超越神话的粘附：与 Bart Van Meerbeek 教授对话

嘿，我想告诉你我为你准备了一些东西。

Hey I want to tell you about something I have put together for you.

我做了一个免费的PDF指南，一步一步教你注塑成型技术。

I created a free PDF guide that walks you step by step through the injection molding technique.

我喜欢这项技术，因为它是获得可预测、美观且高美学效果的前牙复合树脂修复的最佳方法之一。

I love this technique because it is one of the best ways to get predictable, beautiful and highly aesthetic anterior composites.

你实际上是通过一个透明的模板直接将复合树脂注入牙齿，这样更加一致和高效。

You're actually injecting the composite directly into the tooth using a clear template which makes it far more consistent and efficient.

如果你想要这份指南，我让它变得非常简单，只需访问elevatedgp.com/impdf，为了更方便，我也在节目笔记里附上了链接。

If you'd like this guide, I've made it super easy just head over to the elevatedgp.com/impdf and to make it even simpler I've included the link for you right here in the show notes.

嘿，欢迎收听Dental Digest，我是你的主持人医生。

Hey, welcome to Dental Digest and I'm your host Doctor.

赛伯特。

Seibert.

这是我们与医生合作的两部分系列的第二部分。

This is part two of our two part series with Doctor.

巴特·范·梅尔贝克。

Bart Van Meerbeek.

如果第一部分奠定了科学基础，第二部分就是把知识转化为临床判断。

If part one lay the scientific ground, part two is where that knowledge becomes clinical judgment.

这一集，我们在粘接的基本原则之上，深入探讨临床医生每天都会遇到的灰色地带。

This episode, we build on the foundational principles of adhesion and move into gray zones that clinicians navigate every day.

牙本质基质的差异如何影响粘接策略。

How dentin substrate variability could influence bonding strategy.

为什么一种通用粘接剂不能与另一种互换。

Why one universal adhesive is not interchangeable with another.

当我们谈论污染、去污染和长期粘接耐久性时，真正重要的是什么。

And what truly matters when we talk about contamination, decontamination and long term bond durability.

巴特对常常被过度简化或误解的话题提供了罕见的见解，以及10-MVP浓度的重要性。

Bart offers a rare insight into topics that are often oversimplified or misunderstood and role of 10 MVP concentration.

为什么氯己定远没有许多人认为的那么关键，固化灯的热量如何影响酶活性，以及为什么某些粘接系统的附加成分听起来很吸引人，却未能改善效果。

Why chlorhexidine is far less critical than many believe how curing light heat impacts enzymatic activity and why certain add ons to adhesive systems may sound appealing, but failed to improve outcomes.

这段对话强化了一个重要的主题。

This conversation reinforces a powerful theme.

粘接牙科已经非常先进了，但前提是我们尊重它的原则，而不是试图绕过它们。

Adhesive dentistry is already remarkably advanced, but only when we respect its principles rather than try to bypass them.

再说一次，如果这期节目对你有帮助，我真心感谢你的支持。

Again, if this episode has been valuable to you, I truly appreciate your support.

在苹果播客、Spotify或者你收听播客的任何平台上留下评分、评论或订阅，真的会给我和家人带来很大的不同。

Leave a rating and review or subscription on the Apple podcast app, Spotify, or wherever you get your podcast really makes a meaningful difference for me and my family.

这能帮助这个播客触达更多的临床医生，也让我能继续提供那种有深度、基于证据的内容，来支持你和整个牙科行业。

It helps this podcast reach more clinicians and allows me to keep delivering the kind of thoughtful evidence based content that supports you and the dental profession.

好了，我们开始吧。

All right, let's jump in.

我有个东西你一定会喜欢。

I've got something that you are going to love.

如果你一直喜欢这个播客，并且想更深入地掌握种植牙科，这就是你的机会。

If you've been loving the podcast and want to dive deeper into mastering implant dentistry, this is your chance.

我要免费送出一门我的点播课程。

I'm giving away access to one of my on demand courses completely free.

这门课程涵盖了种植体咬合、平台转换，以及打造那种让你的作品脱颖而出的美观穿龈轮廓，所有你需要知道的内容都包含在内。

This course is packed with everything you need to know about implant occlusion, platform switching, and creating that stunning aesthetic emergence profile that sets your work apart.

获取方式如下。

Here's how to grab it.

给播客留个评分，截个图发给我就行。

Leave a rating for the podcast, take a quick screenshot and send it my way.

你可以直接在Instagram上私信我。

You can either direct message me on Instagram.

我的Instagram账号是Doctor。

My Instagram handle is Doctor.

Melissa Seibert，或者发邮件到dr。

Melissa Seibert or send it to me an email at dr.

Melissa Seibertgmail点com。

Melissa Seibertgmail dot com.

你一旦把截图发给我，我就会把课程的访问权限发给你，这样你就能马上开始学习了。

Once you get the screenshot, I will send you access to the course so you can start learning right away.

这是我感谢你支持播客、成为这个优秀社区一员的方式。

It's my way of saying thank you for supporting the podcast and being part of this amazing community.

我迫不及待想听听你的想法。

And I can't wait to hear what you think.

那在备牙时用洗必泰擦洗，这个步骤怎么样？

What about scrubbing chlorhexidine into the prep?

这一步值得做吗？

Is this a worthwhile step or not?

因为你知道，牙医都很忙，尤其是在北美，根据诊所的结构，有些牙医可能面临巨大的效率压力。

Because, you know, dentists are busy and especially in North America based on the sort of structure of the office, some dentists might be facing tremendous pressure to be efficient.

而且，你知道，至少在北美的牙医助理，他们不太喜欢牙医开始加入很多多余的步骤。

And, you know, dental assistants in North America, at least, they don't love it when the dentist starts to incorporate a lot of superfluous steps.

所以，重要的是要考虑，我们是否得到了值得的预期结果？

So it's really important to consider, we getting a worthwhile desired outcome?

那么，把洗必泰擦进备牙面里？

So scrubbing chlorhexidine into the preps?

是的，这是个非常重要的问题。

Yeah, that's a very important question.

我知道不少意见领袖都说这是必须的。

And I know that quite some key opinion leaders are saying that this is a necessity.

但我们不这么认为。

We don't think so.

而且，我再说一遍，我不会这么说。

And, again, I will not say this.

我们这么说是因为我们也有证据支持。

We say this because we have also evidence for that.

临床数据？

Clinical data?

对，我们不是有吗？

Yeah, don't we have?

不，不是临床数据。

No, not clinical data.

但我认为这是目前的问题之一。

But I think that is one of the issues at this moment.

在我看来，没有临床数据能明确地说明黑与白。

In my opinion, there are no clinical data that clearly show black to white.

我用不用氯己定，是否能带来更好的粘接耐久性、更高的保留率或更好的性能。

I use chlorhexidine or not chlorhexidine that give you a better bond durability or a better retention rate or whatever, a better performance.

我觉得这些数据并不存在。

I don't think that they exist.

但我们研究了氯己定，因为正确地说，它涉及酶，而酶如果有效、活跃，就会促进降解。

But we looked at the chlorhexidine has been set, because correctly, are indenting, there are enzymes, and enzymes, they will, if they are effective, if they are active, they will contribute to the degradation.

这一点毫无疑问。

There is no doubt about this.

问题只是，使用氯己定是否能以这种方式起到帮助。

The thing is only will that application of a chlorhexidine help in this way.

我们研究过这个，做了一些非常简单的实验，比较简单的研究，因为可能也不应该夸大这些MMP的作用。

And we have studied this, we have done some very simple studies, rather simple studies, because you may also not exaggerate in that contribution of these MMPs.

我们做了几项研究，比如磷酸，肯定会暴露MMP，激活它们，这是肯定的。

We have done several studies and phosphoric acid, for instance, will expose MMPs, activate them, that is for sure.

但如果你在下一步，在上面加一个酸性底漆，甚至加一层粘接树脂，这些酶其实是脆弱的有机分子。

But if you later on in the next step, add an acidic primer on top of it and even an adhesive resin, these enzymes are really fragile organic molecules.

如果你在上面加别的东西，它们就不再活跃了。

If you put something else on top of it, they are the one they are simply not active anymore.

我们已经测试过了。

And we have tested that.

这是其中一点。

And that is one thing.

我不能一概而论，因为我们只测试了，比如说，两种金标准粘接剂，它们是性能最好的，结果很清楚，我们没再发现任何活跃的MMP。

And I cannot generalize this because we only tested that for, let's say, the two gold standard adhesives for that, which are the best performing that and that was very clear that we didn't find any active MMP anymore.

但不仅如此，我们在那项研究中还进一步做了更多。

But more than that, we went further in that study.

我们研究了MMP对热的敏感性。

We looked at the sensitivity of MMP to heat.

你可能会想，热，是的，我们用固化灯会产生很多热。

And you may think heat, yeah, heat, we are producing a lot of heat with our curing lights.

我们用热电偶放在粘接树脂里面，真的能测到粘接剂内部有多少热量。

We made using a thermocouple placed within the adhesive resin, could measure and really within the adhesive how much heat is present there.

然后你可以清楚地看到，用普通的固化灯很容易就达到超过55度的温度。

And then you can clearly see that you easily with common, curing lines reached, more than temperatures more than 55 degrees.

我说55度，是因为与此同时，我们把MMP暴露在这种热下，55度似乎是一个阈值，超过这个温度MMP就会降解。

And I'm saying 55 degrees, because in parallel of that, we have exposed MMPs to this kind of heat, and 55 degrees seems to be a kind of threshold where these MMP's, they are degraded.

它们会失去活性等等。

They lose their activity and so on.

所以基本上，就像固化，我们在放置修复体时会多次这样做。

So basically, like curing, and we do this several times when we place a restoration.

我们还测试了离表面不同距离的差异等等。

And we have tested differences in how far we are away from the surface and so on.

我们还测试了不同的固化灯等等。

We have done that we have tested different kinds of curing lights and so on.

然后我们清楚地看到，确实产生了不少热量。

And then clearly could see that indeed, quite some heat is produced.

如果你知道这些MMP对热敏感，那你就会想，光固化在这种情况下其实是有帮助的，即使不用氯己定，光固化也能杀死细菌。

And if you then know that these MMPs are sensitive to heat, yeah, then you think okay, light curing is actually helps us in this case, and will also kill the bacteria even if you don't use chlorhexidine, just like curing will be helpful in that.

我们还做了其他测试。

We have done other tests.

我们真的很想自己启动酶降解反应，所以不仅把样本放在水里老化，还在溶液里加了高浓度的MMP，想看看会发生什么。

We have really wanted to trigger an enzymatic degradation reaction to start it up ourselves by exposing our specimens not only to water as an aging procedure, but even adding high concentrated MMPs in that solution in order to say, let's see what happens.

但即使这样，我们也看不出样本有没有受到MMP挑战有什么区别，没有差异，甚至没有降解。

And even then, we could not see any difference if the specimens were exposed to an MMP's challenge or not, there was no difference and there was even no degradation.

我们只能在一个月内进行这种处理。

We only could expose do this during one month.

你可能会说，这时间不够长。

And you could say, this is not long enough.

我同意这一点。

I agree with that.

但你要明白，这些测试用的样本非常小，而且界面直接暴露在MMP和溶液中，这在口腔里是不会发生的，因为口腔里从来不会这样直接接触。

But you must understand that these tests involve very tiny specimens with a very an interface directly exposed to the MMP and the solution, which is not happening in the mouth, because there it is never in this direct way.

而且我们每天都更换新的MMP溶液。

And we have exchanged every day a new solution, a new solution of MMP.

所以我觉得这是一个非常严苛的挑战，但我们甚至看不到任何影响。

So I think this was a very severe challenge, and we could not even see, any effect of that.

综合所有这些数据，假设——我仍然想继续讨论——磷酸可能会在某些地方暴露一些MMP。

And bringing all these data together, let's suppose and I still want to go ahead with that phosphoric acid may expose here and there some MMP's.

但我认为，如果你在上面涂上粘接剂和底漆，这些化学物质基本上会破坏这些活跃的MMP。

But I think if you apply the adhesive and the primer on top of it, which are chemicals, that you will, destroy basically these active MMP's.

但假设你没有这样做，仍然有一些MMP是活跃的。

But let's say that you don't and that there are still, ones, active.

对，这只是一次性的激活，因为这是你做粘接操作时发生的。

Yeah, this is just a one time activation because it's your adhesive procedure that you do.

我们还测量了MMP的寿命，MMP的寿命就是它们能活跃多久？

And we also measure the lifetime of MMPs and the lifetime of MMPs is how long are they active?

它们在第一天内就会失去70%到80%的活性，一周后就不再活跃了。

They lose already 70 to 80% of their activity within the first day, and after one week, they are not active anymore.

所以如果它们只被暴露一次，那还有什么问题呢？

So if they are exposed only one time, what is then the problem?

所以这就是为什么我们认为，如果你觉得用氯己定更好，那也没问题。

So that is why we think I have nothing against if you want to use, you feel better using chlorhexidine, quite okay.

但我也觉得这真的不是必需的，也不是特别有用。

But I also do not think that it is really, needed and that very helpful.

再说，我们做了长期的数据研究。

And again, we have done long term data.

我们有超过十年的长期临床数据。

We have long term clinical data beyond ten years.

我们在那些研究中从未使用过氯己定。

We never used the chlorhexidine, in there.

对，所以目前确实没有足够的证据支持这一点。

And yeah, so the evidence is just not there.

所以我会非常谨慎。

So I would be very careful.

但话说回来，如果你要用，用氯己定也不会有什么坏处。

But again, you can do it, it will not harm to use chlorhexidine.

但我个人并不认为……

But I don't think personally that...

而且我也不是……

And and I'm not...

这不是我个人的想法。

This is not thinking.

这是……

This is...

有证据表明，这样做其实也不是必需的。

There is evidence, there that that it is also not needed, to do that.

我还有一个特别想问你的问题。

Here's another question I've been dying to ask you.

那么，用空气颗粒喷砂来处理牙釉质和牙本质，到底值不值得呢？

So air particle abrasion on enamel and dentin worthwhile or not?

我个人觉得值得。

I personally think yes.

对，为什么？

Yes, why?

因为空气喷砂真的能让牙齿表面更适合粘接。

Because air abrasion, it really prepares the tooth for bonding.

用牙钻当然会形成玷污层之类的。

By bur, of course, bur preparation, make your smear layer and so on.

但空气喷砂的话，你对比一下前后，差别很大，它真的能把表面清理得很干净。

But air abrasion, if you see it before and after you see there is a big difference, and it really cleans the surface.

你让表面变得微观粗糙，微观粗糙就意味着有固位力，有助于粘接。

You micro roughen the surface, micro roughen means retention, will contribute to the bone.

而且你还能得到一个更好的玷污层，更松散、不那么致密，这样粘接剂就更容易渗透进去。

But also you may make a better smear layer and less stick, less compact smear layer, more easy to easily to interact for the adhesive to interact with it.

不过话说回来，如果你手边有喷砂机的话，其实每个洞都值得用一下，而且花不了多少时间。

And but at the same time, if you're basically looking every actually every cavity you should if you have a sandblaster close nearby, then I would always recommend you use it and it doesn't take long.

就五到十秒，不用更多，足够了。

It's only five-ten seconds, not more than that, it's enough.

就是要把你的牙面彻底清洁干净，为粘接做好准备。

And just to make really clean your substrate to really, prepare the substrate for bonding.

所以我绝对是大力支持这个方法的。

So definitely, am very much in favor of that.

我还想提一下我参与过的一篇文献综述，里面评估了各种不同的研究。

I'm also referring to literature review where I was involved and where they checked different kinds of studies.

有不少研究，具体数量我记不清了，但那些研究明确比较了用和不用喷砂的粘接强度。

And there are quite some studies, I don't recall the number of studies that had clearly set and this was just the bone strength test comparing with or without air abrasion.

我记得好像是，对，我记得大约百分之九十的研究都显示有效，百分之九十。

And I think it was Yeah, that I recall it was in ninety percent of the studies done ninety percent.

结果显示骨强度是一样的。

It showed that the bone strength was the same.

所以既没有降低，也没有增加。

So there was no reduction, but also no increase.

或者说有增加。

Or there was an increase.

也就是说，要么有积极效果，要么没有，但肯定不会造成伤害。

So meaning there was either a positive effect or there was not a positive effect, but certainly it doesn't harm.

只有百分之十的研究显示，我记得有三项研究，表明喷砂处理会导致监测结果下降。

There were only ten percent and that was equivalent, I remember that also to three studies, where they showed that there was a reduction in monitoring due to air abrasion.

我没有深入研究那些研究的具体原因。

I didn't study the whole details of that what could have been the reason for that.

但综合所有这些数据，我认为我们可以确定，首先，喷砂不会损害粘接。

But bringing all these data together, I think we can be sure that first of all, abrasion will not impair, bonding.

而且在我看来，它甚至更好，因为你真正让表面准备好粘接，可以粘接到一个干净、有更好更薄玷污层的表面。

And in my belief, I think it is even better because you really make the surface ready for bonding and that you can bond to a clean surface with a better smear layer, thinner smear layer and so on.

让我问你一个问题。

Let me ask you something.

当你从牙科学校毕业时，你有没有想象过自己会接手高难度的挑战性病例，并且在上班路上就为即将做的牙科工作感到兴奋？

When you graduate dental school, did you imagine yourself taking on advanced challenging cases and doing the kind of dentistry that excites you on your commute into work?

比如高级根管治疗、种植、美学修复等等。

Advanced endo implants, aesthetic cases, etc.

还是你发现自己被困在重复、无聊、令人困惑，甚至可能没有成就感的牙科工作中？

Or do you find yourself stuck in dentistry that feels repetitive, boring, confusing, and maybe even unfulfilling?

你是否因为不可预测的失败、牙冠脱落、患者不满意，甚至不知道原因而感到沮丧？

Are you frustrated by unpredictable failures, crowns debonding, patients unhappy, and not even sure why it's happening?

今天，你是你想成为的那种牙医吗？

Today are you the dentist that you want to be?

现在，想象一下成为你一直想成为的那种卓越的全科牙医。

Now imagine becoming the exceptional comprehensive dentist you always wanted to be.

那种以清晰、自信和一致性行医的牙医，他们思考的不只是常规的牙科操作。

The kind of dentist who practices with clarity, confidence and consistency who thinks beyond bread and butter procedures.

你受到尊重，被推荐，也感到满足，因为工作既有意义又有挑战。

Are respected, referred to, and fulfilled because the work is both meaningful and challenging.

这就是我们在Elevated GP里打造的东西。

That's what we build inside of Elevated GP.

我们培养的是卓越、全面的牙医，让他们成为自己一直想成为的临床医生。

We build exceptional, comprehensive dentists who step into the clinical version they've always wanted to become.

在我们的项目里，你每个月都能看到直播的继续教育课程，涵盖社区最想了解的话题，从种植到咬合，从治疗计划到前牙复合树脂修复。

Inside our program you will find live CE lectures every month that cover the topics our community wants most, from implants to occlusion to treatment planning to anterior composites.

我们还有每月直播的问答环节，一起处理你最棘手的病例，教你不仅知道该做什么，更懂得怎么思考。

We also have monthly live Q and A sessions where we tackle your toughest cases together, teaching you not just what to do, but how to think.

我们还有一个专属社区，你可以把真实的临床难题带进来，得到有循证依据的深思熟虑的答案，而不是像在随便一个Facebook群里那样信息杂乱。

We also have an exclusive community where you can bring your real clinical challenges and get thoughtful evidence based answers without the noise of a random Facebook group.

我相信，铁磨铁，才能磨出刃来。

I believe that iron sharpens iron.

你的水平，就是你身边最常接触的五个人的平均水平。

You are the average of the people you surround yourself with.

所以，来加入一个牙医们互相推动、追求最高水平的社区吧。

So come join a community where dentists push each other to the highest level.

如果你对此有共鸣，我亲自邀请你去 elevatedgp.com，成为我们中的一员。

If this resonates, I want to invite you personally to head over to elevatedgp.com and become one of us.

我们来谈谈五类洞修复。

Let's talk about class five restorations.

这类修复的粘接可能相当困难。

These can be quite difficult to bond to.

很多时候，它们包含牙骨质，有时还有硬化牙本质。

Oftentimes, they incorporate cementum, sometimes sclerotic dentin.

我们能做些什么来提高粘接强度呢？

What can we do to improve bond strength?

而且，让我先从这个说起。

And let me let me also actually start with this.

你知道，有一种提高五类洞粘接强度的教学方法，就是创造一定的机械固位，比如在五类洞里做一个沟槽或凹坑。

You know, one idea that's taught to increase the bond strength for a class five is to create a degree of mechanical retention, like put a slot or a pot in the class five.

我坚信，这样做对提高化学粘接力并没有多大帮助。

It's my conviction that that's not going to do very much to improve a chemical bond.

没错。

Exactly.

我觉得我们不需要它。

I don't think that we need it.

我们不再需要任何其他类型的固位了。

We need any other kind of retention anymore.

当然，这是事实。

Of course, it is true.

如果你遇到高度硬化的牙本质，那种长期暴露的玻璃样牙本质，确实是更难粘接的组织。

If you have highly sclerotic dentin, that glassy line of dentin that has been exposed for a long time is a more difficult, tissue to bond to.

我也不是说我们不会失去修复体，当然这也不是完美的。

And I'm not going to say that we also lose of course restorations, it is certainly not perfect.

但我们都知道，口腔是一个非常恶劣的环境。

But we all know that the mouth is a very aggressive environment.

所以，要让修复体在嘴里保持很长时间，本身就已经很难了。

So to hold the restoration in place for a long time is already difficult.

但在这些情况下，难度就更大了。

But in these cases, it is even more difficult.

不过我的建议是，你需要把表面弄粗糙。

But my recommendation is you need to roughen it up.

对于硬化牙本质，我觉得光是弄粗糙还不够，你必须得把它打磨粗糙。

Also the sclerotic dentin, roughing up is in my opinion already a mistake, you have to roughen it up.

然后我会采用一个合适的操作流程。

Then I would go for a good procedure.

如果真的是硬化且不敏感的牙本质，我会选择酸蚀冲洗或者全酸蚀模式，就像我之前解释或提到的那样，以获得更好的结合效果。

I would, if it is really sclerotic and insensitive, would go for an etch and rinse or total etch mode, like I explained or mentioned before, to have a better interaction.

然后呢，对，我会采用两步法，以确保那里有良好的粘接。

And then again, yeah, I go for a two step procedure, in order to have a good bond there.

这是最好的方法。

That's the best is this.

对，我觉得这是处理这类病变最好的粘接方式。

Yeah, I think that's the best way how we can bond to this kind of lesions.

但要是非得做个凹槽或者倒凹什么的，我觉得那根本没用，绝对没用。

But to have to make somewhere a slot or something an undercut, I don't think that will not help, definitely not.

修复体通常粘到牙釉质上就能固定住，因为和牙釉质的粘接很好。

The restoration usually when you bond to the enamel, it will stay in place because you have a good bond to the enamel.

但另一方面，当然，牙本质那边还是可能渗漏。

But on the other hand, of course, it may leak still at the dentin side.

不过我觉得这是最好的做法。

But I think that is the best way to do this.

表面一定要粗化，然后对于高度硬化的牙本质，我会选择酸蚀冲洗法，再用多步粘接剂。

Roughening end up definitely, and I would then go with really highly sclerotic dentin for an etch and rinse approach And again, using a multi step adhesive.

总是回到这一点。

Always come back to that.

这里还有一个问题。

Here's another question as well.

你知道，困扰粘接牙科的一个难题就是C因素，就是C因素的收缩。

You know, one of the challenges that has plagued adhesive dentistry is, you know, C factor, just C factor shrinkage.

而且有很多不同的技术被提出来，关于你应该怎么放置复合树脂，特别是在大型的一类洞中。

And there have been multiple different techniques that have been proposed for how you should place composite, particularly in a large class one.

你知道，有讨论过水平分层、垂直分层、斜向分层。

You know, there's been discussion of horizontal layering, vertical layering, oblique layering.

那你发现了什么呢？

What have you found, though?

嗯，C因素当然是一个重要的因素。

Well, C factor is, of course, an important factor.

这是你作为牙医、作为临床医生必须时刻牢记的。

And that is something that you as a dentist, as a practitioner always have to keep in mind.

但如果你有一个低C因素的洞，那就没有问题，因为有很多自由表面。

But if you have a low C factor cavity, there is no issue because there is a lot of free surface.

所以如果复合树脂可以收缩，那就没问题，因为它会收缩，不会在界面上产生应力。

So if the composite can shrink, then there is no problem because it will shrink and it will not put any stress on the interface.

如果你做的是这类一类洞修复，非常窄的一类洞或者窄的箱状洞，那你就得把这个因素考虑进去。

If you go for these, class one restorations, very narrow class one restorations or narrow boxes, yeah, then you have to take that into account.

然后当然，就像我们说的，我总会在箱状洞里用流动树脂。

And then of course, like we said, I would always use a flowable composite in a box.

流动树脂能提供更好的适应性，它会收缩。

Flowable composites gives you a better adaptation, it will shrink.

但流动树脂有一种固有的流动性，怎么说呢，它产生的聚合收缩应力比较小，我不是说没有，但比普通修复树脂要小。

But flowable composites have a kind of inherent, how you say flow, where it doesn't produce polymerization shrinkage stress, and that is or less, I'm not saying not, but less than with a normal restorative composite.

所以这也是在那些比较难操作、你想确保有良好层次的地方使用流动树脂的另一个原因。

So that's another reason for using a flowable composite in these more difficult areas where you want to be sure to have a good layer.

然后我确实会采用分层技术，因为分层技术意味着你用更薄的层，实际上是在降低C因子。

And then I would go for indeed a layering technique, because the layering technique means that you are actually with thinner layers, you are reducing the C factor.

这很简单，因为你尽可能保持自由表面大，而不同层之间粘接的表面更小，你减少了它们，所以C因子的影响就会更小。

They're simple because you keep the free surface as big as possible, and the surfaces that are bonded with different layers, they are smaller, you reduce them, so you will have less effect from that C factor.

应该是水平分层吗？

Should it be horizontal?

应该是斜着放吗？

Should it be oblique?

我个人觉得这个差别不大。

I personally do not think that that matters a lot.

这取决于你想怎么填充。

It depends a little bit on how you want to fill it.

但现在，我们有时候，更多是为了达到某种咬合形态，会先斜着放一层，这样能更好地贴合边缘，然后再做出一些沟槽之类的。

But nowadays, we sometimes but more for reasons of reaching a certain kind of occlusal anatomy that we would apply a first layer in an oblique way and so on, in order to create a good marginal reach, and then later on to create some grooves and so on.

但这更多是为了达到你想要的形态，而不是为了应对C因素或收缩效应。

But that is more because of the anatomy that you want to reach, and not that much as for dealing with the C factor or the shrinkage effect.

但同时，这样操作也是有效的，因为这样接触面积更小，粘接面积变小了，而自由表面保持不变。

But at the same time, will work like that as well, because then you have smaller areas, the bonded area becomes smaller and the free surface stays the same.

所以实际上你是在降低C因素。

So you are actually reducing the C factor.

所以我觉得这一点还是需要记住的。

So I think it is something that you still need to have in mind.

但尤其是在那些你知道是C因子挑战的病例，C因子高的洞型，那么分层充填应该没问题。

And but especially in those cases where you know, this is an IC factor challenge, IC factor cavity, and then, yeah, the layering should be fine.

考虑到流动树脂的效果以及技术的进步，你觉得它们能不能完全替代可塑形树脂？

With how effective flowable composites are and perhaps improvements in the technology, do you think that they can ever just be used as an entire alternative to pastepackable composite?

嗯，这也是个很好的问题。

Well, is also a very good question.

我觉得现在，关于研究数据方面我有点遗憾，就是真的需要去研究不同类型的流动树脂，并比较它们的基本性能。

And I think that nowadays, and that is something what I miss in regarding research data, that there is really a need to look into different kinds of flowable composites and compare them on their basic properties.

我有些同事正在做这方面的工作，我们就在研究不同类型的流动树脂。

And I as have some co workers who are working in this slide where we are looking to different kinds of flowable composites.

过去，人们根据不同的性能对树脂进行了各种分类。

In the past, there were all kinds of classifications made regarding composite on their different properties.

但实际上，在我看来，流动树脂在这方面还缺少一些分类。

But actually, this is still, in my opinion, missing a bit for flowable composites.

如果拿现在的流动树脂和以前比，变化真的很大。

If I compare the current generation of flowable composites, it has changed a lot.

它们改进得很多了。

They have improved a lot.

这一点我很确定。

I'm sure about it.

但是，我仍然缺少真正好的评估，能让我们看到不同的性能，并且让我们了解更多。

But still, I miss really good evaluations where you can see to the different kinds of properties and that we learn a little bit more.

比如，我们需要知道填料负载的百分比，还有其他一些问题。

We need, for instance, filler loading of so much percentage and other problems as well.

这正是我目前有点缺失的，因为种类太多了。

That is what I currently miss a little bit, because there are so many different ones.

甚至对我来说，也很难说我想用这个，而不是那个。

And even for me, it is difficult to say I want to use this one, and not this one.

我确实没有很好的依据来做这个选择。

And I have not really a good ground to say to make this selection.

但是，是的，种类太多了，而且很多公司甚至有三四种不同的，粘度不同等等。

But yeah, there are so many different and many of them, even companies, they have three to four different kinds, different for viscosity and so on.

但基本上，这意味着，是的，这些都是操作上的问题。

But basically what it means, yeah, this is all handling.

操作当然也非常重要。

Handling is, of course, also very important.

但问题是，在性能和强度方面，这又意味着什么呢？

But yeah, what does it mean in terms of properties and strength and so on?

那是另一个问题。

That's another question.

然后，要把它们真的作为唯一的材料来使用，我认为在某些情况下是可能的。

And then, to use them really as the only material, I think in certain circumstances that is possible.

有必要吗？

Is there a need to?

也许没有必要，因为正如我之前提到的，我们实际上喜欢在不同部位使用复合材料，但为了以可控的方式自动达到一定的咬合形态，确保复合材料在正确的位置，并且减少修整，我们不需要减少它。

Maybe not, because as I mentioned earlier, we like to apply composite actually in different portions, but in order to get to an automatic well in a controlled way to a certain occlusal anatomy, in this way that you know, the composite is on its right place, and finishing will be limited, we don't have to reduce it.

当然，这是流动复合材料做不到的。

Of course, this is something you cannot do with flowable composites.

流动树脂流动性太强了，你没法把它放在特定位置并保持住。

Flowable composites, they flow so much, so you cannot put them in a specific position and keep them in there.

不过当然，在某些情况下，你可以用流动树脂来填充整个洞。

But of course, for certain cases, you can use a flowable composite to fill the whole cavity.

但如果不需要恢复咬合形态，我觉得用流动树脂是做不到的。

But if you don't have to restore the occlusal anatomy, then you cannot do that with a flowable composite, I think.

我们就把这个话题讨论到这里吧。

Let's wrap the discussion with this.

你知道，术后敏感的问题。

You know, postoperative sensitivity.

我不用像格鲁玛那样的脱敏剂来处理术后敏感。

I I don't use sort of agents such as gluma to manage postoperative sensitivity.

我真的觉得，如果所有操作都正确到位，而且我清楚牙髓的位置，我就不太会……

I really find that if everything is properly placed the way it should and I'm conscious of the pulp's position in space, I don't really...

我觉得这几年里，我还没有遇到过病人回来说有术后敏感的。

I don't think I've had a patient come back in a few years saying they have postoperative sensitivity.

你觉得这些用来帮助处理术后敏感的药剂怎么样？

What do you think of these sort of agents that are used to help manage postoperative sensitivity?

没错。

Exactly.

我觉得我同意你的说法。

I think that I confirm what you're saying.

我也觉得真的没必要用那些。

Also do not feel really a need to have that.

但话说回来，这取决于你用的粘接剂类型，尤其是你涂布粘接剂的方式。如果你操作正确，我觉得——回到我用的多步粘接剂——我不觉得还需要其他什么药剂来对付术后敏感。

But again, depending on the kind of adhesive, and especially the way you have applied the adhesive, if you apply it in the correct way, then I don't think, and go back to my multi step adhesive, I don't see a need for any other agent that may work against postoperative sensitivity.

说到gluma，我甚至会更小心，因为它的有效成分是戊二醛。

Talking about gluma, I would even be careful with that because the active ingredient is glutaraldehyde in there.

说实话，在实验室里，我们用戊二醛来固定标本，而且是在通风橱里用，还要遵守很多安全操作要求。

Honestly speaking in the lab, we use glutaraldehyde for fixation of specimens, and then we are using this under the hood with a lot of recommendation on the duties on the duties.

所以我不理解为什么我们会把它用在病人身上。

So then I do not understand that we would use this in a patient.

对患者来说，当然可能只是一次性的接触。

For the patient, of course, it can be a one time exposure.

但作为牙医，如果你经常使用这类产品，那你接触戊二醛的机会就更多了。

But you as a dentist, if you're a regular user of this kind of product, yeah, you are exposed more to this glutaraldehyde.

所以我基本上不想用它，就是因为戊二醛。虽然它可能效果不错，因为它是一种很好的固定剂，但至少在我看来，它存在毒性和生物相容性方面的担忧。

So I don't want to use it basically because of that glutaraldehyde, while it might be, it works fine because it's a very good fixation agent, but there are concerns regarding the toxicity and the bio compatibility, at least in my mind.

第二点是我觉得没必要用它，因为如果你有一种好的粘接剂，并且使用方法正确，你根本不需要它。

And the second thing is I don't see the need for it, because if you have a good adhesive that is applied in the correct way, you don't need it.

在牙科学校里，当然偶尔也会有患者出现敏感的情况，但要说这是个严重问题，那完全不是。

Have here also in the dental school, there is, of course, every now and then there will be a patient that has some sensitivity, but considering this as a major problem, No, not at all.

完全不是。

Not at all.

用现在这一代粘接剂，根本不会。

Not with the current generation of adhesives.

那你认为术后敏感的主要原因是什么？

You know, what would you identify are the major causes of postoperative sensitivity?

因为我看到的是，可能用磷酸酸蚀剂在接近牙髓的牙本质上酸蚀时间过长，边缘封闭不好，或者粘接不当，实际上没有真正粘接到牙齿上。

Because what I see is that perhaps excessive etching with phosphoric etch for an extended period of time over dentin that's beginning to approximate the pulp, open margins, maybe an improper bond, so it's not actually bonded to the tooth.

这些确实是我看到的一些大问题。

Those are really some of the big things I'm seeing.

没有意识到牙髓的状况。

Not being conscious of the pulp.

所以我真的很喜欢用生物陶瓷。

So I really like to use bio ceramics.

如果接近牙髓，我会做直接或间接的盖髓术。

If I'm getting close to the pulp, I'll do a direct or indirect pulp cap.

你觉得术后敏感的根本原因是什么？

What do you think are the underlying causes of postoperative sensitivity?

我觉得你提到的那些是主要原因，如果接近牙髓，如果患者年轻……

I think what you mentioned that are the main causes if you're close to the pulp, if you have a young...

嗯，这又取决于我之前说的那些情况。

Well, again, it depends on what I said earlier.

首先，这取决于牙本质的渗透性。

It depends on the permeability of the dentin in the first place.

如果是年轻牙本质，你需要更加注意，因为它的渗透性很强。

If you have young dentin, you should be more concerned because that's very permeable.

如果牙本质已经硬化，甚至不敏感，那我就不太担心了。

If you have very sclerotic or then it's even not sensitive, I would not be that concerned.

当然，术后敏感就更不用担心了。

Certainly not for postoperative sensitivity.

当然，你永远不知道牙齿是否已经存在某种感染，之后在修复体出现后，甚至变得更严重。

Of course, you never know if a tooth is already undergoing some kind of infection, and that then later on after the restoration pops up or even becomes worse.

但确实，我认为正确的操作是最重要的。

But yeah, I think that a proper application is the most important.

而且，这和疏水层是一样的道理，你需要形成一个良好的封闭，确保牙髓不再受到刺激。

And if you that is the same thing of that hydrophobic layer that is you need to create a good seal, seal and that the pulp is not further irritated.

当然，在操作过程中牙髓总会受到一些刺激，但那是有限的，通常牙髓能够恢复，甚至恢复能力很强，不会因此受损。

Of course, it will always be irritated during the procedure itself, but that is limited and normally a pulp can recover from that or even recovery is too strong, will not suffer from that.

但是，确实，如果有污染的情况，或者操作过程中出了什么问题导致密封不好，那就会出现术后敏感。

But yeah, indeed, if there are contamination effects, if something happened during the procedure where it is not well sealed, then you will have postoperative sensitivity.

作为最后一个问题，你觉得粘接牙科在未来几年会朝着哪个方向发展？

As a final closing question, what direction do

你觉得粘接牙科在未来几年会朝着哪个方向发展？

you think adhesive dentistry is going to be taking in the next few years?

是的，这个问题很有意思。

Yeah, well, that's a very interesting question.

如果今天让我们给粘接技术打个分，从0到100分，100分是完美的粘接，那问题是我们现在处在什么位置？

If I would put you today on a scale from zero to 100100% being the perfect adhesive, let's say, the question is then where are we?

我们的粘接技术现在处在什么水平？

Where are we with our adhesive technology?

我个人感觉我们大概在90分左右，我总是拿钛种植体来类比。

I have a personal feeling that we are somewhere in the 90s, and I always refer that to, it's the same with titanium implants.

我们也是差不多这个水平，而且很难再做得更好了。

We are also there, and it is difficult to do better.

所以，当然，目前很多注意力都放在易用性上，试图在不损失性能的情况下让操作更简单。

So, and that is also, of course, at this moment that a lot of attention goes to ease of use, and trying to make easier assistance with less without losing performance.

不幸的是，我认为减少步骤仍然意味着我们要为此付出代价。

Unfortunately, I think still reducing the number of steps means that we pay a price for it.

就像我提到的，这是一个折中的产品，等等。

Like I mentioned, it's a compromise product and so on.

所以我们肯定还没有达到那个水平。

So we are certainly not there yet.

至于是否有可能达到，我持怀疑态度。

If that will be ever possible, I have my doubts.

那么，在粘接方面，我们还能做些什么呢？

So what can we do more than regarding bonding perspective?

我觉得我们已经做得很好了，而且我已经在这个领域工作了三十多年。

I think we are doing already very and I'm working in the field already for more than thirty years.

我还记得那时候修复体在六个月内就会脱落。

So I still remember the time where restorations dropped out within the first six months.

那个时代已经完全过去了。

That time is totally over.

我们现在能做很多事情，甚至间接方法，完全平整的表面，不需要任何宏观处理。

We can do so many things even indirect ways, fully flat surface without any macro attention.

粘接效果很好，粘接效果很好，但当然总会有一些情况效果不那么理想。

Adhesion is good, adhesion is good, but there will of course always be cases where it doesn't work that well.

但我认为，就我们的牙科粘接技术而言，如果使用多步骤系统，我们已经达到了可能性的90%以上。

But I think that we are with our dental adhesive technology, if you go to the multi step systems, we are above 90% of what is possible.

但同时，这也给我们带来了机会。

But at the same time, that means it gives us opportunities.

这给了我们机会，我们还能做更多吗？

It gives us opportunities, can we do something more?

除了粘接，我们还能做更多吗？

Can we do something more than only bonding?

我们能让它们具有生物活性吗？

Can we make them bioactive?

当然，现在大家都是这么想的。

And of course, everybody thinks now in this way.

而且我个人觉得，做抗菌其实没那么难，比做促进再矿化要容易一些，后者更难实现。

And personally, I do not think it is that difficult to make something antibacterial or that's easier than making something to have an additional remineralization effect, for instance, that will be more difficult to do.

但最大的挑战始终是把这些功能结合起来，同时还要保持粘接的性能。

But especially the biggest challenge is always to combine that and to keep the performance of the bonding.

如果做出来的粘接剂有生物活性，但粘接效果却不好了，那就没有意义了。

It doesn't make sense to make an adhesive that is bioactive, but doesn't bond very well anymore.

所以这才是最大的挑战。

So that is the big challenge.

我们必须保持粘接这个核心功能。

We should keep that primary bonding function.

如果在这个基础上还能增加一些其他特性，那就更好了。

And if we can have then an add on some property, yeah, that is good.

但这对公司来说也很难，因为这意味着你要做出一些声明，甚至是抗菌声明，这会把产品归入另一个类别，需要做更多的研究，成本也会更高。

But that is also difficult for companies, because that means that you are making claims, even antibacterial claims, which will bring the product in another category, another class, where much more studies needs to be done, it will make it more expensive.

所以我能理解，没多少公司真的愿意往那个方向走，因为，是的，也许不做这些宣称，但有这些附加效果会很好。

So I can understand that not many companies are really willing to go into that direction, because yeah, maybe not by not making the claims, but having these additional effects would be nice.

但这是必经之路。

But it's the way to go.

但当然，应该始终保留主要的粘接功能。

But certainly, should keep the primary bonding function always.

这始终是一个目标。

That is always a goal.

如果你是一个追求卓越、重视连接、并且知道和对的人在一起可以改变一切的人，这就是给你的邀请。

If you are the kind of person who's passionate about excellence and who thrives on connection and who knows that being in the room with the right people can change everything, this is your invitation.

Elevated GP 正在举办它的第一次线下现场会议。

Elevated GP is hosting its very first live in person meeting.

活动将于4月10日和11日在科罗拉多州丹佛市举行。

It's happening April tenth and eleventh in Denver, Colorado.

两天实操，高度互动。

Two days hands on, high touch.

这不仅仅是另一个会议，这是一次专为你这样的牙医设计的大师班体验。

This isn't just another conference, this is a master class experience designed for dentists like you.

这些人致力于提升技能，精进技艺。

People who are committed to sharpening their skills and elevating their craft.

我将教授一整天关于陶瓷嵌体、高嵌体和贴面的实操课程。

I'm going to be teaching a whole day long course and hands on course on ceramic onlays, overlays, and veneer lays.

然后我们请来了最顶尖的专家。

And then we are bringing in the best of the best.

Bob Margis将教授一个实操课程，这会彻底改变你处理这些病例的方式。

Bob Margis is going to be teaching a hands on class four course in a way that is going to completely transform your approach to these cases.

我的导师，博士。

My mentor, Doctor.

Mark Lotta，前克里姆院长，将教授一堂关于粘接的大师课，绝对会让你大开眼界。

Mark Lotta, the former dean of cream, is going to be teaching a master class in adhesion that is going to blow your mind.

另外，我们还会深入探讨微创牙科，因为创新让我们与众不同。

And as a bonus, we're going to be diving into minimally invasive dentistry because innovation is what sets us apart.

关键是，这不只是关于技能，也关乎人脉。

Here's the thing, this isn't just about the skills, it's about the people too.

在后疫情时代，我们都意识到自己多么渴望真实的联系。

In a post COVID world, we're all realizing how much we crave real connection.

这是你建立人脉的机会，和那些和你一样充满热情、一样有动力、一样致力于成长的人同处一室。

This is your chance to build your network, to be in the room with peers who are just as passionate, just as driven, and just as committed to growth as you are.

强强联手，这就是一切发生的地方。

Iron sharpens iron, and this is where it all happens.

对于那些知道自己已经准备好、不需要别人催促的人，现在有早鸟优惠，一直到圣诞节。

Now for those of you who know you're ready who don't need commencing, there is early bird pricing available until Christmas.

这是我们庆祝那些行动派的方式，那些知道这就是为他们准备的人。

This is our way of celebrating the action takers, the ones who know this is for them.

座位有限，很快就会满员。

Seats are limited and this is going to fill up fast.

所以，如果你准备好参与真正有变革意义的事情，就去 elevatedgp.com 报名吧。

So if you're ready to be a part of something truly transformative head over to the elevatedgp.com and grab your spot.