我们与吉姆·麦基博士一起探讨对咬合关系的不断深入理解

听着，曾经有一段时间我真的很不喜欢牙科。

Listen, there was a point in time when I really did not enjoy dentistry.

有些日子我甚至非常讨厌它。

Some days I even downright hated it.

我觉得我的牙科学校没有为现实世界做好准备。

I felt like my dental school did not prepare me for the real world.

当你不知道发生了什么的时候，牙科并不是一件有趣的事。

Dentistry is not a lot of fun when you don't know what's going on.

我今天能走到这一步，多亏了导师、三年的住院医师培训，以及良好的继续教育。

I am where I am today because of mentors, a three year residency training, and good CE.

我想把这个带给你：成为ELEVATED GP的会员，这样你就能通过能力获得自信。

And I wanted to bring this to you: Become a member of ELEVATED GP, so you can get confident through competence.

这是一个会员计划，你可以访问按需课程和我们的月度学习俱乐部，也就是期刊俱乐部。

This is a membership program where you'll have access to on demand courses and our monthly study club, also known as journal club.

要注册，请访问theelevatedgp.com。

To get registered, go to theelevatedgp.com.

希望能在那里见到你。

I hope to see you there.

欢迎回到我们与著名吉姆·麦基对话的第二部分。

Welcome back to part two of our conversation with the renowned Jim McKee.

在上一周的节目中，我们探讨了咬合、颞下颌关节紊乱的基础知识，以及全面的诊断方法如何改善患者的治疗效果。

In last week's episode, we explore the fundamentals of occlusion, TMJ disorders, and how a comprehensive approach to diagnosis can transform patient outcomes.

本周的内容，我们将更深入地讨论基于病例的策略、长期稳定性，以及处理复杂咬合和关节问题的细微之处。

This weeks installment we're diving even deeper discussing case based strategies, long term stability, and the nuance of treating complex occlusal and joint issues.

如果你曾经在处理颞下颌关节患者时感到棘手，或者想知道如何创造可预测、稳定的结果，那你一定不能错过这一集。

If you've ever struggled with managing TMJ patients or wonder how to create predictable, stable outcomes, you don't wanna miss this.

顺便说一下，如果你喜欢这个播客，并想支持它，让它继续为你提供帮助，你介意花点时间在Apple Podcast应用、Spotify或你收听播客的任何平台上留下评分并订阅吗？

By the way, if you enjoy this podcast and wanna support it so it can continue to support you, would you mind taking a moment to leave a rating and subscribe on the Apple Podcast app, Spotify, or wherever you get your podcasts?

好了，我们开始吧。

Okay, let's jump in.

所以，这是成功的大型修复病例中最关键的部分之一，甚至可能是最关键的。

So this is one of the most, if not the most critical component in a successful, big restorative case.

而且这看起来就像是那个经常被忽视的缺失拼图。

And it seems as if this is the missing puzzle piece that is so often discounted.

因为在这些大型修复病例中，我们确实会看到这些问题。

Because with these big restorative cases, we see these issues.

我们看到这些有磨损的患者。

We see these wear patients.

我们看到这些牙齿损坏的患者，然后我们只是觉得，哦，这是因为三氧化二锆的不足造成的。

We see these broken down patients, and we just think that, oh, this happened because of a deficiency of three y zirconia.

如果我以某种方式修复了这个问题，他们就会高高兴兴地继续生活，而且这个修复能持续五十年。

If I somehow fix this, then they're gonna go on their merry way, and this is gonna last the next fifty years.

但除非关节问题得到解决，否则他们最终还是会回到同样的状况。

But until the joint is addressed, they're gonna wind up in the same position.

我们换个话题，不谈那些直接的患者。

Let's move away from their straight up patient.

他们会去找那个12岁的二类错颌的女性患者。

They'll go to the 12 year old class two female.

太可惜了。

So sad.

说说那个病例吧。

Talk about that case.

真的挺让人难过的。

It's so sad.

那个病例是怎么回事？

What happens in that case?

通常你会看到的是，正畸治疗中牙齿后缩，口腔容积减小，舌头移位的风险增加。

Typically, you see is you see retractive orthodontics, you see decreasing oral volume, increasing risk for a displacement of the tongue.

现在有人争论这种情况是否会发生，我理解这种争议。

Now, people argue whether that happens or not, and I get that.

但一般来说，我们的做法是尽量把二类错颌的患者变成一类错颌。

But generally, what we do is we try to take the class two patient and turn it into the class one patient.

通过缩小口腔空间来实现。

By making the box smaller.

通过把盒子变小。

By making the box smaller.

但是你知道，为什么我们一定要把病人矫正到一类咬合呢？

But you know, why why do we have to get it to a class one patient?

因为如果做到了，那我们就赢了正畸这场游戏。

Because if then, then we win the ortho game.

我的意思是，那……

I mean, that's...

那些是正畸医生必须检查的标准。

Those are the boxes that the orthodontist has to check.

因为如果我是正畸医生，我会把二类咬合的病人转回给我的转诊牙医。

Because if I'm an orthodontist, I'm going to send the class two patient back to my referring dentist.

我可不想把前牙开合的病人送回去。

I don't want to send them back with an anterior open bite.

我是说，那得花多长时间才能解决啊，你知道，X医生转回来的病例，前牙都咬不上。

I mean, how long is that going to take to get out in the area that, you know, doctor x sends the cases back and they're not coupled in the front?

我们其实已经把我们的正畸医生推向了失败的境地。

We've we've, you know, we've really set up our orthodontist to fail.

这必须改变。

That needs to change.

我们需要在这个问题上把好关，因为我们是……

We need to be the gatekeeper in this problem because we're the...

嗯，我们是第一个看到问题的人。

Well, we're the people that see it first.

你知道，我们信任正畸医生，所以他们应该已经看过这个了。

You know, we believe in an orthodontist, so they should have looked at this.

不，我们应该自己看。

No, we should have looked at this.

如果有一个12岁的女孩是二类错颌，那我们的工作就是把病例准备好。

If there's a class two patient that's a 12 year old female who's class two, that's our job to work up the case.

而不是正畸医生。

Not the orthodontist.

这会让正畸医生在社区里处于竞争劣势，因为他们必须收取诊断记录的费用，这样他们自然会比街对面不这么做的正畸医生更贵。

It's gonna put the orthodontist at a competitive disadvantage in their community because they're gonna have to have a fee for diagnostic records, they're automatically gonna be more expensive than the orthodontist down the street who isn't doing that.

那……

That's...

这根本行不通。

It's just not gonna happen.

另外，就像我说的，最终正畸医生会看这个病人两年。

The other thing is, you know, like I said, ultimately, the orthodontist sees the patient for two years.

而我可能会看这个病人接下来的二十五年。

I may be seeing this patient for the next twenty five years.

所以我才需要对此负责。

So I'm the one who needs to be responsible for that.

正畸医生需要了解情况并参与讨论，但我认为责任在于修复科医生。

The orthodontist has to be aware of the situation and tied in the discussion, but I think the responsibility lies with the restorative dentist.

话虽如此，那里也有巨大的机会。

Now having said that, there's a huge opportunity there too.

因为现在你可以开始用一种以前从未有过的方式帮助患者了。

Because now what you can start to do is you can to help patients in a way that you could never help them before.

你可以避免很多未来的问题。

You can avoid so many future problems.

你知道吗？

And you know what?

现实是，我们会遇到一些二类错颌的患者，他们的前牙根本没法咬合在一起。

The reality is we're gonna see class two patients where they're not gonna be able to get their front teeth together.

所以我们和正畸医生讨论的要点是，第一，你是打算把牙齿往后收吗？

So our discussion point then with the orthodontist is, a, are you going to retract the teeth?

或者第二，我现在告诉他们的是，让他们保持开颌，只是把牙齿放到自然的轴向倾斜角度，尽量把牙弓整平和排齐，以便在上下颌现有的结构基础上，让牙齿以最好的方式咬合在一起。

Or b, what I'm telling them today is leave them with an open bite, just put their teeth at their natural axial inclination, and try and level and align the arches to give me the best possible way the teeth will fit together, given the structural foundation that we're dealing with at the maxillary and mandibular level.

所以，如果我没理解错的话，你的意思是，我们把这些结构基础有问题的患者交给正畸医生。

So what I'm hearing you say, if I'm not mistaken, is that we are sending our orthodontists, these patients that it's foundationally compromised.

这是一个骨骼性的

This is a skeletal

问题。

issue.

而且我们还在说，尽管地基已经裂了，我们还是想要一个完美的结果。

And we're saying we still want a perfect outcome despite the foundation being cracked.

牙齿只是骨骼的延伸。

The teeth are just an extension of the skeleton.

如果牙齿咬合不上，那就是骨骼对不上。

If the teeth don't fit, it's the skeleton doesn't fit.

我们不能神奇地移动牙齿让它们咬合，而骨骼却对不上。

We can't magically move the teeth to make them fit together and the skeleton doesn't fit.

我们可以移动一些牙齿，也许能让它们咬合，可能有效，但骨骼差异越大，用正畸来调整就越困难。

We can move some and we can move them maybe into some way that they fit and it may work, but the larger the skeletal discrepancy, the more difficult it is to use orthodontics to do that.

这最终就是为什么口腔...

That's ultimately why oral...

正颌手术发展起来的原因，就是为了能够改变骨骼的位置。

Orthognathic surgery developed was to be able to change the skeletal position.

你觉得这会不会就是为什么百分之九十九的牙医……

Do you think that this might be one of the reason that for ninety nine percent of dentists...

我是说，真的，百分之九十九的牙医都觉得咬合是个黑匣子，他们花掉买一辆好车的钱去跟人学咬合，你觉得是不是因为我们在这么多讨论中，就是忘了骨架？

I mean, seriously, ninety nine percent of dentists feel like occlusion is a black box, and they go and pay the amount of money it would take to buy a nice car to go to learn from people about occlusion, do you think it's because in so much of this discussion, we are just forgetting the skeleton?

没有这一块拼图，其他一切都说不通。

And without that piece of the puzzle, none of it makes sense.

而且……

And...

但骨架常常被忽略的原因，是因为直到最近，才有像你这样的人开始做影像检查。

But the reason though that oftentimes the skeletons forgotten, because it isn't only until very recently in our history where people like you start doing imaging.

毫无疑问，如果我们只看牙齿，那是不完整的。

There's no doubt that if we just look at the teeth, it's an incomplete picture.

你知道吗，我以前就是这样。

You know, that's what I did.

我出去四年半，听了皮特·道森的演讲，皮特真的是第一个把咬合讲得让我理解的人。

I was out four and a half years, I heard Pete Dawson speak, and Pete really was the first one that presented an occlusion in a way that I understood it.

一年后，我又听了Mark Piper的讲座，这次我从关节层面真正理解了咬合，这是以前没人能讲清楚的。

A year later, I heard Mark Piper speak, and I understood occlusion at the joint level in a way he hadn't understood it before.

把这两点结合起来，如果你能从关节层面搞懂咬合，那牙齿层面的问题也就迎刃而解了……

Putting those together, if you can figure out occlusion at the joint level, then you can figure out a tooth...

也就是牙齿层面的咬合关系。

Occlusion at the tooth level.

说实话，我觉得这……

Honestly, I think it's...

我甚至不确定，在不了解关节状况的情况下，是否有可能确定牙齿的设计方案。

I don't even know if it's possible to be able to figure out how you want to design the teeth, unless you know the condition of the joint.

我们之前讨论过，希望在侧向移动时前牙有接触，以此来关闭肌肉并使后牙分离，但这前提是髁盘覆盖着内侧极。

We talked before about wanting to make sure we had front teeth contact when we move side to side, to shut off the muscles and to separate the back teeth, that's if the disc is covering the medial pole.

如果髁盘没有覆盖内侧极，而我们有前牙引导，你可以把它想象成一种前牙脱位器。

If it's not covering the medial pole and we have anterior guidance, I want you to think about that like an anterior deprogrammer.

因为在侧向运动中，即使我们是用尖牙在接触，但如果髁盘没有覆盖骨头，当我们咬合时，效果就跟咬在前牙脱位器上是一样的。

Because even in a movement and we're out on our canines, but we don't have the disc covering the bone, when we bite down, it's the same as biting on an anterior deprogrammer.

力量分布在牙齿和关节之间。

The forces are distributed between the teeth and the joints.

如果排除后牙的参与，关节处的负荷就会增加。

If you take the back teeth out of the discussion, we're going to increase the load at the joint level.

如果关节盘还在，那没问题；但如果关节盘不在，我就不想这么做了。

That's great if we've got the disc there, but if we don't have the disc there, I might not wanna do that.

我可能会让一些后牙参与进来，帮助减轻前牙的负荷，这样也能减少髁突在无保护状态下所承受的压力。

I may want to include some of the posterior teeth along to help decrease some of the load on the front teeth, which is gonna decrease the load on seating the condyles in a position where they don't have any protection.

我们先稍微回顾一下。

Let's back up a little bit.

DeepMind刚才解释了前牙去程序器的功能。

DeepMind just explaining the function of the anterior deprogrammer.

再说一遍，当然。

And again Sure.

你知道，市面上有各种各样的去程序器。

You know, there's different ones that exist out there.

这是讨论中的一个关键部分。

This is a critical part of the discussion.

前牙去程序器传统上用来让前牙接触，同时让后牙分开。

Anterior deprogrammers have been traditionally used to provide contact on the front teeth and separate the back teeth.

当时的想法是，这样能提供一个好办法，帮你判断问题是肌肉性的还是关节囊内的。

The thought was it would give you a nice way to be able to try and figure out if the problem was muscularly based or intercapsularly based.

他们认为，如果疼痛加重，那可能是关节囊内的问题。

Thinking that if the pain got worse, it may be an intercapsular problem.

他们的思路是，如果问题出在肌肉上，把后牙分开后，就不会有触发翼外肌收缩的因素，那些因为收缩而疲劳或酸痛的肌肉就不需要再那样工作了，这样肌肉就能放松，你也会感觉好一些。

The thought process was if the problem was muscle, if you separated the back teeth, there wouldn't be a trigger for the lateral pterygoid to contract, and therefore those muscles that were tired or sore from contracting would now not have to do that, and then those muscles could release, and you'd feel better.

这就是当时的思路。

Now that's the thought process.

不过现在我觉得，很多情况其实取决于疼痛，而我对这个问题的看法已经变了。

Ultimately, I think today, a lot of that is dependent upon pain, and my feeling has changed on that.

我不认为疼痛像我们以前想的那样，是一个准确的指标。

I don't think pain's as an accurate as barometer as we thought.

有很多年轻患者正在成长，他们没有疼痛，但因为他们骨头上没有椎间盘，所以长得不太好。

There's a lot of young patients who are growing, they have no pain, but they're not growing very well because they don't have the disc on top of the bone.

一般来说，成长中的患者要到十五六岁才会出现疼痛。

Pain you don't see in growing patients generally till they're in their mid teens.

七八年前做过一项研究，分三组，五到八岁、八到十五岁，还有十五岁以上。

Did a study seven or eight years ago, group one, group two, group three, five to eight, I think, to 15 and 15 plus.

他们直到第三组才感到疼痛，尽管他们早期都有关节问题。

They didn't feel pain till group three, even though all of them had joint issues early.

疼痛，你不能只考虑疼痛，我觉得它不是……

Pain pain, you can't think about pain, I don't think is a...

不是有效的筛查工具。

Is an effective screening tool.

所以有疼痛的患者只是这些TMD患者中的一小部分。

So the patients with pain is only one small subset of these TMD patients.

也许小或不大，但我觉得……

Maybe small or not, but I think...

我觉得更好的说法是……

Here's what I guess it would be a better way to...

我会这么说。

That I would say it.

我觉得疼痛之前通常已经发生了什么。

I think something has usually happened before the pain.

疼痛不是他们最先感受到的。

Don't think the pain is the first thing they feel.

通常，最先发现的是咬合问题。

Usually, the first way you pick it up is the bite.

这个问题很基础。

So this is a very rudimentary question.

但对于关节盘健康的患者，牙齿应该怎么咬合呢？

But in the patient with the healthy disc, how should the teeth be occluding?

我问这个是因为，你知道，有不同的学派，不同的理论，你可能会遇到……

And I'm asking this because, you know, there's just different schools of thought, there's different theories out there, you could have.

我跟你说说我的看法。

I'll tell you my belief.

如果我的病人关节正常，我会先看看他们的口腔。

If I have a patient who has a normal joint, I'm gonna look at their mouth.

如果他们没有任何问题，只是有一毫米的滑动，我一般不会做什么处理。

And if they're not having any problems and they have a millimeter slide, I'm generally not going do anything.

现在，假设同样的情况，下第二磨牙折裂了。

Now, let's say the same case, a lower second molar fractures.

那你要在哪里重建呢？

Now where do you build it?

你是把它重建回那个滑动里，还是试着调整牙齿让它们都能咬合在一起？

Now do you build that back into the slide, or do you try and reshape the teeth to get everything to fit together?

这就是问题所在。

That's the issue.

就我个人经验来说，我接受的培训非常强调正中关系，这来自皮特·道森。

Personally, experience, I grew up in a really heavily centric relation based training from Pete Dawson.

所以我几乎给每个人都做了咬合调整。

So I equilibrated almost everyone.

那时候就是这样。

That was the time.

是啊，那时候确实是这样。

You know, it was the time.

我现在做的咬合调整没有以前多了，但我仍然相信它。

I don't do as much equilibration as I used to, but I still believe in it.

而且我要告诉你，回顾我做的每一个修复病例，几乎都做了咬合调整，结果比我预想的要好。

And I will tell you that I think having equilibrated almost every restorative case I did, looking back on it, the results have been higher than I would have thought.

而且我知道，那些我做了咬合调整、努力平衡咬合、并且对此有意识的病例，失败率通常比那些没做的要低。

And I know the cases that I did equilibrate and try and balance the bite and was cognizant of that, generally had less failures than the one I didn't.

所以我觉得……

So I think that...

我觉得我们太纠结于试图制定一刀切的规则，说不能用正中关系……

I think we're get hung up on trying to make blanket statements where can't use centric relation...

有人说应该永远用正中关系，也有人说永远别用。

You should always use centric relation, you should never use centric relation.

有人说必须始终要有前牙引导，也有人说必须始终采用组功能。

You should always have anterior guidance or you should always have group function.

我觉得实际情况是，我们会根据具体情况，从现有的不同方案里灵活选择。

I think the reality is that there's times you will pick and choose from the different options we have.

而且通常来说，这跟颞下颌关节的状况有关。

And generally, I think that's related to condition of the joint.

因为如果我的关节正常，我会尽量采取最简单的方法来支撑咬合力并保持咬合稳定。

Because if I have normal joints, I'm gonna do the easiest thing I can to be able to support the load and to have bite stability.

大家好，欢迎来到ELEVATED GP。

Hey, I wanna welcome you to ELEVATED GP.

这是一个全新的平台，提供按需获取的现代循证课程，供全科牙医学习，并包含期刊俱乐部的访问权限。

This is a brand new platform that includes modern evidence based on demand courses for GPs and access to Journal Club.

期刊俱乐部是一个每月一次的线上学习小组，我们会讨论牙科领域的热门话题。

Journal Club is a once monthly virtual study club where we're gonna talk about hot topics and dentistry.

要注册的话，去elevatedgp.com加入就行。

To get registered, go to the elevatedgp.com to join.

希望能在那里见到你。

I hope to see you there.

我再问你一个问题。

Let me ask you this too.

说到这些比较大的修复病例，嗯。

When it comes to these bigger restorative cases Uh-huh.

比如说有个病人来到你的诊所。

Let's say a patient comes to your office.

他们想做六颗、八颗、十颗左右的贴面。

They're looking for six, eight, 10 veneers or so.

我们没有证据认为存在任何关节紊乱或不稳定。

We have no evidence to think there's any sort of disarrangement, joint instability.

病人不一定在正中关系位咬合。

Patient's not necessarily functioning in centric relation.

这种病人，你会不会在开始做大型修复工作之前，先做咬合调整？

Is this a patient that you would be equilibrating before you do this big restorative work?

换句话说，对于所有这些大型修复病例，如果关节盘是健康的，是不是一定要恢复到正中关系位？

In other words, for all of these big restorative cases, if the disc is healthy, do they always have to be in restored and centric relation?

不是。

No.

我觉得不一定。

I don't think they do.

哦，说说为什么。

Oh, tell me why.

嗯，因为我觉得有些人肌肉力量不够大，不会让系统超负荷。

Well, because I think some people don't generate enough muscle force to overload the system.

我想这就是我的观点。

I guess that would be my point.

但我也想问你同样的问题。

But I'm gonna ask the same question in your case.

在这个病例里，我们要忽略的滑动有多大？

How big is the slide in this case that we're gonna ignore?

好的。

Okay.

假设滑动很大，那可能就有问题了。

Let's say there's a big slide, that could be a problem.

那我说的就不是正中关系了。

Then I'm saying that it's not centric relation.

所以我才说那是……

That's why I'm saying that's...

如果滑动小于两毫米，我大概能接受。

If you have a slide less than two millimeters, I'd be okay probably with it.

但如果是末端牙，那问题就更复杂了。

Now if it's a terminal tooth, that adds complexity to the question.

我的意思是，如果你只做一颗牙，其他都保持原样，那没问题，只要周围有牙能把它固定住就行。

I mean, because if you're gonna do one tooth and just build everything else the way it is, that's great as long as there's teeth around that to hold that in position.

如果是最初的接触点，而且那正是你要修复的牙齿，那就有机会改变人的咬合，而且他们可能再也回不到舒服的状态了。

If it's the initial point of contact that's touching, and that's the tooth you're gonna restore, that's where you have a chance to change people's bites, and they can't get back comfortable.

所以你就得……

So you just have to...

我觉得这不一定总是非黑即白的答案。

I don't think it's always a hard, fast, yes or no answer.

我觉得你得看病例中的所有变量。

I think you have to look at all the variabilities in the case.

这里面有很多细微差别。

There's there's a lot of nuance in this.

你今天早上说过，你知道，有些事，我觉得大多数人都会普遍同意，孩子不应该打鼾。

You made a statement earlier this morning about how, you know, some of this, I think it's most people would widely agree on kids should not be snoring.

对。

Okay.

但你也提到，孩子也不应该有咔哒声和弹响声。

But then you also made the point, and kids should also not have clicking and popping.

绝对不行。

Absolutely not.

那个……

That...

你想想看。

You know, you think about it.

在成长中的患者身上，韧带附着什么时候比现在更稳定、更健康呢？

When is that ligament attaching been more stable and healthy than it is in a growing patient?

这是一个骨科关节。

This is an orthopedic joint.

如果你12岁时前交叉韧带撕裂，他们会给你做手术。

If you had a torn ACL when you're 12 years old, they're going to fix it.

你12岁时颞下颌关节盘撕裂，他们根本不理你。

You tear your TMJ disc at 12 years old, they pay no attention to you.

他们几乎会责备你，说吃饭时别发出那么多声音。

They almost berate you and say don't make so much noise when you're eating.

别嚼口香糖。

Don't chew gum.

别再嚼口香糖了。

Stop chewing gum.

你知道，去做物理治疗吧。

You know, go to physical therapy.

去练瑜伽。

Go to yoga.

去看心理医生。

See a counselor.

试试布洛芬。

Try ibuprofen.

不。

No.

我的意思是，但说真的，我觉得这些病人最可悲的地方就在这儿。

I I mean, but but really, I think that's that's what's really sad about these patients.

这个患者群体是……

This patient population is...

而且，你从诊所管理的角度提出了一个很有意思的观点，我是说，比如说，你知道，在……

And also, you brought up a really interesting standpoint from a practice management standpoint is, I mean, talk about, you know, in...

我想在市场营销里，他们讲红海、蓝海。

I guess in marketing, they talk about red or red oceans, blue oceans.

你知道，红海就是……

You know, red oceans being...

已经过度饱和了。

It's oversaturated.

大家都在那里。

Everybody's there.

人人都想去做。

Everybody wants to do it.

竞争极其激烈。

It's ultra competitive.

然后还有那些蓝海，那里没有人。

And then you have these blue oceans where nobody's there.

没有竞争。

There's no competition.

就是说，整个世界都是你的。

I mean, the world is your oyster.

而且看起来，对于这些TMD患者，你的诊所主要就是围绕他们建立的，需要帮助的患者一点都不缺。

And it seems like with these TMD patients, which you've largely based your practice on, there's no shortage of patients that need our help.

其实，我的诊所主要是做修复治疗的。

Actually, really, my practice is a restorative practice.

我看很多TMD患者，但我不是面部疼痛专家。

I see a lot of TMD patients, but I'm not a facial pain person.

那不是我的诊所的重点。

That's not the focus of my practice.

我不是在找疼痛患者。

I'm not looking for pain patients.

不过最后我还是会接诊一些疼痛患者，因为很多人是来检查颞下颌关节的。

Now I end up with pain patients because people will come in for an evaluation of their jaw joints.

当你做这类检查时，你会发现不少人的解剖结构存在异常，所以你最终还是会治疗他们的疼痛问题。

And when you do that, what you come across is enough anatomy, enough patients with structured altered anatomy so that you will be treating pain.

但再说一遍，我并不是专门寻找头颈部疼痛的患者，我更关注那些疼痛与关节结构改变有直接关联的病人。

But again, I'm not looking for patients with head and neck pain, I'm looking for more patients who have a direct correlation with their pain and the structural alterations in their joint.

我不打算处理头颈部以上以及肩部的所有疼痛问题，那些不是我主要负责的范围。

I'm not looking for all to be all pain above that head and neck, shoulders I'm gonna take care of.

我主要把业务集中在关节和牙齿上。

I'm specifying mine to basically the joints and the teeth.

其他方面当然也有别人能做，但我得专注于自己手头的事，因为如果摊子铺得太大，哪样都做不好。

There's other people that can do the other stuff, but I need to focus on what I'm doing there because if I get too big, I can't do any of it well.

有道理。

Fair.

不过我得再说一遍，你依然是那种很现代的……

But I will say, again, you are still really kind of the modern...

不管你喜欢不喜欢，你确实是现代咬合和颞下颌关节领域的权威之一。

One of the modern preeminent authorities on occlusion T and D, whether you like it or not.

我们再聊聊这个。

Let's talk about this again as well.

当这些病人来的时候，也许他们是来做贴面的。

When these patients come in, perhaps it's the patient seeking veneers.

他们的牙齿磨损得很厉害，远远超出了正常范围。

They have a lot of wear on their teeth far more than they should.

有些牙医就直接给病人做贴面或者牙冠。

Some dentists will just offer their patient those veneers or crowns.

这些病人风险很高，贴面很可能会脱落，牙齿也会裂开。

These are patients so that, again, this is high risk and these veneers are likely going to be popping off, teeth are gonna be fracturing.

我觉得这就像是在问题上贴个创可贴。

I guess, I see it as you're just slapping a band aid on the problem.

你刚才说高风险的情况。

So you said if there is where there's high risk.

对吧？

Correct?

嗯，我现在在重新考虑这件事。

Well, now I'm rethinking things.

我不是不同意你的看法，因为我也觉得这确实带来一定的风险，毫无疑问，而且磨损的牙齿总是会增加风险因素。

Well, I'm not disagreeing with you, because I do think where brings a certain risk with it, no doubt, and worn teeth always, I think, increase risk factors.

但我觉得，对于磨损的牙齿，我们最终要解决的是如何尽量做到最合适的贴合，来避免那种风险。

But I think that ultimately what we have to figure out with worn teeth is how we're going to try and create the best fit to avoid that.

稳定性。

Stability.

我今天学到的是，在最终决定之前，如果可能的话，我更愿意用不同的材料先试试看。

I've learned today that I'd rather test drive that in different materials if I could before I commit to it.

再多讲讲。

Tell me more.

嗯，如果我有磨损的牙齿，很多时候我会试着把它们移回去。

Well, if I have worn teeth, a lot of times what I'll do, I'll try to move them back.

假设你的上前牙唇面磨损了四毫米，已经明显能看出来了。

Let's say you've got four millimeters worn off the facial of your upper interiors, enough where it's noticeable.

我会试着把它们移回正常位置。

I'm gonna try and move those back into their normal position.

所以通常我们会先压低这些牙齿，直到它们回到与CEJ对齐的位置。

So what we're gonna do generally is intrude those teeth until we can get them back up to where the CEJ is aligned.

然后我本可以做贴面，但说实话，我更愿意做树脂修复，延长边缘，重建磨损的部分，把它当作试驾。

Now I could do veneers then, but honestly, I'd rather do some bonding, extend those edges, rebuild where it was worn away, and use that as a test drive.

压低之后吗？

After the intrusion?

压低之后。

After the intrusion.

对。

Correct.

但还是要始终想着把牙齿放到它该在的正确位置。

But again, always thinking about getting the tooth in the right place where it should be.

好的。

Okay.

再说一遍，病人来到你的诊所。

So again, patient comes in your office.

他们有严重的磨损。

They have extensive wear.

当然。

Sure.

牙齿都过度萌出了。

Things are super erupted.

你先压低这些牙齿，然后用树脂修复做试运行，看看这个方案是否可行。

You are intruding those teeth first, then you are using a bonding test drive to see if that scheme is then good.

等一下。

Wait a minute.

我们回到之前的话题。

Let's go back.

你说他们……

You said they...

牙齿……

The tooth of...

牙齿被压进去了？

Teeth have intruded?

不好意思。

Excuse me.

抱歉。

Sorry.

你是把那些牙齿压进去的。

You are intruding those teeth.

我在……

I am in...

我的意思是，那对病人来说可是个大工程……

I mean, that would be quite the write up of a patient...

有意识的病人，他们的牙齿不知怎么就内收了。

Aware patient somehow their teeth intruded.

这，这可以作为一个病例研究。

That's That's a case study.

我正试着内收这些牙齿，因为我想重建被磨损的切端。

I'm trying to intrude those because I wanna rebuild the incisal edge that was worn away.

但我想让完成后的切端位置回到他们原来的切端位置。

But I want the incisal edge position when I'm done to be where their original incisal edge position was.

当然，这是在看了所有东西咬合在一起，看它怎么工作之后。

Now that's after looking at everything fitting together and see how it works, obviously.

然后沿着那条线，打开视频。

And then along that line, opening the video.

什么时候适合做这个，什么时候不适合？

When is this and when is it not appropriate to do?

我不像有些人那样纠结于视频。

I don't get hung up on video as much as some people.

再多说一点。

Tell me more.

我觉得那是基于肌肉的理论。

I think that's a muscle based theory.

我原以为这个理论是说，垂直距离是由咬肌反复收缩的长度决定的，而且肌肉会自动收缩到那个长度。

I thought the theory was that the vertical dimension was determined by the repetitive contracted length of the masseter muscles, and it was an automatic muscle length that they would contract to.

我怀疑我们学过的很多肌肉概念，我并不全都相信。

I suspect a lot of the muscle concepts that we learned, I don't believe all of them.

我觉得肌肉理论当时是唯一的主流观点。

I think that Muscle was the only game in town.

所以它可能被赋予了过多的信任，超出了它在不同理论中应有的地位。

So it probably got more credit maybe than it should have in terms of ideology of different things.

所以我想这就是我的看法。

So I guess that would be my thinking on that.

那么你会说，打开视频到一个合理的程度吗？

So would you say then opening the video reasonable amount?

我我我完全不担心开口度的问题。

I I I have no concern opening video.

你曾经真的有过...

Do you ever really have an...

我的意思是，再说，在某些病人身上，当然，有时候已经很明显了，你可能会做得过头。

I mean, and again, in some patients, of course, it's already somewhat obvious where you can overdo it.

在我心里...

Within me...

抱歉。

Sorry.

那我们我们来说说这个问题吧。

So let's let's have the question.

垂直距离增加多少才算合理？

What's a reasonable amount to open the VDO?

嗯，我想我会从我的...开始。

Well, I I suppose I would start where with my...

治疗方案里的第一步。

The first point in the treatment plan.

我想把中线定在哪儿？

Where do I want the central?

比如有人会说，尖牙想放在哪儿？

So someone say, where do I want the canines?

但我会接着问，上颌前牙想排成什么样？

But then I would say, where do I want my maxillary anterior teeth?

然后也许一切就会顺理成章地发展下去。

And then perhaps everything would go from there.

那太好了。

That's great.

告诉我你希望下前牙的位置在哪里。

Tell me where you want your lower anterior teeth.

所以，关于这一点，不同的学派有不同的看法。

So, again, there's different schools of thoughts on that.

告诉我，如果因为前后向的问题到不了那个位置，该怎么办。

Tell me tell me what to do if they can't get there because there's an AP problem.

好的。

Okay.

当然。

Sure.

这就是问题所在。

That's that's the issue.

因为我们可以讨论上颌中切牙以及它在面部的位置。

Because we can talk about the maxillary central incisor and setting it in the face.

那很好。

That's great.

而且那是我们的起点。

And that's where we start.

但真正的问题应该是，好的，下颌能不能到那个位置？

But then really the question should be, okay, can the lower get there?

如果下颌无法前伸，那就存在组织问题。

If the lower can't get out there, then you have a tissue.

你是打算保持前牙开合，还是尝试移动牙齿？

Are you gonna leave the anterior bite open, or are you gonna try and move the teeth?

所以我觉得整个对话中最重要的一个点，也许我们真正想说的是，我们都希望有一本手册来管理这些患者。

So I think one of the biggest points in this whole conversation that we're perhaps driving at is we all want a cookbook for managing these patients.

我们都希望有一本手册来处理复杂的咬合方案。

We all want a cookbook for managing complex occlusal schemes.

但现实是，让这件事变得如此复杂的是，其中有太多的细微差别。

And the reality is, and what makes this so complicated is that there's so much nuance.

好吧，让我们试着澄清一些。

Well, let's let's try to clear some of that up.

有三种关节类型，世界上99%的人都可以归入其中。

You've got three types of joints that 99% of the world are gonna fit into categorize.

第一种是结构完整的。

Number one is structurally intact.

关节盘附着在外侧极，关节盘也附着在内侧极。

Disc is attached on the lateral pole, disc is attached on the medial pole.

第二种情况是外侧极的关节盘移位，包括可复性和不可复性移位。

Second, lateral pole disc displacement with reduction without reduction.

这是指外侧极的情况。

That's at the lateral pole.

第三种则是内侧极出现同样的问题，以及已经发生穿孔、变成骨对骨接触的案例。

Third of the same thing at the medial pole and cases that have perforated where they're bone to bone.

所以基本上你看到的就是这些。

So that's basically what you're looking at.

如果前两种情况是结构完整，或者仅在侧极有结构改变，通常你可以把髁突就位，然后尝试建立前牙引导。

If you've got the first two structurally intact or structurally altered at the lateral pole only, generally, you can seat the condyle and you could try and get anterior guidance.

我问你个问题。

Let me ask you this.

你是怎么……

How do you...

日常的修复科牙医怎么判断是外侧极还是内侧极的问题呢？

How do everyday restorative dentist determine whether it's at the lateral or the medial pole?

你是怎么判断的？

How do you determine that?

靠影像吗？

Imaging?

靠病史和咬合。

History and bite.

这些是初步诊断。

Those are your tentative diagnosis.

要确定的话，只能靠影像。

The only way to know is to image.

有道理。

Fair.

只能这样确认。

Only way to know.