CBCT能展示什么，不能展示什么——与Chris Matessi博士对话

嘿。

Hey.

欢迎收听《牙科文摘》。

Welcome to Dental Digest.

我是主持人梅丽莎·塞伯特医生，我会帮助大家紧跟循证牙科的尖端进展。

I'm your host, doctor Melissa Seibert, helping you to stay on the cutting edge of evidence based dentistry.

锥形束CT能回答很多问题，但有些牙医想问的，它其实根本回答不了。

A cone beam can answer a lot of questions, but some of the ones dentists ask it, it simply can't.

医生。

Doctor.

克里斯·马特西医生会讲解何时该做闭合位或开口位的关节扫描，什么时候MRI值得花钱和费力，以及那种窄的U形骨缺损如何暴露牙冠根折。

Chris Matessi explains when to scan the joints closed versus open, when an MRI is worth the cost and hassle, and the narrow u shaped bony defect that gives away a crown root fracture.

我们今天的嘉宾是克里斯·马特西医生，他是口腔颌面放射学专家，也是牙科影像诊断公司的创始人，这是一家为牙医提供放射报告服务的机构。

Our guest today is doctor Chris Matessi, an oral and maxillofacial radiologist and founder of Dental Imaging Diagnostics, a radiology reporting service for dentists.

他在佛罗里达大学完成了口腔颌面放射学住院医师培训，期间被选为住院总医师，并担任该校放射学系的客座教员。

He completed his oral and maxillofacial radiology residency at the University of Florida, where he was selected chief resident and holds a courtesy faculty appointment in its radiology department.

好的。

Alright.

我们开始吧。

Let's jump in.

你有没有觉得在牙科这个行业里像在孤岛一样？

Do you ever feel like you're on an island in this profession?

你是否觉得不知道去哪里找高质量的继续教育，也不知道该相信谁？

Do you feel unclear on where to find quality CE and who to trust?

或者，当你在某个病例上遇到瓶颈时，你是否感到不知道该怎么办？

Or have you ever felt unsure about where to turn when you hit a wall in a case?

我理解这种感受。

I know the feeling.

这正是我创立Elevated GP的原因。

That's exactly why I created Elevated GP.

这是一个为想要追求卓越的全科牙医打造的线上学习社群。

It's a virtual study club for general dentists who want to be excellent.

我们每月两次聚会，进行继续教育。

We meet twice a month for CE.

还有一个完整的点播课程库，你可以随时学习。

There's a full on demand course library you can work through anytime.

而我最喜欢的是，有一个活跃的社区，我们每天都在交流，互相解答问题，推动彼此更上一层楼。

And my favorite part, a live community where we're talking every single day, getting each other's questions answered and pushing each other to the next level.

你不再感到孤单，而是觉得有了教育和人来支持你。

You stop feeling alone and you start feeling equipped with the education and the people to back you up.

如果你想加入，就来访问 elevatedgp.com，拼写是 the， elevatedgp.com。

If you want in, come join us at the elevatedgp.com spelled the, elevatedgp.com.

希望在那里见到你。

I hope to see you there.

顺便说一下，我有一个关于二类修复的短课程。

By the way, I have a short course on class two restorations.

你介意花点时间留下一个评分吗？

Would you mind taking a moment to leave a rating?

如果你把评分截图发到 doctor.MelissaSeibert@Gmail.com，我们就让你免费观看这门课程。

If you send me a screenshot of your rating at doctor.MelissaSeibert@Gmail.com, we'll give you access to the course.

感谢你对我们的支持。

Thank you for supporting us.

这对我和我家人来说意义非凡。

It means a lot to both me and my family.

虽然我不是什么顶级音频工程师，但这个播客在全球所有播客中排名前1%。

Despite me not being, like, super great audio engineer, it's in the top 1% of all podcasts globally.

这是排名第一的，太棒了。

It's the number one Awesome.

播客。

Podcast.

所以，感谢你分享你的专业见解。

So thank you for coming your on expertise.

好的，谢谢你的邀请。

Well, thank you for having me.

非常感谢。

Appreciate it.

好耶。

Well, yay.

好的。

Okay.

那我们开始吧，朋友。

Let's jump in, my friend.

我有些问题想问你。

I have some questions for you.

我写的这些问题都是基于你在Elevated GP上的精彩演讲。

So all of these questions that I have written were based on your incredible presentation when you came and presented at Elevated GP.

那我们开始吧。

And here we go.

好的。

Okay.

对，你关于CBCT的讲座讲得真的很棒。

So, yeah, you gave a really good presentation about CBCT.

其实那是个大约三小时的讲座，分两个晚上讲的。

In fact, it was about a three hour long presentation split over the course of two different nights.

太精彩了。

Phenomenal.

而且我从那个讲座里带了好几个问题。

And I have several questions from that presentation.

你讲到了张口和闭口做CBCT扫描的区别。

So thing is that you talked about having an open mouth versus a closed mouth CBCT scan.

确实是这样，

It is

这点我们平时常常根本不会想到。

something that we so often don't even consider.

我们总是默认嘴巴是闭着的。

We always just assume that the mouth closed.

那我们什么时候选择张口扫描呢？

So when do we choose open mouth?

我们什么时候……

When do we...

什么时候闭口扫描很重要？

When is a closed mouth scan important?

好的。

Sure.

那主要是……

So the the main...

这里其实有两个因素。

So there's kind of two two factors here.

一个是如果要评估颞下颌关节。

So there's if you're assessing TMJs.

如果你在检查颞下颌关节并想评估它，可以让患者在闭口位进行扫描。

If you're if you're taking a look at your TMJs and you wanna assess TMJs, You can take the patient in a closed a closed mouth position.

理想情况下，其实是在最大牙尖交错位。

Ideally, actually, like, in a maximum intercuspation position.

所以这需要用下巴托来拍摄，而不是咬合棒。

So this would be taken with a chin cup, not a bite stick.

因为如果用咬合棒，会让下颌稍微张开一点。

Because if you're on a bite stick, that opens the jaw just a little bit in two.

有时候，如果关节有功能障碍，髁状突可能在关节内位置不良，在最大牙尖交错位时也处于不佳位置。

Now sometimes the condyles might be malpositioned in the joint if there is some dysfunction in the joint and they're just in poor position when in MI.

然后，如果你想评估患者张口时髁状突的位移量，可以再做一次扫描。

And then you can take a second scan if you want to assess the amount of translation of the condyles when the patient's open.

第二次扫描用低分辨率，可以是最低分辨率设置，配合咬合块和某种固定装置。

You take a second scan at a low resolution, could be the lowest resolution setting you can have, with a bite block and something that stabilizes them.

你不想让他们感到疼痛，而是让他们在咬合块下处于最舒适的开口位置。

You know, you don't want them to be in pain, but just their most comfortable open position with a bite block.

你进行第二次扫描，这样我们就能评估张口时髁状突的位移程度。

You take that second scan, and that allows us to maybe assess how much the condyles will translate upon opening.

所以这算是其中一个因素。

So that's kind of one factor.

然后还有像种植体规划和牙科评估这类事情。

And then there's also things like implant planning and dental assessment.

这些通常来说，大多数情况下都希望在咬合棒上进行。

Those typically, for the most part, you want taken in on a bite stick.

虽然是闭口的，但在咬合棒上，牙齿会稍微分开一些。

Closed, but on a bite stick, the teeth are separated a little bit.

不过有些例外，比如全牙弓规划时，需要患者处于正确的垂直咬合距离，你可能希望患者完全闭口，在颏托上，牙齿接触，或者让他们处于理想的垂直咬合距离，但这主要是针对全牙弓种植规划的情况。

With some exceptions for full arch planning where you want the patient in the proper VDO, you may want the patient fully closed in a chin cup with the teeth touching, or you may wanna have them positioned in the ideal VDO, but that's for kind of full arch implant planning stuff.

所以这取决于具体情况。

So it sort of depends on the on the scenario.

但特别针对颞下颌关节，我……

But for TMJ specifically, I...

当我查看扫描结果时，我喜欢看到患者在最大牙尖交错位闭口、高分辨率下的影像。

When I see the scans, I like to see them in an MI closed position, a high resolution.

然后，如果你还想评估髁突的移动情况，可以让他们保持张口的姿势。

And then optionally, you know, if you wanna assess condylar trans...

就是让他们处于张开下巴的位置。

Translation, have them in that open open jaw position.

不过，我们也要谈谈CBCT在评估关节患者方面的局限性。

Let's also talk, though, about the limitations of what CBCT can assess on a joint patient.

什么时候需要做MRI呢？

When does an MRI come into play?

我觉得我们常常忘了还有这个选择，总想靠CBCT得出所有结论。

I think so often we forget that that's an option available to us, and I think we try to draw a lot of conclusions with the CBCT.

是的。

Yes.

这个问题问得好。

So that's a good question.

关节的软组织在CBCT上基本看不到。

So the soft tissues of the joint, we just can't see on CBCT pretty much at all.

真的什么都看不到。

There's nothing really available at all.

我们只能通过髁突的位置来间接推断软组织的某些变化。

We can sort of infer some changes to the soft tissue by the condylar positioning.

所以如果髁突被卡在关节后方，或者关节间隙明显变窄，那很可能存在一些内部紊乱的问题。

So if that condyle is jammed far back in the joint or the joint space is really reduced, good chance there's probably some internal derangement issues.

但我们没法直接看到。

Now we can't see it directly.

我们只是推断。

We're just inferring.

什么时候需要考虑做核磁共振呢？我通常会建议，如果……

When you need to consider taking MRI, I typically recommend it if...

很多患者有内部紊乱，而且你也可以通过临床检查来评估，比如关节有弹响之类的，但我建议先尝试保守治疗。

You know, a lot of patients have internal derangement, and you can assess it clinically too, you know, clicking in the joint, you know, that sort of thing, but I recommend it when you try the conservative measures first.

夹板、热敷、按摩这些。

Blint, warm compress, massage there.

不管你对TMD采取什么保守治疗，先做那个。

Whatever your conservative measures are for TMD, do that first.

如果症状持续，那就考虑做MRI，因为那样我们能更仔细地看关节间隙，看看关节里有没有炎症，评估有没有关节盘移位，是不是有移位的修复，这能帮我们稍微指导一下，如果可能需要手术干预，比如关节盘复位之类的。

If it's persisting, then probably consider MRI, because then we can take a closer look at the joint spaces, see if there's inflammation in the joint, see if there is, you know, assess the internal derangement if there is any, is it a displacement with production or not, and that can help maybe guide us a little bit if potentially surgical intervention is needed, disc repositioning, that sort of thing.

所以MRI不是便宜的项目。

So MRI is not a cheap modality.

我通常不会说每个有关节盘移位的病人都要做MRI，但如果已经尝试过治疗，没有效果，没有成功，可能就要进入下一步，做影像检查了。

I usually don't say every patient who has internal derangement should get it, but if it's a scenario where it's been attempted to be treated, no no results, no success, maybe move on to the next step, imaging modality.

MRI能给我们提供哪些信息？

What are some of the information that we can get from MRIs?

顺便说一句，我很理解，MRI不一定是我们要做的第一线影像检查，因为我自己就做过TMJ关节的MRI，那真是麻烦。

And by the way, I do appreciate that, hey, an MRI is not necessarily the first line imaging that we're gonna get because, you know, I myself have had an MRI on my TMJ joint, and it's a hassle.

提供这项检查的机构很少。

You know, very few centers offer this.

所以我得开一小时的车。

So I had to drive an hour.

我得

I had to

自掏腰包，付了好几百美元。

pay out of pocket, several $100.

做核磁共振真的很不舒服。

Going through an MRI is very uncomfortable.

哦，那确实…

Oh, that's...

会让人感到幽闭恐惧。

It's claustrophobic.

所以，是的，核磁共振有它的难处。

So, yeah, MRI has its challenges.

不过，一两年他们推出了一种专门用于牙科的颞下颌关节核磁共振设备。

Now, do have a dental specific TMJ MRI machine they came out with a year or two ago.

我想它是来自…

I think it's from...

我想这就是为什么Sirono会和……合作。

I think that's why Sirono teamed up with...

另一家公司我忘了。

I forget another company.

但那台机器非常贵。

But it's a very expensive machine.

而且体积很大。

It's very large.

可能现在很多诊所还没有，但那是未来的趋势。

It's probably not in many offices yet, but that's coming down the pipeline.

也许以后，随着机器能缩小一些，价格更实惠，更容易普及，但目前显然还不是这种情况。

Maybe eventually, as they can sort of shrink the machine down, make it more affordable economically, and maybe something that's more easily accessible, but obviously, right now, that's not the situation.

所以就像我说的，它确实能评估关节的软组织、关节盘、关节间隙以及关节盘的位置。

So like I mentioned, it it really, obviously, assesses the the soft tissue components of the joint, the disc, the joint space, the position of the disc.

我们还能评估炎症变化。

We can assess for inflammatory changes.

我们能够判断关节里是否有积液或者液体积聚。

We can tell if there's effusion or fluid buildup in the joint.

这样我们就能得到更深层次的信息。

So it kind of gives us that next level of detail.

不过我们对骨性结构的了解就没那么多了。

Now we don't get as much idea...

这正是CBCT擅长的部分。

A good idea on the osteo structures, which CBCT excels at.

所以两者配合得很好，能进行全面关节评估。

So they kind of pair well nicely together with where you're getting a full joint assessment.

是的，这确实是核磁共振在关节位置，抱歉，是椎间盘位置和炎症这些方面的重要应用。

But, yeah, so that that's really the big things with with MRI, you know, joint position sorry, disc position, inflammation, that sort of thing.

颞下颌关节的核磁共振真的有市场吗？

Is there really a market for MRIs for the TM joint?

我认识的人很少。

I mean, I know so few people.

非常非常小众的市场。

A very, very niche market.

确实是。

It is.

我觉得如果你治疗很多颞下颌关节患者，我想他们……

You know, I think if you're somebody who treats a lot of TM joint patients, you know, I I think they're...

你可能多少会想用一下这个。

You're probably gonna wanna use it to some degree.

如果你只是……

You know, if you're somebody who's just...

把所有有TMJ问题的患者都转诊出去，那你就不太会去碰这个。

Refers every patient out who has TMJ problems, you're not gonna be messing with it too much.

所以我觉得，如果这是你诊所的重点，我建议为患者提供这个服务。

So I think if it's something you focus in on on your practice, you know, I would encourage, you know, facilitating it for the patients.

我知道，比如，和医生……

I know, like, with, you know, Doctor.

麦克唐纳医生实际上和中心协调，他基本上就是设置一个固定费用的安排，给他他想要的，然后他可以把所有病人都送到那里，让过渡更顺利一些。

McDonald, he actually coordinates with the center, and he kind of, yeah, sets up a, like, a a situation where it's kind of a flat fee, gives him what he wants, and he can send all his patients there to make the transition a little easier.

我觉得他们通常尽量保持一个固定的自费价格。

I think they typically try to keep a flat fee, out of pocket fee.

我知道有些保险可以覆盖一部分，但老实说，我既不是医疗保险专家，也不是牙科保险专家。

I know you can get some insurance coverage, but I'm no medical insurance expert, or dental insurance expert, to be to be honest.

所以我觉得如果你试图通过保险来报销的话，事情会变得很复杂。

So I think it gets messy when you try to get it with insurance.

是的，所以确实存在一些障碍。

So, yeah, there are barriers to it.

只要有障碍或者麻烦，使用率就会降低。

So anytime there's barriers or friction, you know, it's gonna be something that's used less.

但正因为使用的人很少，所以可能也没有那么多从业者在那里跟你竞争。

But because there are probably so many so few people using it, there's probably less practitioners that, you know, that are out there taking that sort of competition away.

不过，从临床医生的角度来看，如果你经常处理这类问题，尤其是更复杂的病例，这些信息还是很有价值的。

But, yeah, from a from a clinical a clinician standpoint, I should say, there's value in the information if it's something you treat regularly and you especially if you deal with more complex cases.

当然。

Sure.

当然。

Sure.

说得有道理。

That makes sense.

好的。

Okay.

那我们换个话题，来聊聊骨质流失和冠根纵裂吧。

So let's pivot a little bit here and now talk about bone loss, crown root fractures.

关于CBCT能看到什么、看不到什么，外面有很多误解。

A lot of misconceptions out there about what we can and cannot see on a CBCT.

那在CBCT上，哪种特定的骨质流失模式能帮你发现那些非常难发现、隐藏的问题？

So, you know, what is the specific type of bone loss on a CBCT that helps you to spot those very difficult hidden Yeah.

冠根纵裂，尤其是那种你根本看不到断裂线的情况。

Crown root Especially when you can't even see the fracture line itself.

所以十有八九，就像你说的，我们看不到裂纹本身。

So nine times out of ten, like you said, we can't see the fracture fracture line itself.

但有时候你能看到，或者在牙冠上能看到裂纹的开始部分。

Now sometimes you can, or you can see the the start of it in the crown.

通常，如果你在影像上直接看到裂纹，那临床上大多已经很明显了。

Usually, if you see it on imaging, the fracture directly on imaging, it's pretty evident clinically for the most part.

但偶尔，我们确实能在影像上直接看到裂纹线。

But on occasion, we do actually see the fracture line.

但当我们看不到的时候，我们就非常依赖伴随的骨丧失，这是一种相当特定的骨丧失类型。

But when we don't, we really rely on the bone loss associated with it, and it is a fairly specific type of bone loss.

就是这样……

It's this...

虽然你在播客里很难描述影像，但如果你看轴向切面，从上往下看牙齿，在牙根分叉区域或者正好在牙槽嵴顶，你会看到一个小U形的骨缺损区域。

If you kinda are trying to describe imaging on a podcast, but if you're looking at an axial view, looking down the tooth, around the C and J region or right at the crestal bone, you'll see this little u shaped area of bone.

这是一个狭窄的骨内缺损。

It's a narrow infrabony defect.

这就是你探诊时感觉到的，探针一下子陷下去很深的那种感觉。

That's what you're feeling when you're doing your probing and you drop in deep.

就是那个窄窄的骨内缺损。

That's that little narrow infrabony defect.

临床探诊的问题在于有时候容易漏掉。

The problem with probing clinically is sometimes it can be easy to miss.

如果你跳过了它，而且它也不是总那么可靠。

If you hop over it, you know, and it's not always super unreliable.

所以，是的，那种窄窄的U形骨区，经常出现在最远端的磨牙，很多时候是第二磨牙，你会看到那种骨丧失的模式。

So, yeah, that little sort of narrow U shaped area bone, very often at the distal most molar, so a lot of times second molars, and you'll see that pattern of bone loss.

但也会在第一磨牙和其他牙齿，比如前磨牙上看到。

But see them on first molars and other teeth, premolars as well.

这主要发生在后牙。

This is sort of mostly on posterior teeth.

前牙发生裂缝时表现会有点不同，但就是这样。

Anterior teeth act a little different when they have fractures, but yeah.

所以这能很好地说明那是裂缝引起的。

So that sort of gives you a good idea that that's from a a fracture.

通常在重度修复过的牙齿、做过根管治疗的牙齿上，但烂牙也会有。

Usually on heavily restored teeth, endotreated teeth, but on rotten teeth too.

我见过……

I mean, I've seen...

其实这个月我有好几个病例，牙齿完全没有修复过，但也有这种骨质流失模式，还有症状。

I've actually had several cases this month of teeth that are not restored at all, and they have that pattern of bone loss, symptomatic sort of thing.

我们能识别出这种骨质流失，这让我们可以判断，这里是不是有冠裂。

We can identify that bone loss, and that gives us an idea, okay, is there a crown fracture here?

当然，你还需要结合临床检查，比如咬物测试、探诊症状等，另外这个也能帮助我们判断裂缝的深度。

Now, obviously, you have to kind of correlate it with the clinical side of it as well, you know, bite stick testing, probing symptoms, that sort of thing, and then the the other thing it can help us tell is the depth of the fracture.

所以它能告诉你裂缝有多深，这能让你对这颗牙的预后有个大概了解。

So it can tell you how deep the fracture is, and that'll give you some idea on the prognosis of the tooth.

对于某些冠根裂，如果裂得比较浅，而且根管治疗做得好，能密封到裂缝水平，这些牙的存活率其实挺高的，但总是有进一步裂开的风险，最终可能需要拔掉并做种植牙。

With some of these crown root fractures, if they're more shallow and endodontic treatment's done well and you can seal it off to the fracture level, the teeth actually have a pretty high success rate, but, you know, they're always gonna be at risk for eventually further fracture, and it may need extraction implants.

所以，每次患者有冠根折的时候，你都得提醒他们。

So it's something you always need to warn the patient anytime they have a crown root fracture.

做好心理准备。

You know, Just be prepared.

大概有一天得攒钱做种植牙。

Save up for an implant one day, probably.

但，是的，这能告诉我们深度，这也能让我们对骨折的预后有个大概的了解。

But, yeah, it sells us depth, which can give us some idea on prognosis of of the of the fracture as well.

市面上不同的CBCT在分辨率和准确性上有没有差别？

Is there variability in just the resolution and the accuracy of the different CBCTs available on the market?

比如说，

So for example,

我可以举个例子

I can give a time

比如说2018年，我有一个患者就出现了冠根折。

in 2018, for example, had a patient crown root fracture.

我们做了个局限视野的CBCT，但就是没法得到明确的影像来帮我们排除有没有冠根折。

We took a limited field CBCT, just could not get definitive imaging that really helped us to rule out, is there a crown root fracture?

结果很不幸，我们最后不得不做探查性手术，结果确实有冠根折。

We ended up, unfortunately, having to do an exploratory type surgery where in fact there was a crown root fracture.

但是你有没有看到市面上CBCT的进化特别大？

But, you know, have you seen dramatic evolution in the type of CBCTs available on the market?

而且，说真的，我们现在能看到的东西也大不一样了。

And really, yeah, what we're able to visualize.

对，我觉得确实有厂家比其他的要好。

So, yes, I I would say there are manufacturers that are better than others.

我不会在播客里点名太多厂家，因为我不想把任何公司推出去，但确实有些公司在生成高质量高分辨率影像方面比其他公司强得多。

I don't name many here on the podcast because I I don't wanna put any companies out there, but there are companies that are much better than others in terms of, like, producing really good high resolution imaging.

除了制造本身，还有其他因素也在起作用。

There are other factors come into play, not just manufacturing.

厂家，一个就像你提到的，研究的分辨率，有限视野高清研究会比更大范围低分辨率的视野捕获得更好，还有伪影，很多金属伪影、运动伪影，都可能遮挡物体，增加一些难度。

Manufacturers, one, like you mentioned, the resolution of the study, a limited field of view, high res study will capture it better than a larger low res field of view artifacts, lots of metal artifacts, motion artifacts, can obscure things, make it a little bit more difficult.

还有一个难点，就是骨折发生的时间。

The other thing that can be difficult too is when the fracture occurred.

我其实有一个病例，就在……

I actually had a case just...

嗯，我前几天刚写了报告。

Well, I did the report a couple days ago.

影像上看完全正常。

Looked totally perfect on imaging.

牙槽嵴骨水平看起来很好，牙是完整的。

Crested bone levels looked good, virgin tooth.

病人只是咬东西时有点痛，我就想，可能只是骨裂。

Patient was having just a little bit of pain on the tooth with biting, and I'm like, it could be just a fracture.

是前磨牙。

It's a premolar.

可能是骨裂，我就建议拍片。

Could be a fracture, and I recommend it.

我可能会试着做个牙冠，看看它能不能...

I might maybe try a crown, see if it...

就给这颗牙做个牙冠，看能不能管用。

You know, just do a crown on it, see if that'll help.

更多是取决于病人的情况。

More on a patient.

可能需要做根管治疗。

Could need endo.

也可能需要种牙。

Could need an implant.

病人那边，医生开始备牙准备做牙冠的时候，发现裂缝一直延伸到牙根了。

Patient, doctor started prepping the crown, visualized the fracture all the way through the root.

所以问题是，这裂缝太新了，骨吸收还没来得及发生。

So the problem was it was such a new fracture that the bone loss hadn't occurred yet.

骨吸收是需要时间的，所以这里有个局限性。

It takes time for the bone loss to occur, so there is a limitation there.

如果是全新的骨折，在影像上可能看得到也可能看不到骨吸收。

If it's a brand new fracture, you may or may not visualize some bone loss on the imaging.

通常大多数情况不是这样，但当患者来就诊时，如果骨折延伸到骨嵴下方，你会在影像上看到一些骨吸收，不过每个病例都不一样。

That's not most of the cases usually, but when they're coming in, you'll see some level of bone loss with the fracture if it extends subcrestally, but every case is different.

每个病例都有点不同，而且确实有些制造商比其他的好，随着时间也有改进。

Every case is a little bit different, and yes, there are some manufacturers that are better than others, and there has been improvement over time.

这种改进是细微且渐进的。

I mean, it's it's kinda subtle and incremental.

不过是的，我觉得现在的影像肯定比十年前好。

But, yeah, I mean, I think our imaging for sure is better than it was ten years ago.

也许你可以买到更好的，但确实，它会不断变好。

Maybe you can buy it, but, yeah, it it continues to get better.

今天的节目由Garrison Dental Solutions赞助播出。

Today's episode is brought to you by Garrison Dental Solutions.

我多年来一直是Garrison的用户，非常感谢他们赞助本期播客，因为他们和我一样重视质量和卓越。

I have been a Garrison user for years, and I'm so grateful to have them sponsoring this podcast because they share my values of quality and excellence.

用Garrison的产品，我从来不用担心质量问题。

With Garrison, I've never had question whether I'm using a high quality solution.

他们为了确保每件产品都出类拔萃，费了很大功夫。

They go to great lengths to make sure everything they put out is exceptional.

我来告诉你几个我最喜欢的。

Let me tell you about a few of my favorites.

首先是stratigy牙邻面成形系统。

First, the strategy sexual matrix system.

它的成形圈、成形片和楔子一起配合，能封闭备牙区，把飞边降到最少。

The rings, bands, and wedges work together to seal the prep and keep flash to a minimum.

而且边缘嵴的优化设计直接做在成形片和成形圈上，所以你的轮廓会非常漂亮。

And the marginal ridge enhancements are built right into the bands and rings, so your contours come out beautifully.

如果你要连续处理二类洞，他们的quad成形系统就是为此设计的。

If you're doing back to back class twos, their quad matrix system is made for exactly that.

至于前牙修复，有fusion前牙成形系统。

And for anterior work, there's the fusion anterior matrix system.

深边缘提升是我经常教授的内容。

Deep margin elevation is something I teach a lot.

而我会选择Garrison的RealMatrix和深边缘提升套件。

And Garrison's RealMatrix and deep margin elevation kit are what I reach for.

它们是由顶尖仿生临床医生参与设计的，能提供所需的密封性和控制力，让你可靠地重新定位深边缘。

They were designed with input from top biomimetic clinicians, and they give you the seal and control you need to predictably relocate a deep margin.

这意味着可以保留牙齿结构，让你的患者免于冠延长手术。

That can mean saving tooth structure and sparing your patient a crown lengthening procedure.

Garrison还是Elemental器械在美国的经销商。

Garrison is also The US distributor for Elemental instruments.

我的El Marte复合树脂器械是我非常喜欢的一些工具。

My El Marte composite instruments are some of my absolute favorites.

而深色宝石版本带有不粘涂层，让雕刻复合树脂变得容易得多。

And the dark gem version has a nonstick coating that makes sculpting composite so much easier.

你的洁牙团队也会喜欢他们的铝制金刚砂洁牙器和刮匙，这些器械永远不需要磨锐。

Your hygiene team is also gonna love their alum sharp diamond scalers and curettes, which never need sharpening.

Garrison 还刚推出了 Loop 固化灯，我打算在我的诊所里用。

Garrison also just introduced the loop curing light, which I'm gonna be using in my practice.

Loop 每秒测量和调整输出超过500次，所以即使角度或距离不完美，也能获得一致的固化效果。

Loop measures and adjust its output more than 500 times a second so you can get a consistent cure even when your angle or distance isn't perfect.

它甚至还能自我校准。

It even calibrates itself.

如果你喜欢这个播客，请通过支持我们的赞助商来支持我们。

Now if you enjoy this podcast, please support it by supporting our sponsors.

使用代码 26 podcast。

Use the code 26 podcast.

就是数字26加上单词podcast，全部连在一起，直接从Garrison订购可以享受10%的折扣。

That's the number 26 and the word podcast, all one word, for 10% off when you order directly from Garrison.

链接在节目说明里，这个代码到年底前有效。

The link is in the show notes, and the code is good through the end of the year.

好了。

Alright.

那我们往积极的方面说吧。

So let's be positive here.

但市面上有哪些比较好的CBCT呢？

But what are some of the good CBCTs available on the market?

当然，这都不是赞助内容。

Of course, none of this is sponsored.

你也没有在推荐任何品牌。

You're not endorsing anybody.

但确实。

But Right.

了解这些会很有帮助。

It would be very helpful to know.

有哪些比较有信誉的制造商呢？

What are some, like, very reputable manufacturers out there?

这最终还是要看个人喜好了。

I mean, it somehow comes down to preference.

有几个我比较喜欢的……

I mean, there's a couple that I like for...

这要看情况……

It depends...

而且再次强调，也取决于具体场景。

And again, depends on the scenario too.

Mireta 在根管治疗方面非常好。

Mireta is a very good one for endodontic treatment.

很多牙髓病医生都有 Mireta。

A lot of endodontists have a Mireta.

通常大多数牙髓病医生都会用 Mireta 或者 Carestream，这两个都不错。

Usually, most endodontists have a Mireta or a Carestream, and those are both good units.

我也挺喜欢 Dexus OP 3D，它比较适合大家日常使用，因为它的扫描范围稍大一点，适合做种植牙定位。

I do also like the Dexus OP three d, and that's more of a good sort of general use for everybody because it's also good for a little bit larger scans, for implant placement.

他们新款机型还提供更大的视野，能更好地捕捉颞下颌关节气道。

They even offer their new line has a larger field of view that can capture TMJ airways a little bit better.

虽然不是全尺寸的，但在大多数情况下应该够用了。

It's not full, full volume, but it's pretty good enough probably in most cases.

那些都挺不错的。

Those are kinda good...

这是一台很好的全能型机器，尤其是对牙科诊所来说，什么都得做一点。

That's a good middle ground machine, especially I think for dental desk to do a little bit of everything.

我更倾向于那台。

I I prefer that one.

Fine那款更适合大体型的扫描，比如正畸，虽然它们也有不错的普通扫描。

Fine is good, you know, more for, like, larger field of views than ortho, although they have just a general good scan...

即使是小视野扫描也没问题。

Scanner for even small field of view.

我确实很喜欢fine mecca。

I do like fine mecca.

所以，这些就是我用过的一些机型。

So, yeah, those are some of the ones I...

算是这个领域里比较主要的几个，大部分我都很喜欢。

You know, kind of the big ones in the field that for the most part I like.

当然还有很多其他的也不错。

There's there's obviously a bunch of others that are good as well.

有些我不喜欢的，我就不提了。

There are some I don't like, and I won't mention those.

我不想点名批评任何公司，但那些是我比较欣赏的。

I don't wanna put any companies on glass, but those are some of the some that I would like.

我很想看看它们。

I'd like to see.

当然可以。

Sure.

那么，是确实存在专门的牙髓用CBCT，还是说只是牙髓专科医生倾向于使用某一款CBCT？

So is it that an actual endospecific CBCT exist, or is it more so just that there's a particular CBCT that endodonts tend to gravitate toward?

不是这样的...

It's not...

所以，我会说Merida，我不会说它是专门用于牙髓科的。

So, like, I would say Merida, I wouldn't say it's endospecific.

它的最大视野大概是10乘10，就这么大。

It just has the largest field of view is only, I think, 10 by 10 or something like that.

如果你是牙医，想要比这个更大的视野，那他们就没有VeriVue 800这种选项了。

So, you know, if you are a dental dentist, you do want anything bigger than that, they just don't have an option for the VeriVue 800.

他们确实有另一款设备，视野更大一点，但不是那么常见。

They they do have another unit that has a larger one, but it's not as common.

那款设备是……

So, I mean, that unit was...

它不是专门用于牙髓的，但大部分情况下确实卖给牙髓科医生，而且拍出来的图像质量真的很好。

It's not endo specific, but it's really sold to the endodontists for the most part, and then it it does produce a really great image.

一个缺点是，他们导出并发送给我的时候，图像质量会稍微下降一些。

The one downside with it is I have troubles when they export it and send it to me, the image quality gets degraded a little bit.

我觉得这可能是他们的内部查看器的问题，而不是导出的DICOM文件的问题，但我也不确定为什么会这样。

I think that's just their internal viewer versus an exported DICOM, but I don't I don't know why that happens.

这对我来说更让人烦，

That's more of a...

而不是对做根管治疗的医生或者牙医来说。

Annoying for me than it is for the endodontist or the dentist using it.

Carestream 也一样，不过他们的成像和视野范围更广一些，适合不同专科，而且他们有不同型号……

Carestream as well, but they have a little bit wider range of imaging and field of views for different specialists, and they have different models that are...

所以我觉得那也不算真正的根管专用。

You know, so I wouldn't say that's really endo specific.

我觉得 Mirena 是唯一一个有点那种……

I'd say Mirena is the only one that's kinda kinda...

如果你……

If you...

如果你是做根管治疗的，或者你只做很多根管治疗，那这可能是你能买到的最好的机器，但你在视野更大的方面会有点受限。

If you're an endodontist or you're doing just a lot of endo, that's probably the best machine you can get, but you're kinda a little bit a little bit limited when it comes to, like, larger field of view things.

我们也做其他东西。

We do other stuff.

好的。

Alright.

你提到了气道问题。

You brought up the airway.

很高兴你提到了这一点。

So glad that you brought this up.

你在讲座中提到的一个误区，现在已经明确了，就是我们不能仅仅通过CBCT就断定一个人有睡眠呼吸暂停。

So a bit of a misconception that you even talked about in your lecture and has now come to light is that we can't just take a CBCT and say, Yes, this person has sleep apnea.

不，不幸的是，我们完全不能那样说。

No, that's not Unfortunately, we can't say that at all.

睡眠呼吸暂停必须由至少在美国，必须由内科医生或睡眠专家来诊断。

Sleep apnea has to be diagnosed by at least in The US it has to be diagnosed by a medical physician, a sleep expert.

所以他们需要进行睡眠监测。

So they need a sleep study done.

所以我们做的任何事情都不能明确诊断患者患有OSA。

So nothing we can do can definitively diagnose a patient with OSA.

我们可以在一定程度上治疗它，这取决于我们用气道推进装置做什么，然后……

We can treat it to some degree depending on what we do with airway advancements, you know, devices, and then...

或者正颌手术，一定程度上正畸也可以。

Or orthognathic surgery, orthodontics to some degree.

所以我们可以做很多事情来帮助治疗，但无法诊断。

So there's things we can do to help treat it, but we can't diagnose it.

所以，是的，带气道的CBCT更像是一种筛查工具。

So, yeah, CBCT with airway is really more of a screening tool.

它根据气道的狭窄程度、是否有肥大的扁桃体或其他软组织阻塞、舌头和下颌的位置等，给我们一个风险分层，我们可以评估这些情况。

It gives us sort of a risk stratification based on sort of the, you know, the constriction of the airway, the presence of hypertrophic tonsils or other soft tissue obstructions, the position of the tongue and the mandible, we can assess those things.

我们也可以评估上气道和鼻腔，看看是否有鼻中隔偏曲，或者其他阻碍气道的问题，如果我们不能治疗，可以转诊出去进行进一步评估或治疗。

We can also obviously assess the upper airway, the nasal cavity, see is there deviated septum, is there other issues obstructing the airway that we can, if not treat, refer out for treatment or further assessment.

好的。

Okay.

所以我们可以有效地用它来识别可能成为问题的解剖结构，但它不是诊断性的。

So we can effectively use it to identify perhaps anatomical structures that could potentially be problematic, but it's not diagnostic.

你能量化一下吗？

Can you quantify?

有没有一个特定的气道体积，可以告诉我们这个人可能有更高的风险？

Is there a certain volume of the airway that we're looking for that could potentially tell us that this person might be a higher risk?

有具体数字吗？

Do we have numbers?

我通常用的，也是研究最多的，是气道的最小横截面积。我具体指的是我们最常处理的那段可活动的气道，也就是口咽部气道空间。

What I typically use and what's most studied is the minimum cross section of the airway, and I'm gonna specify it to the movable part of the airway that we deal with most, the oropharyngeal airway space.

这通常就是导致阻塞性睡眠呼吸暂停的地方，因为睡觉时软组织后坠，把气道给堵住了。

This is typically the one that causes obstructive sleep apnea as soft tissues fall back and close off the airway while we sleep.

通常，最小横截面积，就像我提到的……

Usually, the minimum cross sectional area, like I mentioned, the...

所以这算是气道的瓶颈处，也是与OSA风险分层关联度最高的指标。

So it's sort of the choke point of the airway, and that's sort of the highest corollary with risk stratification for OSA.

所以这是最公认的数字。其他测量值，比如软腭长度、某些比值，也可能对风险分层有一定影响，但我通常主要就看最小横截面积。

So that's sort of the most recognized number, and those other measurements you can take, there's things like even soft palate length, the ratio that may have some influence on wrist stratification, but I typically use mostly just minimum cross sectional area.

从数字上看，这又是一个大概的数值，但对成年人来说，低于……

Numbers wise, this is again kind of a ballpark number, but for adults below...

这是针对18岁以上成年人的。

And this is over 18 adult age.

对成年人来说，横截面积超过155平方毫米就算正常。

For adults, anything above 155 millimeters squared cross sectional area is considered normal.

大约在100到155之间的属于低风险范围，抱歉，是155。

Anything between about one hundred and one hundred and fifty five is in the low risk range, 155, sorry.

155以上算中度风险，低于55就算高风险。

Between 155, that's sort of a moderate risk, and below 55 is a high risk.

再说一遍，这不是一个硬性的标准，只是一个大概的风险评估。

Again, it's not a hard cut number, and it's more of just a general risk.

而且，因为……

And and just because...

从两方面来说都是这样。

Kind of in both ways.

仅仅因为气道狭窄，并不代表他们患有OSA，而且他们也可能即使气道看起来正常，仍然患有OSA。

Just because a airway is constrict, it doesn't mean they have OSA, and they may have OSA even though it's...

看起来正常。

It looks normal.

他们的最小横截面积是正常的。

Their minimal cross section area is normal.

所以这也不是决定性的，但就像我说的，它可以给我们一个风险分层。

So it's not, again, not definitive, but it can just give us a, you know, like I said, a risk stratification for it.

随着对气道的兴趣增加，一些牙医可能会提倡，为每个来诊所的新患者提供这项服务。

With this increasing interest in airway, some dentists perhaps will advocate for, you know, every new patient that comes in their office as a service to them.

我会给他们拍一张全视野的头颈部X光片。

I'm gonna take a full field head and neck radiograph.

那么让我

So let

先问你一个问题。

me ask you this, first of all.