约翰·科伊斯博士重新审视咬合关系

嘿，我想告诉你我为你准备了一个东西。

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.

我特别喜欢这个技术，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模板直接将复合树脂注入牙齿，这样操作起来更加一致和高效。

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，我把它弄得特别简单，只需访问elevatedgp.com/impdf，而且为了更方便，我还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《牙科文摘》。

Hey, welcome to Dental Digest.

这是一个播客，旨在让你始终站在循证牙科的前沿。

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

我是你的主持人，医生。

And I'm your host, Doctor.

梅丽莎·塞伯特。

Melissa Seibert.

这是我们两部分系列节目的第一部分。

This is part one of our two part series.

本周的节目，我的嘉宾是医生。

This week's episode, my guest is Doctor.

约翰·科伊斯。

John Kois.

医生。

Doctor.

科伊斯是一位修复牙科医生、教育工作者，也是修复牙科领域最有影响力的声音之一，他在牙周病学和修复牙科方面都接受过高级培训。

Kois is a prosthodontist educator and one of the most influential voices in restorative dentistry with advanced training in both Periodontics and Prosthodontics.

他经营着一家专门从事修复牙科的私人诊所，是华盛顿大学的附属教授，曾担任美国修复牙科学会和美国美学牙科学会的主席，并且是科伊斯中心的创始人，在那里他继续培训来自世界各地的修复牙科医生。

He maintains a private practice limited to prosthodontics, is an affiliate professor at the University of Washington, a past president of both the American Academy of Restorative dentistry and the American Academy of Aesthetic dentistry, and the founder of the Kois Center, where he continues to train restorative dentists from around the world.

这段对话的第一部分，医生。

Part one of this conversation, Dr.

科伊斯挑战了我们大多数人被教导的关于咬合的传统观念。

Kois challenges the way most of us were taught to think about occlusion.

我们深入探讨了为什么传统的静态咬合定义在真实患者中常常失效，咬合实际上是一个动态系统，以及为什么像MIP磨损和磨牙症这样的概念经常被误解。

We dive into why traditional static definitions of occlusion often fail in real patients, how occlusion is actually a dynamic system, and why concepts like MIP wear and Bruxism are so frequently misunderstood.

这一集为评估咬合的全新方法奠定了基础。

This episode lays the foundation for a completely different way of evaluating occlusion.

这种方法关注功能适应和长期可预测性，而不是机械的检查清单。

One that focuses on function adaptation and long term predictability rather than mechanical checklist.

好，我们开始吧。

Okay, let's jump in.

我有个你会喜欢的东西。

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学，这是你的机会。

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

我正在免费赠送我的一个在线课程。

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

这门课程涵盖了关于种植体咬合、平台转换以及打造令人惊艳的美学穿龈轮廓的所有知识，能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.

获取方式如下。

Here's how to grab it.

给播客打个分，截个图，然后发给我。

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.

收到截图后，我会把课程访问权限发给你，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.

我迫不及待想听听你的想法。

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

你知道，你教学几十年了，牙医们为了进你的课程，愿意等上好几年。

You know, you have been teaching for decades, and dentists will wait multiple years just to get into one of your courses.

你以很多方面闻名，但其中之一就是咬合和制定治疗计划，真正让牙医们有能力处理复杂病例。

You're known for many things, but one of them is occlusion and treatment planning and really enabling dentists to tackle difficult cases.

我想问你的第一件事是，这些年来，自从你开始教咬合以来，你对咬合的看法是如何演变的？

The first thing I want to ask you about is, you know, over the years, how has your thinking about occlusion evolved since you first began teaching it?

你觉得全科医生最常见的误解是什么？

And what do you see as the most common misconception around GPs?

博士。

Dr.

哇，这个问题真够开场的。

What a quite a opening question.

那让我想想怎么把这个讲得清楚一点，然后慢慢展开。

So let me let me see how I can break this down a little bit and and work this out.

我知道你在这里待过，所以相比听众或者其中一些人，你有个优势，因为你问问题的时候已经知道我要往哪个方向走了。

I know having you having been here at the center, you have an advantage over the listeners or some of them, because you know where I'm already going as you ask the questions.

所以我知道这真的很有帮助。

So I know that's really helpful.

首先，简单介绍一下我的背景可能对听众有帮助。我接受过牙周病学和修复学的训练，职业生涯的头十年，我一直在努力掌握那些专科培训中学到的东西。

First of all, a little bit about my background might be helpful For people that are listening, I've trained in both Periodontics and Prosthodontics, and I spent the first ten years of my career trying to master what I had learned during those specialty training opportunities.

那是第一个十年，然后我意识到自己还是有问题。

That was the first ten years, and then realizing I was still having problems.

接下来的十年，我一直在想办法解决这些问题，因为作为专科医生，我觉得我的治疗效果并不比当全科医生时好多少。

I spent the next ten years trying to figure out what to do about the problems, Because as a specialist, I didn't think my outcome was really much better than it was when I was a general dentist.

而职业生涯的剩余时间，就像你提到的，几十年，我一直在努力传授我认为能让我们在临床中做两件重要事情的新机会，因为我在教学中心关注的是临床实践，就是让电话只因为两个原因响起。

And I spent the rest of my career, as you mentioned, decades trying to teach what I believe is a new opportunity for us to do two important things in practice, because my focus in the teaching center is practice, is to have the phone ring for only two reasons.

第一个原因是新病人。

And reason number one is new patients.

第二个原因就是表扬。

And the second reason is praise.

我这么说，大家可能会笑，但我的意思是，要避免那些不良事件和负面互动。

And my point in that, and people do laugh, my point in that is to avoid the adverse events and the negative interactions.

比如我的牙敏感、咬合不对、我得取消预约，所有这些事情。

And my tooth is sensitive, my bite's not right, I have to cancel my appointment, all those things.

那我现在就进入你的问题吧。

So let me jump into your question.

作为修复科医生，在我的训练中，我觉得——而且当时也确实如此，我只代表我个人受训的经历——训练有点教条和机械。

As a prosthodontist in my training, I felt, and rightly so back then, and I'm only speaking for my personal training, the training was a bit dogmatic and mechanical.

我从来没能真正理解，那种教条式的训练或者我学到的机械解决方案，是如何解决真实的人身上的咬合科学或咬合力学问题的，比如他们怎么咀嚼。

And I never really could truly understand how that dogmatic training or the mechanical solutions I received in my training resolved the science of occlusion or the mechanics of occlusion in terms of a real person and how they chew.

那让我从对我来说最重要的一个范式转变开始讲起，就是每个新患者来的时候，首先要看他们的咬合，我说的咬合是指，正中接触位是正常运作还是在崩溃？

So let me start it off by the number one paradigm shift for me in any new patient is when a new patient comes in, is their bite, and what I mean by bite, MIP working or breaking down?

现有的咬合关系能不能经得起时间的考验？

Is there existing occlusion something that will be able to stand the test of time?

我能不能在现有的咬合基础上做其他修复？

Can I build other restorations in this existing occlusion?

还是说我正走进一个所谓的噩梦，或者某种可能会让我翻车的情况，然后最后责任都落在我头上？

Or am I walking into some sort of quote unquote nightmare, or something that could unravel on me, and then I take the hit for the blame of what's going on.

所以对于听众朋友，我想用这个播客开头，先讲一个根本性的思维转变。

So for the listener, I would start this podcast with maybe a fundamental paradigm shift.

在学校里，MIP是我们学的一切的起点。

In school, MIP was the origin of everything we learned to do.

那就是侧向运动，右侧工作侧，左侧工作侧，前伸运动。

That would be excursive movements, right working, left working, protrusive.

现在在我的诊所里，以及我教学的时候，MIP是终点位置。

In my practice now and what I teach, MIP is the terminal position.

它是下颌如何找到头部的位置。

It's how the lower jaw finds the head.

而它怎么做到这一点，正是我们问题的根源。

And how it does that is the root of our issue.

问题在于，这和我受训的方式完全相反，差了整整一百八十度。

And the problem is it's totally 180 degrees opposite from the way I was trained.

因为如果你看大多数牙医观察到的MIP位置，他们把它看作一个静态的位置。

Because if you look at most MIP positions that dentists observe, they observe them as a static position.

换句话说，就是形态学。

In other words, it's morphology.

要么是一类、二类、三类，我们可以定义这些。

It's either class one, class two, three, and we could define that.

但这和它是否正常工作没有关系。

But that doesn't have a relationship to whether it's working or not.

这就是为什么在牙科领域，没有人能把学校里定义的咬合和功能异常联系起来。

That's why there's no there's no one in dentistry that hasn't been able to take occlusion the way it was defined in school and relate it to functional anomalies.

所以这就是为什么今天很多口腔医学的人都不相信咬合和牙齿问题、头痛或许多颞下颌关节紊乱症有关。

So that's why even many oral medicine people today don't believe occlusion has anything to do with what happens to the teeth or headaches or many of the TMD issues.

我觉得这几乎让人生气，因为这取决于你怎么定义咬合。

And I find that almost offensive, because it depends how you define occlusion.

而且我觉得大多数人都是根据形态、反颌、开颌来定义的。

And I would say most people define it based on the morphology, crossbite, open bite.

这些都是静态的关系。

Those are static relationships.

而这是一个更动态的东西，我们必须去理解它。

This is a much more dynamic entity that we have to understand.

希望在播客里，我们能揭开一些这些问题，帮助大家换个角度思考。

And hopefully during the podcast, maybe we can uncover some of those issues to help people maybe think differently.

因为如果你不换思路，你就没法做出改变。

Because if you don't think differently, you can't do different.

所以如果你想真正进步，就必须获得更好的知识和更深的理解。

And so if you want to really get better, you have to really get better knowledge and better understanding.

这就是你在这里做播客的原因。

That's why you do what you do here in the podcast.

我知道你为此付出了多少，也知道你投入了多少心血来帮助牙医们提升。

I know how dedicated you are to that end and how much you've poured into this entity to help dentists improve.

因为如果牙医在临床实践中无法进步，我发现我们会对牙科感到失望。

Because if dentists can't get better in practice, I find we get disenchanted with dentistry.

因为当实践中出问题时，很容易自责。

Because when things go wrong in practice, it's very easy to blame yourself.

也许是以错误的方式。

Maybe in the wrong way.

因为如果我们不知道更好的方法，也许我们遇到问题的原因是我们培训中的差距，而不是我们能力上的差距。

Because if we don't know better, maybe the reasons we're having a problem is the gap in our training, not in the gap in our ability.

所以我认为这非常重要。

So I think it's really important.

那么我这样总结对吗？

So am I summarizing this correctly?

你是说我们花了太多时间在MIP上，关注那个静态的终末位置，而我们应该花更多时间评估整个系统？

Are you saying that we're spending way too much time with MIP and concerning ourselves with that, that being just a static terminal position, whereas we should be spending much more time evaluating the entire system?

嗯，那当然。

Well, that's for sure.

我不是说每个人的诊所都这样。

And I don't mean that in everybody's practice.

但我的重点是，MIP被大家想当然了。

But my point is MIP is taken for granted.

你让人咬合。

You ask somebody to close.

但咬合的方式千差万别。

But how they close has a huge range of variability.

比如，听这个节目的人里，有些人的MIP——我在牙医身上经常看到这种情况，因为我们总是拿真实患者当演示病例。

For example, there are people listening to this that their MIP and I see it in the dentist all the time because we always take a live patient and use them as the demo patient.

我们看到的咬合看起来很棒，牙齿好得我都羡慕，因为我的咬合可能没有我选作患者的那些牙医那么好。

We take occlusions that look amazing, teeth that I would personally kill for, because my occlusion might not look as great as some of the dentists that I choose as a patient.

但我的咬合是正常的，而他们的咬合有问题。

But my occlusion works and their occlusion is not.

他们磨牙、紧咬牙关，需要打肉毒素，有睡眠障碍，还有咬合问题，这些都是可以修复的。

They're squeezing, they're clenching, they need Botox, they have sleep disturbances, they have issues with the occlusion that are fixable.

而且不幸的是，牙医们喜欢用一个方便的标签。

And dentists unfortunately use a convenient label.

要么是磨牙症，要么是气道问题，要么总是别的什么，而不是他们可能能修复的、实际上可能是问题根源的东西。

It's either BruxZing or it's airway or it's always something other than something they could maybe fix that actually may be the root of the problem.

我认为这就是问题的根源，因为我们无法理解问题，因为我们看不到全局。

And I think it's the root of the problem because we're not able to understand the problem because we can't see the big picture.

那他们能修复的到底是哪些问题呢？

What are some of those things then that they can fix?

你说他们太急于归咎于磨牙症或睡眠呼吸障碍，但有哪些诊断是他们实际上能修复的呢？

You said they're too quick to blame it on bruxism, sleep disordered breathing, but what are some of the diagnoses that they can actually fix?

医生。

Dr.

所以首先，有三个因素影响健康的咬合，或者说就是那三个因素。

So first of all, there's three things that impact a healthy occlusion or those same three things.

如果这三个中的任何一个或多个不能正常运作，咬合就不会正常工作。

If any one of the three or many of the three are not working properly, the occlusion doesn't work properly.

而且这个范围是可以扩展的。

And scalable.

它还有一个严重程度的变化范围。

It's also a range of severity.

有些人在这三个方面之一有轻微问题，但他们没事，因为他们能适应。

Some people have minor issues in one of these three things, and they're fine because they're adapting.

但强迫人们去适应可能很危险，因为适应的代价会带来负担。

But forcing people to adapt is potentially dangerous because the price of adaptation takes a toll.

我一会儿再回到这个话题。

And I'll come back to that in a minute.

先让我说说这三件事。

Let me mention the three things first.

这三件事是：第一，你的下颌相对于头部的位置。

The three things are one, the position your lower jaw is referenced to your head.

当你试图闭嘴时，你是否需要用力把下巴推到一个位置？

When you try to close, do you have to force your jaw into a position?

你需要把下巴往后拉吗？

Do you have to pull it back?

你需要把下巴移到某个特定位置吗？

Do you have to shift it in a given position?

因为这告诉我们，你的牙齿其实并不能自然咬合。

Because what it's telling us is your teeth don't actually fit together.

你是在强迫自己的牙齿咬在一起。

You're trying to force fit your teeth together.

这是第一个问题。

That's number one.

第二个问题，当你看到我们称之为MIP的咬合，觉得它看起来很棒时，它真的那么好吗？

Number two, when you see the bite that we call MIP, that we believe looks amazing, is it really amazing?

你有没有问过患者，他们是否需要用力咬紧或者紧咬牙关？

Did you ask the patient, do they have to squeeze or clench?

因为很多人不使劲咬紧或者不紧咬牙关，就没法让牙齿合上。

Because many people can't get their teeth together without squeezing or without clenching.

这里有问题。

Something's wrong.

当我们使用扫描技术时，实际上可以通过碰撞的形式看到这一点。

When we use scanning technology, we can actually see that in the form of collisions.

所以当我扫描咬合时，我可以打开或关闭扫描仪的碰撞显示，看看患者实际上是怎么让牙齿咬合上的。

And so when I take my scan and scan the bite, I can turn on my scanner, the collisions on or off, and I can see what the patient is actually doing to make the teeth fit.

他们越费力去让牙齿咬合，就越容易出现那些可能被误认为是副功能、磨牙症或其他问题的症状。

The more they have to work hard to actually make them fit, the more symptoms they have that can be confused with parafunction, bruxing, many of these other things.

第三点不是右侧咬合、左侧咬合或前伸咬合。

And the third one is not right working, left working, protrusive.

而是下颌是如何闭合到牙齿上的。

It's how the jaw is closing into the teeth.

它会不会摩擦牙齿？

Does it rub on the teeth?

它会不会造成磨损？

Does it create wear?

这些被称为路径问题，或者我们以前说的功能包络。

Those are called pathway issues, or what we used to call envelope of function.

这三件事对今天的任何牙医来说都非常重要，必须掌握。

Those are the three things that are very important for any dentist today to master.

再跟我们多讲讲路径磨损吧。

Talk to us a little bit more about Pathway wear.

这个问题太关键了，一定要识别出来，而且最初就是你帮我认识到这一点的。

This is something so critical to recognize and it was really you that helped me to first recognize this.

这真的非常重要。

And this is so important.

你知道，你提到过你的使命之一就是帮助牙医减少执业中的烦恼。

Know, you talked about how part of your mission is to help dentists to have fewer headaches than practice.

而牙医们遇到的一个大麻烦就是，他们接诊了一个有路径磨损的患者，却没有识别出来。

And one of the big headaches dentists see is that they'll have a patient with Pathway wear that they didn't recognize.

然后他们就和这个患者开始了一个大型修复病例。

They'll embark on a big restorative case with this patient.

然后那个修复病例就变成了一场噩梦。

And then that restorative case turns into a nightmare.

它变成了很多计划外的复诊，很多病人的抱怨，还有牙医自己胃疼。

It turns into a lot of unplanned visits, a lot of complaints from the patient, loss of stomach lining on the part of the dentist.

所以识别路径磨损非常关键。

So recognizing pathway wear is so critical.

对，我觉得，你知道吗，挺有意思的。

Yeah, I think, you know, it's funny.

我平时讲咬合的时候都会用视觉辅助，比如图表和幻灯片。

I'm not used to talking about occlusion without visual assets and my diagrams and slides.

所以现在我只能用手来比划，就当是手偶来替代一下。

And so I have to use my hands as a hand puppet so I could substitute.

我中心里有价值几百万的技术设备，现在却沦落到用手比划了。

I have millions of dollars of technology here at the center, and I resorting to hand puppets now.

所以就这样……

So that's...

这招管用。

It works.

这招管用。

It works.

所以我想对那些正在观看的人说，如果你看我的手，这部分可以代表你的牙根扭矩。

So my point for for those just watching, if you watch my hands, this part could be your root torque.

我觉得我的手指和顶部之间发生的情况，让我把它放在一个黑色背景前，这部分叫做间隙。

And I think what happens between my finger on the top, and let me put it against maybe a black background, this part is called clearance.

它不是从上排前牙的外侧到下排前牙的外侧。

It's not from the outside of the upper front tooth to the outside of the lower front tooth.

它是两者之间的空间，因为下颌不是上下直着咀嚼的。

It's the space in between because the jaw doesn't chew up and down.

它有一个运动范围。

It has an envelope.

所有在听的人都知道这个运动范围。

And everybody listening knows about the envelope.

这对谁来说都不是新鲜事。

That's not new to anybody.

问题是，如果你通过正畸治疗把牙齿往后推，并且如何建立合适的牙根倾斜度，你可能无法正确暴露舌侧凹陷。

The question is, if you push the teeth back with maybe your orthodontic treatment and how you create the proper inclination of the root, you might not expose the lingual concavity properly.

或者在冠桥修复中，当我们制作新牙冠时，我们是如何尊重这种关系的？

Or in crown and bridge, when we manufacture new crowns, how are we respecting this relationship?

这种情况不仅发生在前牙，也发生在所有后牙上，上牙的颊侧斜面在颌骨移动和咀嚼时也会出现。

And this occurs not only around the front teeth, it occurs on all the posterior teeth, the buccal inclines of the the upper teeth as the jaw is moving and chewing.

如果发生摩擦，会产生三种情况之一。

If it rubs, it creates one of three things.

它会产生磨耗，我们看到那些小平面，有些人会误认为是副功能。

It creates attrition, where we see those as facets that some people misinterpret as parafunction.

我们会看到牙齿松动，我们正式称之为原发性咬合创伤。

We see mobility that we call officially primary occlusal traumatism.

这意味着下颌或牙齿过早地撞到对面的牙齿。

That means the lower jaw or the teeth bump into posing teeth prematurely.

而且我们知道，这种负荷会导致牙齿松动或者术后敏感。

And we know that we get mobility or we get post op sensitivity from the load.

第三种情况，大家都熟悉，就是出现回避性咀嚼模式。

Or the third, everybody knows this one, is we get an avoidance pattern.

下颌想咀嚼，但有什么东西挡着，所以它就绕开，寻找不同的运动轨迹。

The jaw wants to chew, something's in the way, so it avoids it and finds a different envelope.

这会导致肌肉疲劳和肌肉酸痛。

That creates muscle fatigue and muscle tenderness.

所以我们在临床上看到三种失败模式，表现为牙齿松动、疼痛或肌肉功能紊乱，而牙医往往把这些当作疾病来看待。

So what we see in practice are three modes of failure, where mobility and pain or dysfunction in the muscles that dentists look at as diseases.

其实这些都是身体的适应机制。

Those are adaptive mechanisms.

身体通过这些机制来调整系统，让它继续发挥应有的功能。

That's what the body is doing to adapt the system and help it continue to do what its purpose is.

也就是咀嚼、说话、吞咽和呼吸。

That's to chew, speak, swallow, and breathe.

它用于这四件事。

It's used in those four things.

所以如果任何东西干扰了这个系统，它会试图自我修复。

And so if anything disrupts the system, it will try to fix itself.

这就是风险稳态的全部含义。

So that's what risk homeostasis is all about.

所以当牙医来到中心时，讽刺的是，他们说我想学习治疗磨损病例。

And so when dentists come to the center, it's ironic, they say I want to learn to treat a wear case.

那并不是你真正应该关注的。

That's not really why what you should be focusing on.

你应该关注的是他们为什么会磨损。

You should be focusing on why they get wear in the first place.

你想要学习的是病因，理念，并治疗理念，以获得更好的结果潜力。

What you want to be able to learn is the is the cause, the ideology, and treat the ideology to have much better outcome potential.

我们倾向于治疗症状。

What we tend to do is treat symptoms.

我们用夜用护齿套和肉毒杆菌。

We use night guards and we use Botox.

我们用一些方法来减轻症状，却没有真正意识到也许我们可以治疗根本原因，因为没有人天生就磨牙，也没有人天生就要毁掉自己的牙齿。

We use things to reduce symptoms without really realizing that maybe we can treat the parent reason, because nobody was born grinding their teeth and nobody was born to destroy the dentition.

这说不通。

It doesn't make sense.

所以我相信，通过我们的理解和学习，我们可以为患者做得更多，修复这个系统，而不需要夜用护齿套，不需要肉毒杆菌，不需要药物，也不用受苦。

So I believe that we could do more for our patients in through our understanding and learning to fix the system and not need a night guard and not need Botox and not need medication and not suffer.

我看到很多牙医在受苦。

I see so many dentists suffering.

我的意思是，如果你问自己一个简单的问题，我们诊所里都有颞下颌关节紊乱的患者。

I mean, if you ask yourself this one easy question, we all have patients with TMD in the practice.

你们诊所里有多少颞下颌关节紊乱的患者是超过70岁的？

How many patients in the practice with TMD do you have that are over 70?

他们都去哪儿了？

Where did it go?

它适应了。

It adapted.

这些患者要么关节适应了，要么消除了干扰因素，或者其他什么病因因素。

These patients found ways to either have an adaptation in the joint or took out the interference or whatever that was an ideologic factor.

他们自己痊愈了。

They healed themselves.

但他们是付出了代价才痊愈的。

But they healed themselves at a price.

而你现在要为余生付出代价。

And now you pay the price for the rest of your life.

这就是为什么气道对帮助孩子正常发育如此重要，这样他们就不会长大后成为牙齿残废。

This is why airway is so important to help our kids grow properly, so they don't grow up as dental cripples.

所以这是少数几件我们可以为年轻人做的事情之一，帮助他们超越基因的预设。

So it's one of the few things we can do to younger people and help them through beyond even what their genetics have planned for them.

我问你一个问题。

Let me ask you something.

你从牙科学校毕业的时候，有没有想过自己会接手那些高难度的复杂病例，做那种让你上班路上都兴奋不已的牙科工作？

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?

就是那些复杂的病例。

Cases, etc.

还是说你发现自己被困在那种重复、无聊、让人困惑，甚至可能让你觉得没有成就感的牙科工作里？

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

你是不是因为那些不可预测的失败而沮丧，比如牙冠脱落、病人不满意，而且你甚至不确定为什么会这样？

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，你成为了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.

那种思路清晰、自信、稳定，而且不局限于常规治疗的牙医。

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

他们受人尊敬，被同行推荐，而且感到满足，因为他们的工作既有意义又有挑战性。

They 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.

我们培养出卓越、全面的牙医，让他们成为自己一直想成为的临床角色。

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，每个月都有直播的继续教育讲座，覆盖我们社区最想了解的话题。

Inside our program, you will find live CE lectures every month that cover the topics our community wants most.

从种植牙到咬合，从治疗计划到前牙复合树脂修复。

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，不仅教你该怎么做，还教你如何思考。

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，你可以在这里提出真实的临床挑战，获得深思熟虑、基于证据的答案，而不会被随机的Facebook群组里的噪音干扰。

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，能磨出刃来。

I believe that iron sharpens iron.

你的水平就是你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.

如果你有共鸣，我想亲自邀请你去 elevatedgp.com，成为我们中的一员。

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

那么，路径磨损的解决方案是什么呢？

So what then is the solution to Pathway wear?

你觉得其中一部分可能只是正畸或正颌手术吗？

Would you say part of it could just be orthodontics or orthognathic surgery?

博士。

Dr.

所以首先，当我们看到牙齿上的磨损面时，我们认为——你用的“路径磨损”这个词，非常适合我们的讨论，我可以这样描述。

So first, again, it would be when we see wear facets on teeth that we believe, and the term you're using pathway wear, and it's perfect for our discussion, I can describe it this way.

我们所说的“路径磨损”有两个原因。

There's two reasons for what we'll call Pathway wear.

一个可能是，你正在修复的牙齿是否在患者正常的咀嚼范围内，也就是他们咀嚼的方式。

One would be, is the tooth that you're building in the way of the patient's normal envelope, the way they chew?

而牙医们看不到这一点，因为要理解真正的运动路径，实验室里这个空间是静态的，就是这个空间。

And dentists are not able to see that because to understand the actual pathway, this space that is in the lab is a static space, this space.

这个空间并不是用来闭合的，因为一旦闭合，我们就会干扰运动路径，造成磨损，或者移动牙齿，或者把下颌往后推。

It's not a space meant to close because when we close it, we disrupt the pathway and we create attrition or we move the teeth or we drive the jaw back.

所以一个原因或问题就是，如果我们放了一颗牙，或者由于生长发育，这颗牙挡在了下颌想要咀嚼的路径上。

So one reason or one problem is if we place a tooth or through growth and development is in the way the jaw wants to chew.

这是第一个原因。

That's one reason.

第二个原因是，如果大脑找不到你的正中咬合位，它就会寻找，运动路径就会比正常的大，然后你就会撞到牙齿，结果前牙就磨平了。

The second is if the brain can't find your MIP, it searches and the pathway is larger than it should be, and you bang into teeth, and now you get flat front teeth.

我是说，如果你的前牙边缘有磨损，那肯定有问题。

I mean, if you have worn edges on your front teeth, something's wrong.

这种情况不应该发生。

That should never happen.

我们应该在牙齿后面咀嚼。

We should chew behind our teeth.

我们绝不应该在牙齿的边缘上咀嚼。

We should never be out on the edges of our teeth.

我告诉牙医们，把下颌移到牙齿边缘试试。

And I tell dentists, take your lower jaw and move it to the edges of your teeth.

如果那样感觉舒服，那你就有问题了。

If that feels good to you, you have a problem.

肯定哪里不对劲。

Something is wrong.

所以我觉得我们可以在这方面大有作为。

And so I think we could go a long way to fix that.

所以我想你提到的正是学习过程的第一步，就是识别哪些有效，哪些无效。

So I think what you're alluding to is the first part of the learning part is recognizing what's working and what isn't working.

为了我们今天讨论方便，我们稍微回顾一下，我简单点说。

And to roll that back a minute for purposes of our discussion today, I'll make this easy.

你的牙齿一生中的磨损不应该超过一毫米。

Your teeth should not have more than one millimeter of attrition or wear in your lifetime.

为了这个播客的目的，我就不详细讲文献综述了，直接说重点。

And for purposes of the podcast, I'm not going into all the lit review or cutting to the chase.

所以当你看到二三十岁的人牙齿磨损一到两毫米时，跟他们解释就简单多了，比如：先生，

So it's much easier when you see 20 and 30 year olds with one to two millimeters of attrition on their teeth to explain to them, Mr.

琼斯先生，你的门牙边缘磨损了两毫米。

Jones, you have two millimeters of wear on the edges of your front teeth.

这通常相当于两百年的使用量。

That would be normally two hundred years of use.

我的意思是，一百年内，你不应该磨损超过一毫米。

I mean, in one hundred years, you shouldn't lose more than one millimeter.

但牙医们没意识到的是，我们可以要求患者达到的标准其实比我们现在允许他们达到的要高得多，因为我们总是假设这是磨牙症，是没法控制的事情。但实际上，我认为你可以控制它，或者比你想象的更能控制那些不良后果。

And so what dentists don't realize is the standard that we could hold accountable to patients is much higher than we're allowing them to achieve because we just assume, it's Brux saying, it's something we can't control When in fact, think you can control it or control the adverse events more than you think.

你提到大脑可能找不到那条通路。

You talked about how the brain might not be able to find the pathway.

你能解释一下是什么原因导致的吗？

Can you explain a little bit what would cause that?

我先讲个小故事吧。

Let me start with us a little story.

我们今天一开始聊的是关于咬合的神话传说。

We started the conversation today with the discussion about the heritage of mythology or occlusion.

我总结的时候说得有点机械。

And my comment to summarize it was a bit mechanical.

为了让听众更容易理解，其实这跟装一颗牙冠没什么两样。

And so to help the listener maybe relate to that a little better, it's no different than when you place a single crown.

你做的第一件事就是调整上下咬合，也就是正中咬合。

What's the first thing that you do is adjust the the up and down bite or the MIP bite.

我故意说得特别简单，因为我觉得这正好能说明单颗牙冠是怎么操作的，然后我再详细解释一下。

And I'm keeping it overly simplified for a reason because I think it just demonstrates how practice works for single units, and then I'll explain a little more.

装上去之后，如果有点高，病人会告诉你，你就一直调，直到他说完美为止。

And so when it's placed, it's a little high, patient tells you, and you adjust it until they say it's perfect.

但当你去检查正中咬合的时候，可能根本碰都碰不到。

Well, when you go in and check the MIP bite, it probably doesn't even touch at all.

他们说很完美，是因为他们没察觉到上下咬合有干扰，而不是真的完美。

And they say it's perfect because they don't recognize an interference in the up and down part, not because it's really perfect.

然后我们就想，希望这样没问题吧。

And we go, I hope it's going to be okay.

因为外面的人常说，留低一点，让它自己长。

Because out there people say things like leave it low and let it grow.

因为它会适应。

Because it'll adapt.

这是一种积极的适应，牙齿会自己找接触，所以没问题。

And that's a positive adaptation, where teeth seek contact, and it's going to be okay.

但记住，首先，这长期来看是行不通的。

But remember, first of all, that doesn't work long term.

如果你要做整排牙，或者种植牙也一样。

If you're going to do an arch, or even in implants.

你知道，你去上课，人家会说种植牙的咬合和普通咬合不一样，因为它是骨性结合界面。

You know, you go to courses and people say implant occlusion is different than regular occlusion because it's an ankylosed interface.

所以当你放上修复体时，应该故意做得轻一点，这样它就不会干扰，也无法调整。

So when you place the restoration, it should be light on purpose so that it doesn't interfere and it can't adjust.

那我怎么教别人做全口呢？

Well, how am I going to teach someone to do a whole arch?

因为全口不可能都做得轻，总得有接触的地方。

Because you can't put a whole arch in light, something has to touch.

所以人们误解的是把风险管理策略当成了概念。

So what people misinterpret is a risk management strategy for a concept.

这是第一点。

That's number one.

所以我认为让牙齿均匀接触、力度相等绝对是一个正确的方法。

So I would say having the teeth touch evenly, equal intensity is absolutely a proper method.

第二件事是，我简直不敢相信我作为专家这么多年都这么做，就是放上牙冠。

The second thing that we do is I can't imagine I did it for so many years even as a specialist, is we place the crown.

然后我们对病人说，我需要检查一下你下颌的运动。

And now we say to the patient, I have to check the movement of your jaw.

所以你让病人上下闭合，然后把下巴往右移。

So you ask the patient to close-up and down and move their jaw to the right.

对我们来说，科学的部分就是检查右侧工作侧。

And the science part for us is we're checking right working.

我的病人会问，你要我动哪边下巴？

And my patients would say, which jaw do you want me to move?

我就会想，这问题也太离谱了吧？

And I would think, what kind of a ridiculous question is that?

但我还是会回答他们，不让他们觉得难堪。

But I would answer them without hurting their feelings.

嗯，我们今天先只动下颌吧。

Well, we'd like to move for today just the lower jaw.

我这么做了，他们却告诉我动不了。

And I get through that, and they tell me it won't go.

我心里就想，你这是什么痉挛体质啊？

And I'm thinking, what kind of spastic person are you?

你的下巴怎么会动不了呢？

How could your jaw not go?

然后我伸手帮你……

And I give you a hand...

我拿一面手镜放在你面前，让你看着镜子，闭上嘴，把下巴往右移，结果他们的眼珠子动了。

Hold a hand mirror in front of you, ask you to look in the mirror and move your look close and move your lower jaw to the right, and their eyeballs move.

不不不不，不是眼珠子。

No, no, no, no, not your eyeballs.

我拍拍你的肩膀，让你把下巴往右肩移，结果他们的头往右偏了。

I tap you on your shoulder, move your lower jaw to the right shoulder, and their head moves to the right.

不不不。

No, no, no.

我需要你闭上嘴，把下巴往右移，就像我在研究生院学的那样。

I need you to close your jaw and move it to the right, just like I learned in graduate school.

现在回想起来，我觉得这太可笑了。

And I think about that now and I think, how ridiculous is that?

怎么可能在咬紧、激活咬肌和颞肌、完全闭合的情况下再移动呢？

How is it possible to close, activate masseter temporalis muscles, full closure and now move.

因为要移动，就必须放松这些肌肉。

Because to move, you have to release them.

我们不是让他们完全放松。

And we're not asking them to just release them.

我们只是让他们放松到刚好够的程度。

We're asking them to release them just enough.

这样你还能保持尖牙接触，然后进入这个叫右侧工作侧的运动。

So you can still make maintain contact inside the cuspid and go into this movement called right working.

实际上，只有我们这些人会做右侧工作侧、左侧工作侧和前伸运动，因为我们在学校就是这么被训练的。

And the only people that actually go right working, left working and protrusive are us, because we were trained to do that in school.

这不符合生理学。

It is not physiology.

普通人根本做不到。

It can't be done by laypeople.

如果他们不这样做，那就不是他们能完成的动作。

If they don't do that, it's not a movement that they accomplish.

所以我们做的咬合评估，其实并不是他们平时会做的事情。

So what we're doing is our evaluation of occlusion is not something they actually normally do.

这不是生理功能的一部分。

It's not part of physiology.

所以人们在牙齿使用和我们治疗牙齿的方式之间，存在一个很大的分歧和脱节。

And so there's a big divergent break, a breakdown in what people do with their teeth and how we treat their teeth.

而这个差距，我们需要去弥合。

And that gap, that gap we need to close.

这个差距就是要细化你刚才问我的问题——最佳咬合，让牙齿没有碰撞，均匀闭合。

And that gap is refining what you just asked me, the best bite, so there are no collisions, the teeth close evenly.

比如，你现在做不到，因为我知道你正在接受治疗。

For example, you you can't do it right now because I know you're undergoing treatment.

但如果有人只是轻轻闭合然后咬紧，却感觉到其他部位有压力，那就不对了。

But if somebody just closes lightly and squeezes, and they feel intensity in other areas, something's not right.

所以你的大脑必须去适应这种情况。

And so your your brain has to adapt to that.

要么你适应它，要么它就成了不舒服的来源。

And either you deal with it or it's a source of discomfort.

另一个是，当你咀嚼时，不应该碰到你的牙齿。

The other one is when you chew, you shouldn't bump into your teeth.

它本来就不是那样设计的。

It wasn't designed like that.

所以如果我们制造了干扰，身体就会去适应，把它磨损掉，把它移开，打开空间，形成磨损面，或者产生回避模式，导致肌肉不适。

And so if we create interferences, the body is going to adapt, wear it out, move it out of the way that open spaces, creates wear facets, or avoidance patterns creates muscle discomfort.

于是整个循环又开始了，人们会感到不舒服，但我们可以修复它。

So that whole circle starts again and people become uncomfortable, but we can fix it.

所以如果我听得没错的话，你是说我们评估修复体咬合的方式是不准确的。

So if I'm hearing correctly, you're saying that the way that we're evaluating occlusion on restorations, it's inaccurate.

它并不能很好地反映患者实际的功能情况。

It's not very reflective of the way the patient actually functions.

不过我还是想再听一遍。

I just want to hear this again, though.

那你建议牙医怎么评估修复体的咬合呢？

How are you proposing dentists evaluate occlusion on a restoration?

咱们先拿一个后牙单冠来说吧。

Let's just start with a single posterior crown.

好，那就这么办。显然，为了直奔主题，我会说我们现在做的……

Let's do that because, obviously, to try to cut to the chase, I would say what we're doing...

我不会用的词是“不准确”。

The word I I wouldn't use is is not that it's inaccurate.

我会说，首先，可能是不够。

I would say maybe number one, it's not enough.

因为显然，你不会希望任何病人在你日常的诊所里带着修复体和早接触离开。

Because obviously, you don't want anybody leaving your day to day practice with the restoration and premature contact.

我的意思是，大家都知道这一点，从……

I mean, everybody knows that from...

这是牙科学校的基础概念。

This is dental school 101 concept.

所以我们都在用现有的有缺陷的方法尽力去做，因为咬合纸是一种医学诊断工具，它有假阳性和假阴性。

And so we all do that the best we can with the flawed methodologies that we have, because articulating paper is a medical diagnostic and it has false positives and false negatives.

所以学会正确操作需要一些功夫。

So learning how to do that properly takes some work.

但假设我们都能学得不错。

But let's just say we all learn to do that reasonably well.

我觉得对大多数人来说，这不是一个很大的学习曲线。

And I don't think that's a big learning curve for most people.

但我觉得下一个问题是，当你让他们做右侧工作侧、左侧工作侧时，即使他们能做到，也没有人会回来说你的新牙冠在闭口和向右移动下颌时，右侧工作侧不工作。

But I think the next one is when you ask them to go right working, left working, even if they can do it, nobody comes back with your restoration saying, your new crown doesn't work when I close and move my jaw to the right, right working.

他们只会说吃饭的时候不行。

They tell you it's not working when I'm eating.

他们会给你一个生理上的原因来解释为什么会出现这种情况。

They give you a physiologic reason that this is happening.