复合树脂与陶瓷在磨损病例中的对比，与迪迪埃·迪特希博士

嘿，我想跟你分享一个我为你准备的东西。

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

我做了一份免费的PDF指南，手把手教你掌握树脂直接粘接技术。

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

我特别喜欢这个方法，因为它能帮你稳定地做出自然又美观的前牙树脂修复。

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

你直接通过透明模板把树脂注入牙齿里，这样操作更一致，效率也更高。

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，非常简单，去 elevatedgp.com/impdf 下载就行，我还在节目笔记里给你放好了链接。

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.

欢迎收听《牙科前沿》。

Hey, welcome to Dental Digest.

这是一档致力于帮你掌握循证牙科最新进展的播客。

This is a podcast with the mission of enabling you to stay on the cutting edge of evidence based dentistry.

我是你的主持人，医生。

I'm your host, Doctor.

梅丽莎·塞伯特

Melissa Seibert.

医生

Doctor.

迪迪埃·迪特斯基回来了，这是系列的第二部分。

Didier Dietschi is back and this is part two of a two part series.

提醒一下，如果你错过了第一部分的节目，医生。

As a reminder, if you missed the first part episode, Doctor.

迪迪埃·迪特斯基是粘接修复领域最受尊敬的研究者和临床专家之一。

Didier Dietschi is one of the most respected researchers and clinicians in adhesive anesthetic dentistry.

他拥有牙科学位和博士学位，并且在日内瓦大学获得临床教学资格，目前在那里担任高级讲师。

He holds both a dental degree and a PhD along with a private dosing degree from the University of Geneva where he serves as a senior lecturer.

他还是凯斯西储大学的兼职教授，已发表超过115篇学术论文和教材章节。

He is also an adjunct professor at Case Western Reserve University and has authored over 115 scientific publications and textbook chapters.

他在粘接修复领域享有国际声誉，是《无金属粘接修复》一书的合著者。

He is internationally recognized for his contribution to adhesive dentistry and is the co author of adhesive metal free restorations.

不过，他还是我目前最喜欢的教材之一《微创基础方案的早期干预治疗》的作者。这本书提出了一种非常现代、甚至可以说是颠覆传统的治疗理念，帮助我们在处理牙齿磨损患者时，不必非得选择全口陶瓷修复。

But he is also the author of one of my current favorite textbooks Interceptive Treatment Approach with Minimally Basic Protocols, which presents a very contemporary and frankly paradigm shifting approach to managing wear patients without defaulting to full mouth ceramic reconstruction.

在这一集里，我们将把话题从理论理念转向临床实操和决策制定。

In this episode we are going to move from philosophy into clinical execution and decision making.

迪迪埃医生

Dr.

详细拆解了如何根据严重程度、风险因素以及患者的配合度，对磨损病例进行分级，并如何制定真正个性化的治疗方案。

Didier breaks down how to stratify rare cases based on severity, risk factors, and patient compliance, and how to build a truly individualized treatment plan.

接下来我们会深入探讨复合树脂和陶瓷的生物力学特性，为什么复合树脂往往在生物学上更有优势，以及如何合理安排治疗顺序，在保护牙体组织的同时，还能实现良好的功能和美学效果。

We are going get into the biomechanics of composite versus ceramic, why composite can often be more biologically favorable material and how to sequence treatment in a way that preserves tooth structure while still lowering functional and aesthetical outcomes.

我们会深入探讨复合树脂和陶瓷的生物力学特性，为什么复合树脂往往是最具生物学优势的材料，以及如何合理安排治疗顺序，在保护牙体组织的同时，还能实现良好的功能和美学效果。

We get into the biomechanics of composite versus ceramics, why composite can often be the most biologically favorable material, and how to sequence treatment in a way that preserves tooth structure while still delivering functional and aesthetic outcomes.

我们还会讨论一些实际临床中遇到的挑战，比如夜间护齿套的佩戴依从性、修复体的失效模式以及材料选择，还有如何负责任地与患者沟通。

We also discuss real world challenges like night guard compliance, failure patterns and restorative materials, and how to communicate responsibly with patients.

这是一次对长期牙科治疗的深入且坦诚的探讨，因为最终效果不仅仅取决于材料，还取决于患者的行为、生物学因素以及时间的考验。

This is a nuanced honest look at long term dentistry where outcomes are not just determined by materials but by behavior, biology, and time.

这期节目能帮你提升判断力，让你行医更有目标感。

This is the kind of episode that sharpens your judgment and helps you to practice with more intention.

好了，最后如果这个播客让你对牙科有了新的思考，能不能麻烦你给个评分和评论，再分享给一位同行？

Okay finally if this podcast has helped you to think differently about dentistry would you mind considering leaving a rating and review and sharing this with a colleague?

这样的支持能让这个平台持续发展，带来更多像这样的深度对话。

That kind of support really allows this platform to keep growing and continue bringing you conversations like this one.

好，我们开始吧。

Okay, 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，又想深入掌握种植牙技术，现在就是绝佳机会！

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

我免费赠送你一门线上课程的访问权限！

I'm giving away access to one of my on domain courses completely free!

这门课涵盖了种植咬合、平台转换，以及如何打造惊艳的美学过渡轮廓，让你的作品脱颖而出。

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.

领取方式很简单：给这个播客留个评分，截个图，然后发给我就行。

Here's how to grab it: Leave a rating for the podcast, take a quick screenshot and send it my way.

你可以通过 Instagram 私信我，我的账号是 Doctor.

You can either direct message me on Instagram, my Instagram handle is Doctor.

Melissa Seibert，或者发邮件到 dr.

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

MelissaSeibert@gmail.com。

Melissa Seibertgmail dot com.

你把截图发给我之后，我就把课程权限发给你，你可以马上开始学习。

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

这也是我感谢大家支持播客、成为这个精彩社区一员的方式。

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

我也很期待听听你们的反馈。

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

所以我想问问大家。

So let me ask you this.

顺便说一句，我得感谢你们，因为很多牙医都会面临这样的问题——随着年龄增长，我们的修复工作会逐渐老化、出问题，我们总觉得是自己的责任。

And by by the way, I have to thank you because so many of us dentists, our dentistry will begin to age and it'll begin to fail and we feel responsible for it.

我们做了大量复杂的修复，可患者不戴硬质夜磨牙垫，甚至拒绝戴，结果修复体一崩，我们心里就特别难受。

So, you know, we do these extensive restorations, patient's not wearing a hard night guard, patient refuses a hard night guard, and then the restoration chips and it eats away at us.

就在前几天，我给一位牙齿磨损严重的患者做了个很漂亮的四类修复。

I mean, just the other day, I did a really nice class four restoration on a wear patient.

她不肯戴硬质夜磨牙垫，现在又回来了，因为修复体有点小崩瓷。

She declined a hard night guard, and she's already back because the restoration slightly chipped.

如果你太在意，真的会觉得自己很失败。

And it it can really lead you to feel like a failure if you let it.

不过你刚才提到，对于不戴硬质夜磨牙垫的患者，修复体坏了可以修补。

But, you know, you mentioned repairing the restorations, especially for patients that don't wear hard night guards.

你会让患者承担修复的费用吗？

Do you require the patient to pay for the repairs?

这笔钱该谁出？

Who's paying for this?

最大的问题在于，我一开始以为，虽然我知道牙齿修复体崩裂的原因，但我还是觉得，头一两年就当是善意举动，免费帮他们修吧。

The big problem, because I thought initially, even though I knew the reason for the chipping, I just thought, okay, for the first year or the second year, I had a kind gesture, I'm going to do it for free.

而且通常修复起来也不花多少时间。

And it's usually not a very long procedure.

但我现在明白，这完全是个错误。

And I realize it is completely wrong.

事实上，我们和患者之间是有约定的。

So because in fact, we made a deal with the patient.

但现在，当患者拒绝佩戴夜磨牙护具时，我会非常坦率地跟他们讲清楚，因为我觉得这件事已经很自然地该说开了：你看，夜护具每晚都戴着，能100%防止磨牙和紧咬这类行为，而这些正是对修复体造成最大压力的根源。

But now when the patient refuses the niGov, and I talk very openly about this now, because I think it became very natural to express this issue or to speak about this issue, to say, look, the night guard, you wear it every night, it's 100% protection against parafunctional activities, which we know are those which will create the highest stresses on your restorations.

白天即使清醒时磨牙或紧咬，也会产生不小的力道，但那时你有意识反馈，会自己察觉到。

Because during the day, even awake parafunctions, clenching can still generate quite some strong forces, but the pressure feedback is active.

你做得越多，可能就越容易忽略这种感觉。

So there is a certain sensation that you, of course, more often you do it, maybe less you pay attention to this sensation.

但我们都知道，最大的力量其实来自睡眠中的磨牙。

But we know that the highest forces are recorded during sleep bruxism.

但我得让他们明白，你施加在修复体上的压力，可能正是当初损伤你天然牙齿的那股力量，已经超出了修复体本身的机械强度。

But I'm telling them the amount of stress that you might exert on the restorations and which created that damage to your natural teeth might exceed the mechanical strength of your restorations.

所以我现在可以给你做一个全咬合重建，用相对合理的价格，防止你的牙齿继续受损。

So I can do a full occlusal buildup to protect your teeth now from further degradation for a relatively reasonable amount.

如果用陶瓷材料，我就得磨掉你一点牙体组织，因为我见过不少二硅酸锂瓷冠最终都失败了。

If I do it with ceramics, then I need to cut a little bit of your tooth structure because if we want to be I've seen Emax, lithium disilicate restorations failing.

如果你是重度磨牙的人，还用超薄修复体，我可以肯定告诉你，只要你不戴夜磨牙护具，它们迟早会碎。

If you go with the super thin restorations in a heavy clencher, I can tell you they will break them if they don't wear a nightclub.

不是百分之百，但概率很高。

Not 100%.

我们从来不是非黑即白的。

Now we are never in a binary.

我们总习惯把情况简单看成要么成功、要么失败。

It's true that we tend to think as a binary situation, failure or success.

但很多时候，其实我们处在两者之间的某个位置。

But very often we are somewhere in between.

但如果戴薄层贴面的人咬合力太大，又不戴丁腈护具，出问题几乎是必然的。

But if you go with thin overlays in heavy clenches, I can tell you that it can very easily fail if they don't wear the nitrile.

这样一来，沟通起来就更难了——你跟患者说这是超强材料，贵是因为实验室制作，他们自然觉得这种修复体绝不可能坏。

And then it's getting a lot more difficult to negotiate because you told them that this is super strong material and that is basically explaining why it's more expensive, it's done in the lab, and patients expect those restorations never to fail.

我要说得非常清楚：所有机械性失败，归根结底都是患者不配合造成的。

Now, I'm really, really very clear to say failures are only mechanical failures will be the result of non compliance.

如果你不愿意戴护齿器，那我就不做。

If you don't want to wear an eye guard, I will not.

当然，我也可以用传统的三氧化二锆做一颗2.5毫米厚的牙冠，白得跟我家浴室的瓷砖一模一样。

Yes, I can fret a crown of 2.5 millimeters in classical three terbium zirconia, white like the ties of my bathroom.

这种东西，你根本不可能把它弄碎。

And this image, you not break.

但它会磨损对颌牙，这也是我不太喜欢玻璃陶瓷的地方——现在患者根本不戴护齿器。

It will generate some wear on the antagonist, which is one of my issues with glass ceramics, is that at the moment, the patient doesn't wear an eye rod.

如果是树脂材料，反而更合适，因为树脂对EMAX修复体的釉面磨损更小。

If we have composite, that's probably a nicer couple because it's less composite is less prone to damage the glazed surface of our Emax restorations.

但我现在看到过E-max对E-max的情况，表面磨损得非常厉害。

But I've seen now Emax against Emax, you see the surface really suffering.

E-max和天然牙配对时，天然牙会被磨掉不少。

Emax against natural teeth, you're wearing off the natural teeth quite a bit.

最好的搭配，我觉得是氧化锆或者玻璃陶瓷，再配上复合树脂。

The best couple is, let's say, liter or glass ceramics, again, composite.

这大概是最理想的组合了。

That's probably the best couple.

我不太确定文献里有没有最新数据，我现在记不清了。

I don't know if the literature, I don't have recent data in mind.

实验室测试可能支持，也可能不支持这种说法。

We might have or not complete support from, let's say, lab test.

但这一点在临床上是清清楚楚看得出来的。

But that's something you see absolutely clearly in the nose.

我跟患者说的是，没有哪种方案能无视风险因素而万无一失。

But I'm telling them that there is no miracle solution with no control of risk factors.

尤其是机械性断裂，往往是因为患者不遵从医嘱。

And especially mechanical fractures is by the lack of compliance.

这一点我也一直在强调。

And it's also something that I'm saying.

我不能过度磨削你的牙齿，因为如果预备得太厚，就会带来生物学风险。

I cannot damage your teeth to a certain excess because if I prep thick enough, we take biological risks.

这太具侵入性了。

It's very invasive.

只有当你在进食时遇到问题，才需要确保修复体能真正替代功能，因为我们做的假牙质量非常好。

It's really when you have a problem with your food just to be sure because we fabricate excellent prostheses for replacing the food.

你手指感染了，我总不能把你的手或食物都切掉吧。

I'm not going to cut your food or your hand if you have an infection on one finger.

这不只是技术问题，更是伦理问题。

It's not just, it's unethical.

我不能这么做。

I cannot do this.

所以换句话说，如果你要接受我的治疗，就得接受我现在的说法——我怎么说，你就得怎么听。

So to say, you are, if you want to be treated by me, you need to assume I say it nearly as I'm speaking to you right now.

我要说的是，如果因为你不戴机械保护装置导致失败，或者你干脆不想戴，那责任在你。

I say, you need to understand that mechanical failures with noncompliant denial guard, or if you don't want the denial guard, it's on you.

就算我用的是业内最严谨、循证的最佳方案，依然存在失败的可能。

Because even if I use the best technique that the profession evidence based, the best protocol which we know, it still has potential to fail.

除非我把你的牙齿磨得几乎毁了，但我觉得我们不该走这条路。

Unless I nearly destroyed your teeth, but I think we cannot go along that path.

作为医疗专业人员，我们不该这么做。

We as healthcare professionals, this is not what we are supposed to do.

我个人到现在还是坚持，要让患者自己面对并承担这些决定带来的后果。

And I personally, still today, I prefer to face the patient with these own decisions that he needs to assume.

最后，如果他还是不满意……

And at the end, if he's not happy.

但说实话，我遇到过很多这样的病人，他们总觉得夜磨牙护具根本没必要。

But honestly, I've got many of those patients cases where they think the night guard is not needed.

他们并不信服。

They are not convinced.

第一次见面时，我们很难让他们明白。

We don't find the first time a way to convince them.

现在我有不少患者都经历过这种情况。

And now I have quite a number of patients who went through that situation.

当他们的修复体不断损坏时，总有一天会突然意识到问题。

And when they continue to break their restorations, one day it's clicking somewhere.

我一直说，这有点像口腔卫生方面的迹象，你能看出来。

And I've always said that it's sort of something with hygiene that you might observe.

当你进行一项重要的治疗时。

You do a treatment of a certain importance.

有时候你会看到患者对口腔卫生的重视程度明显提升。

You see sometimes a real increase in the motivation of the patient for oral hygiene.

我觉得这是‘账单效应’，但不会一直持续下去。

I think this is the invoice effect, but it's not lasting forever.

但当他们渐渐忘了自己花在治疗上的钱，积极性就突然下降了。

And while they start to forget about what they paid for the treatment, all of a sudden the motivation is going down.

一旦出现崩瓷、断裂或失败，如果还得自费重新治疗，他们才会意识到：也许他们觉得这点钱根本不算什么，不在乎；但也许他们会介意再来你这儿折腾一趟。

And when we get chipping or fractures or failures, if they need to pay again for the retreatment, that will bring them to realize that at certain moment they are forced to understand either they have so little, let's say, that the financial impact is so little for them that they don't care, but maybe they might care to have to come to your practice.

但我也会明确告诉他们，我不会选择那种过度侵入性的修复方式，因为这类做法带来的失败率我见得太多了。

But I'm telling them also very clearly that I would not accept to go with extremely invasive restoration, which damage that it is, because I've seen a release of failures.

当然，如果磨损严重，你磨除太多牙体，就可能违背牙齿本身的生理结构。

Okay, you might go depending on the amount of wear if you prep a lot, then you might again be in, let's say, in conflict with the biology of the tooth.

我不想让牙齿失去活力，否则后续还得处理正畸问题，而死髓牙本来就更容易发生机械性损坏。

I don't want to undergo loss of vitality, then I need to do an orthodontic problem and a non vital tooth is always at higher risk for mechanical failures down the road.

所以，这不是我想引导患者走的路。

So it's not really the path I want to bring the patients on.

我有个问题想问你。

Let me ask you something.

你刚从牙科学校毕业时，有没有想过自己会接这么多复杂棘手的病例，每天通勤路上都因为要做这样的牙科工作而充满热情？

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?

还是说，你发现自己被困在一种重复、枯燥、让人困惑，甚至毫无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?

你是不是对不可预测的失败、牙冠脱落、患者不满却说不清原因而感到沮丧？

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

今天的你，就是你理想中的牙医吗？

Today are you the dentist that you want to be?

想象一下，成为你一直想成为的那位卓越的综合牙医。

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

那种做事清晰、自信，能超越常规治疗、看得更远的牙医。

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

他们受人尊敬，被频繁转诊，内心充实，因为他们的工作既有意义，又充满挑战。

They're respected, referred to, and fulfilled because the work is both meaningful and challenging.

这些，正是我们在 Elevated GP 里所打造的。

That's what we build inside of Elevated GP.

我们培养的是那些真正蜕变为理想中临床状态的卓越综合牙医。

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

在我们的项目里，每个月都有实时继续教育讲座，内容全是社群最想了解的课题，比如种植、咬合、治疗计划，还有前牙树脂修复。

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.

我们每个月还安排实时问答环节，大家一起解决你遇到的最难的病例，不只是告诉你该怎么做，更教你该怎么思考。

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群，你可以提出真实的临床难题，获得有依据、有深度的解答，而不是像在普通Facebook群组里那样杂乱无章。

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.

我坚信，良师益友能互相砥砺。

I believe that iron sharpens iron.

你身边的人，决定了你的水平。

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

来加入一个牙医彼此激励、共同追求卓越的社群吧。

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

如果你有共鸣，我诚挚邀请你访问 elevatedgp.com，成为我们的一员。

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

我也很好奇。

I'm curious as well.

我的意思是，你是迪迪耶·迪特施基，绝对是全球最顶尖的复合树脂专家之一，做这种复合树脂修复真的需要极高的技艺。

I mean, you're Didier Dietschi, you are really one of the premier authorities in the world on composite, And you doing these composite restorations requires a great deal of artisanship.

那为什么你的复合树脂修复收费，却只有陶瓷修复的一小部分呢？

So why are your composite restorations why do you charge a fraction of what you would charge with ceramic?

是的。

Yeah.

如果你谈的是经营方面的事，那你找错人了。

If you touch the business side, you have reached the wrong person.

我可能属于上一代人。

I'm from probably a different age.

我一直把我的职业当成一种爱好。

I have really looked at my profession as a hobby.

我对自己做的事充满热情。

I'm passionate about what I'm doing.

我从来就没太在意过盈利或者收入。

I never looked so much at the I can't think rentability or income.

但说实话，话虽如此，我知道像牛顿·福尔这样的人。

But honestly, having said that, so I know, for instance, Newton Fowl.

你有没有邀请过牛顿·福尔来做访谈？

Did you have Newton Fowl for one of your interviews?

我真的很想请他来。

I would love to have him on.

我们一直很难协调出合适的时间见面。

We have had a hard time finding our schedules to connect.

我应该再主动联系他一下。

I should actually reach back out to him.

好的。

Okay.

我希望你能请到他，他真的太棒了。

I hope you I hope you will He's incredible.

他是个了不起的人，出色的临床医生，顶尖的导师，更是一个难得的好人。

He's he's he's an amazing an amazing person, an amazing clinician, an amazing teacher, and also an amazing human being.

他总是告诉我，我错了，我应该把价格定得和间接修复差不多。

And he always told me that I was wrong, that I should charge nearly the same as an indirect restoration.

但在这一领域，我清楚材料的局限性。

But especially in the domain, I know the limits of the material.

有时候我会稍微引导患者往这个方向走，因为我相信这才是该优先做的。

Sometimes I'm pushing a little bit of the patient toward that direction because I believe this is the first thing to do.

不过除此之外，说实话，如果只是处理一个典型的磨耗病例，比如有I类或II类蛀牙需要替换修复体，那这就是常规治疗了。

But apart from that, honestly, if I just refer to a classical wear case, if I have some class one, class two decays or restorations to replace, that would be, let's say, the normal treatment.

明白吗？

Okay?

我会在第一次就诊时就把这些蛀牙都补好，修复所有旧的修复体，全程录像。

I'm going to restore all those or replace all those restorations, treat those decays in the first session, maintaining the video.

因为虽然偶尔我也会一次做完所有项目，但那样会拖得太久。

Because to do everything, occasionally I do it, but it creates very, very long sessions.

如果我把所有的I类和II类修复都安排在同一 session 里，再加上录像，时间就更长了。

If I redo all the class one and two in the same sessions, integrating the increase of video.

因为通常我们喜欢一天只做一颌，左右两边同一天完成。

Because normally we like to do one arch at a time in one day, left and right on the same day.

所以我更倾向于让患者能接受和承受的方式，一次性把所有的I类和II类蛀牙都用直接修复处理掉。

So I prefer to do at the reason the patient can, let's say, accept and tolerate, replace the class one and two, everything direct.

明白吗？

Okay?

如果是需要做间接修复的，我只会预备那些真正需要间接修复的牙齿。

If I have indirect, I would prep only the teeth which require an indirect restoration.

这样就能建立新的咬合记录。

That will set up the new video.

这个过程会和蜡型设计一起进行，基于我们之前确定的功能分析和新的咬合记录。

It's done together with the wax up according to a functional analysis and the new video that we have decided.

然后我再进行直接修复。

And then I go with the direct resurrections.

但一旦涉及到咬合关系调整，每颗前磨牙我都会花上十到十五分钟。

But when it comes to the video change, I will work ten, fifteen minutes per premolar.

大多数时候，我都需要重建前磨牙的形态。

And most of the time I need to rebuild the cost of the premolars.

其实没多少工作量。

There isn't so much to do.

就算要重建整个解剖结构，十五分钟也够了，因为通常只用一层树脂，最多也就二十分钟。

Even if I need to build up the entire anatomy, fifteen minutes is enough because it's going to be most of the time a single layer and maybe twenty minutes for the moment.

即使我每颗牙的修复收费平均在400美元左右。

Even if I charge for, in average, around $400 per restoration.

我一个半小时就能做完，有时候还能更快。

I do everything in an hour and a half, even even more.

所以我觉得，做这份我热爱的工作，收入相当不错了。我也得说，当我做直接堆塑时，其实并不完全是自由手绘。

So this is really I feel that it's a very decent income for doing something that I love to do, because I must also say that when I have a case and I do a freehand buildup, it's not always complete freehand.

就在我们开会前，我刚规划了一个病例，有几个牙需要间接修复，但只要有可能，我都尽量选直接修复，我真的很开心。

I might have a couple of, I was just treatment planning one case before we started our meeting, and I have a couple of indirect restorations and wherever I can, I go direct, but I'm so happy?

这活儿做起来特别有成就感。

It's such a lovely work to do.

当然，我们得不断学习。

And of course, we need to learn.

你知道，瑞士人可没有意大利人的天赋。

Was, you know, Swiss are not having the genes of Italians.

我姓迪特施，听着像意大利姓氏，其实祖上是德国北部的。

I found that my name Dietschi would sound like Italian, but in fact it's Northern Germany.

家族源自德国北部，但已经很多代以前了。

The family comes from Northern Germany, but many generations before.

不只是要当个有名的画家或雕塑家的后人，关键是要反复练习同样的动作，靠积累才能进步。

Not only being a famous ancestor painter or sculptor, I had just to learn, but with just repeating the same movements and we improve by practice.

如果客观来看，我觉得自己更擅长从概念上理解，通过观察解剖结构来掌握。确实，我当年轻牙医时做了大量传统蜡型，因为我特别喜欢。但同时，我前二十年基本都在学术环境里，根本没机会接触新的技工室来做这些准备工作。

And I didn't feel if I'm very objective, I think it was more conceptual I was able to visualize and observing anatomy I've done it is true that I've done a lot of wax up classical wax up when I was a young dentist because I love to do it but also since I spent really the first twenty years of my life mostly in the academic environment, I didn't have access necessarily to a new lab for doing this preparation work.

所以，学习解剖、做蜡型对我而言特别有帮助。

So it was good for me to learn anatomy and do some wax ups.

这方面的技能，我可是下了不少功夫练习的。

So it is something that I train myself a lot.

不过我们还有其他成型技术，你可能在书里已经见过，只要蜡型做得好，现在借助现代牙科技术，轻松就能做出漂亮的蜡型。

But we have also molding techniques that you might have already seen in the book that with a nice, a good wax up and now it's a little through dentistry, we can fabricate easily beautiful wax ups.

我们只需要把表面处理光滑，要么密封，要么抛光，避免成型修复体上出现印痕。不过现在有很多替代方法，效果一样，甚至更快。

We just need to make the surface smooth either to seal the surface or polish the surface to avoid the print lines to show on the molded restorations, but we have a lot of alternatives that will provide the same result, even maybe a little quicker.

所以喜欢自由手塑的人，完全可以自己动手做。

So for those who like freehand, they can do freehand.

没必要做得特别复杂。

It doesn't need to be super sophisticated.

但三手法要求对厚度有很好的掌控。

We need to but it is what the three hand approach requires good control of the thickness.

而用成型法，你可以从后牙到前牙精准控制各部位的厚度。

While with the molding approach, you control the respective thickness from the back teeth to the front teeth.

这样更简单。

It's easier.

只要严格按照流程操作，效果会非常好。

And if you follow the protocol precisely, great it's tool.

另一个问题来自你的书。

Another question coming from your book.

你在书中强调了牙齿磨损的多因素诊断，包括侵蚀、机械和功能路径，这些我们已经简单讨论过。

So in your book, you emphasize multifactorial diagnosis for tooth wear erosion, mechanical and functional pathways, which we've talked a little bit about already.

当患者出现多种病因重叠时，你是如何构建你的诊断流程的？关键的判断节点在哪里？

How do you structure your diagnostic decision tree in cases where patients present with overlapping etiologies, And what do you consider the tipping point?

这个问题的核心部分就在这里。

So this is the biggest part of the question.

你觉得什么样的临界点才需要进行积极的修复干预？

What do you consider the tipping point that determines whether active restorative intervention is necessary?

因为我觉得在北美，很多牙医都很难判断到底什么时候该介入治疗。

Because I think many dentists in North America, it's always difficult to decide when do we actually intervene and treat.

你是说要增加垂直距离吗？

I mean, you mean increasing the VDO?

增加多少？

How much

没错。

Correct.

甚至开始进行全面的全口修复。

And really even embarking on the quote full mouth rehabilitation.

当然，我们之前已经提到过，实际情况远比这复杂。

And of course, we've already talked about how it's far more nuanced than that.

治疗方案必须根据患者的具体情况量身定制。

It's far more customized to the patient.

但到底在什么时候，你才会决定该进行修复治疗并介入了呢？

But when do you make that decision when it's actually time to do the restorative dentistry and intervene?

我会先确认，我们是否遵循的是整体的功能或咬合设计，而不是简单地看是全口修复还是部分修复，因为有些情况可能只需要修复一个牙弓。

So I check to make sure that basically it's more that the global functional or occlusal scheme that we follow when we engage into the treatment or versus, let's say, full mouth versus partial treatment, because in some cases we might restore only one arch.

我不确定是不是你的问题包含多个方面，你可以明确一下，希望我重点回答哪一部分吗？

I'm not sure if I I think there are multiple aspects of your question, but if you can just confirm which aspects you would like me to cover.

那这样如何？

So how about this?

或许更该问的是，在北美，很多牙医常常照搬一套固定的全口重建方案。

Maybe an even better question to ask is oftentimes in North America, dentists will sort of do the same copy paste full mouth rehabilitation.

患者来的时候牙齿有磨损，他们就认定是陶瓷材料不足导致的，于是给患者做全口所有牙齿的重建。

They will have a patient that comes in with some wear and then determine that that wear is caused by a deficit of ceramic and then patient gets a full mouth rehabilitation on all their teeth.

更好的问题是，当症状发展到什么程度，才真正到了需要干预的时候？

Perhaps a better question to ask is, at what point do the symptoms in the presentation become bad enough that it's time to intervene?

是患者开始感到敏感的时候吗？

Is it once the patient's reporting sensitivity?

还是患者因为牙齿磨损影响了笑容，主动表达不满的时候？

Is it once the patient's saying that they're dissatisfied with their smile as a result of the wear?

还是说你有一套不同的判断标准？

Or is there a different sort of decision matrix that you follow?

其实，牙齿磨损造成的笑容问题，往往是患者前来就诊的主要原因。

Well, the smile, let's say the smile damage that is created by tooth wear is clearly the element that brings the majority of patients to consult.

他们主要担心的是美观问题。

So they have an aesthetic concern.

事实上，在大多数情况下，如果不采取其他措施，我们根本无法解决这个问题。

The reality is that we can't address that problem in the majority of cases without doing something else.

我们通常需要腾出一些空间，才能做好修复工作。

We need to create most of the time some space to restore the warranties.

所以，这正是我们向患者说明的关键点：我们理解您的需求和期望。

So that is probably a critical element that brings us to tell the patient, look, we understand your requests and your expectations.

但要真正满足您的要求，光是修复牙齿表面是不够的，我们还得做更多。

But in order to answer your needs and your expectations, we will need to do a little bit more than just restoring the fonts.

这时候我们就得跟患者沟通了，不过有时候确实也能做到。

So that is when it brings us But sometimes it can be done.

举个例子，比如一个咬合过紧的患者，和一个磨牙的患者，情况就完全不同。

If we consider one example that might allow me to implement a little bit more, We take a D pipe case, a class 22 case, in a bruxer versus a clencher.

咬合过紧的人，主要是靠咬紧牙齿施加压力。

The clencher, it is many clenching.

确实，很少有人只是单纯地咬紧牙关。

It's true that it's very rarely only clenching.

但正如我们之前说的，后牙可能会有明显磨损，而前牙几乎没什么损伤。

But then you might have damage on the back teeth, as we said before, very little on the front teeth.

但如果患者主要是磨牙，只要一动嘴，就会出现约翰·柯林斯所说的‘限制性咬合’——这时候后牙会立即脱离接触，磨损几乎不会发生。

But if it's really mainly a bruxer, as soon as the patient is moving, this is what we call John Collins calls constrictive occlusion, but as soon as the patient is moving, we will disclude posterior dentition and there is nearly no wear.

所以你可能会看到前牙严重磨损，而后牙几乎完好无损。

So you might have severe wear in the front, nearly nothing in the back.

不过有时候，下牙的颊侧和上牙的腭侧也会有磨损。

But still sometimes, since you also wear buccal the lower, palatal on the upper.

这种情况必须加以处理。

This needs to be taken care of.

要解决这个问题，唯一的方法就是增加咬合高度。

So the only way to take care of this is to increase the video.

但也许只需要在下牙上稍微加一点修复体就够了。

But it might be just a little cost build up on the lower.

但我们不能加得太多，否则不仅会改变垂直距离，还会像大家都知道的那样，造成前后向的咬合不协调。

We can never augment so much because otherwise we create not only we open the vertical dimension, but as we all know, we also create sagittal discrepancy.

所以是有极限的，解剖上的限制，哪怕只是稍微打开一点。

So there are limits, anatomical limits, if we just open up a little bit.

但要制造一点空间、开始堆砌前牙，其实很简单。

But it's very easy to generate a little space and start building up the front teeth.

有时候，这类问题的答案可能出乎意料地简单。

So occasionally, we might have very simple answers to this kind of problem.

美观绝对是促使患者愿意接受治疗的首要因素。

So aesthetics is definitely the number one element that might bring the patient to engage in the treatment.

相比之下，对冷热或酸性物质的敏感就没那么常见了。

Less frequent is the antin hypersensitivity to cold, to acids.

患者通常在刷牙时，或者经常感到不适。

So patients are disturbed regularly or when brushing.

也可能逐渐变得敏感。

Also, might become sensitive.

他们照镜子看自己的嘴，发现有些地方不对劲。

They look in their mouth and they see something's going on.

这是第二个原因。

This is the second reason.

功能方面的问题，通常跟颞下颌关节紊乱无关。

Functional problems seems to happen mainly apart from TMD cases.

但如果排除了颞下颌关节的病理情况，真正的功能受限主要发生在后牙支持丧失的时候，也就是患者开始掉后牙的时候。

But otherwise, if we exclude TMD or TMG pathology, true functional problems limitations comes when we lose posterior support, when patient starts to lose posterior teeth.

这时候，垂直距离就可能真的塌陷了。

And then we might have a true collapse of the VDO.

不过这类情况相对少见，尤其是在今天。

But those are relatively rare cases, especially in today's world.

所以我会拍照片给患者看，试着评估牙齿磨耗对咬合的生物力学影响，看看如果不阻止磨耗继续发展，这些牙齿将来会变成什么样。

So I will otherwise make pictures, show the patient, try to also evaluate the biomechanical impact of wear on the teeth, trying to somehow figure out what will be the situation of those teeth if we don't arrest the progression of tooth wear.

当然，这还得结合患者的年龄来看。

And of course, that comes together with the age of the patient.

还有已知的风险因素，以及患者的配合程度。

The known risk factors, compliance of the patient.

所以，这其实就是这三个因素。

So this is really those three factors.

我会通过观察牙齿磨损的类型来识别风险因素。

I have, let's say, the risk factor identification that goes through the observation of the type of lesions we have.

然后是磨损的严重程度、口腔不同区域的情况、患者的年龄，以及配合度。

And then we have severity of wear, area of the mouth by area of the mouth, age of the patient, and compliance.

当然，这些情况的程度也各不相同。

And of course, we have different degrees.

我们通常会结合临床分析和专业判断，综合评估这些因素，看看是该立即干预，还是继续观察。

We compute a sort of a it's done through HI, from analysis, human intelligence analysis, to say, okay, if I balance now or if I try to bring those elements together, that will help me to define.

有时候我们需要采取措施，有时候只需持续观察。

And sometimes if we need to take action or if we just observe.

而防止磨损进一步加重，关键在于控制磨牙行为。

And there is always this interception of tooth work that can happen through only preventing vermin.

因此，我们会给出饮食建议，必要时转诊给儿科医生，有时还会建议患者调整生活习惯，因为很多时候，我们第一步就是帮患者控制这些风险因素。

So trying to provide diet advice or refer the patient to a pediatrician and go with a neighbor because occasionally and not so rarely, we start by checking if we can help the patient to control the risk factors.

和患者一起，我们可以判断是否走在正确的路上，是否可以停下来。

And together with the patient, then we can see if we are on a good path or not, if we can stop.

我见过一些暴食症患者，他们没接受治疗，因为医生只给他们全口重建这个选项。

I've seen a few patients like bulimic patients who didn't do treatment because the only option for them was full mouth rehab.

其实我们可以采取更简单的方法。

We could have done something simpler.

他们十年什么都不做，等再回来时，情况已经彻底崩溃了。

They do nothing for ten years and when they come back, it's an absolute disaster.

你书里第二章或第三章应该就有一个这样的案例。

You have one of those cases, I think in chapter two or chapter three.

情况真是惨不忍睹。

And it's an absolute disaster.

不采取行动，后果可能极其严重。

The lack of action can be an absolute disaster.

严重的磨损通常需要尽早干预。

So severe wear normally requires at least interception early enough.

但不幸的是，大多数时候，人体有着惊人的适应能力。

But unfortunately, most of the time, have an incredible adaptation capability.

你见过一些病人，根本没法理解他们是怎么在功能和外观上适应自己糟糕的牙齿状况的，对吧？

You see some patients, you can't understand how they could functionally, aesthetically adapt to their dental situation, right?

但这也给我们带来一个麻烦：口腔组织对病变和磨损的适应能力实在太强了。

But this is something, of course, a factor that works a little bit against us is that the cavity has a very, very wide capacity of adapting to pathology and fertility.

所以我们专业人士得想办法让患者看清现实，得用大量证据来说明——比如传统的X光片、三维CBCT扫描，还有口内扫描的图像，把这些都给他们看。我经常还会拿一些健康牙齿的案例对比给他们看，因为如果你只给他们看自己的牙齿，而他们从来没见过健康牙齿是什么样，他们根本意识不到自己有多严重。

So it's mainly us professionals who can open the eyes to the patient with a lot of documentation that we can show to the patient with two d paths, classical radiography, three d radiography with intraoral scanning pictures, show them really and what I do also very often is I have some cases show them a healthy dentition so that they can when they can look at it these ways the pictures because when we show only their pictures if they've never seen the mass of a healthy patient, they might not understand where they are.

这是健康牙齿和牙弓的样子，这是你现在的状况。

And showing this is a healthy dentition, a healthy arch, this is your situation.

突然间他们就会说：天啊，差别这么大！因为他们早就记不清自己年轻时牙齿原本是什么样子了。

And all of a sudden they say, oh wow, it's very different because they might not remember what the mass was looking like years back.

再说回核心问题，美观确实是促使患者愿意接受治疗的关键动力之一。

But aesthetics, just to come back to the central question, aesthetics is in fact one of the key elements that can key incentives for patients to engage into a treatment.

确实非常有效。

Well, has been phenomenal.

我还有好多问题都没来得及问你。

I have so many more questions that I didn't get a chance to ask you.

不过明天是北美地区的假期。

But tomorrow is a holiday in North America.

我们马上就要启程去度假了。

So we're actually going to begin our holiday travel.

你有什么最后想说的吗？

Do you have any closing remarks?

这真是一次太棒的交流了。

Because this has been incredible.

我想，这或许更像是一种哲学上的总结，不知当讲不当讲。

Well, I would say maybe it's more a philosophical conclusion, if I may say.

我觉得我们得保持开放的心态。

I believe we need to remain open.

要对这个行业的发展保持开放。

We need to remain open to the evolution of the profession.

我们知道确实如此，我所做的这些比较，我认为并非与牙齿磨损这个话题无关。

We know it is, and I'm making comparisons which are not, I believe, irrelevant to the topic of tooth wear.

整个行业花了多久才承认，粘接不仅在牙釉质上有效——这一点大家早就接受了——在牙本质上也同样成功呢？

How long did it take for the profession in general to admit that adhesion is successful, not only on enamel, which everybody admitted quite early, but also on dentin.

就在不久之前，我还听到一些大型会议上有权威导师、知名专家说，牙本质粘接根本行不通。

And it's not such a long time ago that I heard in congresses, even by big mentors or big names, recognized mentors that dentin adhesion doesn't work.

我想，到了2025年，不会再有人这么说。

I think no one will ever say this again in 2025.

所以，我们花了整整几十年才终于认识到，粘接才是修复体在口腔内固位的核心原则。

So it a couple of decades to admit that adhesion is the key principle that we use to retain our restorations in the mouth.

这意味着，我们几乎不需要做冠延长手术，对根管治疗的需求也大大减少——过去我们常为了机械固位而做这些治疗，但现在我们更清楚，根管充填对牙齿生物力学和长期寿命的负面影响。

So it means no need for crown lengthening, very limited need for crown lengthening, limited need for endodontic treatments just to create also the conditions to retain mechanically a restoration, understanding the negative impact of root canal filling on the biomechanics of a tooth and its long term impact on the tooth's lifespan.

但我们在修复与义齿领域取得的所有成就，都离不开粘接技术。

But all the successes which we have achieved in the field of restorative and prosthetic dentistry go through adhesion.

而今天我们必须明白，我们手头有多种生物材料，它们的力学和生物性能各不相同，每一种都有其特定的适用场景。

And we need to understand today that we have different biomaterials, which have different biomechanical, mechanical properties, and each of them is having some indications.

我认为，当今在治疗牙齿磨耗以及整体修复与义齿治疗中，最需要破除的一个重大误解，就是认为只有陶瓷材料才能在中长期为患者提供有效修复。

And I think probably that the biggest myth and misconception that we need to fight today in the treatment of tooth wear and in restorative prosthetic dentistry in general is to believe that only ceramics can work for the patient on the medium long term.

这是一种错误的认知。

It a false conception.

这违背了我们目前所有基于现代循证医学的理念和原则，但每种材料的适应症确实不同。

It's against any modern evidence based, let's say, approach and concepts which we have, but indications are not the same.

我们没必要去跟支持复合树脂的人或支持陶瓷的人争个对错。

There is no point to fight people who are supportive of composite or those supportive of ceramics.

它们各自都有自己的适用场景。

They both have their, let's say, own indications.

把任何一种材料用在它不适合的场合，都是不正确的。

Pushing outside its real indication, one material or the other, is not correct.

每种材料都有它的优缺点。

So each material has its advantages and disadvantages.

我认为，如果整个行业真正接受这一点——这不是观点，这是事实——我们才能真正为患者提供更好的治疗。

I think if the profession really accept this fact, it's not a concept, it's a fact, I believe we can really do much better for our patients.

年龄是一个需要考虑的因素。

Age is a factor.

牙齿的整体生物力学状况、生物功能环境，也要理解生物力学和功能环境，把这些因素都纳入材料选择的考量。

The general biomechanical status of teeth, biofunctional environment, understand also biomechanics and biomechanical environment, functional environment, integrate this with the choice of material.

还有一个非常重要的点：没有任何科学依据支持所有牙齿都必须用同一种材料治疗。

And the last point, very important, there is no scientific rationale to support the fact that all the teeth need to be treated with the same material.

我觉得更具体一点，混合使用不同材料是非常合理的。

I think being more specific, combination of materials make a lot of sense.

想想那些看起来比陶瓷更弱的材料，其实韧性不错，陶瓷本身也有不同类型，这点也要注意。

Thinking about the resilience of materials which seem at first to be weaker than ceramics, different kind of ceramics as well, by the way.

所以，还是要保持开放，为患者提供更细致、更个性化、更精准的修复方案。

So again, to remain open to a more detailed and specific and individualized answer, restorative prosthetic answer to what patients need.

我觉得这是我们最需要进步的地方。

I think this is the biggest aspect on which we need to progress.

保持开放的心态。

Remain open.

别以为我们固守经验，或者大多数人不愿改变，是因为害怕走出舒适区，这就成了进步的障碍。

Don't stay that we don't stay with experience or the majority of us is a very negative factor to evolve, because we are afraid to get out of our comfort zone.

我是在几年前开始意识到这一点的，那时候我就想，我得改变这种状态。

And this I started to realize, maybe I don't know, years ago, and I said, okay, I need to fight this.

别因为习惯了某种做法，或者熟练掌握了某个流程、某种生物材料，就以为它一定对患者和你自己最好，就一直沿用下去。

Don't continue to do the same because you are used to doing it and you master this protocol, the use of this biomaterial, and you believe it will be the best for the patient and yourself.

不，现在有新的产品、新的方案，我们得保持开放，但也不能盲目追新。

No, there are new products, there are new protocols, and we need to remain open with us jumping too early on something new.

但只要有了充分的证据，我们就该睁大眼睛，随时准备改进，为患者做得更好。

But as soon as we have evidence that we open our eyes and remain open to improve and do better for our patients.