2 - Cleaning and Shaping in Endodontics

Cleaning and shaping
Prof. Dr. Safouh Al-Bunni 1

The general objectives of canal preparation
defined as follows: "Root canal systems must
be cleaned and shaped:

cleaned of their organic remnants and
shaped to receive a three dimensional
hermetic filling of the entire root canal
space."

CLEANING

Debridement

By definition, debridement is the removal
of existing or potential irritants from the
root canal system.

These irritants consist of the following,
either singly or in combination: bacteria,
bacterial byproducts,

necrotic tissue, organic debris, vital tissue,
salivary byproducts, hemorrhage, and other
contaminants.

Technique

The principle of debridement is simple
Ideally, instruments contact and plane
all walls to loosen debris.

The chemical action of irrigants further
dissolves organic remnants and destroys
microorganisms.

Irrigants then flush the loosened and
suspended debris from the canal space.
This rids the canal space of irritants.

Criteria

Unfortunately, there are no totally reliable,
easily definable criteria for determining the
end point of debridement.

One suggestion has been to obtain clean
shavings.

One suggestion has been to obtain clean
shavings. However, shavings are difficult
to see on files at all, whether clean or

When this criterion has been used in studies
evaluating canal debridement, there is little
relationship between clean shavings and the
quality of debridement.

Attainment of clean irrigating solution
is another criterion.
However, this is also inaccurate and serves
only as a crude indictor.

Achievement of glassy smooth walls is the
preferred result. Smoothness is evaluated by
firmly pushing the side of the tip of a small
instrument along each wall on the outstroke.

The walls should become and feel smooth in
all dimensions.

Although the best indicator to date, this
criterion is not totally accurate either.
Other and better determinants are yet to
be identified.

SHAPING

To develop a continuously shaped
conical form from apical to coronal.
The apical preparation should be as
small as is practical and in its original
position spatially.

In addition, removal of a uniform layer of
den tin in all dimensions and all regions of
the canal is also desirable.

Is such uniform removal of dentin from all
canal walls achievable?

The answer is "seldom" for either straight
or slightly curved canals and "almost never"
for more curved canals.

The nature of canal dimensions, shape, and
curves as well as the physical properties of
shaping instruments prevents the possibility
of a uniform, tapered, flowing preparation.

Essentially all canals are curved, and most
instruments are relatively inflexible.
It has been suggested that instruments be
precurved to fit the canal.

However, the files will cut to the outside of
the curvature ("transportation") regardless of
whether files are precurved and whether the
files are stainless steel or nickel-titanium.

In curved canals, files do most of their work
by stripping away layers of raw dentin from
one or two walls in certain areas ; they may
not touch or may enlarge many other regions
of the canal.

Recognizing these deficiencies, the dentist
attempts to minimize this action by using
certain techniques of preparation.

Enlargement

The eternal question is, how much should
the canal be enlarged?

The answer is simple ( although
implementation is difficult): enough
to permit adequate debridement as
well as manipulation and control of
obturating materials and instruments,

But not so much that the chances of making
procedural errors and needlessly weakening
the root are increased.

Taper

Generally, taper should be sufficient to
permit deep penetration of spreaders or
pluggers when obturating with gutta-
percha.

Excessive taper may result in unnecessary
removal of dentin and weakening of the
root.

Criteria

Adequate shaping basically reflects adequacy
of preparation for obturation.

That is, whether the technique is lateral
or vertical condensation , the canal must
Be flared and enlarged to permit control
and to achieve adequate depth for spreader
or plugger insertion during obturation.

When taper is sufficient to permit spreader
penetration deep into the canal (0 to 1 mm
from the apical stop ) with some space
adjacent for gutta - percha, the flare is
adequate

With vertical condensation, sufficient flare
is required to allow placement of pluggers
within 3 to 5 mm of working length.

MASTER APICAL FILE
DETERMINATION

The master apical file (MAF) is by
definition the largest file that binds
slightly at the corrected working
length.

The MAF is determined by passively
placing successively larger files at the
correct working length until a size is
reached that slightly binds at the tip.

This determination is made after straight-
line access .

Straight-line access allows files to be
introduced without binding through the
chamber and into the canal until the first
canal curve is reached,

thus eliminating interference cervical
to the apical constriction.

After MAF determination, the next
procedure is step-back cleaning and
shaping.

APICAL PREPARATION

An additional objective is adequate
preparation of the apical region.

Length is important, but even more critical
is the creation of an apical "matrix" or
constriction.

The apical matrix has two purposes:
(1) to help confine instruments, materials,
and chemicals to the canal space; and
(2) to create (or retain) a barrier against
which gutta-percha can be condensed.

Depending on apical foramen configuration
and canal shape and size, an apical stop,
apical seat, or open apex will be created .

Apical stop Apical seat Open apex

Whichever of these three occurs, the result
will influence the choice of the obturation
technique and possibly affect the ultimate
prognosis.

The apical patency concept has been
proposed as another means of managing
the apex.

The technique is to perform apical
"trephination," i.e., to pass small files
through the apical foramen (without
widening it ) at times during canal
preparation.

The idea is that this will prevent hard
or soft tissue blockage of the foramen,
thereby improving debridement and
reducing irritants.

Variations

Apical Stop

A barrier at the preparation end is
an apical stop.

Apical Seat

Lack of a complete barrier but the presence
of a constriction represents an apical seat.

Open Apex

The apical preparation resembles an open
cylinder (neither barrier nor constriction).

Open apex is undesirable and will probably
not confine materials to the canal space.

In addition, there is no semblance of
a matrix against which to condense
gutta-percha; often, no apical seal will
be created.

Criteria

An instrument one or two sizes smaller
than that used for apical preparation (i.e.,
the MAF) is the instrument used for
evaluation.

If this smaller instrument is placed to
length, tapped around, and hits a dead
end in all areas, this is an apical stop.

If the file meets some resistance but can
be passed through the constriction, this
is an apical seat.

If the instrument passes unimpeded through
the apical preparation, neither seat nor stop
is present; this represents an open apex.

Techniques of Pulp Extirpation and
Cleaning and Shaping

Preparation includes removal of vital pulp
(extirpation) as well as cleaning and
shaping.

Cleaning and shaping methods have
historically varied according to the
situation and the obturating material
selected.

However, at present, two basic approaches
are used: the standardized taper and the
flaring (step-back or crown- down) taper.

PULP EXTIRPATION

Bulk Removal

Pulpotomy is removal of the coronal vital
pulp.

Complete removal of necrotic and vital
radicular pulp is referred to as debridement
(cleaning and shaping).

The description “ access with no vital
pulp" or "debridement with no vital pulp"
should be used instead of "pulpotomy" or
"pulpectomy " to describe situations in
which the pulp is necrotic.

The preferred time for pulp extirpation
is during access.

Technique

A barbed broach should fit the canal
dimensions approximately (according
to radiographic size) but does not bind.

Caution must be used with broaches
because they are somewhat fragile
instruments and are difficult to
remove when separated.

The broach is measured at estimated length
and teased into the canal short of working
length.

The handle is rotated a few times and then
withdrawn.

The broach is not reused if it is bent or has
bound in the canal—a new instrument is
selected.

A technique used in larger canals is the
"broach wrap." Two smaller broaches are
inserted, and then the handles are wrapped
several times around each other; this often
engages and dislodges the pulp.

STANDARDIZED PREPARATION

This is the classic technique initially
described as the preferred method of
cleaning and shaping.

Objective

The desired end result is the creation of
a preparation that has the same size, shape,
and taper as a standardized instrument.

The technique was an outgrowth of size
standardization, which was introduced
in the 1950s as a guide for endodontic
instrument manufacturers.

In fact, creating a true standardized tapered
preparation is difficult in ideal situations
and impossible in curved canals.

Standardized preparation is indicated for
silver cone obturation but may also be
used for gutta-percha.

Preparation with large instruments around
curves transports the preparation, which
tends to create irregularities (ledges and
zips) and subsequent problems.

Method

FLARING PREPARATION

This is a tapered preparation, using
a step-back or crown-down technique
or a combination of the two.

A series of research reports indicated
its superiority over the standardized
preparation techniques.

In addition, the step-back technique
creates a smoother flow and a more
tapered preparation from apical to
coronal direction.

The crown-down (also known as step-down)
technique is also relatively new and also
creates a tapered preparation.

Objective

The objective is to keep the apical preparation
as small as practical (but well debrided ) with
an increasing taper throughout the canal.

Also, the final apical preparation should be
at or close to the original canal position.

It is desirable to remove a layer of dentin
from all canal walls from apical to coronal.

Method

The basic method of canal preparation for
any flaring technique is as follows:

1. Negotiate the canal space with small files
to length.

2. Remove coronal dentin ( enlarge the
coronal canal) to facilitate placement of
larger files in the middle and apical
regions.

This is performed with Gates-Glidden burs,
orifice openers, or hand files.

3. Determine the size of the file that corre-
sponds with the size of the most
apical canal space.
This is the "master apical file."

4. Enlarge the apical and middle canal
spaces with a flaring preparation (step -
back or crown-down) to clean and shape.

Note that apical preparation has two
phases, initial and final.

The initial phase is small to minimize
transportation.

In the final phase the apical preparation
is increased three to four sizes larger
during apical clearing; this will improve
debridement and obturation.

Apical Preparation

This is the next step after straight-line
access is made and the MAF size is
determined.

Care is required to not overprepare the
apical region, particularly in the curved
canal!

As the curvature becomes greater ,
a smaller apical preparation is needed.

If the canal is small and the curvature is
more than slight, the MAF is usually no
larger than a No. 20 file.

A straight or slightly curved canal
allows more latitude for a larger MAF.

If the apical portion of the curved canal
is anatomically larger than a No. 25 file,
to minimize transportation, no attempt
should be made to enlarge this region
further than the size of the file that
shows slight binding.

Taper

After apical preparation, tapering of the
remaining canal is created by shortening
the working length of each successively
larger instrument by 0.5 mm and by
performing peripheral filing. This creates
the step-back.

Recapitulation

After each step - back file is used,
recapitulation is performed by returning
to length with the MAF (or smaller file) .

The instrument is rotated carefully to
loosen debris but not enlarge the apical
canal.

Irrigation

At least 2 ml of irrigant is used between
each file size after recapitulation .

Size of Preparation

Step-back instrumentation up to at least
a size 70 file is usually necessary.

This should give adequate debridement
of most of the canal as well as sufficient
taper to permit deep spreader (or plugger)
penetration.

A larger step-back is indicated in larger
canals.

Final Apical Enlargement

This will improve debridement of the apical
portion of the canal. See the upcoming section
on "Apical Clearing."

Crown-Down

The "crown-down pressureless" techniqueand
the step-down technique are modifications of
the step-back technique.

Advocates propose that the canals will be
somewhat debrided before the instruments
are placed in the apical region, thereby
decreasing the chance of debris extrusion.

The crown-down is often suggested as
a basic approach using nickel-titanium
rotary instruments.

PASSIVE STEP-BACK

The passive step-back technique uses
a combination of hand instruments
(files) and rotary instruments (Gates -
Glidden drills and Peeso reamers ) to
achieve adequate coronal flare before
apical root canal preparation.

The passive step-back technique provides
an unforceful and gradual enlargement of
canals in an apical-coronal direction.

In addition, it is applicable in every canal
type, is easy to master, reduces procedural
accidents , and is convenient for both
operator and patient.

Instruments

No. 10 to 40 K-type files, No. 2 and 3 Gates-
Glidden drills, and Peeso engine reamers as
well as highspeed round and diamond burs
will suffice for most situations.

Clinical Techniques and Rationale

Step One: Access Preparation.

With the use of an appropriate sized bur
in a highspeed handpiece, the pulp
chamber is penetrated and unroofed .

After the canal orifice is located , the
access cavity wall(s) are flared adjacent
to the orifice with a thin, tapered diamond
bur.

With use of the diagnostic film, a No. 15
file is placed in the canal at the estimated
working length of the root canal either as
determined radiographically or with an
electronic apex locator.

Step Two: Passive Step-Back Hand
Instrumentation.

After depositing sodium hypochlorite in the
pulp chamber, a No. 10 or 15 K-type file is
placed to the radiographic apex with a very
light one eighth to one quarter turn and push-
pull strokes to establish apical canal patency
with little or no resistance.

With the same motion, No. 20,25,30,35,
and40 K-type files are carried into the
canal as far as they can be inserted
passively to remove small amounts of
dentin.

After passage of these files, the canal is
irrigated with sodium hypochlorite solution.

Step Three: Passive Use of Gates-
Glidden Drills.

A No. 2 Gates-Glidden drill is inserted into
the mildly flared canal to a point where it
binds slightly.

It is then pulled back about 1 to 1.5 mm
and the slow-speed handpiece is activated.

With an up-and-down motion and slight
pressure, the desired canal wall(s) is planed
and flared.

A similar technique is used to plane and flare
the coronal region with No. 3 Gates - Glidden
drill. A No. 4 Gates-Glidden drill is used in
large canals.

A No. 4 Gates-Glidden drill is used in large
canals.

The root canals should be irrigated with
sodium hypochlorite solution between the
engine-driven instrument.

Step Four: Passive Use of Peeso Reamers.

A No. 2 Peeso reamer is placed into the
canal to a point where it binds slightly.

It is then pulled back about 1 to 1.5 mm
and the slow-speed handpiece is activated.

With a gentle up-and-down motion, the
coronal portion of the canal is shaped and
flared further.

With the use of a similar technique, the
coronal 2 to 3 mm can be flared with
a No. 3 Peeso reamer.

Step Five: Confirmation of Working
Length.

Because flaring and removal of curvatures
reduce the working length, it is essential to
confirm the corrected working length before
apical preparation.

After placing a No. 15 (patency file) or
No. 20 file in the canal, the working length
should be confirmed either with a radiograph
or an electronic apex locator.

Step Six: Apical Preparation.

After the canal is flared and the corrected
working length is determined, a No. 20 file
should penetrate to the working length
without any resistance.

The canal is then prepared with sequential
use of progressively larger instruments
placed successively short of the working
length.

Narrow or curved root canals should not
be enlarged beyond the size of No. 25 or
30 files.

Evaluation Criteria

There are basically three criteria for
evaluation of canal preparation.

1-Debridement.

After preparation, the MAF tip is pressed
firmly against each wall on the outstroke.
All walls should feel smooth.

2-Taper.

The selected spreader passes easily to or
within 1 mm of the working length with
space alongside for the master gutta-percha
cone.

3-Apical Preparation.

A seat or a stop or neither (open apex) is
identified by using a file smaller than the
MAF at the working length.

APICAL CLEARING

Apical clearing results in:
(1) better debridement,

(2) enhanced obturation, and

(3) a more defined apical stop.

Performed in a prepared canal with an
apical stop, apical clearing enlarges the
apical region at the corrected working
length .

There are two steps: final apical enlargement
and dry reaming.

Apical clearing is indicated only if there is
an apical stop.

Further apical enlargement in the presence
of an apical seat or open apex configuration
increases the chance of an overfill

by removing dentin chips that are forming
a partial plug or seal, or it may actually
open the apex further.

Final Apical Enlargement.

This step is performed after canal
preparation is complete and has met
the criteria of adequate cleaning and
shaping.

Instead of final recapitulation, instruments
three to four sizes larger than the MAF are
carefully spun (reamed) in a clockwise
manner at the working length in the wet
canal.

Therefore, the final apical size in a smaller
canal would be No. 35 or 40.

Final irrigation with 2 to 3 ml of irrigant per
canal is followed by drying with paper points.

Final apical enlargement is not done in
canals greater than a size 40.

If MAF size is already greater than 40 and
there is an apical stop, dry reaming is done
with the MAF only.

Dry Reaming.

Dry reaming is done after final apical
enlargement and irrigation and drying
with paper points.

The last size file used for final apical
enlargement (or the MAF if larger than
a size 40) is then spun carefully in
a clockwise manner to length. This is
the final apical file.

Chemical Adjuncts

Important adjuncts are irrigants and agents
that aid in debridement and that may alter
dentin to facilitate enlargement.

Other adjuncts are lubricants, which facilitate
the negotiation of small canals, and desiccants,
which aid in drying before obturation.

IRRIGATION

With filing, the other important process
in canal debridement is irrigation.

In theory, files loosen and disrupt materials
within canals and remove dentin from the
walls as shavings; the whole sludge is then
flushed out with an irrigant.

Irrigants

Many types of solutions have been used,
such as distilled water, concentrated acids,
and antimicrobials.

Properties of Ideal Irrigant

1-Tissue or Debris Solvent.

2-Toxicity: The irrigant should be
noninjurious to periradicular tissues.

3-Low Surface Tension. This property
promotes flow into tubules and into
inaccessible areas.

4-Lubricant. Lubrication helps instruments
to slide down the canal .

5-Sterilization (or at Least Disinfection).

6-Removal of Smear Layer. The smear layer
is a layer of microcrystalline and organic
particle debris spread on the walls after
canal preparation.

7-Other Factors. Other factors relate to
irrigant utility and include availability,
moderate cost , user friendliness ,
convenience, adequate shelf life, and
ease of storage.

An additional important requirement is that
the chemical not be easily neutralized in the
canal to retain effectiveness.

Solutions

Sodium hypochlorite , in various
concentrations, is the most popular
and most advocated irrigant.

This inexpensive, readily available, easily
used chemical usually rates the best in
research.

Chelators (calcium removers), such as
ethylenediaminetetraacetic acid (EDTA)
or citric acid, remove the smear layer.

The combination of chelators alternating
with sodium hypochlorite has potential as
the ultimate clinical debriding agent to
soften dentin and to reduce the smear
layer and organic debris

Recommendation.
A suggested concentration of sodium
hypochlorite is common household bleach
(5.25%) diluted with equal parts of water
for a 2.6% solution.

This is just as effective as full strength and
is safer and more pleasant for both patient
and dentist.

Technique

Needles.

A 27- or 28-gauge needle is preferred.

These needles have the potential to pass
farther into the canal for better delivery
and flushing.

Smaller needles tend to clog; this tendency is
minimized by aspirating air into the needle
after each irrigation.

Safety. To avoid forcing irrigant or debris
out of the apex, the needle tip must not bind
in the canal.

Nickel-Titanium Instrumentation

The importance of nickel- titanium (NiTi)
instruments has recently become significant.

This metal, when cut to the shape of a file,
has desirable physical properties.

These relate to the flexibility of the
instrument without memory ( the
instrument can be bent significantly,
but returns to its original shape).

NiTi may be used in a rotary, slow speed
(150 to 300 rpm) handpiece.

HAND

NiTi hand files have advantages and
disadvantages compared with more
commonly used stainless steel files.

The major advantages are flexibility
and superelastic behavior (memory)
upon deformation.

These are useful when a small, curved
canal is prepared; there is evidence of
less transportation.

Other claimed advantages include strength,
anticorrosive properties, and no weakening
after sterilization.

Disadvantages include cost (much more
expensive), inability to precurve, lack of
some stiffness (stiffness is desirable when
trying to locate or negotiate a small canal),
and a tendency for breakage if overused.

NiTi hand instruments seem to be less
efficient in removing dentin compared
with stainless steel files because of their
cross-sectional and flute designs.

NiTi hand files are used in a manner similar
to that used for stainless steel files.

ENGINE-DRIVEN ROTARY
Systems

Many designs of NiTi instruments are
available. Most resemble a basic file,
with flutes along the length and a latching
or attaching system to affix the file to
a handpiece.

Some are available in different tapers and
with noncutting tips .

Another unique design (Lightspeed)
resembles a Gates-Glidden drill, with
a small shaft and a short, flame-shaped
cutting head; this instrument also has
a latch to attach to a rotary handpiece .

Both types can be used with either
conventional or special low-torque,
controlled speed motor systems,
including battery-operated handpieces.

Techniques

After negotiating the canals and determining
the corrected working length, NiTi rotary
instruments are used to flare either with the
step-back or the crown-down methods.

Straight-line access to the canal space is
established (usually with Gates-Glidden
drills or with special orifice shapers).

A small hand file (No. 10 stainless steel) is
used to explore the canal to the corrected
length.

Hand instrumentation (reaming) is performed
at the corrected length through two or three
sizes with either stainless steel or NiTi files.

This is followed by rotary instrumentation.

Very light pressure is used along with
lubrication (irrigant) to place the NiTi
rotary instrument into the canal until
resistance is felt.

The instrument is then immediately
withdrawn in a smooth motion from
the canal space,

although recommendations of advancement
of the instrument apically in an up-and-down
"pecking" motion have also been made.

Slow speed is preferred to minimize
instrument distortion.

Light pressure (force is never used!) is
applied; the instrument is withdrawn
when resistance is felt to prevent
breakage.

After each withdrawal, the flutes are
cleaned with wet gauze or an alcohol
sponge, and the file is examined for
distortions and/or deformations

This process is repeated by using a sequence
of larger instruments to the desired length,
with recapitulation and irrigation between
each instrument size.

Intracanal Medicaments

Intracanal medicaments have traditionally
been integral to root canal treatment and
have been considered important to success .

273
Prof. Dr. Safouh Al-Bunni
There is no demonstrated usefulness for
the traditional phenolic or fixative agents
such as camphorated monochlorophenol
(CMCP), formocresol, and Cresatin.

In contrast , calcium hydroxide
(Ca(OH)2) usage is increasing
because of its demonstrated
antimicrobial properties, coupled
with some initial evidence of its
aiding in reducing periapical
inflammation.

APPLICATIONS

Antibacterial Action

The most popular antimicrobials are calcium
hydroxide, CMCP, and formocresol.

Pain Relief

Reducing or preventing inflammation
presumably decreases its byproduct, pain.

Clinical studies on phenolics, formocresol,
and calcium hydroxide show that routine
use as intracanal medicaments has no effect
on prevention or control of pain.

However, steroids have been demonstrated
to decrease post-treatment pain somewhat,
but with mixed results.

However, steroids do not reduce the
incidence of flare-ups (severe pain).

Rendered Inert

Chemicals used for this purpose are
fixatives, or aldehyde derivatives.

They fix fresh tissues for histologic study;
however, aldehydes do not effectively fix
necrotic or decomposed tissues.

Fixed tissues are not inert. In fact, when
both necrotic and vital tissues are fixed with
aldehydes, they become more toxic and
antigenic.

CALCIUM HYDROXIDE

Properties

Calcium hydroxide may be used as a canal
dressing between appointments, particularly
when pulp necrosis has been diagnosed.

Calcium hydroxide also has some tissue-
altering effects, but it does not aid in
debridement when placed in the canal space.

Placement

Calcium hydroxide should ideally be placed
deep and densely in the canal space so that its
biological effect can be exerted in close
proximity to the appropriate tissues.

Techniques that deliver dry calcium
hydroxide powder alone are difficult
or impossible in smaller, more curved
canals.

In most cases, the calcium hydroxide
must be mixed with a liquid such as
anesthetic solution water, glycerin ,
other intracanal medicaments, or methyl
cellulose to facilitate placement.

To use, calcium hydroxide is mixed with
glycerin (water is less effective in terms
of density to length) to a thick paste and
placed in the canal with either a plugger
or spun into a lentulo spiral using a counter-
clockwise motion.

The lentulo spiral (use with caution!) is
most effective device for carrying calcium
hydroxide paste to length in small, curved
canals.

The powder alone may be placed with
a Messing gun or pluggers in large,
straight canals.


2 - Cleaning and Shaping in Endodontics

Diunggah oleh

Informasi Dokumen

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

2 - Cleaning and Shaping in Endodontics

Diunggah oleh

Hak Cipta:

Format Tersedia

Cleaning and shaping

Prof. Dr. Safouh Al-Bunni 1

Prof. Dr. Safouh Al-Bunni 2

Prof. Dr. Safouh Al-Bunni 3

Prof. Dr. Safouh Al-Bunni 4

Prof. Dr. Safouh Al-Bunni 5

Prof. Dr. Safouh Al-Bunni 6

Prof. Dr. Safouh Al-Bunni 7

Prof. Dr. Safouh Al-Bunni 8

Prof. Dr. Safouh Al-Bunni 9

Prof. Dr. Safouh Al-Bunni 10

Prof. Dr. Safouh Al-Bunni 11

Prof. Dr. Safouh Al-Bunni 12

Prof. Dr. Safouh Al-Bunni 13

Prof. Dr. Safouh Al-Bunni 14

Prof. Dr. Safouh Al-Bunni 15

Prof. Dr. Safouh Al-Bunni 16

Prof. Dr. Safouh Al-Bunni 17

Prof. Dr. Safouh Al-Bunni 18

Prof. Dr. Safouh Al-Bunni 19

Prof. Dr. Safouh Al-Bunni 20

Prof. Dr. Safouh Al-Bunni 21

Prof. Dr. Safouh Al-Bunni 22

Prof. Dr. Safouh Al-Bunni 23

Prof. Dr. Safouh Al-Bunni 24

Prof. Dr. Safouh Al-Bunni 25

Prof. Dr. Safouh Al-Bunni 26

Prof. Dr. Safouh Al-Bunni 27

Prof. Dr. Safouh Al-Bunni 28

Prof. Dr. Safouh Al-Bunni 29

Prof. Dr. Safouh Al-Bunni 30

Prof. Dr. Safouh Al-Bunni 31

Prof. Dr. Safouh Al-Bunni 32

Prof. Dr. Safouh Al-Bunni 33

Prof. Dr. Safouh Al-Bunni 34

Prof. Dr. Safouh Al-Bunni 35

Prof. Dr. Safouh Al-Bunni 36

Prof. Dr. Safouh Al-Bunni 37

Prof. Dr. Safouh Al-Bunni 38

Prof. Dr. Safouh Al-Bunni 39

Prof. Dr. Safouh Al-Bunni 40

Prof. Dr. Safouh Al-Bunni 41

Prof. Dr. Safouh Al-Bunni 42

Prof. Dr. Safouh Al-Bunni 44

Prof. Dr. Safouh Al-Bunni 45

Prof. Dr. Safouh Al-Bunni 46

Prof. Dr. Safouh Al-Bunni 47

Prof. Dr. Safouh Al-Bunni 48

Prof. Dr. Safouh Al-Bunni 49

Prof. Dr. Safouh Al-Bunni 50

Prof. Dr. Safouh Al-Bunni 51

Prof. Dr. Safouh Al-Bunni 52

Prof. Dr. Safouh Al-Bunni 53

Prof. Dr. Safouh Al-Bunni 54

Prof. Dr. Safouh Al-Bunni 55

Prof. Dr. Safouh Al-Bunni 56

Prof. Dr. Safouh Al-Bunni 57

Prof. Dr. Safouh Al-Bunni 58

Prof. Dr. Safouh Al-Bunni 59

Prof. Dr. Safouh Al-Bunni 60

Prof. Dr. Safouh Al-Bunni 61

Prof. Dr. Safouh Al-Bunni 62

Prof. Dr. Safouh Al-Bunni 63