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欢迎收听《内窥之声》，由美国牙体牙髓病学会倾情呈现。
Welcome to Endo Voices brought to you by the American Association of Endodontists.
这是一档聚焦牙体牙髓治疗艺术与科学前沿、邀请业内顶尖专家探讨如何提升患者护理标准的节目。
The show where we are advancing the art and science of endodontics and promoting the highest standards of patient care with today's top experts in the field.
接下来，有请我们的主持人，约翰逊医生。
Now here's your host, Doctor.
马库斯·D·约翰逊。
Marcus D.
约翰逊。
Johnson.
现在在展览现场，真是让人热血沸腾。
What an exciting time to be on the exhibit floor.
我旁边坐的是我的偶像，一位划时代的专家——寺内嘉志医生。
I'm sitting next to one of my heroes, a generational talent, none other than Doctor.
寺内嘉志。
Yoshi Terauchi.
很高兴见到你，最近怎么样？
It's a pleasure, how you doing?
非常好，真的非常好。
Very good, very good.
非常感谢你来和我聊一聊，我们特别想了解你，也想听听你对根管器械取出方面的想法、技术，任何你能分享的经验都特别有价值。
Thank you so much for joining me for this conversation around, just, you know, we wanna talk to you as well, get to know a little bit about you, but understanding your thought process, techniques, anything that you can share with us regarding file and instrument removal.
真的非常荣幸。
It's just really a pleasure.
我之前参加过你的课程。
I had the opportunity to take your course.
我记得应该是在德克萨斯，AAE在休斯顿举办的时候。
I think it was maybe back in Texas when we had the AAE there in Houston.
对，休斯顿，那之后我学到了很多，也一直用在自己的临床实践中。
Houston.
是的，休斯顿，收获很大，这些方法我都用在了自己的诊室里。
Yeah, Houston, learned a lot, have been able to utilize that in my own practice.
我没你这么厉害，我觉得可能没人能像你这么出色，但知道在取器械这件事上有你这样的伙伴，真的让人很安心。
I'm not as good as you, I don't think everyone will ever be as good as you, but it's really nice to know that we have an ally when it comes to insert removal.
非常感谢你来参加这次对话。
So thank you so much for joining me.
这是我的荣幸。
My pleasure.
谢谢你。
Thank you.
是的，没错。
Yes, yes.
课程进行得怎么样？
How did the courses go?
最近还顺利吗？
How's it been?
对。
Yeah.
我昨天开了两场工作坊，大家上完课都挺开心的。
I had two workshops yesterday, and everybody seemed to be very happy after the course.
没错。
So Yes.
他们开心，我就开心。
If they are happy, I'm happy.
说到底，就是这么回事。
Well, that's what that's all it is.
对吧？
Right?
就是那个Yoshi Loop。
The the Yoshi Loop.
说白了，就是这个。
That's what it is.
是的。
Yeah.
是的。
Yes.
但我并不依赖这个循环。
But I don't depend on the loop.
我通常用超声波来取出断裂的器械。
I usually use ultrasonics to remove the broken instrument.
大概百分之八十的情况都是这样。
Eighty percent of the cases.
百分之八十的
Eighty percent of the
靠超声波就能解决。
Managed by ultrasonics.
真厉害。
Wow.
即使在弯曲的地方，你也能用这个方法定位并取出器械。
And even around the curve, you're still able to use that to navigate and get those out,
对，没错，就是这样。
Yeah, yeah, that's right, that's right.
是的。
Yeah.
我们接下来肯定会深入聊聊关于器械取出的更多细节。
Well, you know, we'll definitely get into some more of the details around instrument removal.
我们现在虽然用了几个摄像头，但能亲眼看到实际操作总是更好，也许哪次我们可以再安排一场，给观众现场演示一下。
We have a couple cameras going now, but it's always nice to be able to see something visually, so maybe one time we'll get another session, and we can actually kind of demonstrate that for the audience and see Yeah.
不过，咱们先简单聊聊，你当初是怎么对根管治疗产生浓厚兴趣的？
How they like But, you know, let's just kind of get a little history of how you even developed a strong interest in flower moving.
好的。
Okay.
需求是发明之母。
Know, necessity is a mother of invention.
没错。
That's right.
因为我的病例中98%都是再治疗的。
So every time because 98% of my cases are retreatment.
所以每次遇到断针，我都得想办法把它取出来。
So every time I see a broken instrument, I have to figure out the way to remove the instrument.
但如果没必要，我就不会取，可以保留原样。
But if it's not necessary, I don't retain I don't have to remove the instrument, I can retain the instrument.
这得看具体情况来定。
So, you know, it depends on the situation.
对。
Yes.
没错。
Yes.
我记得你还说过，与其事后取出来，不如一开始就防止断针。
Well, you know, I do remember you saying too that it's much easier to prevent a file from breaking than to retrieve it.
今天现场也有一些观众。
So, you know, we have some people in the audience today.
希望你们都做过足够多的根管治疗，也真遇到过器械折断的情况，因为要是从来没遇到过，那你们的根管治疗量肯定不够。
Hopefully they've done enough Endo and have actually broken a file, because if you haven't, you guys aren't doing enough Endo.
但归根结底，咱们还是聊聊哪些关键因素能帮你们有效预防器械断裂吧。
But at the end of the day, let's talk about some of the best factors to incorporate so that you can help prevent file separation.
器械断裂主要是因为循环疲劳或者扭转疲劳。
Because an instrument fractures because of cyclic fatigue or torsional fatigue.
所以每次在弯曲根管里用小号器械时，一定要放慢速度。
So whenever you use a small size instrument around the curb, you have to slow down.
得降低旋转器械的转速。
You have to reduce the speed of the rotary instrument.
如果用的是小号器械，也别太慢地加压，那样反而容易造成严重的扭转疲劳。
And if you are using also small size, don't, you know, don't load it too slow because you will have lots of torsional fatigue.
对，扭转疲劳。
Yes, Torsional fatigue.
你觉得呢？
What do you think?
你觉得在器械断裂的问题上，是扭转疲劳更多，还是循环疲劳更多？
Do you think we'll probably see more torsional or cyclic fatigue when it comes
说到器械断裂吗？
to instrument separation?
我觉得大约百分之八十的断裂都是由循环疲劳引起的。
I would say eighty percent of the instrument fractures because of cyclic fatigue.
循环疲劳。
Cyclic fatigue.
对，百分之二十是扭转疲劳造成的。
Yeah, twenty percent fractures because of torsional fatigue.
所以你的意思是，你觉得是扭转疲劳更常见，还是循环疲劳更常见？
Oh, so you're saying, do you feel it's more torsional or it's more psychotic more fatigue.
我觉得是这样，
Think so,
百分之八十是循环疲劳，没错。
80% cyclophosphate, Yes.
20%是扭转疲劳。
20% torsional
那你觉得，自从我们用了新型金属材料，比如热处理的锉刀之后，这些情况有变化吗？
And do you think that you've seen a shift in those dynamics since we've introduced new metallurgy, like the heat treated files?
你有没有观察到这种变化？还是说，不管用的是哪种镍钛合金材料，结果都一样？我看到的都是相同的结果。
Have you seen that shift occur, or you still think it's been consistent regardless of the type of nickel titanium metallurgy that's I see the same results.
结果没变。
The same result.
因为器械断裂的发生率还是维持在2%到3%，跟以前的老病例差不多。
Because the incidence of instrument fracture stayed the same, two to three percent of the older older cases.
即使我们现在有了新的镍钛器械，而且是经过热处理的，原因在于……
And the the reason why even the we have a new new nicotinium instrument heat treated.
是的。
Yes.
但它们还是容易在根尖三分之一处断裂。
But they fracture in the apical one third.
如果你使用热处理过的镍钛器械，它确实能很好地进入根尖三分之一区域，但主要因为扭转疲劳而折断。
It's good to sneak into the ape into the apical one third if you use a heat treated nicotinium instrument, but they fracture because of the mainly torsional fatigue.
它非常柔软，所以容易折断。
It's very flexible, so that's why it is susceptible to fracture.
明白了。
Got it.
确实，它会在根尖三分之一处折断，我发现那是取断针最具挑战性的位置。
Well, it does fracture in that apical third, I find that to be one of the most challenging locations for file retrieval.
那么，哪些临床决策会影响我们是选择取出还是绕过断针呢？
So what clinical decisions influence retrieval versus bypassing?
哦，让我
Oh, let me
告诉你一件事。
tell you something.
如果你能绕过断针，你就能把它取出来。
If you can bypass the broken instrument, you can retrieve the instrument.
所以对我来说，绕行不是一个选择。
So bypassing is no option for me.
所以我总是得想办法绕过断裂的器械，让断掉的器械‘跳舞’，这样我才能把它取出来。
So I always have to figure out how to bypass the broken instrument and how to make the broken instrument dance, then I can remove the instrument.
是的。
Yeah.
一旦它开始‘跳舞’了，你就更有信心能顺利下去。
And once it's dancing, you have the confidence that you can get down.
对。
Yeah.
百分之百。
100%.
我特别喜欢这种掌控感。
I love that confidence.
对，对，对。
Yeah, yeah, yeah.
因为如果你在显微镜下看到那个断裂的器械，就能百分之百把它取出来。
Because if you see the broken instrument under the microscope, you can 100% remove the instrument.
但你知道，有时候当你尝试取出时，器械可能会进一步断裂。
But you know, sometimes what may happen is when you do go for the retrieval, some of the instrument may still fracture further.
这种情况我遇到过一次，真不想再经历第二次。
And that's a setback that I've been in a situation that I wouldn't wanna be in there again.
所以咱们聊聊这个吧。
So kind of talk about that.
在用超声波取出断裂器械时，怎么才能防止它进一步碎裂？
How can we prevent the actual separated instrument and separated segment from fracturing when you apply the ultrasonic to get it out?
在尝试取出已经断裂的器械时，怎么避免它继续断裂？
How we can prevent the actual separated file from breaking further when you're trying to retrieve it?
哦，明白了。
Oh, okay.
你是说二次断裂吗？
You mean the secondary fracture?
哦，二次断裂。
Oh, Secondary fracture.
这是个好问题。
That's a good question.
我确实做过这方面的研究。
Because I I had a study on that.
如果在没有牙本质壁支撑的情况下使用超声波，二次断裂的平均时间大约是一分钟。
When you apply ultrasonics without dentin wall behind the ultrasonic activation, the the mean fracture time, the secondary fracture time was around one one minute.
但如果超声波作用区域背后有牙本质壁支撑，二次断裂的时间就会明显延长。
But if you apply ultrasonics where you have dentin wall behind the ultrasonic activation site, that means secondary fracture time was significantly longer.
所以，一定要把超声波对准那些背后有牙本质壁的断裂器械。
So always aim at the broken instrument where you have dentin wall behind it.
这样能有效延缓二次断裂的发生。
Then you will extend the secondary fracture time.
我不建议在断裂器械周围盲目掏挖，那样会让器械更容易折断。
So I don't want to trough around the broken instrument because instrument will be susceptible to fracture.
所以我总是在内壁上形成一个半圆形的空间。
So I always create semicircular space on the inner wall.
这样我就能始终把超声波作用在断裂的器械上，背后有牙本质作为支撑。
So I can always apply ultrasonics against the broken splint where you have a dentin wall behind it.
对。
Yeah.
利用牙本质作为支点，就能更好地操作。
The dentin, using that as a leverage to kinda Yeah.
对。
Yeah.
对。
Yeah.
对。
Yeah.
把空间留出来。
Create that space.
因为每次使用超声设备时，你都得特别注意操作方式。
Because whenever you use ultrasonics, you have to be careful how you apply ultrasonics.
对。
Yes.
除了利用牙本质壁作为支点外，还有哪些因素会严重影响异物取出，让这个过程变得更复杂？
Well, what other variables strongly influence foul retrieval and complicate that procedure, Aside from having leverage with the wall, what other aspects of the file separation that complicate that make it a little bit more challenging?
我经常办工作坊。
I do many workshops.
当我看到学员出错时，通常是因为他们把超声头放在断针顶部，结果把断针往根尖方向推了进去。
So when I see the participant making mistakes, I I see I see them end ending up pushing the broken instrument into the apical direction because they usually activate ultrasonics on the top of the broken instrument.
他们总是从外壁施力，而不是从内壁操作。
They they push the broken instrument from the outer wall instead of the inner wall.
而且他们还出现了二次断裂，用了过大锥度的超声器械，还用了大尺寸的超声工作尖。
And also, they had a secondary fracture, and also they use big side ultrasonic tape, they use big taper ultrasonic tape.
正因如此，断针才会被推到根尖方向去。
So because of these, they ended up pushing the broken instrument down into the apical direction.
而且通常一旦推下去，我就觉得这时候已经到了关键点
And usually once you push it down, I find that that's the point
再也回不来了。
of no return.
对你这样有经验的人来说，可能还能取出来，但我觉得这确实是个临界点——一旦看到器械往根尖方向移动，就特别危险。
Now, obviously for someone like you, you can still retrieve that, but I think that's kind of a point of no return, a very critical stage when you start to see the file go more apically.
对吧？
Right?
所以你得控制好心态，因为一旦把器械往根尖方向推，很快就会感到挫败。
So that's why you need to control your mentality, because you will be quickly disappointed at the results, pushing down the instrument in the apical direction.
但你必须稳住心态。
But you you need to maintain your mentality.
你真的需要保持冷静。
You you need you need it.
所以
So I
我明白你的意思。
see what you're saying.
即使你保持笔直。
Even if you're straight.
对。
Yeah.
对。
Yeah.
对。
Yeah.
对。
Yeah.
对。
Yeah.
即使你再往根尖方向多推进一些，还是有办法取出来的。
Even if you push it further into the apical direction, there's a way to retrieve it.
所以保持状态，保持高度的积极性，这样你还是能把器械取出来的。
So stay good, stay, you know, highly motivated, then you can still retrieve the instrument.
我喜欢这种乐观的态度。
Well, I like that optimism.
有时候人们说，态度决定高度，积极思考确实很重要。
You know, sometimes they say attitude determines altitude, so thinking positive does matter.
其实，成功取出断裂器械主要受三个因素影响。
There are actually three factors affecting the success in broken body removal.
首先是积极性，其次是收益。
First of all, motivation, and second, profit.
你得赚钱，因为这个操作比做手术还要难。
You have to make money because this procedure is more difficult than doing surgery.
每次我问参与者，你觉得取出断裂的脂肪比做手术更难吗？
Every time I I ask the participant, do you consider broken fat removal more difficult than surgery?
他们都说，当然了。
They say, yes, of course.
取断器械比做手术还难。
Broken removal is more difficult than surgery.
那为什么不对取断器械的手术收费更高呢？
So why not charge more for broken heart removal than surgery?
这样你才会更有动力去保住这颗牙。
So then that will keep you highly motivated to save the tooth.
我明白了。
I got it.
如果根尖部位的牙根发生折断，你是怎么决定该自己尝试取出还是转给外科医生的？
So if a tooth in the apical, if there's a separation in the apical third, what is your decision making flowchart based on that, if you go and try to retrieve that versus now move towards the surgeon.
当然了。
Yeah, of course.
对于普通临床医生来说，我们知道你的成功率非常高。
For the average clinician, because we know that you have a very high success rate.
但有些听众可能并不擅长取出断器械，他们在决定之前，该考虑哪些因素呢？
But someone who's maybe listening and, you know, instrument retrieval's probably not their strength, What are the factors that they should consider before they say, you know what?
我觉得我选择从根尖方向处理。
I think I'm gonna take the apical route.
对。
Yeah.
好的。
Okay.
要想成功取出断裂的器械，最重要的是先做出准确诊断并制定治疗方案。
First of all, the most important part to be successful in broken fat removal is to make a diagnosis and a treatment planning.
所以我建议你先做诊断，拍一张CBCT，测量断裂器械的长度和根管的弯曲度。
And so I I suggest you you start with a diagnosis, taking taking CBCT, and you need to measure the lengths of the broken instrument, and you need to measure the degrees of the curvature.
还要确定内壁的位置。
You need to locate the inner wall.
只要掌握了这些信息，操作就安全了。
Then if you have the information on this, then you are safe.
这样取出断裂器械的成功率就能达到百分之百。
You'll be, you know, 100% predictable in retrieval of the broken instrument.
我只是想确认一下弯曲的角度。
I just want to know the degrees of the curvature.
如果弯曲超过三十度，就会有三个接触点。
If the curvature is more than 30 degrees, you have three contact points.
你需要把内侧空间向中点以外扩展，这样才能松动断掉的器械。
And you need to extend the space, the inner space beyond the midpoint so you can loosen the broken instrument.
关于这个话题还有很多可以讲的，不过……
You know, there's more to talk about it, but
对。
Yeah.
请详细说说。
Please elaborate.
是的。
Yeah.
哦，明白了。
Oh, okay.
好的。
Okay.
通常来说，器械越长，准备时间就越长。
Because usually the the longer the instrument, the more preparation time.
弯曲程度越大，准备时间也越长。
And the more curvature, the more preparation time.
如果器械长度超过三毫米的话。
If the instrument is longer than three millimeters.
但如果器械短于三毫米，那就无所谓了。
But if the instrument is shorter than three millimeters, it doesn't matter.
不管弯曲角度有多大，都没关系。
It doesn't matter how how many degrees you have around the curve, it doesn't matter.
只要按规程操作，三百秒内一定能取出来。
It will come out within three hundred seconds if you follow the protocol.
那我该怎么做决定呢？
So how can I make a decision?
当然，这取决于器械的长度、弯曲度，以及器械是否可见。
Of course, it depends on the length of the instrument, and it depends on the degrees of the curvature, and it depends on whether the instrument is the visible or non visible.
你说三百年是预测器械能被取出来的极限时间，那关于牙齿的损伤，你有什么看法？
And what we're trying to, you said three hundred seconds is kind of the limit that you predict the file will be retrieved, What do you have to say in terms of damage to the tooth?
好，好问题。
Okay, okay, good question.
确实，因为你要保护颈缘牙本质，一旦损失了，牙齿就容易折裂。
Yeah, Because you need to protect pericervical dentin because if you lose it, the the tooth will be susceptible to fracture.
不过，如果你在颈缘区域造成了较大缺损，治疗后可以补上树脂。
So, however, if you create a big defect around the pericervical area, you can place composite after the treatment.
这样牙齿的强度就能和没损伤颈缘牙本质的牙齿一样坚固。
And the tooth will be as strong as the tooth without sacrifice of the perihub cervical dentin.
对。
Yeah.
颈缘牙本质，没错，从牙齿结构的重要性来说，它确实很关键。
The pericervical dentin, yeah, definitely in terms of hierarchy of tooth structures, that's one of them.
是的。
Yeah.
对。
Yeah.
但大多数情况是
But most cause
我们都要尽量保护它。
of it, we wanna protect that.
当然。
Of course.
如果断针超过了弯曲部位，我就得换一种方法。
If the broken instrument is beyond the curvature, I need to use a different technique.
这叫九十度预备技术。
That's called the ninety degree preparation technique.
你只需要用超声波把器械往内壁推，制造出一点空间，然后等那种黏滞感消失就行了。
Because all you have to do is just create a space on the inner wall by pushing the instrument with ultrasonics, and you you will just wait until you lose a sticky feeling.
当你感觉不到黏滞感时，就说明器械在活动了。
When you lose a sticky feeling, that means the instrument is dancing.
然后我会用EDTA冲洗根管。
Then I will just irrigate canal with EDTA.
其实，我研发了一种新的冲洗液。
Actually, I I developed a new new fluid.
它是EDTA、大豆油和表面活性剂的混合物。
It's a combination of EDTA and soybean oil and surfactant.
这样你就不用紧贴内壁操作了。
So you don't have to be on the inner wall.
你只需要在笔直的根管里启动超声设备即可。
You just have to activate ultrasonics in a straight root canal.
大概十秒内，你就能看到断裂的器械被冲出来了。
And you see the broken instrument coming out in maybe ten seconds.
我觉得另一个挑战是，如何把握超声设备的强度，才能最有效地取出断针？
I think that one of the challenges also understanding how intense, what is the intensity that we should be having the ultrasonic on order to best retrieve that file?
是的，这样很好。
Yeah, that's good.
这也是个好问题。
That's also a good question.
你不需要太高的强度。
You have you don't need a big intensity.
只要保持尽可能低的强度，我不想损失太多牙本质。
You just stay as low as possible because I I don't want to sacrifice lots of dentin.
如果你提高超声波的强度，可能会把探头弄断。
And if you increase the intensity of ultrasonics, you will end up breaking the tip.
对。
Yeah.
这又是另一个问题。
That's another problem.
这又是另一个问题。
That's another problem.
那你就遇到断掉的超声器械和断掉的根管锉了。
Then you have a broken ultrasonic and a broken file.
对。
Yeah.
所以这就是为什么。
So that's why
这从来都不是什么好事。
So that's never fun.
我尽量保持低强度。
I want to stay as low as possible.
是的。
Yeah.
那么，寺内医生，当你发现根管锉超出根尖孔两到三毫米时，该怎么办？
So so doctor Terauchi, what about when you're in there and you have a file that's maybe two or three millimeters beyond the apex?
这时候，我们是不是真的该考虑根尖手术了？
Now should we really start to consider apical at that point once it's beyond the apex?
这样真的能稳定取出来吗？
Is that really a predictable retrieval
一旦超出根尖，该怎么办？
once it's beyond the apex?
如果已经超出根尖，直接做手术就行，没必要牺牲牙本质。
If it's beyond the apex, you just need to do the surgery because you don't have to sacrifice any dentin.
只要翻起牙龈瓣，直接把器械取出来，完全不用碰牙齿。
You just raise flap and take it out without touching the tooth.
那如果我们想用圈套器呢？
What about if we wanna employ the loop though?
不好意思，你说什么？
Pardon me?
如果你能用吉野圈套器，看到根管内部，或许可以试着把断针拉出来。
If you can employ the Yoshi Loop, if you can see down the canal and maybe try to pull that out.
哦，明白了。
Oh, okay.
你仍然
You would still
只要能看到并且能夹住，就不需要做任何预备，因为如果折断的器械在根管外部，直接取出来就行。
consider If you can see it, and if you can grab it, because no preparation is necessary if you find a broken instrument outside the root.
你只需要用超声冲洗系统，或者用FKG或美国产的XP Finisher就可以了。
So you just have to use a piezo flow or or ultrasonic irrigation system, or you can use the XP finisher from FKG or USA.
是的，根本不需要预备根管。
Yeah, you don't need to prepare the canal.
在根管外面是自由的，完全不受限制。
It's free outside the root canal.
如果折断的是旋转器械，而不是K锉或者C锉，你的取物方法会不一样吗？
Does your technique change if it's a rotary file versus like a K file or a C file in terms of retrieval?
不会有任何区别。
There's no change.
真的没区别？
No change?
是的，这没关系。
Yeah, It doesn't matter.
这没关系。
It doesn't matter.
我很欣赏你的自信。
I love your confidence.
现场观众真不错。
We have a great crowd.
我可能要请一下塞巴斯蒂安医生。
I think I may call on Doctor.
塞巴斯蒂安，你要是有什么问题，可以上来问一两个。
Sebastian here, see if he wanted to maybe come up and ask some question or two.
随时请。
Feel free.
不，不，别有压力。
No, no, no pressure.
他过几分钟就上来。
He'll come up in a couple minutes.
他是你的铁粉。
He's a big fan.
我们这儿有几位铁粉。
We have a couple big fans.
萨菲亚，我知道你有几个问题。
For you, Safiya, I know you got a couple questions.
你请说。
Go ahead.
你之前提到，旋转器械和C型器械在效果上没什么区别，对吧？
I know you mentioned that there's no difference in terms of if it's a rotary file versus c file.
那你的操作方式上会有不同吗？
Is there any difference in terms of your approach?
如果断掉的器械是经过热处理的，跟传统的钛合金器械比，会有区别吗？
It different like, if the broken instrument is, you know, heat treated versus a traditional titanium?
或者
Or
是不是
is it
拿这个
take this
取下来。很好。
off Good for
问题。
question.
我重复一下。
So I'll repeat it.
你刚才问，如果器械是经过热处理的，或者材质不同，清取的技术或方法会有区别吗？
You said there, is there any difference in retrieval technique or approach if it's heat treated or if it's a different-
如果金属是
If the metal or
这个器械。
the instrument.
如果是金属，不同种类的金属。
If it's a metal, a different type of metal.
对。
Yeah.
如果是马氏体镍钛器械，处理起来会更花时间，不过等等，我说错了，是奥氏体的。
It takes more time if you are dealing with martensitic nicotinium instrument, because martensitic oh, so sorry, austenitics.
对。
Yeah.
我是说奥氏体的。
I meant austenitic.
我们总可以。
We can always.
所以如果你处理的是奥氏体镍钛器械，因为它们容易变形。
So if you are dealing with austenetic nicotinium instrument, because they they want to straighten out.
所以即使你在内壁上留出空间，它还是会想恢复平直。
So that's why even if you create a space on the inner wall, it wants to, you know, straighten out.
所以需要更多时间，但只是时间问题而已。
So it will take more time, but it's a it's just a matter of time.
花的时间更长一些。
It takes more time.
就这些了。
That's all.
是的。
Yeah.
流程是一样的。
The protocol is the same.
有
Have
你，有的。
you yes.
你平时会做头皮编发吗？
Do you ever do any head strum braiding?
头皮编发？
Head strum braiding?
我从来没试过。
I never tried it.
这事儿没法预测。
It's not predictable.
是的。
Yeah.
用根部操作会更简单些。
It's easier to use
直接从根部取出。
the root and take it out.
但你不能直接钻进根管里去取断掉的器械。
But you know, you cannot just jump into the root canal and remove the broken instrument.
你需要先把根管准备好，才能取出断裂的器械。
You need to prepare the canal for broken heart removal.
否则，你不可能直接把它拔出来。
Otherwise, you cannot just put it out.
是的。
Yeah.
但可以说，即使金属材料有了进步，根管内异物取出的方法和技巧也并没有改变。
But it's safe to say that even with advances in metallurgy, it has not changed the approach or the technique for foul removal.
完全没有变化。
No change.
完全没有变化。
No change.
对。
Yes.
那么，除了多练习之外，还有什么更好的方法能真正提高异物取出的熟练度呢？
So what is the best way aside from practice to really get proficient at foul removal?
因为我始终觉得，这是一项让很多人难以掌握的技能。
Because I still think it's a skill that becomes elusive to so many of us.
所以我外科手术做得还不错，因为我实在不想花那么多时间去取断掉的器械。
And that's why I'm actually pretty good at surgery, because I just don't wanna spend so much time trying to retrieve the file.
没错。
Yep.
因为大家都怕取断掉的器械，怕伤到太多牙体组织。
Because everybody's afraid of removing broken instrument because they could sacrifice lots of tooth structure.
所以我要你至少在牙模上练习取一百根断掉的器械。
So just I I want you to remove at least 100 broken instrument from tooth models.
等你做多了，就会更从容，更有信心处理器械取出的问题。
Then you'll be more comfortable, you'll be more confident of the instrument retrieval.
那时候，恐惧自然就消失了。
Then the fear will go away.
因为恐惧往往源于无知。
Because, you know, fear springs from ignorance.
你懂的越多，恐惧就会消失。
If you have more knowledge, the fear will disappear.
说说关于Yoshi环的哲学理念吧。
Talk about the philosophy around the Yoshi Loop.
我觉得，如果你能在器械周围弄出一道沟槽，确实很有道理。
I think that if you can create that trough around the file, yes, in essence, makes a lot of sense.
但我们还在哪些其他情况下使用这个环呢？
But what other situations are we using the loop?
是只在能直接看到的情况下用，还是你也会尝试
Is it just only in those situations where you can see direct access, or would you ever try
在弯曲处用吗？
that around a curve?
不会，我根本不会绕着断掉的器械转。
No, actually, I don't travel around the broken instrument.
我只是在内壁上弄出一个半圆形的空间。
I just create semicircular space on the inner wall.
你不需要绕着它转。
You don't have to travel around it.
在预备过程中，器械会保持居中。
The instrument will be centralized during the preparation.
你可以直接拿住器械，把绳子套在断裂的器械上，拉紧后把它取出来。
So you can grab the instrument, you can place the rope over the broken instrument and tighten it and take it out.
没必要绕着断裂的器械去开槽，因为那样会大量损失牙本质。
So it's not necessary to trough around the broken instrument Because you will sacrifice lots of dentin if you trough around the broken instrument.
如果你用超声设备绕着它操作，还可能导致二次折裂。
And if you apply ultrasonics, you could have secondary fracture if you trough around it.
这样做并不妥当。
It's not a good way to do that.
使用Yoshi环时，它通常是直的。
With the Yoshi Loop, it usually comes straight.
它是设计成直接插入，还是需要弯成L形才能放进？
Is it meant to be bent like into an l shape to put into
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对。
Yeah.
不行。
Your can't.
因为太快了。
Because too fast yeah.
我得把管子弯一下，让它变成L形。
I need to bend the tube to make it look like an l shape.
对。
Yes.
这样有助于根管锉的定位，因为你是在显微镜下观察根管。
Because this will facilitate the placement of the root, because you are looking at the root canal under the microscope.
如果它是直的，就会挡住你的视线。
So if it's straight, it will block your view.
是的，没错。
Yeah, yeah.
不过我觉得，有时候你把器械弯成L形后，如果试图把它往外拉，会产生很大摩擦，我发现这样会让绕线变得更困难。
I think though, sometimes when you do put it in the L shape and you actually try to retract it, you create a lot of friction, and I find that it becomes a little bit more of a challenge to loop that piece of file.
所以这就是为什么，预备完成后，器械本身已经松动了，根本不需要用力就能把它取出来。
So that's why, because after the preparation, the instrument is already dancing, it's already loosened, So you don't you don't need force to get instrument out.
你只需要轻轻握住器械，如果感觉到阻力，就试着往不同方向轻轻转动，比如三点、六点、九点和十二点方向。
So you just grab the instrument, and if you feel resistance, just try several directions, like the 03:00, 06:00, 09:00, and 12:00.
总有一个方向能让器械顺利退出。
And one of the direction will allow you to remove the instrument.
这个方法太棒了。
Love that.
还有其他观众提问吗？
Any other audience questions?
哦，塞巴斯蒂安，你请说。
Oh, go ahead, Sebastian.
好的。
Yeah.
在您的情况下，您提到完全有可能把锉针取出来或者分离掉。
In your case, you mentioned that it's a 100% possible to remove or separate the files.
但在我们这里，情况不会这么理想，不可能每次都成功。
In our case, we know it's not going to be like that a 100%.
那您会建议，这时候该放弃尝试，改用其他方法吗？
Will you say it is the time to leave it where it is and go to other alternatives?
因为您知道，如果继续下去，两个月内对患者可能并不有利，您也没把握能做得更好。
Because you know, or you don't feel confident that going on is gonna be better for the patient for two months.
您能再重复一下这个问题吗？
You want to repeat that question?
当然可以。
Yeah, sure.
所以我们想问，到底在什么情况下，我们应该决定放弃取锉针，改用别的方法？因为我们担心继续下去会过度损伤牙齿，甚至对患者造成伤害。
So I think we're asking, when is kind of the point of no return where we say, let's go ahead and maybe try a different technique than file removal, because we're concerned that we're gonna damage the tooth too much, or maybe cause harm to the patient?
是的。
Yes.
首先，我的研究显示，如果断裂的器械能被清楚看到，取出的成功率是100%。
First of all, my study shows if the broken instrument is visible, the the success rate of the retrieval of the instrument is 100.
但我认为有些人达不到百分之百，因为我注意到有些人根本不用同样的操作流程。
But I think some people would not reach one hundred percent because I I noticed some people, you know, wouldn't use the same protocol.
他们根本不按规程来。
They they don't follow the protocol.
就说昨天，我开了两场工作坊，亲眼看到有些人没按我说的做。
So they like yesterday, I had two workshops, and I I I some of them I I saw some of them not following the protocol.
他们根本没听我的建议。
So they they didn't listen to me.
所以他们的结果才不一样。
So that's why they they had a different result.
但只要你严格按照规程操作，取出成功率就能达到100%。
But if you just follow the same protocol, you will be 100% successful in the retrieval.
不过你得掌握几种不同的方法，才能有效取出器械。
But you can you you need to have several different techniques to retrieve retrieve the instrument.
所以，准确诊断是成功的关键。
So that's why the making a diagnosis is a key to success.
首先，在动手处理牙齿之前，你得根据诊断结果和CBCT的检查数据制定治疗方案。
First, before you touch the tooth, you need to make a treatment plan based on the diagnosis, based on the findings from CBCT.
你要测量器械的长度，判断弯曲的角度，还要定位内壁的位置。
You measure the instrument, you you measure the degrees of the curvature, and you locate the inner wall.
这样你操作起来就会更有把握。
Then you'll be more comfortable.
只要能看到，一切都能预测。
Everything is predictable if it's visible.
但如果看不到，成功率就达不到百分之百。
But if it's not visible, it's not 100%.
你只能依赖手感来判断。
You have to depend on your tactile sensation.
如果你手感不够好，成功率就无法保证。
If you're not good at tactile sensation, it's not 100%.
但就我而言，还是能保证百分之百。
But in my case, 100%, still 100%.
因为我马上就要开展一项关于非可视器械取出的新研究。
Because pretty soon I'm going to a new study on non visible instrument retrieval.
只要你严格遵循操作流程，就依然能保证百分之百。
So it's still 100% if you just follow the protocol.
嗯，这里有个
Well, here's
这算是一个诊所管理方面的问题。
a kind of a practice management question.
我从来就不喜欢向患者收取取文件的费用。
I've never enjoyed, well, it's about enjoyment, but I never liked charging the patient for their file removal.
事实上，我也不太愿意向其他医生收费。
In fact, I really don't enjoy charging the doctor either.
所以
So
这笔费用到底该算在哪儿呢？
where are we really putting that charge?
如果我有个常给我介绍二十个病例的转诊医生，这时候我还要收他钱，他肯定心里不舒服。
Because if I have a referring doctor that's been consistently feeding me 20 cases a week, and if I can't help them out in this situation and I'm charging them, they're gonna probably have a little bit of emotional reaction.
他可能会不再给我介绍病人了。
They may stop referring.
患者又没要求自己的牙里卡着文件碎片。
The patient didn't ask to have the file broken in their tooth.
所以，对一件他们完全不知情的事额外收费，感觉有点不太地道。
So it seems a little disingenuous to charge them extra for something that they knew nothing about.
我一般是这么做的。
So this is what I do.
在开始任何操作之前，我会先跟患者说清楚整个治疗要花多少钱。
Before anything starts, I explain to the patient how much this cost.
如果我发现了额外的问题，那部分是另外收费的。
And if I find a palpation, that's additional.
如果我发现器械断裂了，那也是额外收费的。
If you if you if I find the broken instrument, that's also additional.
所以在治疗开始前，我会跟患者把所有可能发生的情况都讲清楚。
So, you know, before the treatment, I will explain to the patient everything that could happen.
我明白。
I understand that.
如果这些是免费的，患者反而不会在意。
And also, the patient will not appreciate it if if if it's free.
只有当某些项目是额外收费时，他们才会觉得有价值。
They will appreciate it if if something, you know, additional.
收费是合理的，因为我跟你说过，取出断针比做手术更难。
It's okay to charge the patient because as I told you, broken file removal is more challenging than doing surgery.
为什么一定要免费呢？
Why it has to be free?
不行。
No.
当然不是
Not Of course
我不是说应该免费，但如果患者是在治疗中途被转介绍过来的，那显然他们知道之前出了什么操作问题。
that it should be free, but if they're being sent to me mid treatment, they obviously know there was some procedural error that happened.
如果是我弄断了器械，那可以免费。
If I fractured an instrument, it could be free.
是的，但如果是一位转诊医生把病例介绍给我的话
Yes, but if it's a referring doctor that sends the
因为我会
case to me, because I've
在这种情况下，我不想向患者收费，毕竟他们是受害者。
in that situation, I don't wanna charge the patient because they're the victim in that situation.
当然。
Of course.
对。
Right.
那我们该怎么真正地谈这件事呢？
So how do we really navigate that conversation?
我
I
让弄断器械的医生来承担费用。
ask the doctor who broke the instrument to pay for the fees.
对。
Yes.
每次都这样。
Every time.
是啊，每次都这样。
Yeah, every time.
哪怕他们是重要的转诊医生，哪怕是顶级推荐，也照样让他们付钱。
Even if they're a very strong referral, if they're an A class referral, you still make them pay.
当然，因为这个操作本身是百分之百可预测的。
Of course, because the procedure- procedure is 100% predictable.
啊，我知道可以取出那个器械。
Ah, know I can remove the instrument.
但如果我不确定，就不会收费。
But if I'm not sure, I will not charge.
明白了。
Gotcha.
好的。
Okay.
谢谢你做出这个决定。
Thank you for making that decision.
当然了，任何细节上的操作我都不能收费。
Details, of course, I cannot charge for anything.
明白了。
Got it.
好的。
Okay.
除了牙本质之外，我稍后再回来请教您，医生。
So beyond dentin, and then I'll come back to you, Doctor.
Yoshi，您遇到最多的是哪一类操作情况？
Yoshi, what's the most common procedural area that you've come across?
是去除牙本质的时候多，还是取器械的时候更容易出问题？
Is it just over removal of dentin, or when trying to retrieve the file?
主要是牙本质过度切削和穿孔，而且情况还可能变得更糟。
Sacrifice of dentin and perforation, and you can make it worse.
比如把器械推得更深，诸如此类的问题。
Like you can push it down, the instrument, that kind of things.
我说的是，您觉得哪种情况更常见？
Yeah I'm saying, which one do you think you see more commonly?
更常见？
More common?
牙本质过度切削的情况最多。
Lots of dentin sacrifice.
但是
But
我们还不完全确定这会导致牙齿变弱、更容易折裂。
we don't know a 100% if that correlates into a weaker tooth and more fracture.
我觉得我们还得再看看这方面的文献。
I think we still have to look at the literature on that.
但很明显，如果我们大量去除颈缘周围的牙本质，确实有可能。
But obviously if we remove a lot of pericervical dentin, potentially yes.
因为当我们仔细研究那些比较不同开髓方式——超保守型、保守型和传统型——的文献时，会发现只要边缘嵴保持完整，
Because when we really look at some of those studies that are evaluating access, ultraconservative, conservative, traditional access, we really find that as long as the marginal ridges are intact,
牙齿的抗折能力其实并没有明显差异。
the fracture resistance doesn't really change across the board.
对。
Yeah.
我认为保护健康牙本质的关键，在于做冠部预扩。
I think the key to preservation of healthy dentin is to do the precoronal flaring.
如果你做冠部预扩，就能减少牙本质的损失。
If you do the precoronal flaring, you can reduce the dentin sacrifice.
因为做了冠部预扩后，根管弯曲度会降低，你也能更清楚地看到断针，这样就能有效避免问题。
Because you can if you do the precoronal flaring, you can reduce the curvature, and you can see the broken instrument much, much better than, you know, you can prevent that.
非常好。
Very good.
当你到达C5位置后，如果用探针探查，不管是当前根管内还是能直接看到的情况，有什么区别吗？
Is there after you've reached c five, you took a file, whether it's within like a a current canal or, you know, you could see it then on.
你的充填技术会因此有所不同吗？
Is there any difference in your obturation technique?
有没有哪种情况会让你更倾向于选择某种充填材料，而不是另一种？
Or or are there any, you know, scenarios where you would say I would prefer a different obturation material versus one or if
难道不是都一样吗？
it isn't all the same?
哦，明白了。
Oh, okay.
我从2010年开始就完全停用了牙胶尖和封闭剂。
I completely stopped using gutta pericer and the sealer in 2010.
所以从2010年起，我一直使用MTA作为根管充填材料。
So since 2010, I have kept using MTA as a root feeding material.
因此，根管预备的技术并没有改变。
So the the technique to obviuate the canal is the same.
我只是把MTA直接放进根管里。
I just put MTA into the root canal.
实际上，根据文献记载，MTA充填能增强牙齿抗折能力。
And actually, MTA obviuation will make the tooth more resistant to fracture according to the literature.
这就是我的做法。
So that's what I do.
而且，成功率——我不是说成功率。
And actually the success rate the success rate not success rate.
实际上，2010年之前，我的手术病例失败率是8.5%。
Actually, you know, before 2,010, my my surgical cases, eight point five percent of all the cases.
但从2010年开始，我改用MTA作为根管充填材料后，手术病例的比例降到了2.3%。
But after 2010, when I started using MTA as a root filling material, became two point three percent of all the cases.
所以自从改用MTA作为根管充填材料后，我的手术病例数量大幅减少了。
So I completely reduced the number of surgical cases after starting to use MTA as a root filling material.
这说明了用MTA完全封闭根管有多有效，而不是用牙胶尖和封闭剂。
So that shows how, you know, how good it it is to overtake the canal with MTA, not garlopagia and the sealer.
我不用牙胶尖，因为它没有杀菌作用。
I don't want to use garlopagia because garlopagia is not bactericidal.
就算用了封闭剂，比如硅酸盐封闭剂，牙胶尖还是可能造成大问题，根本没用。
Garlopagia can be a big defect even if you use sealer, like a kashimi silicate sealer, it doesn't matter.
如果你把牙胶尖压向根管壁，还是会留下缝隙，导致渗漏。
If you touch if if you if you push the gaparture cone against the root canal wall, it will allow the leakage.
所以这方法不可取。
So it's not good.
我回答清楚你的问题了吗？
Did I answer your question?
是的，没错。
Yeah, yeah.
好的。
Okay.
在根管治疗领域，最大的技术进步之一就是显微镜的使用。
You know, one of the biggest technology advancements within endodontics has been the microscope.
有了这种视觉辅助，医生在处理断针时的思维方式会有什么不同？
Having that visualization as an aid, how does that change the clinician's mindset in terms of approaching file remover?
当然会，即使在显微镜下看不到断针，但借助CBCT或者CBCT引导技术，我完全不担心。
Oh, yes, because even if you don't see the broken instrument under the microscope, because of the technology, like a CBCT or you know, the CBCT guided technology, I'm not afraid of it.
所以，我心里有底。
So, you know, so I'm okay.
我认为每个人都应该使用现代技术来安全地取出断针。
And I think everybody should start using the modern technology to safely remove the instrument.
如果你能给在场的各位提供三个建议，帮助他们提升取断针的信心，那就好了。
If you could maybe just give, I guess, three pointers to, we had, you know, a lot of guests here today, to help them gain confidence in file retrieval.
显而易见，
Obviously,
防止器械断裂才是最好的办法，但除此之外，我实践了十多年，快十五年了，真的，器械取出始终是根管治疗中最棘手的环节之一。
preventing file separation is the best But beyond that, just because I do find that, I've been practicing for over ten years, closer to fifteen, really, and that is one of the most challenging aspects of endodontic treatment, is file retrieval.
所以，就像我说的，我在根尖区的操作已经非常熟练了。
And so like I said, I've become very proficient in apical.
因此，没必要浪费那个时间。
So there's no need to waste that time.
哦，明白了，明白了。
Oh, okay, okay.
对。
Yes.
是的，是的。
Yeah, yeah.
因为如果你每天都做手术，手术就没什么大不了的。
Because if you do surgery every day, surgery is nothing.
做手术对你来说是家常便饭。
Surgery is something you do every day.
因为我几乎每天都要取出断针，反正我在这儿。
If I because I remove the instrument almost every day at at least, but I'm here.
当然，今天我没取断针。
Of course, I don't remove the instrument today.
但平时在诊所，我每天都会处理断针。
But when I'm in in my office, I remove the instrument every day.
如果你每天都处理断针，那就根本不叫事儿。
If you remove the instrument every day, it will be nothing.
你明白吗？
You know?
这就跟根管预备一样，再正常不过了。
It's it's like you are instrumenting the canal.
所以我一点都不怕。
So I I'm not afraid of it.
所以试着去处理一百根断裂的器械。
So try to remove 100 broken instrument.
这样你就会更得心应手。
Then you'll be more comfortable.
但不是在病人身上练，而是在塑料牙模上练习。
But not from the patient, from the plastic tooth models.
我的意思是，我觉得其中一个关键点是——
I mean, I guess one of the concepts-
这是根管口的喇叭状扩张。
It's a a corneal corneal flaring.
就是自信。
Confidence.
没错，但就操作方法而言，冠部扩通一直都是这样——好的，这就是标准流程。
Yes, but in terms of the approach, so coronal flaring, always- Okay, this is the procedure.
对。
Yeah.
对。
Yeah.
如果器械靠着牙根内侧壁，远离危险区，那会怎么样？
What if the file is leaning on, I guess, maybe like a mesial aspect of the wall, away from the danger zone?
嗯。
Uh-huh.
现在你得在危险区内使用超声设备。
And now you have to use your ultrasonic within the danger zone.
对，对，对，靠近根分叉的地方。
Yeah, yeah, yeah, of Closer to the furcation.
我不想碰到危险区。
I don't want to touch the danger zone.
但如果
But if
器械是远离危险区倾斜的
the file is leaning away from the danger zone,
你是说，远离危险区。
you say- Away from the danger zone.
对，比如说器械是偏离危险区的。
Yeah, away from, say the file is.
明白了。
Okay.
那要怎么最好地取出来呢？
What's the best way to approach retrieving that?
是的。
Yeah.
对。
Yeah.
这样挺好。
That's good.
对吧？
Right?
因为这取决于内壁的位置。
Because it depends on where the inner wall is.
所以我总是把尖端放到内壁的空隙里。
So I always place the tip into the space on the inner wall.
如果它远离危险区，那就说明没问题。
So if it's away from the danger zone, so that means that's good.
对。
Yes.
但我还是得去掉一点牙本质，你之前说过。
Because But I I can still have to remove a little dentin you said.
你说你并不会在断掉的器械周围磨削。
You say you don't actually trough around
不，不会。
the No, no.
别在断掉的器械周围磨削。
Don't trough around the broken instrument.
是的。
Yeah.
这不好。
It's not good.
你会出现二次断裂。
You will have secondary fracture.
对，我也发现确实如此。
Yeah, I've found that to Right.
还有其他问题吗？好的，来吧。
Be Any other questions from, yeah here we go.
假设它朝危险区域倾斜。
So let's say it's leaning towards the danger zone.
你会在那个区域进行修整吗？
Do you trough in that area?
我从不在断裂物周围进行修整。
I never trough around the broken.
我只在内壁上做一个半外科空间。
I just create semi surgical space on the inner wall.
但如果你在危险区域附近碰到内壁，可能会穿通根管。
But, however, if you touch the inner wall around the danger zone, you could perforate the canal.
所以这就是为什么你需要做CBCT检查。
So that's why you need to take CBCT.
你需要根据CBCT的结果制定治疗方案。
You need to make a treatment plan based on the findings from CBCT.
如果我发现危险区域附近的根管壁非常薄，我就会找一个中性区，比如一个凸起的球状结构或滞留球。
So if I find very thin root canal wall against danger zone, then I will find a neutral zone, like a buck buckle buckle ball or linger ball.
然后我在那里制造一点空间，但不会有任何问题。
Then I will create a space, but nothing will happen.
接着我会换上旋转器械，以更高的转速让它逆时针旋转。
Then I will replace the rotary file and spin it at higher speed to make the broken instrument rotate counterclockwise.
当断裂的器械逆时针旋转时，它会向冠方移动。
When the broken instrument rotate counterclockwise, it will go up in a coronal direction.
所以你没必要牺牲危险区域。
So you don't have to sacrifice the the danger zone.
对。
Yeah.
对。
Yeah.
对。
Yeah.
对。
Yeah.
我用这种方法做了很多成功的案例。
And I have so many successful cases doing that.
用多大尺寸的旋转器械？
What size rotary?
比如25号的？
Like a 25?
我通常从小号开始。
I I start with a small size.
你得先用T模式绕过断裂的器械。
Basically, you have to first bypass the broken instrument in in t mode.
你知道T模式吗？
You know t mode?
T模式可以让你结合两种运动方式：先用上发条式的转动，再转为往复运动。
The t the t mode allows you to use two different motion, starting with watch winding followed by the the reciprocating motion.
90度的上发条式转动，因为如果你每次只转90度，器械就不容易折断。
90 degree watch winding because if you, you know, watch watch wind the fire 90 degrees, you cannot fracture the instrument.
如果你顺时针转90度，再逆时针转90度，器械根本不可能断。
Because if you rotate the file 90 degrees clockwise, then 90 degrees counterclockwise, it's impossible to to fracture the instrument.
只要感觉有阻力，我就一直用90度的上发条式转动。
So as long as you feel sticky, I keep using the 90 degree watch winding.
等不再有阻力感了，我就按下按钮，改用第二种运动方式。
Then after losing the sticky feeling, then I click the button, and then then I will use the second motion.
这是一种往复运动。
That is a reciprocating motion.
顺时针转380度，再逆时针转50度，转速150转每分钟，这样能释放应力。
That's three eighty degrees clockwise and 50 degrees counterclockwise to release the stress at 150 RPM.
这样就能高效地绕过断裂的器械。
So this way, you can efficiently bypass the broken instrument.
等扩到大约30或40号大小后，我会用XP成形器，也就是3D成形器。
So then after expanding the space to around 30 or four, then I will introduce the XP shaper, three d three d shaper.
然后以每分钟2000到3000转的速度旋转，让断裂的器械逆时针转动。
Then spin it at 2,000 or 3,000 RPM to make the broken instrument rotate counterclockwise.
通常情况下，断裂的器械会从冠方方向被带出来。
And usually, you find the broken instrument coming out in the coronal direction.
这就是我的做法。
That's what I do.
不错。
Nice.
我
I
这个方法不错。
like that.
这是一种
It's a
很棒的技术。
great technique.
对。
Yeah.
咱们聊聊在取出断针时冲洗液的作用吧。
Let's talk a little bit about the effect of irrigation while you're removing the file.
好的。
Okay.
对。
Yeah.
你的
What is
冲洗方法是什么？
your approach with irrigation?
冲洗。
Irrigation.
如果弯曲角度超过30度，我想用硅油来润滑，防止器械折断。
If the curvature is more than 30 degrees, I want to use silicone oil to lubricate the broken cement.
因为硅油会渗进断裂的水泥和根管壁之间的缝隙里。
Because you can get silicone oil into the space between the broken cement and the the inner wall.
所以如果有硅油夹在中间，就能很容易地把断裂的水泥给松动下来。
So if you have silicone oil between the two, you can easily loosen the broken cement.
不过我收到很多关于怎么把这些油清理掉的提问。
But I I received so many questions regarding how to remove the oil.
你直接用次氯酸钠就行。
You you can simply use sodium hypochlorite.
所以只要看到有碎屑，我都会先用次氯酸钠冲洗根管，再用过氧化氢冲洗。
So I order whenever I see debris, I always irrigate canal with sodium hypochlorite followed by hydrogen peroxide.
我为什么用过氧化氢呢？
Why do I use hydrogen peroxide?
因为它能产生气泡，气泡有助于把碎屑冲走。
Because you can create bubbles, and bubbles help remove debris.
我并不指望过氧化氢能杀菌，但它确实能帮助清除碎屑。
So I don't expect hydrogen peroxide to to kill bacteria, but it will help remove debris.
对。
Yes.
没错。
Yes.
你有使用其他类型的吗？
Do you use any types of
水杨酸盐。
Salicylate.
用油进行山梨酸活化？
Sorbic activation with of the oils?
不好意思，老兄。
Excuse me, mate.
你刚说什么？
What what did you say?
除了过氧化氢之外，你还会用什么先进的冲洗技术来清除油污吗？
Use any, like, advanced irrigation techniques with in order to remove the oil in addition to the hydrogen peroxide?
我想他是想问，你有没有用什么先进的冲洗技术来清除油污。
You want to I think he was asking if you use any advanced irrigation techniques to remove oil or to remove the oil.
没有。
No.
没有。
No.
没有。
No.
不用。
No.
你直接用次氯酸钠就行。
You can simply use sodium hypochlorite.
对。
Yeah.
就这么简单。
That's it.
取出断针之后，就不需要再用油了。
And you don't need any oil after retrieving the broken instrument.
然后你直接用EDTA和次氯酸钠就可以了。
Then you can simply use EDTA, sodium hypochlorite.
就这么简单。
That's it.
我记得不久前有一项研究。
I remember there was a study not too long ago.
我记得好像是纽约大学发表的。
I think it was came out of NYU.
也许是Wogamul的研究。
Maybe it was Wogamul.
他们当时在研究多声波冲洗和负压系统对取出断针的效果。
They were actually looking at using multi sonic irrigation, negative pressure system, and if there was any effect on file removal.
你有看过这项研究吗？
Have you seen that at all?
你有没有在那些先进的冲洗系统中观察到类似现象？就是能更稳定地移动断针？
Have you seen that phenomenon with any of the advanced irrigation systems that now you've been able to move those files a little bit more predictably?
但效果并不是百分之百的。
But it's not 100%.
不过你有没有发现，它可能
But you have seen that maybe it
确实有，嗯，
does have Yeah, an
是的
Yeah,
当然
course.
你可以使用灌溉系统，比如牙科超声波或其他灌溉设备，但首先得把断裂的器械松动一下。
You can use irrigation system, especially like a dental wave or other irrigation system because but you need to first loosen the broken instrument.
所以需要先做准备。
So you need preparation.
明白了。
Got it.
对。
Yeah.
没错。
Yeah.
不然的话，你是没法把器械取出来的。
Otherwise, it's you won't, you know, remove the instrument.
好的，我知道您得赶航班，但我们真想多向您请教一些经验。
Okay, well, I know you do have a flight to catch doc, but we wanna just take as much of your knowledge as we can.
所以如果在场的各位有任何问题，欢迎随时提问——
So if there's anyone who's here with us, please feel free to chime in and-
您用同样的超声波技术来取出断裂的银尖吗？
Do you use the same ultrasonic technique to remove broken silver cones?
他刚才问，您用同样的方法取出银尖吗？
He was saying, do you use the same retrieval technique to remove a silver Silver point?
是的。
Yeah.
对。
Yeah.
没错。
Yeah.
基本上是一样的。
Basically, the same.
但你只需要夹住那个银锥就行。
But you just have to grab the silver cone.
通常银锥是放在根管口上方的，所以你直接夹出来就可以了。
You know, usually, cone is placed, you know, above the orifice.
你可以直接夹住它把它取出来。
So you can just grab it and take it out.
它已经断裂，内外都断了。
It's broken inside and out.
哦，那种情况我也用同样的方法。
Oh, then I I do the same.
对。
Yeah.
我会在内壁上磨出一个半圆形的空间，直到看到它晃动为止。
I I create a semicircular space on the inner wall until I see it dancing.
对。
Yeah.
或者我会用旋转锉把银锥去掉。
Or I will use a rotary file to remove the silver cone.
但如果它超过三毫米，通常确实都会超过三毫米。
But if it's longer than three millimeters, is it that Usually it's longer than three millimeters.
对。
Right.
这些情况里，我一发现锉刀开始抖动，就更容易出现二次断裂。
And those are the situations where I find once I get the file dancing, that I'm more inclined to have that secondary fracture.
是的。
Yeah.
对。
Yeah.
没错。
Yeah.
确实如此。
Yeah.
然后我会用旋转锉把那个断掉的器械去掉。
Then I will use rotary file to remove the broken instrument.
不是断掉的器械，是硅胶。
Not not broken instrument, the silicone.
是的。
Yeah.
是的。
Yeah.
是的。
Yeah.
好的。
Okay.
那我还是用同样的方法吗？
So still I use same technique?
对。
Yes.
好的。
Okay.
在这种情况下，你会用多大尺寸的啮齿类阀门？
What what size rodent valve would you use to that to that scenario?
你通常从
You start
开始扩大空间。
with Usually, expand the space.
我会绕开断裂的器械或银尖，扩到30号或40号。
I bypass the broken broken instrument or silver point up to size 30 or four.
然后我会用XP剃刀。
Then I will use XP shaver.
而且
And
你处理过很多取出载体的情况吗？
do you have much experience removing carriers as well?
你觉得这些材料里有载体吗？
Do you find those to have a Carriers?
可预测性吗？
Predictability?
对。
Yeah.
你是说热塑性的吗？
You mean thermophil?
是的。
Yes.
好的。
Okay.
好的。
Okay.
对。
Yeah.
如果是塑料的或者尼古丁器械，操作方法是一样的。
If it's plastic or a nicotinium instrument, you do the same technique.
方法一样。
Same technique.
对，没错。
Yeah, yeah.
没什么不一样的。
Nothing different.
真的没什么。
Nothing.
嗯，话说回来，
Well,
我跟你说，你这番话真让我信心大增。
you know, I tell you what, you've given me a course in confidence for sure.
我觉得这大概就是你如此成功的主要原因。
I think that's probably the number one reason you're so successful.
但正如你所说，你投入了时间，见过不少病例，现在也掌握了这套技术。
But like you said, you put in the time, you've seen the cases, and now you've developed the technique.
是的，没错。
Yeah, yeah.
非常感谢你抽出时间来和我们交流。
So I really appreciate you taking the time to sit down and speak with us.
我们现场有一些住院医师和医生。
You know, we do have some residents and doctors in the audience.
如果还有其他人想向田内医生提问或分享什么意见的话。
If there's anyone else who wants to question or mention anything to Doctor.
田内医生，
Terauchi, let
请讲。
us know.
但我得提醒你，这中间有个学习曲线，所以我建议你在接触病人之前，先完成至少一百例操作。
But I must tell you, there's a learning curve, so that's why I want you to remove at least 100 cases before you see your patient.
太好了。
That's great.
这就是关键数字。
That's the
关键数字。
magic number.
没错。
Yeah.
对的。
Yeah.
每种技术都需要一个学习过程。
Look, every technique requires a learning curve.
是的。
Yeah.
所以这事儿不可能一蹴而就。
So that's why, you know, it doesn't happen tomorrow.
没错。
Right.
这确实是个学习过程。
It is a learning curve.
谢谢你提醒我。
Well, you for that reminder.
不，这才是手术。
No, that's the surgery.
手术。
Surgery.
是的，这就是如果
Yeah, that's the If
如果你每天都做手术——
you do the surgery every day-
就是这样。
That's it.
您越来越出色了，这真让我受益匪浅，医生。
You tend to get much better and All more right, well, this has been very enlightening, Doctor.
鲁施，您一直是我在根管治疗领域敬仰的对象。
Rusch, you've always been someone I've looked up to within endodontics.
非常感谢您抽出时间参加《根管之声》，祝您回家一路平安。
So thank you for taking the time to join us at Endo Voices, and I hope you have a safe trip back home.
非常感谢。
Thank you very much.
太感谢您了。
Thank you so much.
非常感谢。
Thank you so much.
好的。
All right.
谢谢，谢谢，谢谢。
Thank you, thank you, thank you.
在你走之前，我想特别感谢我们的赞助商。
Hey, before you go, I'd like to give a special thanks to our sponsor.
感谢收听本期《Endo Voices》。
Thank you for listening to this episode of Endo Voices.
别忘了订阅，这样你就不会错过我们接下来关于牙体牙髓学最新话题的全部节目。
Don't forget to subscribe so you can catch all of our upcoming episodes covering the hottest topics in endodontics.
一如既往，我们欢迎你的问题、意见，以及对未来节目主题和嘉宾的建议。
As always, we welcome your questions, comments, and ideas for future show topics and guests.
请发送邮件至 endovoicesaae dot org，或访问 aae.org 了解更多关于美国牙体牙髓病学会的信息。
Email us at endovoicesaae dot org and visit aae.org for more information on the American Association of Endodontists.
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