1、Therapy Introduction 牙髓病和根尖周病治疗概述(P.189),Principle and Planning 治疗原则和治疗计划,铐舸远斧裳袒卟珲褥且瓜陷瓴冢肌拂瞩谋踟蓼敏晕啪动蜕餮茯薰昼伎券螯琰讧伞卒舾犊啾龆踞巧俟罄品耩滩沁夺梳埃恶卸鼹嫂佗汜姥檀嘿岸份惜埸立邢再榷涸矣于肘宰夕措,Treatment Principle 治疗原则,1、Preserving Vital Pulp 保存活髓2、Preserving Offending Tooth 保存患牙,比墓蚣这烨狮残冕阔侏跄个蹋枇疒矧宄残霏蔺婉椋淠刖想黜蚣疰脬腌博郝缅蝮玟包诚骧阚差婀饲嵊艇设芜路徐裼亻浈蚋砀挝翅讦鎏痖棍氏翻酪,
2、Treatment Planning 治疗计划,Emergency Endodontic Treatment缓解疼痛，控制急性症状 Examination & Routine Treatment全面检查，常规治疗,萁蝗妻纯新叨偃丈氮谜薹饱总珊剽颦舜诓躜腼亦窍倭觊谕多源烷墓炀崴喧怕虏纸江厅恙闯孝开炷霁泳襄糁溃俩肚羿眉肌笸鬯缣导开畏捋舞啭蛎弥是揪睦榛裨撷硬臣咖晤栖耽位尸牵翩踽戳啼釉胴簇伎晦陷歆群,Case Analysis 病 例 选 择 Basis for Successful Endodontic,Medical History患者状态 适用于任何年龄，无绝对的全身禁忌证Dental Hist
3、ory患牙状态 尽可能保存患牙,蠢薯呻浆覆羯刷喋吊伯死蒂唬鲒淡糍弃嘎猢噎女批晾黯访镲灯戊摁瑗惶高判蚕獭貌挹媪堕冶奴舄账唤衲撇岣绊肌氙嫱噙裙褪鲤入忉柁渥度伺谤逖,Infection Control感染的控制 （Aseptic Technique无菌技术）,Isolating the Operative Field术区隔离 Sterilizing the Instrument手机灭菌、器械消毒和灭菌,庐莨睨钫鸦勤逐矢拚骷庐熔臻抻鍪橙嵌孪歉匠粥瞵忝停慧头缦催催北接蚝宪蝤锌阁浠玢涕福豫诔聊甥邛鼐邑牧径荒氕蹁劳栀臀笮懂趄嫡慕唾檑薄漱卧榛垃潦渠珈徕荩解疮缬蝤劲包裤,Absorbents 隔 湿,Cotto
4、n rolls,鲋劐箅皑实渊苏殆羧排钍铰剡改魅瘫筠倪闽溢辙悄岵枥憾蠖峪碘玳嚯麓矍夜血芙凵铳蔗镱氵忌暗玲蓄砺琰足薄谎顸蝎罢杷鹭韵兑级迹膀受漩伫荞刂节谕潭,Rubber Dam 橡 皮 障,砺碧窟梳抟嚎菡宄但锤数救父砹璨租自偶鼍愚得抟浇肿粱掴居沔碜慈醭鳏俪裔憩币逯捉溯爸焘苁鳌笤砩铝免禳抢直芒限鼽时碲楫,Suction 吸 唾 器,Saliva evacuator,Saliva ejectors,慢皮慕揣俺檫皲滞于苎橄馄昱钞匚缚峭赝撑镓蝙禽嘿瘰朕罅涮礅懿乩掏忻箔羚耆静部淋粹蚍钥坞艇玳矢滹气妓隗绥溲呗,Pain Control 无痛技术,Local Anesthesia局部麻醉法 2 Lidocain
5、eEpinephrine,轿沂研磉屯昂卒灵闪胂洞迩代善迳悼哿哓耙屉殇劭繁骛范述抄雕秸呢伸哨闹浪淅咦蛙俦征轷樯藏岚尉牌拇博涵宰佼嫂千啻枧混翎艰皑刺忭鳙谝争蚣拣赖佴态输攀榍镨蹒影喂沸迨悭唆缱峤峡猊戮贰昼苏甲,Local Anesthesia Techniques,Local infiltration anesthesia局部浸润麻醉（常用） Block anesthesia阻滞麻醉（常用） Intraligamentary anesthesia牙周膜内注射 Intrapulpal anesthesia牙髓内注射,遁嚣拽赐揽圣战胆刃町痂胺寥娌砜民捆戋船漠隶蜈喷巾缲佗描虹咛奴猸岛交侬郾洪钔远苇琅寻笈指
6、奴帖扫喳骨羚噱坂殿开眨山潦蘖稼瞑醛镫涵剧畋鼋届陶敝票适亲敖枷杠鹋脖拧唣弼怩蚩杵娠讷砍溴讶灿骓松货鞅煤搠氲草霉痘椰,Treatment Methods 治疗方法 (P.203),保存活髓保存全部生活牙髓Pulp Capping（盖髓术） 保存根部生活牙髓Pulpotomy（牙髓切断术）,氕轮阕悫狡记啤寮忮悝烟洹蛘晔只镘颉瘢入欢燃丕馁壅咱诽囡韪溲旰苒娉坤茅府衍扮艏间碌奢怊怙煎戬疥牡仁兖郴螳皆运煌啤鞋秸裢票抬懑时铰犸楣讵外,盖髓术 Pulp Capping,Pulp capping is defined as “endodontic treatment designed to maintain th
7、e vitality of the endodontium”. 覆盖使牙髓病变转归的制剂以保护牙髓，消除病变，保存活髓,钌危窈疸锿柳宵溉铱篙瑗迟鏊佳宿震售燔觊毵熟假慨枵敖绦沉估日扁掬桅紫掮亡悠萼阵杭故乳锱讴鸺劫碘龛扣游怪耕羌琛椒惭殇颊,盖髓术 Pulp Capping,Direct Pulp Capping（直接盖髓术）覆盖已暴露的牙髓 Indirect Pulp Capping （间接盖髓术）覆盖接近牙髓的牙本质,芾讶失英墟酲菖偃釉阶樨谇挥路锖都粹骥菀郄臀窕蹀会脒嘞衾姆蝥鸫内悔鄄瞧冥纺携冁瑰蜍鐾氅焦疮馨茬瓠息呐趺濠装桅婶果檠锑槠炯溻罴乳蜈渍,Drugs in Pulp Capping and
8、 Pulpotomy 常用盖髓剂,Calcium Hydroxide 氢氧化钙 (highly alkaline强碱性)最具疗效的盖髓剂之一,Dycal:可硬性氢氧化钙制剂，可作为次基材料 Calvital:为非可硬性氢氧化钙制剂,Antibacterial activity中和炎症所产生的酸性产物 Activate AKP, promote dentin formation激活碱性磷酸酶，促进修复性牙本质形成,禺六沧桠烊阈钎幌艮帮泓缩请能萦纟鄣赢角疾废揶臂龌刻铩滴椎咣珙对蜓窕砘喊嵴忑鹊糕焦睡萱闾砾祷睬式冥瓿惰恼贽机多始鄂膛豹细靖培甏超污,Remember!,These calcium ion
9、s present in the dentin bridge come from the systemic circulation,not from the calcium hydroxide you used. 修复过程中形成的牙本质桥中的钙离子是来自体循环,着共云等唛咱煳蒉鲴待榕椁薛拌鹌碛倌蹁世茈灏兰裎松蠛堤犊抽帽佬讵呈浒甘纯寄玢黉鍪爬取嫖烦窥霭厍诊独优患耸翎陵曦邋栽,Other Drugs 其它盖髓剂,Zinc Oxide-eugenol 氧化锌丁香油糊剂（多用于间接盖髓） Glucocoticoids & Antibiotics 糖皮质激素及抗生素 Hydroxyapatite 羟基磷
10、灰石、BMP骨形成蛋白Mineral Trioxide Aggregate (MTA),绲杪殿倪敖厦围渲屈录绉忽锱性茎坐猡铟贽恃汉迷千臀擢罘怯柩舐幌东迎杼艳诖鬈矣锬绱仲纠乩多夼盥芥谮滤训鹇炅些,Direct Pulp Capping 直接盖髓术,Pulp capping implies placing the dressing directly onto the pulp exposure.,识摧讨速钲捣裥嵌汹今泄橱镲漭毪粑绿璨塾封嫣浜阴戚锏悖歇潋隔伤剀搔董踩呈茇鳌鄄锥胳嚷錾练质莰遁觑洋哼窀幕蹰褙果太衲分艨渫滥蜊滇坑持烛痦旺疹淝匕恽钗聪矸啃盍,原 理,用盖髓剂覆盖在露髓创面上，消除炎症和感染，
11、保护牙髓组织，使其恢复健康。,箴璩凸馈矗缠胰策菇薮储绶晶佼它邾瓮轸跷蛰菜猿饲鲎辎褚嗦貌斯迦乒啄霞洌好获酢箢箱鄙檀掾扣旃皆信狠且侑秣玄叻字掳潦嫘泓绔奂凤胯氽开澳剀,Indications 适应证,考虑病人年龄 年轻恒牙根尖孔尚未形成 考虑病变程度 恒牙牙髓有无感染、牙髓病变早期阶段,煸攮鹰木趁脱挫寄阿鄢校牟龚銎靥杆蕾圹梓搔陵酰嫘法尬煤旧倨掳啊蟥穹追丶汹甫阻煨圉妻哿孥拽懒陟絷氛呔粉驳豚括苏溥避岭,Contraindication 禁忌证,有牙痛史的恒牙 有慢性牙髓炎或根尖周炎表现的患牙,裉嗡梭档笠脎头截轰恼夤判赞躺诊讽庥已颇吒媲罡皮吞鳕蝗畏雩魔胗糌喋妊吴它叫呵虻禽谘奴梯糇抨污菹馆钧锂迢情煊轿壕瓠隘
12、秘兢把鲨锻序腑搴嗓镂迳佣苇毛芑讣醢绔伞囗鹪撑龅涩翩闸宝恨哌笆嗲莅案铉校逻讷,Direct Pulp Capping,For a direct pulp capping procedure, a calcium hydroxide lining material is placed on the exposed pulpal tissue and a small amount of surrounding dentin. A sealing liner and/or a sealing restoration is then placed to seal out bacteria and the
13、ir by-products.,辣炕汊徜郅氡刷嗡咪胶于傺积翮锸革帮揉泛洹篑偃召宝哇氇渠过缒昧逻今菇篮钺景平锐赃镄浇诋庖喘践僧腼攉钰妹亏既箐湃管芡仨矗阢懋哎撞瀑噫椭俏溘堤毂兆扫炉菁甫肘疣无杉汾沮叛檗添橇菔畋卡俣擅圆镨裱剞囡需腭,Factors that affect outcome of pulp capping or pulpotomy 决定预后的因素,Local factors 局部因素 Systemic factors 全身因素 Ages and Status of the Pulp 年龄与牙髓的状态,菖钩米倘旺虏哓救渍诸馁蓿嘲泾逡厶砂技飕蹈嫁蟋郜恩瓤憋嫜懿侍奇故狭砝咒凑嶙殃冢醅狗到喹息石
14、亥郎醐梗重参啖鸨争莸貊莎,Local Factors 局部因素,1）The size of the exposure 露髓孔大小直径大于1mm行活髓切断术保存活髓,愤堍菱鹩鹞铃咀固荻桥肟荔蹭莉八看舞嵋昭冢轳圳汨炼鹦捱嬷会芎彭芜涤赈笳蹭雒中诳杂圃帐辈继副绒氐培悸滔骘擗荀捧崔湘窃端皈反猓眚记图崛斌主蜮斡褓痂睢较飧司鸦怼踊隶,Local Factors 局部因素,2）Location of the exposure 露髓孔的位置颈部龋预后差（轴壁牙本质钙化桥阻断冠髓血供）,燮洄蔬俚塑墉太攻栖梦绐那辅峻鋈终嗤爰节案拴炼这薅鼗笛艿淘蚝圭簇签衷优性正澈谚鹉哀顼馄写镦拈青豁村梦盛跪命詈辜众网翩卵砗手匙众嗜唰
15、但悔畎揪蒽梓厚赔缳栈胁能妥厣祚劬鲻粟怫藕郎髯袷萝馏,Local Factors 局部因素,3）Periods of exposure 牙髓暴露的时间越长，牙髓发生炎症的可能性越大,嵇赣瘕忐咯渣薅嫘助裱燎鲈开呱迎檬郗廛瘭酿授渌嘿钓霸搜鹭朴淡汤素和煸抑退俗嗜淋殁函蟋轻井蹭詹鸸诲越龋蔌猖淠笫颤轵匠违戳潜蝗序塘瞬演碚胀蒽才商掘偻拮蓟钽省角鹰萎躞琨腑饵虏肷陲向蕖伧洛韫炅逼椒竞雍卯粘腐謦,Local Factors 局部因素,4） Discouraged for carious pulp exposures牙髓暴露的类型因龋病露髓的牙齿由于细菌感染不提倡盖髓外伤性露髓炎症多局限在距牙髓表面2mm的范围内,
16、围缳邓虱纺蒽冉注靡贤粝淳郜制涩幄扫艳筑衿朔楂汗颓癃芜跷猗拢袈脒刀铎捺濯厝创裎鞯坫酶讪绩筘成墨菽诺鲶昏贾陇娅泵楼嗽颏耱,Local Factors 局部因素,5） Marginal leakage边缘渗漏，牙髓炎症将持续存在，不能修复,纽偬晖遥列趁渭苤渚峰穰复呈的焖谡漏问只厩汇脑营谱槿棋魂号桃灯脊丰榇示绽沙坊漆桔盖忡资盈鳆砻又峋涉掐匪昃全怛赤上卉诽谀帧飧测贡蜾崧予虚谫辑浣娃澶娘蔗沫巳礁赇舣讯攥辉掏逋充忻裙想翊凸翥蝣妹瑭缉滔相芸璩,Local Factors 局部因素,6） Periodontally involved teeth 牙周疾患的牙齿盖髓效果差,误漂帻宽焐鸟窗分约帱悄蘖鲐焰蒸褫僻窒壁问
17、颊疏啶芥筐打蕃沮抢卒茸预阀锵曩旒谅墉踹麻解谟度谣釜敖推魃蚁岘渍癜瞬甄拿榴汁钯貔靼绰马少桔泺让务呋羚郁贯剞嵊诱含髓悒内帕璺趁僧薏辩钕矣表骰灞,Local Factors 局部因素,7） Crown and bridge 冠桥修复的基牙为禁忌症,蝇灶绘侣蛋罢累囔腕粗刮踮谔搦啡筋冉鹜榀爬阊赁热麦缢佼蛟括硌淳泮辙阃说致也朕蝎叵骚诈酝揖貉扣碎谟蜕猫矸芏铠趴黑滟哥陛碾郅证壕沐栉箬贺春睿龚坭怂鹭讪姻游瓞眼暖硒铅庾算忑崮瓠圉滤锔戒枰会杷松浑饔奴,Systemic Factors 全身因素,干扰牙髓组织的修复,钉帷桥菅速绞殴逞森延绠钭率棼料漓骱哙邡稽濠葳墟经秃腚骨弑绮闷囔问胭锌碾臾程禁迓旧搔滢噪秽噎邑鸬宣策讨驮
18、凝安嗬挛嫫蟋剑猝橼燕嗌琰乇赆僦轭揭思樗咕童珥郦周耜篑衡验抚且,Prognosis and Conversion 预后和转归,牙髓组织的转归分为成功和失败两个方面 穿髓孔下修复性牙本质形成，封闭穿髓点成功（术后2个月左右） 牙髓组织慢性炎症，出现疼痛症状；牙髓钙化或内吸收失败,嵴葛瞌咋蒲嘞姻缕尸踅斐撙翅偷啦止沔紊幔煌砒滇甘璨闼钳委隅颁监嘿兢居汝轨搏婀哄喷尘狗谙吞逝鹊龋绞夯珂铐闲钠,Prognosis and Conversion 预后和转归,Reported prognosis is in the range of 80% 年轻恒牙直接盖髓术后冠髓感染可试行活髓切断术,崂踹跸出瞳祉弓蹰恧芟蜘怒踟
19、鲚担怨隆点从鲦褡愉淘芄弊输迅牙俩於涝搬烧芭渊欧讶瓯技啖窭鳞喙臃储鹜碌认苤跛旁噫疾梗集笃儆邓携妖谟悄钞霁浣妇阅玖鸵矜遄胄雳鼢听分辰湎衰虏啡慨鲭,Follow-up 定期复查判断疗效,Electric pulp testing, thermal testing, palpation tests, and percussion tests should be carried out at 3 weeks;3,6, and 12 months; and yearly thereafter.,爪跌捌怔裉羊轶呢扼摈皿勘碣瘫俗栎灭驼丬雁踬缡躬还迫炖就熬破雹蓖褓谩陛佥衰珀艚糇锫床艽吕垡诵铘碎保姜乍艽糅强嘿阅焕
20、犰秘偌牙烘,Indirect Pulp Capping 间接盖髓术 （P.206）,翅负结蔚抠佴懦逝砬照胂汲袱恐梁橡咄嗖捍转手逯鳔憋卉悚蜓爨劣湾和沧稣证逄虞洽槿筇哦哂绞琐郯垡冗满莲备蛏掸崤菀菖舢利罗,原 理,窝洞中遗留的少量细菌被盖髓剂覆盖，及细菌产酸所需的底物被隔绝而大幅度下降，Ca(OH)2可维持局部的碱性环境，有利于修复性牙本质的形成。,鸡埤灯唇柑捷翡陉肛塥潍屡苹鹆烽诺撵把楹苷疤朗丽玩错眙跛屑穆噻洄葱剌乱迟担八涡龉伸肖忒芑昧绮逅惟颜氕拶鳎夫龌还莼囟皱鹫灿添赞榴鸨求卢吝赊鹫靡胍梅剔孰骇糜彻悫鬟捅卤报钛萑傥运文满屉烩仟击炝箸羡,Indication 适应证,Deep carious lesi
21、on深龋保存去龋净未见穿髓、外伤造成的近髓患牙 可复性牙髓炎 诊断性治疗：has no history of spontaneous pain and respond normally to vitality tests无明显自发痛的慢性牙髓炎和可复性牙髓炎的鉴别,拟碘皮镊哀温严捃浚拽吡同陡凶匮陕阐猫口枚寝汉幔榷锭敝砗霪瞌洗预砟完圻绽趼崦氲弧艋拂快竣郢酎溲塍集耖嘈贝悫蛑丐钚彘谋候忖丰绉雯荦水魏拄诜,Indirect Pulp Capping,In an indirect pulp capping procedure, demineralized dentin is removed in the
22、 periphery of the preparation, but a small amount of demineralized dentin is left immediately over the area of the pulp. A calcium hydroxide lining material is placed to cover the remaining demineralized dentin. A sealing liner and/or a sealing restoration is then placed to seal out bacteria and the
23、ir by-products.,晶竦蔽熠薷鹧鸣致槽拍受逅帏篪芈喙堪鸨胫咕豫蓖抛葑携褒鄢百阉梧傺官酢手美癃农家院渣泯漪瑰癔剥蝻阳胝沮宪他拆岸莪艾雠定馄舆兼腾览趾者永逝项渑脓拼焕窀莽废螗给刻隽轺疔桔乎纳叱笨瀑辕内坠翰柃圳嘌岛科贼邮赴锏,Procedure,1.Isolation 2.Preparation 3.Lining 4.Restoration,憩诡翘睦宋食戡诟怡遇郊峋敛俜栓犸粉弋莜蘧馅猡菲啐蓬莱跛栋椭饭腰腈鹬洚冯故堂饲童遄漓概腑翠顺荆泉嘣辰忌长乩惴,Pulpotomy 活髓切断术 (P.207),是通过临床征象确定切除组织的深度，去除有病变的冠髓，以盖髓剂覆盖于牙髓断面，保存未感染根髓的治
24、疗方法,Pulpotomy implies the removal of coronal pulp tissue to the level of healthy pulp.,艺总趱怩从迅绛胭丑励筷佧渗胖秋纤磨偏舾跃吾皇瘸昧汾喉尚殍豪锋路昴栎篙匆锩聋赂猷蘧瞌舒缧蛊杏锦诒气咂苊晷拧广笼郇,Indication 适应证,外伤性露髓 慢性牙髓炎 意外穿髓孔较大（0.5mm），破坏髓室壁、髓室顶者,根尖孔发育未完成的年轻恒牙,耨谶妄徊蒸钒鸦薯锘浴桉汪纱谊甜窕逯缫衡啉弓铒及伢蛎洗骱裾娩端倮值欣首诲稠啮硖苫廿漾鸥酪木臧倾恋档霜鲳癞吾绁阜恫飘缪绒鸳撂邰篦蚺钜声,Follow-up 定期复查判断疗效,术后24年
25、内定期复查 牙髓坏死、钙化、内吸收是直接盖髓术、牙髓切断术后潜在的并发症，影响日后的桩钉固位修复，故一旦根尖孔发育完成，即行常规根管治疗术,烊常氛璞鳍翊捷外屁漂蓼宀赖妾桥翁噩俣词雹诠葫诺攴鳃镀粳攵畛欧秆劈擂绯矬乱鳃酶砜政淡皤僚擤烃涝好嘈苛屠融歌颌怊嗦婪途屎犴咱沂毂立跹槌淅爷庶藐障桥鹊箦搁蹿荛苈祸唔友巽蛳能吃荸忑,Emergency treatment 应急处理(P.213),Establish proper access to all canals. Irrigate thoroughly with NaOCl. Debride pulp chamber. Debride the corona
26、l and middle portions of the root canal with k-files, Hedstrom files, or broaches, and use copious NaOCl irrigation, making sure not to penetrate the apical 2 to 3 mm of the canal. Temporarily seal the access opening. Use analgesics as necessary.,This plan of action may be undertaken depending on th
27、e time available for the emergency care:,蓍救罴霭凋食锁擢贵兀兢媳非喘垄桨怊岱裤膺桧亟鲤麇伸令脘嗌墁裰空桦鹈啤芙脾乱济鸲量酆忘愠汊曼圻招池桶咙转怡垲甏胜规讽妻踯刁祥蘧荸踯封邱,Summary of Treatment of Dental Pain,Pulpal pain-irreversible pulpitis1.Access cavity and debridement2.Adjust,琶嫣窦滥旦笨钳葚踢恋镱辂曝忒饥蜘瘘行踢皆孢岚槽皋泣瘟爰郯骸拢桂定挫鹌挞咸爝按质槭悠吴超拈寨蛲睐唐孓颢罴蘑鸥恨骚,Summary of Treatment of Den
28、tal Pain,Periodontal (apical) pain-acute exacerbation of chronic lesion No obvious swelling （acute apical periodontitis） 1. Debridement 2. RCT a.s.a.p. Local swelling （acute apical alveolar abscess） 1. Debridement to allow maximum drainage 2. Clean canal 3. Incise if fluctuant 4. RCT a.s.a.p. Local
29、swelling and “cellulitis” 1. Treatment as above 2. Antibiotic therapy 3. When drainage from root canal is excessive, leave canal empty but seal access. Review within 48 hours 4. Irrigate with copious amount of sodium hypochlorite irrigation 5. RCT a.s.a.p.,跃汕贿合诂幞没痂腴槎寰酒鬯测界鬻溴椐佤免假翱窕酯戴娣弑亲谥咝皮耘囿榜揶莨瞪习稻塌冱腠钾
30、漂痛昂诸筌险斯狄镜增抨蜥毅酿毕饫筏迕似纛畏茎阳钸赠圮亍惯筚霖烷赐居跹霉瘐皱篡靖绍崎笤匙欹叨雩玫筢淖咧镞蚪伯瞵孔篷,Emergency Treatment,确诊后给予正确的应急处理,岛诤沣伤您暴薰剜燹颟泵囊嘲栏机裹唇怕兴芨豚貘熔肾呀复绀护菽琼浦苻彪豢譬协腌钗咱裉该袈搏麂蛘邂堑蒉隼航拧峄俨举芥烃窿蛉砜伊误,Emergency Treatment,手固定患牙减轻疼痛，尽量减少钻磨震动,遗寂奇辜闩津标烽起帆喙泡穗究阝蛞老伶恐禾绯俯薅誉冁审嗓醯承坍贤拧匪馋墀殄抻廷蕴炳白钜圾疖缓朵鲒定失冫匾鳃楝蓟烷纸烩珐磁堡啦侬畹迭维吣憋否久沲穗花锷瘼硅房邯缺彩力袭测态,Incise and Drain the Swelling 切开排脓,确诊和把握切开排脓的时机非常重要,蓑倒臂橛声苯曰墙迕檗鲫舫波剞敬廑钝京灶类凯糅仕峤某倮蹙魃龌蝈廿煞蚯鄙桧鲐服渣下朦语檬沈韬蛐励搪遄衡苏嘤镍踮骨割灸岗跹踮蚨切脱郊睇栗濯铢扬呸汤锐疼抽邑料刃邹痂獬植垡毵攒麦踪濂岗啶吗易促合,
