectures, when I give seminars because I'm so proud.

我有活生生的证据证明，粘接修复术真的能治愈牙齿隐裂综合征。

I have the living proof of my, that adhesive dentistry can really cure a cracked tooth syndrome.

当然，这并不是每次都有效，如果牙髓损伤已经不可逆，还是需要做根管治疗。

Now, it's not always working and sometimes you will need a root canal when the damage to the pulp is irreversible.

我知道刚才的回答有点长，但咱们开头聊的是科学、常识和经验，所以我可以很肯定地说，这三点都清楚地告诉我：汞合金已经完全不该再被考虑了。

So just again, it was a long answer to your question I know but we were talking at the beginning about you know science, common sense, experience So I can say securely that all those three reasons for me are telling us clear and loud that amalgam is not anymore a material that should be considered.

有意思的是，世界上最早禁用汞合金的国家是斯堪的纳维亚地区，对吧？

It's very interesting because if you look at the first countries in the world where amalgam was banned and we are talking about Scandinavia, right?

比如挪威，做出这个决定的不是卫生部长，而是环境部长——因为他们有更安全的替代材料，而汞合金带来的环境风险已经完全没有必要承担了。

And it is in Norway for instance, it is Minister Environment, not the Minister of Health, but the Minister of Environment that decided that amalgam should be faced down because there were viable alternatives and you know, it was not necessary anymore to know risk environmental problems with the mercury in the amalgam.

我觉得特别有意思，替代汞合金的理由这么多，但让我震惊的是，很多牙科学校还在教学生用它。

And so I think it's really interesting, there are so many reasons for substituting amalgam and it is really shocking to me that many dental schools are still teaching amalgam.

从历史角度讲，教一教汞合金没问题，但拿宝贵的课程时间去教这种过时的技术，我觉得真不值得。我们更该把时间用在传授正确的技术上，学生毕业前根本练不够足够的树脂修复操作。

It is okay to teach amalgam from a historical perspective but to lose precious curriculum time to teach amalgam I think is really not a good decision because we need the curriculum time to teach the right techniques and I think students will never do enough composites before they graduate.

所以我们别剥夺学生多练习粘接修复的机会，反而教他们那些将来根本用不上的老技术。

So let's not take away opportunities for students to practice more adhesive dentistry and teach them these old techniques that they are not going to use anymore anyway.

我也想问一个问题。

Let me ask as well.

说到您自己嘴里的修复体，您在论文中提到过：‘在缺乏其他证据的情况下，对于牙尖覆盖、嵌体和所有类型的非活髓牙修复，应优先使用陶瓷材料。’

Speaking of the restorations that you have in your mouth, you stated in your work that quote, in the absence of additional evidence, use of porcelain should be favored in cusp coverages, overlays in all types of restoration and non vital teeth.

不过，这个观点是几年前提出的。

However, this statement was made several years ago.

考虑到您之后发表的大量研究，您现在还会坚持这个说法吗？

Considering all the literature you've since put out, would you still say that this is the case?

是的，我依然这么认为。

Yeah, it is.

我仍然会坚持这个观点，但我想补充一点：我们当然可以不断讨论各种材料，但归根结底，只要回到生物仿生原则的本质，就会明白——就像我开头说的那四个要素：科学、常识、经验，还有患者，我始终会回到这四点上来。

You know, I would tend to still maintain the statement but I would add this because, you know, we can debate a lot materials and obviously if we look at the essence of the biomimetic principle and we are back to you see, for me this is why those four elements that I mentioned at the beginning, the four elements science, common sense, experience and the patient, I always go back to that.

这正好能回答您的问题。

And that is really allow me to answer your question here.

每个病例都要单独分析。

We have to look at the case, case by case.

用陶瓷做的间接修复体，成本总是会高一点。

Consider that indirect restorations made with ceramic will always cost a little bit more.

不过，随着CAD/CAM材料的发展，这种差距已经缩小了。

Now these differences have decreased with CADCAM materials.

现在，聚合物类的CAD/CAM材料特性非常出色，因为它们没有手工堆塑树脂那种缺陷、气孔和空隙。

So CADCAM materials in polymers also polymer based CADCA material have really interesting properties because of course we don't have the defects and the porosities and the voids that we have in hand layered composite resins.

这也让我们的考量发生了一些变化。

So that's something that has also changed a little bit the considerations.

但我越深入思考这个问题，就越觉得答案不在于材料本身，而在于粘接的质量，对吧？

But the more I look at this question, the more I think the answer is not in the type of material, it's in the quality of the bonding, right?

在仿生修复中，有一个基本原理：粘接得越好，需要预备的牙体组织就越少。

And so in biomimetic there are many, how to say, there is an equation, you know, the more you bond the less you need to prep.

粘接得越好，对固位形和抗力形的依赖就越低。

The more you bond the less you need retention, resistance form.

粘接得越好，修复材料就越变成次要的。

The more you bond the more the restorative material becomes secondary.

所以如果一个修复体粘接得非常好，我觉得陶瓷和复合材料之间的区别也会变小，对吧？

And so if a restoration is very well bonded, I think the difference between ceramic and composite becomes also less, right?

我知道很多担心牙齿开裂或劈裂的人，觉得二硅酸锂嵌体是非常稳妥的选择。

And I know that for many people who are afraid of cracked teeth and split teeth, lithium disilicate onlays are a very secure restoration.

但你猜怎么着？

But guess what?

我也见过二硅酸锂修复体导致牙齿劈裂的情况，所以这并不是绝对可靠的保障。

I have seen also lithium disilicate split teeth and so it's not an absolute warrant.

所以结合我现在的经验和对这四个因素的考量，我们必须看清楚：对颌牙是什么情况、费用多少、临床医生用的是什么粘接方案——比如他们有没有做即刻牙本质封闭，因为在我看来，这一点能带来巨大差异。

So I want to say this with now my experience and all the considerations of those four elements, have to look at what is the antagonistic tooth, what are the costs, what is the bonding protocol that's used by the clinician, like are they using immediate dentin sealing because to me that will make a huge difference.

我们知道即刻牙本质封闭能让修复体更坚固，这方面的证据很多。就连二硅酸锂修复体，巴西的一位同事斯波尔做过研究，他们发现，只要即刻牙本质封闭操作得当——当然他们也模拟了操作不当的情况，这个我们以后可以再聊——当IDS做对了，二硅酸锂冠的强度会明显高于没有做IDS的情况。

We know that immediate dentin sealing makes a restoration stronger and again there's lots of evidence about that and even with lithium disilicate there was a study made in Brazil by a colleague called Spor and they were showing that even lithium disilicate crowns when bonded with immediate dentin sealing done correctly because they also simulated immediate dentin sealing done incorrectly and maybe we can talk about that later, but when immediate dentin sealing is done correctly, the lithium disilicate crown were much stronger than when IDS was not used.

所以真的，所有这些因素都得综合起来考虑。

So really it's very important to consider all those elements together.

再者，我们在谈科学的时候要谨慎。

And again, let's be careful about science.

要综合考虑所有相互作用的因素。

Let's look about all the elements interacting together.

还有一点，就是对颌牙是什么情况？

Another thing is, yeah, what is the antagonistic tooth?

如果对颌牙是天然牙釉质，我会更倾向用复合树脂，因为它对牙釉质的磨损比陶瓷小得多。

Because if the antagonistic tooth is made of natural enamel, I would tend to favor composite resin that is much more wear friendly to the antagonist enamel compared to porcelain.

如果你问我这方面的科学证据，其实很难说，因为我见过不少研究支持高强度陶瓷更优，也见过研究指出复合树脂的柔韧性和顺应性在无髓牙中优势明显。

And so again, if you tell me what's the scientific evidence here, it's really hard because I have seen lots of study giving the strong reinforced ceramics as the winner and I have seen studies showing that the flexibility and the compliance of the composite resin is a big advantage in the non vital tooth.

但我认为，大家普遍认同的一点是，建立最牢固的粘接方案才是关键。

But I think that where everybody would agree is that developing the strongest bond protocol that is the key element in this equation.

所以，我可能不会像当年写那篇文章时那么绝对了——那时候我们还在大学里制定临床政策，我和同事们达成共识，认为对于需要覆盖牙尖的根管治疗牙，优先选择间接陶瓷修复体。

So I would not be maybe as radical as I was saying in the article back then, know, we were also trying to establish policies at the university when we wrote this article, when I wrote this article and it was my colleagues, we came to this consensus that we would favor the use of indirect ceramics when we have endodontically treated teeth requiring cusp coverage.

不过我希望，通过我刚才的回应，已经对那个观点做了一些更新。

But I hope that in the way I answer, I kind of updated a little bit that statement.

我们干脆直接聊聊即刻牙本质封闭吧，正合我意。

Let's absolutely jump into immediate dentin sealing just like you thought of.

昨晚我有机会和普雷兹纳医生聊了聊。

Last night, I had the chance to talk to Doctor.

他是生物仿生牙科学会的前任主席，是个重量级人物。

Sal Prezner, the former president of the Academy of Biomimetic Dentistry, big figure there.

他称你为即刻牙本质封闭领域的奠基性研究者。

And he called you the seminal researcher on immediate dentin sealing.

那这个概念在修复牙科中为什么会有这么深远的影响呢？

So why has this concept in restorative dentistry been so profoundly influential?

是的。

Yeah.

没关系。

It's okay.

没错，我觉得这个理念确实影响深远，虽然遗憾的是，我仍看到一些知名同行拒绝正视证据，这让我很痛心，因为证据实在太充分了。即刻牙本质封闭最早是日本同行在90年代初提出的，早在1992年东京大学就有研究了，当时有一位叫渡边博士的人。

So yes, I think it has been very influential even though I still unfortunately see prominent colleagues who refuse to look at the evidence and it always breaks my heart because the evidence is overwhelming and immediate dentin sealing was first introduced in dentistry by our Japanese colleagues in the early 90s, as early as 1992 at the University of Tokyo and there was someone by the name of Toru, Doctor.

来自田上教授团队的田岛彻博士。

Toru Nikaido from the team of Doctor.

他发表了一篇关于树脂涂层技术的文章。

Tagami who came up with this publication talking about the resin coating technique.

所以最初这个技术叫树脂涂层技术。说实话，我之前完全不知道，因为那篇文章只用了日文发表，所以我从没听说过。

So the original name was the resin coating technique but I didn't know about it to be honest with you I had never heard that because this article was only published in Japanese language.

后来是通过一位德国同事，也就是……

So it was through a colleague from Germany, Doctor.

斯特凡·保罗，我第一次听说这个想法是在取模前先在牙齿上涂一层粘接剂。

Stefan Paul that I first heard about the idea of applying an adhesive to the tooth before taking impression.

斯特凡·保罗后来去了美国，在帕斯卡尔医生团队里工作过一段时间。

Stefan Paul was working, came to The United States, worked for a little bit in the team of Doctor.

1995年他访问我们日内瓦的团队，给我们做了分享。他当时没用“树脂涂层”这个词，而是叫“双重粘接技术”。意思就是，你在取模之前先把牙本质粘接剂涂上去。

Pascal back then and in 1995 he visited us in Geneva and he presented us, he never used the word resin coating, he used the word dual bonding technique and what he meant by that is that you would basically apply your dentin bonding agent before taking your impression.

然后取模，做临时冠，等回来粘固的时候，再把粘接剂按第一次的方式重新涂一遍。

You would take your impression, provisionalize, come back for the cementation and you would apply the adhesive again the same way basically you applied it the first time.

所以你要涂两遍，这就是为什么叫‘双层粘接’，但这个名字有点让人困惑，因为那时候我们也在用双固化复合树脂，可这跟双固化完全没关系。

So you apply it twice hence the name dual bonding technique which was a little bit confusing because back then we were also using dual cure composites and it had nothing to do with the dual cure.

不是固化过程是双的，而是操作步骤要重复做两次。

It was not the polymerization process that was dual, it was the application mode twice.

对吧？

Right?

我其实不太喜欢‘双’这个说法，太容易搞混了。

So so I didn't like too much the name because of the this name dual.

但这个想法真的特别有道理，我们就把它拿过来，努力把它提升到一个新的水平，因为这完全说得通——Paul医生的意思是，你不想在戴修复体的时候，粘在被污染的牙本质上。

But I I it made so much sense to me and we really took this concept and tried to bring it to the next level because it made complete sense that the dentin, the point of Doctor.

当你取下临时冠，牙齿表面已经脏了。

Paul was that you don't want to bond to a contaminated dentin when you deliver your restoration, you remove the provisional, the tooth is dirty.

你其实可以低速重新预备一下牙体，把残留物清理干净。

You could actually, you know, re prep the tooth a little bit at low speeds to eliminate the debris.

但粘接的时候，这正是我们后来才发现的——其实早在1990年我写论文的时候，就已经无意中注意到了：当我们把嵌体粘到牙本质上，如果粘接剂还没预聚合，那么在粘固时的压力会把杂化层压垮。

But when you bond, and that's really what we discovered actually without knowing it in the even way before that in 1990 when I was doing my thesis, we noticed that when we bond an onlay to dentin and the adhesive was not pre polymerized, then the problem is that the hybrid layer would be crushed during the cementation by the pressure.

修复体和复合材料施加的压力会压垮混合层，我们在扫描电镜下看到粘接剂与牙体之间出现了缝隙。那时候我们根本没用厚的粘接剂，用的是双固化粘接剂，但还是不管用。

The pressure of the restoration and the composite would crush the hybrid layer and we would see on our scanning electron microscope views these gaps between the luting composite and the tooth and we were not even using thick luting agents back then we were using dual cure bonding agents but it wouldn't work.

我们在修复体就位当天直接粘接，根本没法实现牙本质的完全封闭，因为粘接剂不起作用，缝隙清清楚楚，可我们当时完全不知道该怎么解决这个问题。

We couldn't get sealed dentin by bonding on the day of delivery of the restoration because the adhesive would not work and we could see those gaps but we didn't know what was the solution to resolve that problem.

但当我们开始在取模前直接对牙本质做封闭处理后，问题就立刻解决了——混合层完全聚合，没有受到任何干扰，因为粘接是在无应力的状态下完成的。

And as soon as we started to apply the sealing of the dentin straight before impression, it became obvious that we didn't have this problem anymore because the hybrid layer was very well polymerized without alteration because you apply the adhesive in a stress free situation.

你只要把粘接剂涂在牙本质上，光照固化，然后就别再去碰它了。

You just apply the adhesive to the dentin, polymerize it and leave it alone.

所以混合层变得完美、完整，一点缝隙都没有。

And that's why the hybrid layer was beautiful, intact and no gaps.

其实，从双层粘接技术演变到现在，我最近又重新回到了这个方法，接下来我来解释为什么。

What we did from the dual bonding technique, it's really interesting because I kind of moved back to the dual bonding technique today and I will explain you why.

不是因为我自己的偏好，而是因为现在很多人犯的错误，我稍后会详细说明。

Not because of my own ways but because of the mistakes that people do and I will develop that just after.

当初我们采用双层粘接技术时，心想：我不想像斯蒂芬·保罗那样涂两遍，我们只想涂一次，就一次，根本不需要再涂第二遍。

So when we took the dual bonding technique, we said, I don't want to apply it twice like Stefan Paul, we want to apply it once for all and we don't have to apply again the second time.

因为斯蒂芬·保罗认为，第二次操作时牙本质可能仍然外露，清洁牙齿时可能会重新暴露牙本质，毕竟之前的粘接剂可能太薄之类的。

Because Stefan Paul was assuming that you may still have dentin exposed the second time, you may still have areas that when you clean the tooth, you re expose the dentin because the adhesive maybe was thin and so forth.

所以他建议把整个流程再重复一遍。

So he would recommend to reapply the whole thing.

再次使用牙本质的酸蚀底漆和粘接剂。

Again, primer, you know, etching primer for the dentin and bonding.

而我们当时的做法是，专注于使用一种强效粘接剂——Optibond FL，它本身带有自酸蚀成分，现在还添加了放射不透性，这一点非常关键。

And what we did is because we geared our efforts towards the use of a strong adhesive, Optibond FL, that has a field adhesive and nowadays a field and radio opaque, very important, that's another very important element.

使用Optibond FL时，我们把它当作最终的封闭层来涂布，借助放大设备仔细涂抹，确保没有任何牙本质外露。

So when we were using Opti Bonded FL, we applied the adhesive like a definitive liner and with magnification you apply this liner, you don't leave any exposed dentin.

如果第一次用Optibond FL操作得当，牙本质就完全被密封了，那么第二次粘接修复体时，理论上甚至可以不用麻醉，除非为了上橡皮障必须麻醉患者。

So if you do that the first time perfectly with Optibond FF, then the second time the dentin being 100% sealed, if you did it well, then you can bond the restoration even theoretically without anesthesia unless you need to anesthetize the patient for rubber dam.

因为牙齿已经完全脱敏，你只需轻微喷砂清洁预备体，酸蚀釉质，再涂一层新的粘接树脂，完全不需要重新处理牙本质。

But the tooth is completely desensitized so you would be able to just slightly air abrade the prep to clean, etch the enamel and apply a fresh layer of bonding resin without primary.

根本不用重做整个牙本质粘接流程，只需要重新做釉质的粘接就够了。

No need to redo the whole dentin adhesion protocol, just the enamel bonding.

所以在整个预备体表面再涂一层新的粘接剂。

So a fresh layer of adhesive over the entire preparation.

就这样。

And that's it.

这对我来说是个顿悟，也正是因此我们决定改个名字——因为我们并不觉得是重复涂了两次粘接剂。

And that was for me the revelation, you know, to make and that's why we decided to change the name because we were not feeling we were applying the adhesive twice.

我们觉得是一次性彻底涂好，第二次只是针对牙釉质和之前涂好的粘接层进行再粘接。

We felt we were applying the adhesive once but once for all, you know, and the second time was only to bond mainly to enamel and bond to the previously placed adhesive.

所以我们称之为即刻牙本质封闭；顺便说一句，我后来了解到的第二篇相关文章也是1992年发表的，由大卫·帕斯卡尔·马涅的妻子撰写，是一篇修复学论文，她提出：在临时冠阶段，我们应该封闭牙冠预备体，防止细菌渗漏。

So that's why we called it immediate dentin sealing and by the way the second article that came to my knowledge about this was in 1992 also by the wife of David Pascal Magne in a prosthodontic article where she said, We should seal our crown preparations to prevent bacterial leakage during the provisional phase.

在临时冠阶段，应该用牙本质粘接剂保护牙冠预备体。

We should protect the crown preparations with a dentin bonding agent during the provisional phase.

但她也提醒要注意，如果在取模后再涂粘接剂，容易堆积在肩台区域，等你回来粘固冠的时候，冠就戴不进去了。

But she said also be careful because if you apply the adhesive after the impression and it accumulates on the chamfer area, you come back to bond your crown it will not seat anymore.

所以关键是要在取模之前就做，对吧？

Hence the idea of doing it before impression, right?

所以这是帕斯卡尔夫人最早提到这项技术的时候。

So that was the too early mention of the technique by Mrs.

还有那个日本团队。

Pascal and by the Japanese group.

后来斯特凡·波尔提出了双重粘接法，那其实也相当于涂了两层，所以我们最终定名为即刻牙本质封闭，也就是IDS。我们做了大量研究，考察了从涂布IDS层到最终戴入修复体之间的时间间隔。

Now Stefan Pol came with the dual bonding which was also like a double application so that's why we end up you know with the name immediate dentin sealing IDS and we did all the research and we looked at the delay, you know, between the placement of the IDS layer and the delivery of the restoration.

我们的结论是，即使等待长达十二周，树脂粘接强度依然可以正常形成。

We came to the conclusion, you know, we waited up to twelve weeks and the resin bond could be still developed etc.

到现在为止，我对这项技术依然很满意。

And I'm still happy today with this technique.

不过，现在我得回过头来解释一下，为什么我们在教学中又回归了双重粘接技术。因为我了解到，很多牙医用错了方法，选错了粘接剂，而且还不使用放大设备，结果出了问题，却把责任推给 IDEA 技术，这其实是不对的。毕竟，IDEA 技术要是操作不当，确实很容易出错。

However, now I come back to why we kind of returned in teaching the dual bonding technique is that it came to my knowledge that many dentists apply ideas the wrong way and with the wrong adhesive and they don't use magnification and then they have problems and they put it on the account of ideas which is not true because of course there's a lot of ways to mess up ideas.

所以，我发现大家在应用 IDEA 技术时主要有两个问题。第一，他们没用够粘接剂的厚度。

And so the two main problems I see people have with ideas is number one, they don't use a thick adhesive.

他们用的是那些新一代的超薄型粘接剂。

They use those new generations of thin adhesives.

我为什么说‘薄’呢？

Why do I say thin?

因为粘接剂树脂是未填料的，有时候还会用空气吹薄，尤其是在那些全合一型或酸蚀-涂布型粘接剂里，为了挥发溶剂，你得吹一下，结果就形成了一层非常薄的树脂膜。

Because the adhesive resin is unfilled and the adhesive resin is also air thinned sometimes and in those all in one adhesives or let's say those etch and prime adhesives, you have to air thin the adhesive because of the solvent and you end up with a very thin resin coating.

如果这层薄膜没涂好，又没用甘油隔绝空气，等你第二次回来时，单是清洁牙齿的动作就可能把这层膜彻底破坏掉，这时候你就得重新做双重牙本质粘接，才能再次密封牙本质——否则，患者肯定会出现明显的敏感。

That thin resin coating, if it's not placed properly and maybe air blocking with glycerin is not used, when you come back the second time, just the fact of cleaning the tooth will destroy that layer and now you would theoretically have to use the double, the dual dentin bonding in order to seal again that dentin because if you don't you will have significant amount of sensitivity.

所以，IDS出问题的根本原因，就是粘接剂涂得太薄，解决办法是用像Optibond FFEL这样的流动型粘接剂。我敢打赌，戴夫·奥尔曼斯之前在某个播客里已经跟你们提过了：在粘接剂上再加一层流动树脂，就能让这些薄型粘接剂真正发挥作用——因为现在你有了更厚的树脂底层，它被保护起来了，不会在清洁牙齿时被刮掉。

So if you want the problem with IDS is when you don't apply a layer of adhesive that is thick enough and that is resolved with the use of a field adhesive like Optibond FFEL and I'm sure that Dave Allmans told you that already maybe in a previous podcast, but by adding a layer of flowable composites to your adhesive and the addition of a flowable layer will make those thin adhesives work because now you have a thicker resin liner, it's protected and it's not damaged during the cleaning of the tooth.

薄粘接剂的另一个问题是固化不充分。

Another problem with thin adhesive is that they don't polymerize well.

也就是说，当你清洁牙齿时，粘接剂根本还没固化好，一擦就没了。

So that means that the adhesive is not polymerized well when you clean the tooth, you basically remove the adhesive.

你要记住，氧气抑制效应可以影响到30甚至40微米的厚度，而被吹薄的粘接剂，厚度很容易就降到这个水平。

You have to keep in mind the oxygen inhibition can go up to 30, maybe 40 microns of thickness and a thinned adhesive can easily be thinned down to those level of thicknesses.

你以为你照光固化了，其实根本没固化，全让氧气给干扰了。

So you think you polymerize but you're actually not polymerizing anything because of oxygen inhibition.

所以为了澄清一下，当然我们尽量不提及具体品牌。

So just to clarify, and of course, we don't wanna use any brand names as much as we can avoid it.

但与此同时，这款产品实在太流行了，不得不把它讲清楚。

But at the same time, this is such a popular product that it kind of it has to be clarified.

所以这里用的是那种流动性树脂吗？

So is that flowable that's being used?

这是用来弥补 Clear Fill 中粘接剂不足的吗？

Is that compensating for the adhesive in clear fill essay?

因为那个

Because that's

填料含量非常低。

not very filled at all.

没错。

Exactly.

对。

Yes.

对。

Yes.

不对。

No.

透明填充材料的填充量不够。

Clear fill essay is not filled enough.

它的放射不透明度还不够。

It's not radio opaque enough.

所以这就是为什么Optibond FL这种粘接剂非常特别——它含有填料，具有放射不透明性，就算你想用气流把它吹薄，也很难像其他粘接剂那样变得很薄，就是因为有填料的存在。

So this is why, you know Optibond FL is a very unique adhesive because it is filled and radio opaque and even let's say if you would like to air thin Optibond FL will be difficult to thin to the level of other adhesives because of the presence of the filler.

所以默认情况下，如果粘接剂必须偏厚，那它就必须具备放射不透明性。

And so by default, if the adhesive has to be thick, it has to be radiopaque.

这一点也很关键，否则在X光片上，你的修复体下方会出现那些线条，如果患者换了一位牙医，新牙医一看就会说：‘这没密封好，有缝隙。’

That's another very important because otherwise you will have those lines underneath your x rays there, your restoration and you will not know if the patient goes to another dentist, the dentist will say, Oh, this is not sealed, know, there's a gap.

所以Optibond FL的放射不透明度，和修复材料的水平完全一致。

So optimal naphtha has a level of radio opacity that is absolutely similar to that of a restorative material.

其他简化型粘接剂要么没加填料，要么因为溶剂原因需要吹薄，这时候虽然可以光固化，但效果不会太理想，因为厚度变薄了，还会受氧气抑制影响。

So with other simplified adhesives that are either not filled or let's say you need to air thin because of the solvent, then you can light cure them even though light curing will not be optimal because of the reduced thickness and oxygen inhibition.

但如果你在上面覆盖一层流动型衬层，就能确保完全固化——因为流动衬层会带来新的光引发剂，帮助原本固化不良的混合层彻底聚合，形成一层难以磨损的保护层，即使你用喷砂 aggressively 清洁牙面，也很难把它去掉。

But when you cover them with a flowable liner, you are going to allow the complete curing because the flowable liner will bring new photo initiator that will allow the badly polymerized hybrid layer to be polymerized well and will create this protective layer that will never be abrade able that you cannot remove easily even if you clean the tooth quite aggressively with air abrasion for instance.

喷砂是粘接修复前清洁预备体的最佳方式。

Because air abrasion is the best way to clean the preparation just before cementing the restoration.

如果你对吹薄后固化不良的粘接层直接喷砂，很可能会穿透到牙本质，如果不采用双重粘接法，术后敏感几乎是必然的。

So if you use air abrasion on a air thinned badly polymerized adhesive you will go through into the dentin and then if you don't use the dual application then you will be in trouble and have postoperative sensitivity.

所以，我们甚至专门做了一项研究，想看看如果像 OptiMoDFL 这样的粘接剂，第二次使用时重新涂布底漆——也就是把底漆直接涂在已有的粘接层上——会不会污染原有层，从而影响粘接强度。

And that's why, you know, we even conducted a research to check what would happen, let's say if you use an adhesive like OptiMoDFL a second time completely, like including the primer and the primer goes on top of your existing adhesive layer, is that contamination of the existing adhesive layer by the primer going to affect the bond strength?

答案是不会。

And the answer is no.

为了保险起见，你完全可以考虑：第二次还是重新涂一遍底漆，特别是当你怀疑清洁过程中可能重新暴露了牙本质，或者不小心漏掉了某个牙本质区域——毕竟人总会疏忽，我本人也遇到过没注意到有牙本质暴露的情况。

So to be on the safe side, you could say, you know what, the second time I still going to reapply the primer, especially if you have doubts that you may have re exposed dentin during cleaning of the tooth or you may have missed dentin because we are humans and it happens to me too, didn't see there was an exposed dentin area there.

当然，为了预防术后敏感，重新涂底漆是强烈推荐的做法。这也就是我为什么说，我倾向于回归双重粘接技术——尽管我仍然称之为即刻牙本质封闭，因为我们始终希望第一次就能把整个牙本质完全封闭住。

Now it's really recommended to reapply the primer of course to prevent post operative sensitivity and in that sense, that's what I meant when I say I tend to be back to the dual bonding technique even though I would still call it immediate dentin sealing because we really aim and hope that we seal the entire dentin the first time.

我来问一下，因为我觉得大家肯定都很想知道。

Let me ask because I think people are going to be dying to want to know.

你能给我们讲清楚，具体该怎么做即刻牙本质封闭吗？

Can you just make this actionable for us how to do immediate dentin sealing?

你刚才讲了很多不同的技术，但如果是第一次听的人，比如在预备一个较大的二类洞时，你能一步步教我们怎么做即刻牙本质封闭吗？

You've talked a lot about the different techniques, but someone listening to this for the first time, if they were prepping, let's say, class two, a large class two restoration, can you walk us through your steps for immediate dentin sealing?

所以，说到即刻牙本质封闭，通常只适用于较大的二类洞，因为小一点的本来就不需要，直接用复合树脂充填就够了。

So, yeah, immediate dentin, you know, a class two restoration would have to be first a large class two, right, to require immediate dentin sealing because otherwise it's an indication for a direct composite.

顺便说一句，我们做直接修复的时候，其实都会常规做即刻牙本质封闭，因为粘接剂是在放修复体之前就先聚合固化的。

And by the way, you know, when we do direct restorations, we systematically do immediate dentin sealing because the adhesive is polymerized and cured before placing the restoration.

对吧？

Right?

即刻牙本质封闭的核心，就是在放置修复体之前，让粘接层已经完全密封并固化。

And that is the essence of immediate dentin sealing is to have a sealed polymerized adhesive before placing the restoration.

没错，我们之前已经详细发表过这些步骤了。

Yeah, we published a lot the steps.

我有一篇文章可以推荐，是发表在《粘接牙科学杂志》上的，来自国际粘接牙科学会，详细介绍了实施即刻牙本质封闭的全部步骤，包括为什么做、怎么做。如果你需要，我可以发给你。

There is an article I would refer to which is called, it's for the International Academy of Adhesive Dentistry, was published in the Journal of Adhesive Dentistry is basically all the steps for it was a clinical instruction why and how to remediate dentin sealing and I can send you this article if you wish.

第一步永远是将粘接剂应用于新鲜切割的牙本质。

So the first step is always bond to a freshly cut dentin.

在涂任何粘接剂之前，必须确保窝洞是刚刚切割好的，也就是说，切割完后几秒内就要上粘接剂。

Before application of any adhesive we should have a freshly cut preparation which means cut seconds before applying the adhesive.

就我而言，这一步是酸蚀，因为我用的是三步法全酸蚀系统。

So in my case would be etching because I use a three step total etch rinse system.

那么，怎么才算新鲜切割的牙本质呢？

So now how to freshly cut dentin?

对于全酸蚀粘接系统来说，这里有个很大的优势。

Well, in the case of a total etch adhesive there is a huge advantage.

这个优势就是可以用粗粒度的金刚石车针来新鲜切割牙本质。

The advantage is to be able to freshly cut the dentin with a coarse diamond.

为什么要用粗粒度的金刚石车针？

And why a coarse diamond?

因为粗粒度的金刚石钻头能形成非常粗糙的表面，我们搞粘接和粘合材料的都知道，粗糙表面更利于粘接，因为它增大了接触面积，提供了更好的粘接基底。

Because a coarse diamond will create a very rough surface and all of us work, know, all engineers work in adherence and adhesives, we know that a coarse surface, rough surface is better for adherence because it increases the contact surface and it's a better substrate for bonding.

如果你观察牙本质，就会明白仿生学就是模仿自然——看看我们粘接时的牙本质-釉质交界处，做个横截面，在显微镜下一看，你会发现这个交界根本不是一条平直的线。

So if you look at the dentinol, you know biomimetics is mimicking nature and if you look at our model of bonding the dentinoenamel junction and you make a cross section and you look with the microscope you will see that this junction is not a flat line.

而是一个波浪状的界面。

It is a scalloped interface.

它有多层波浪起伏，非常粗糙，事实上粗糙到釉质和牙本质是相互交织在一起的。

It is, it has multiple levels of scalloping and very rough and so as a matter of fact it's so rough that enamel and dentin are interconnected.

牙本质里的胶原纤维会延伸进入釉质。

There is collagen from dentin going into enamel.

这些结构叫做釉梭。

Those are called the enamel tufts.

对吧？

Right?

所以釉质和牙本质是这样交错的，它根本不是简单的界面，而是一个复杂的嵌合结构。

So the enamel and dentin are like this and so it's not an interface, it's an interface.

所以为了复制牙本质-釉质交界处的结构，我坚信，而且我们最新的研究也证实了，粗粒度的金刚石磨头能形成这种完美、高度不规则的表面。

So in order to copy the dentinoenamel junction, I am absolutely convinced and our most recent research is really demonstrating that the coarse diamond will create this beautiful, very irregular surface.

但这里有个问题：粗粒度金刚石会产生一层厚厚的碎屑层，如果这层太厚，对自酸蚀粘接剂来说就不理想。

But there is a problem and the problem is coarse diamonds generate a thick layer of smear and the smear layer, if it's very thick, it's not ideal for self etching adhesives.

但我根本不在乎，因为我从不用自酸蚀粘接剂，我用的是全酸蚀法。

But I don't care because I don't use a self etch, I use a total etch.

不过我还是想提醒一下，如果你用粗磨处理了牙本质，又想用自酸蚀粘接剂，最好先用喷砂系统清理一下牙本质表面，把碎屑层去掉，再上粘接剂。

But I just want to let you know that if you coarse prep the dentin and then you want to use a self etching adhesive, you should clean the dentin maybe with an air abrasion system, know, before applying the self etch to remove the smear layer.

所以我们在酸蚀之后——也就是第二步——记住，第一步是新鲜切割的牙本质，第二步是把酸蚀剂涂到牙本质上。

So after we etch, so which is the second step, so remember first step is freshly cut dentin, second step we apply the etchant to the dentin.

涂酸蚀剂时，一定要稍微覆盖到釉质边缘，千万别漏掉任何牙本质区域，这正是IDS技术的关键所在。

It is very important to slightly overlap the enamel margins when you apply the etching because you don't want to miss any dentin and that's the whole point for the IDS technique.

否则，你就等于退回到传统的双层粘接法了。

Otherwise you are going back to the dual bonding technique.

所以我每次酸蚀牙本质时，都会刻意多覆盖一点釉质，确保万无一失，一点都不会漏。

So I always, by safety overlap the enamel when I etch the dentin to make sure I don't miss any spot.

通过酸蚀，我们还能区分出硬化牙本质和普通牙本质，这也是酸蚀的一个巧妙优势。

We miss, and there's another beautiful advantage of etching dentin is that you can make a difference between sclerotic dentin and the regular type of dentin.

我通常会对硬化牙本质延长酸蚀时间。

And I would always etch longer the sclerotic dentin.

普通牙本质酸蚀十到十五秒就够了，但遇到硬化牙本质时，可以延长到二十到二十五秒，这样就能明显区分这两种牙本质，非常关键。

So for a normal etching time of ten, maximum fifteen seconds on the regular dentin, you can extend that time to twenty-twenty five seconds when you deal with sclerotic dentin and that's a significant substantial advantage to be able to differentiate those two types of dentin.

酸蚀完成后，我们要仔细冲洗，冲洗时间至少和酸蚀时间一样长，然后轻轻吹干牙本质。

After this time of etching, we carefully rinse, you know, at least the same amount of time that you etched, you want to rinse and gently dry the dentin.

这里还有一个非常重要的细节。

You see this is another very important point.

和你们一起过这些要点，我特别享受，因为这正是最关键的问题。

I love going through this with you because this is the most important question.

细节决定成败，这些看似微小的地方，其实都至关重要。

It's, you know, the devil is in the details and all those little things count.

比如，有些粘接剂对脱水更敏感，这取决于底漆中亲水成分的含量。

So for instance, if you some adhesives are more sensitive to dehydration than others, you know, depending on how much hydrophilic components is in the primer.

我用的粘接剂亲水性很强，即使我吹得过干，里面的酒精和水溶剂也能重新润湿牙本质。

The adhesive I use has a lot of hydrophilicity and so it will, even if I over dry the dentin, the solvent being made of alcohol and water, re wets the dentin.

所以我在酸蚀后吹干牙本质时不会太紧张，因为我知道底漆能重新润湿已酸蚀的牙本质。我会花时间让底漆充分渗透，轻轻按摩，让底漆慢慢渗入牙本质。

So I'm not so so careful when I dry my dentin after etching but because I know that the primer will re wet the dentin that has been etched and so I take time for the application of the primer and I let the primer soak the dentin, know sink in the dentin by gently massaging, you know, agitating the primer.

我把这叫作牙本质SPA。

I call it the dentin spa.

就像非常轻柔地按摩——我跟我的同事，尤其是男同事说，想象你正在温柔地给妻子按摩背部，对待牙本质也要这样温柔，把底漆轻轻揉进小管里，持续二十到四十秒，时间再长也没关系。

It's like very gentle massaging of the, I tell my colleague, know, my male colleague, imagine you are massaging the back of your wife gently and be kind with the dentin as you massage the primer into the tubule and you do that for twenty-forty seconds and it's never too much.

做完这一步，牙本质就会变得充分湿润。

And after that, you have this soaked wet dentin.

接下来，你需要把溶剂——酒精和水——去掉。

Now you need to get rid of the solvent, the alcohol, the water.

方法是用轻柔的气流吹干，从颊侧方向吹入空气，同时从舌侧用高速吸唾器抽走空气。

And so you can do that by gentle air drying and you create a laminar flow from the buccal area you blow air and from the lingual area I suck the air with the high speed suction.

这样就在颊侧到舌侧之间形成了一股稳定的气流。

So you create this laminar flow from buccal to lingual.

这就像飞机能飞起来，靠的是负压原理。

And by the, you know, it's like an airplane flies because of negative pressure.

当空气在牙面形成层流时，它会把窝洞里的水分吸走，而不需要直接对着牙齿吹风。

So when you have a laminar flow of of air at the surface of the tooth, it sucks out the moisture from the cavity without having to air dry directly into the tooth.

对我来说，这其实再简单不过了，说到底还是常识，对吧？

And to me, this is so you know, those are so again, we are back to common sense, right?

如果你直接对着窝洞吹干，只是把水分往旁边推。

If you air dry inside the preparation, you push the moisture away.

一旦你停止吹风，水分又会回到牙面上。

As soon as you stop drying, it comes back on the tooth.

所以，通过配合吸唾和气流形成定向流动，水分其实被直接吸进了高速吸唾装置里。

So by using a suction and air and creating a flow, really the moisture is taken away into the high speed suction.

但因为你不是直接对着窝洞吹气，而是让气流平行于牙面，所以牙齿不会被彻底脱水。

But you are at the same time because you are not blowing air directly into the preparation but parallel to the surface of the preparation, you are not dehydrating completely the tooth.

现在我最关键的控制点，就是让牙本质表面看起来有光泽，但没有任何流动的液体。

My control now because this is the most important part of the procedure is to have a dentin surface that is shiny but without any moving fluids.

所以表面应该有光泽，但不能有任何可能被气流带动的液体。

So the surface should be shiny, but there is there is no fluid that can potentially be moved by air.

另一个使用粗粒金刚石的优点是，它能帮助我控制水分量——当牙本质干燥到恰到好处时，我能清楚看到金刚石留下的纹理。

And another advantage of using the rough diamond at the beginning is that it allows me to control the amount of moisture because when I have the right amount of dentin dried, I could see, I can see the texture left by the diamonds on the dentin.

这就是我的判断标准：如果想确保底漆涂得足够，牙本质要有光泽，但不能干过头。

That's my control if you want to make sure I have applied the primer enough, which means the dentin is shiny, but I have not overdried.

我也没让牙本质太湿，因为看不到流动的液体，但能看见金刚石留下的细微凹凸，表面依然有光泽。

I have not left the dentin over wet because I don't see moving fluid, but I can see those little irregularities of the dentin created by the diamond, but it's still shiny.

现在我涂粘接剂，天啊，这里面的讲究真多，说来有趣，我教学生的时候，他们眼睛都瞪圆了，说：‘原来还有这么多细节要注意。’

And now I apply the adhesive and oh my gosh, there are so many tricks, know, it's funny because when I teach my students, their eyes are like that, they said, I wouldn't know there were so many things to care about.

还有一点，如果你用的是像Optibond NF L这种填料型粘接剂，就有两种用法。

So another thing, if you are using like an adhesive that is filled like Optibond Nf L, there are two different ways.

你可以买瓶装的，也可以买管装的。

You can buy bottles or you can buy rockets.

挺有意思的，我们大学用的就是那种管装的。

It's very interesting because the rockets that is that we use what we use at the university.

火箭型的优点是一次性使用，每位患者用一支。

The advantage of the rockets is you use it once for one patient.

对吧？

Right?

用完就扔，一次性处理。

And and then it's disposable.

好处是它完全密封，外面还有一层紧贴的塑料套。

The advantage is it's sealed 100% and it's in a very tight sleeve, plastic sleeve.

你一拆开塑料套，里面的火箭就是密封好的。

You open the sleeve, the rocket is sealed.

你只要拆开火箭的密封，就能用上全新的材料。

So the rocket, you unseal the rocket itself and you have fresh product.

要是用瓶装的，打开后搁在台子上，学生常常忘了盖紧，容易挥发。

You know with bottles, you open the bottles, leave them on the counter, students often forget to close them, there is evaporation.

放上几个月，产品的质量就没刚买来时那么好了。

The quality of the product is not the same after a few months as it is at the beginning.

还有，使用瓶装的现场粘接剂时，灌装口在瓶底，这又带来另一个问题。

And with the field adhesive, there's another problem with the bottle that the filler goes at the bottom of the bottle.

所以制造商想做出合格的现场粘接剂真的特别难，我跟你说真的。

And that's why manufacturers have such a hard time to create a field adhesive, believe me.

所有试过的人，都遇到了实实在在的困难。

And all those who have tried, they have really real challenge.

而火箭型设计的好处是，用刷子能直接伸到火箭底部，轻松操控，每次都能挤出量非常均匀的粘接剂。

So the advantage of the rocket is that you with the brush, you penetrate with the brush all the way to the bottom of the rocket and you can steer it and you have a very consistent amount of filler.

这样就能保证最佳的产品效果。

So you have the best product.

还有一件事，我们最近才发现：如果你把这两个火箭型粘接剂放进复合树脂加热器里——你知道的，我们做修复时用的是预热的复合树脂，不再用粘接用的复合材料了。

And there's another thing, oh my gosh, we discovered recently is that if you put those two rockets into a little composite resin heater and you know that we use, we bond our restoration with preheated composite, don't use luting composites anymore.

我们用的是加热后更流动的修复型复合材料，所以专门配了个加热器。

We use a restorative composite that we warm up to make it more fluid and so we have a little composite heater for that.

这设备叫Calcet，可以把两支Optibond FL火箭放进加热器，加热到155华氏度，大概十到十五分钟，就能显著提升粘接剂的效能。

It's called Calcet and you can put the two little rockets of Optibond FL into the Calcet unit and you can heat them up to 155 Fahrenheit for like say ten-fifteen minutes and that will increase the efficiency of your adhesive.

所以如果你在刚加热十分钟、155华氏度的时候涂上粘接剂，它会更高效，因为能更好地渗透到牙本质里。

So if you apply the adhesive when it's just warmed up like that ten minutes at 155 Fahrenheit, the adhesive will work more efficiently because it penetrates better into the dentin.

这种粘接树脂你可以这么做，底漆也可以，但厂家提醒我们，底漆预热不要超过十五分钟，不然溶剂会出问题。

And so you take this adhesive resin, you can do that with the primer but the manufacturer told us that we should not preheat the primer more than fifteen minutes because of the solvent.

而粘接剂火箭瓶这边就没这顾虑，因为它不含溶剂，可以长时间预热。

The adhesive rocket on the other side can be preheated for much longer time because there is no solvent that can evaporate.

用预热好的粘接树脂，再用刷子把填充剂一直推到瓶底，然后均匀地涂上去——我习惯说，是‘刷’粘接剂。

So with your preheated adhesive resin and you dig for the filler all the way to the bottom of the rocket, you paint on, I like to say you paint on the adhesive.

这其实更像涂一层封闭层，它不是单纯的粘接剂，而是含填料的封闭层，能形成厚度均匀的层，大概100微米，具体要看牙面是凹面还是凸面。

It's really like applying a liner, You line your it's not an adhesive, it's a liner because it's filled and it's going to create a consistent layer of about 100 depends on concavity versus convexities.

凹面的话，轻松就能达到200微米，也就是0.2毫米。

In concavity, you can go easily to 200 microns, 0.2 millimeter.

如果是凸面，厚度可能会薄到80微米左右。

If it's a convexity, it can thin down to maybe 80 microns.

但无论如何，厚度都不会低于80微米，这正是Optibond FL的妙处——它永远不会薄过氧抑制层。

But it's never less than 80 microns and this is the beauty of Optibond FFl is it will never be less than the oxygen inhibition layer.

所以我在做即刻牙本质封闭时，会很慷慨地涂上Optibond FF。

And so you apply Optibond FF, I'm very generous for immediate dentin sealing.

我涂粘接剂的时候用的是高倍放大镜，我的放大倍数是9.0倍。

I paint on my adhesive and with the loops you can see I use high magnification, my loops are nine point zero.

很多人会觉得惊讶，但确实很重要，因为你得像刷一层漆一样涂在牙本质上，稍微盖过一点牙釉质才安全。

Most people are shocked but yeah, it's very important because you want to apply like a layer of paint on your dentin and slightly overlapping the enamel for safety.

涂完之后，要给粘接剂一点时间，让它充分渗入牙本质表层。

And once you do that, you want to give the adhesive a little bit of time to sink in into the prime dentin.

所以我不会建议你立刻光照固化，而是让它静置20秒，让其充分渗透，再进行光照。

So we don't, I would not suggest you polymerize the adhesive straight away but you leave it for twenty seconds to soak in and then you light cure.

光照时间保持20秒就够了。

You light cure for twenty seconds.

在即刻牙本质封闭时，绝不能用气流吹薄粘接剂。

You never air thin the adhesive for immediate dentin sealing.

这一点非常关键，否则涂层会太薄。

That's really important because otherwise it will be too thin.

粘接剂固化后，如果需要，可以加一层流动树脂或常规树脂，填平倒凹，改善预备体的形态。

And then if you need, after polymerizing the adhesive, if you need, you can add flowable composite or regular composite to fill in undercuts to improve the geometry of your preparation.

比如，如果预备很深，嵌体或高嵌体太厚，会影响粘接剂在修复体下方的固化，这时我会用树脂做一层垫底，减薄修复体厚度，方便后续粘接和固化。

For instance, if we have a very deep preparation and the onlay or the inlay is going to be very thick which will challenge the polymerization of the luting cement through the restoration, then I will do a little buildup with composite to decrease the thickness of the restoration and facilitate the luting and the polymerization when we apply the inlay later.

粘接剂涂完，可能还加了树脂来调整形态后，我们会再照一次光，这次在表面涂一层甘油凝胶，减少氧气对固化的影响。

And so after the adhesive is placed and possibly composite resin is added for geometrical reasons, then we like to cure again, we use a layer of glycerin gel lead to decrease the amount of oxygen inhibition.

把甘油涂在表面，再照一次光，这样能获得一个干净的固化表面。

We apply that to the surface and polymerize again for having a clean surface.

然后冲洗掉甘油，最后一步是用细金刚石车针稍微修整釉质边缘，小心去除多余的粘接剂，形成你想要的边缘形态——这本身是另一个话题，但我喜欢用小圆钻做一个轻微的凹形肩台，让嵌体或高嵌体和牙齿之间过渡得更自然。

And then we rinse off the glycerin and the last step is to take a diamond, a fine diamond bur and slightly refinish the enamel margins and carefully remove the excess of adhesive from the enamel margins and then create the margin you like which is a completely different discussion but I like to use a small round bur and create a slight hollow chamfer for my inlays and onlays to create a nice transition with the tooth.

这些就是基本的操作步骤。

So yeah, those are the basic steps.

如果是经过根管治疗的牙齿，我强烈建议在做任何其他步骤之前——在你清理牙本质、开始操作之前——先用玻璃离子封闭根管口，防止粘接剂里的溶剂接触根管封闭剂。像酒精、有些粘接剂含丙酮，会溶解封闭剂，造成污染性底涂，对牙体强度也不好。

I would say if you have an endodontically treated tooth, I highly recommend before all of this, before everything we said, before you know refreshing the dentin and starting the procedure, I would command to use a glass ionomer barrier to close the orifice of the canals and avoid the contact between the solvents of the adhesive and the canal sealer, the solvents like alcohol, some adhesives have acetone, it will dissolve the canal sealer while you apply them and it will create a smear of a contaminated primer that's not good for the bone strength either.

所以，当你的嵌体或高嵌体从技工室或CAD/CAM机器出来后，操作就很简单了：用喷砂清洁预备体，酸蚀釉质，如果是即刻牙本质封闭，就重新涂一层粘接剂；如果是双重固化粘接，就重新涂底涂和粘接剂。

So that's it and then when your inlay or your onlay comes from the lab or from your CADCAM machine, it's very simple, you just have to air abrade the preparation to clean and then etch the enamel and reapply a fresh layer of adhesive if you do immediate dentin sealing or reapply the primer and the adhesive if you do dual bonding.