Vital pulp Therapy

and Regeneration

Prof. Abeer Elgendy

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 Objectives:
The primary goal of the vital pulp therapy is to preserve, protect and maintain a
healthy pulp that may have been compromised by anatomical anomalies, caries,
trauma or restorative procedures through the formation of a tertiary reparative
hard tissue barrier/calcific bridge and therefore, postpone more aggressive
endodontic and restorative therapies that may decrease the long-term prognosis
Importance of pulp therapy:
1- Maintain arch length
2- Prevents abnormal habits
3- Maintain esthetics
4- Helps mastication
5- Prevents infection
6- Prevents speech problems
7- Helps in timely eruption of permenant tooth
8- Allows normal root development and apical closure in young permenant
teeth as loss of pulp vitality will lead to thin diverge and fragile root end
poor crown/root ratio.
9- To relief pain immediately with uncooperative patients
The living pulp:
 Structure:
The dental pulp is a highly vascular tissue that has the unique distinction of
being encased within a rigid chamber composed of dentin, cementum, and
enamel where these hard tissues provide mechanical support and protection
from oral microorganisms and these tissues are refered to as the dentin pulp
complex having several functions including:
1) immune defense and surveillance
2) Dentinogenesis
3) Nutrition
4)Proprioreceptor recognition
5)Formation of reparative, secondary and peritubular dentin as protective
response to pathological and biological stimuli

Dental Pulp Defense and Repair Mechanisms in response to microbial

invasion (Caries):
 Bacteria are responsible for most of the pulpal diseases. Kakehashi et al. has
proven since many years ago that bacteria has the major role in inducing the
process of pulpal inflammation when he noticed that exposed pulps in germ free
rats showed no signs of inflammation but a well formed dentin bridge was
formed to protect that exposed pulp 1 .
 The response of the pulp may vary depending on whether the caries process
progress rapidly ( acute caries ) or slowly ( chronic caries ) , or it is completely
inactive ( arrested caries ) 2.

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 Products of bacterial metabolism, notably organic acids & proteolytic enzymes
destroy enamel and dentin.
 Deep penetration of dentin by bacteria results in acute inflammation and
eventually infection and necrosis of the pulp.

 Basic reaction that tend to protect the pulp against caries include:
1) Decrease in the permeability of the dentin due to dentinal sclerosis
 It develops at the periphery of all slowly progressing carious lesions, where the
odontoblastic body and process undergo fatty degeneration, and as a response to
this degeneration, the dentinal tubules become filled and obliterated with
mineral deposits consisting of hydroxyapatite crystals (intratubular dentin).
 Dentinal sclerosis reduces the permeability of dentin, thus shielding the pulp
from irritation by being more mineralized than the surrounding peripheral
dentin.
 In highly active carious lesions, odontoblast may die before sclerosis has
occurred. This disintegration of odontoblasts processes within the tubules result
in dead tract.

2) Formation of new dentin (tertiary dentin)

 There are two types of tertiary dentin based upon the cell type responsible for
dentin production; reactionary dentin and reparative dentin.
 Compared with primary dentin, reparative dentin is less tubular and less
calcified.
 Sometimes, no tubules are formed, this type of tertiary dentin has been
characterized as a calcified matrix only and called " atubular dentin".

Indications for vital pulp therapy:

1. Teeth with open apex. This is an excellent indication for pulpotomy
since the prognosis of routine root canal treatment would be doubtful due
to lack of apical constriction needed to pack the root canal filling.

2. Primary teeth. Various types of vital pulp therapy are suggested to retain
primary teeth until the normal time of shedding.

3. Teeth involved in simple restoration with Reversible Pulpitis. If a

pulp exposure does occur in a tooth that is surrounded by sound adjacent
teeth, vital pulp therapy may be performed knowing that the
consequences of failure would not jeopardize a complex prosthesis

Contraindication
1. Teeth involved in a complex restoration. If a tooth that is to be used as
a splint, fixed bridge or precision partial denture abutment is exposed, it is

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 better to perform routine root canal treatment to avoid jeopardizing this
complex prosthesis.

2. Teeth in which the root canal space is needed to hold a post and core.
3. Teeth involved in a complex periodontal therapy: In such teeth, there
is great chance that the pulp can experience a great degree of inflammation
that contraindicates performing vital pulp therapy.

Criteria must be fulfilled to undergo vital pulp therapy

1. pulp is asymptomatic or show symptoms of reversible pulpitis.
2. pulp vitality test show normal positive response.
3. radiographic examination show no signs of periradicular disease. (no
widening of PDL or per radicular radiolucent lesions).

Techniques for vital pulp therapy:

1) Indirect pulp capping
2) direct pulp capping
3) Pulpotomy

Pulp capping
Pulp capping is a procedure in which an exposed or nearly exposed pulp is
covered with protective dressing that protects it from additional injury and
permits healing and repair. Two types of pulp capping are recognized the
indirect and direct pulp capping.

1-Indirect pulp capping:

The indirect pulp capping is the procedure in which a protective a dressing is
placed on exposed remaining dentin to seal dentinal tubules and enhance
secondary dentin formation.
2-Direct pulp capping:
The direct pulp capping is the procedure in which an exposed pulp is covered
with a protective dressing that protects it against additional injury and permits it
to heal and repair itself.

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 Materials for vital pulp therapy:
 Requirements for a pulp capping material:
1) must create an artificial barrier between the vital pulp and the oral cavity to
prevent the ingress of microorganisms
2) should have antimicrobial properties without being toxic to the pulp.
3) the disinfection and sealing of dentin
4) promote the innate capacity of pulpal cells to form hard tissue by pulp cell
induction and thus preservation of pulpal vitality
5) release fluoride to prevent secondary caries
6) adhere to dentin, adhere to restorative material
7) resist forces during restoration placement and under the restoration

1)Calcium Hydroxide:
Calcium hydroxide has long been considered the “standard” material in vital
pulp therapy
 Advantages:
The high alkaline pH provides a favorable
bactericidal characteristic that also promotes pulp
tissue irritation, which in turn stimulates pulpal
defense and repair

 Disadvantages
 cell culture cytotoxicity
 poor marginal adaptation to dentin
 inconsistent stimulation of reparative hard tissue
 degradation and absorption beneath restorations
 hard tissue bridges beneath CH exhibit tunnel
defects
 Microorganisms can find a pathway for
penetration into vulnerable pulpal tissue and the
subsequent activation of circulating immune cells, thus promoting pulpal
irritation, pulpal calcification and potential canal obliteration
 Types:
1. Aqueous calcium hydroxide suspensions
2. Hard setting calcium hydroxide cements
3. light-curing liners and cements with CH preparations

2-Adhesive Resins and Resin-Modified Glass ionomer:

• initially showed favorable outcomes with nonhuman primates. However,
in human subjects did not demonstrate the corresponding
biocompatibility or consistent reparative bridge formation

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 • Alternatively, adhesive resins have shown some promise when combined
with additives or growth factors, such as hydroxyapatite powder, dental
matrix protein-derived synthetic peptides, calcium chloride (CaCl2),
calcium phosphate, and antibacterial agent
3- MTA
 Composition:
 tricalcium silicate
 dicalcium silicate
 tricalcium aluminate
 tetracalcium alumino ferrite
 calcium sulphate
 bismuth oxide

 Compositional modifications:

 ProRoot MTA:
substitution of dicalcium silicate for tricalcium silicate and the addition of
tetracalcium aluminoferrite, calcium sulfate dehydrate and bismuth oxide
for radiopacity
 White MTA (WMTA):
was later produced to resolve esthetic concerns by ferrite (Fe3O3)
reduction with no detectable change in clinical performance compared to
the original gray powder. However, staining from WMTA is still an
undesirable characteristic
 advantages:
1. the ability to harden in the presence of blood and moisture
2. Set MTA exhibits superior marginal adaptation (Excellent sealing ability)
3. It forms a reactionary interfacial layer with dentin.
4. The slow calcium release and combined alkaline pH of 12.5 may contribute
to the reduction of microorganisms (antimicrobial activity).
5. The high pH also encourages the extraction of growth factors
6. compressive strength of the set cement provides minimal compression under
heavy occlusal loading.
7. Biocompatible
8. Low solubility
 Disadvantages:
1. Difficult manipulation
2. Irreversible application
3. High cost

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 4-Calcium Silicate-Based Cements (CSCs)

 Advantages:

1. Due to their hydraulic properties, calcium silicate compounds attain immediate

strength on hydration
2. bio inductive capacities that positively influence cell proliferation,
differentiation and induction of hard tissue barriers while producing minimum
inflammation.

 Types:

1. MTA-Angelus:

composed of 75% Portland cement and 25% bismuth oxide.

 The removal of calcium sulfate in the formulation allows for a shorter setting
time of 10 minutes, making the CSC superior for one-visit pulp capping or
pulpotomy procedures.
 The crystalline structures of MTA-Angelus are similar to gray and white
ProRoot MTA, and when used as a pulp capping material in humans, MTA-
Angelus produces hard tissue bridges comparable to those of ProRoot MTA.

2.Biodentine:

 features a short setting time of 10 minutes

 shows remarkable bioactive properties that can have beneficial applications for
pulptomies and both indirect and direct pulp capping procedures.
 Non cytotxic
 The sealing ability of Biodentine at the dentin interface appears to be similar to
that of MTA
 This compound exhibits pulp tissue compatiblity that induces fibroblast
(odontoblast-like) cell recruitment and encourages calcific bridge formation
comparable to MTA when used as a pulp capping or pulpotomy agent

3-BioAggregate:

The cement has been shown to promote mineralization in osteoblast cells,

inhibit osteoclast differentiation, and inhibit inflammatory bone resorption

4.Endosequence root repair: shows a high potential as a pulp capping and

pulpotomy agent demonstrating exceptional bioactivity, and impressive healing
characteristics when used in endodontic surgery

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Procedure for pulp capping:

 The tooth is anesthetized and isolated with rubber dam.

 All caries is to be removed (except that is immediately overlying the pulp
in case of indirect pulp capping).
 Cavity is swabbed with a mild antiseptic (9-amino acridine
hydrochloride).
 Apply MTA or calcium hydroxide paste over the cavity floor (and over
the exposed pulp in case of direct pulp capping).
 Restore the cavity with permanent restoration material.
 Follow up the case.

Fig 1: pulp capping

Criteria for success:

1-tooth has vital pulp and dentin bridge formation within 75 to 90 days.
2-absence of pain.
3-absence of any signs of pulpal or periapical lesions.
4-completion of root development (in case of immature teeth).
Criteria for failure:
1-continous pain.
2-abscess formation.
3-periapical radiolucency can be detected in RG.
4-internal resorption can be detected in RG.
Causes:
1-non-sterile procedure
2-bacterial microinfilteration.

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II. Pulpotomy
The surgical amputation of the coronal portion of an exposed vital pulp, usually
as a mean of preserving the vitality of the remaining radicular portion.

1. Indications for pulpotomy:

1. Immature teeth with exposed pulp.

2. Primary teeth.
3. Emergency treatment in posterior teeth

2. Contra indications for pulpotomy

1. Tenderness to percussion or palpation.

2. Swelling or fistula.
3. mobility.
4. non-restorable teeth.
5. Profuse hemorrhage.
6. Necrotic pulp.
7. Spontaneous pain.

3. Clinical diagnosis:
a. No abscess, no fistula
b. No mobility
c. Large carious
d. Mechanical or traumatic exposure
4. Radiographic diagnosis:
a. incomplete root development
b. normal bone structure
c. no internal or external root resorption

5. Types of pulpotomy:
A- Pulpotomy in primary teeth.
B- Partial pulpotomy.
C- Full pulpotomy

1. Partial pulpotomy
Def: procedure involve partial removal of pulp tissue beneath exposure site
judged to be inflamed (about 1-3 mm) to reach healthy tissue below then
application of Ca(oH)2 or MTA
Advantage: Preserve cell rich coronal pulp tissue which is necessary for pulp
healing

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 2. Full pulpotomy
The total surgical amputation of the coronal portion of an exposed vital pulp,
usually as a mean of preserving the vitality of the remaining radicular portion.
Procedure for full pulpotomy:
1. Tooth anesthetization and isolation with rubber dam.
2. Total exposure of the pulp chamber.
3. Amputation of the coronal pulp tissue using either sharp spoon excavator or
large diamond round bur with water spray.
4. bleeding control by using cotton pellet socked with 6% NaOCl (sodium
hypochlorite)
5. Pulp chamber is thoroughly flushed with sterile saline and dried with sterile
cotton pellet.
6. A layer of calcium hydroxide preparation or MTA is placed against the
amputated pulp stump.
7. All cavity walls to be sealed by permanent restoration.

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 Prognosis of pulpotomy:
The success of the pulpotomy procedure depends on several factors among
which:
1- Size of the exposure:
The larger the size of the exposure, the greater the damage to the pulpal tissue
resulting in less favorable prognosis.
2- Exposure to saliva:
The longer the time the pulp is exposed, the greater the chances of pulpal
contamination with less favorable prognosis.
3- Micro leakage:
If access cavity was not sealed very well salivary contamination decreases the
chances for healing and repair.
4- Systemic factors:
Systemic condition of the patient interferes with repair of connective tissues.
Patients suffering of anemia, liver diseases, malnutrition, and uncontrolled
Diabetes are considered bad candidates for pulpotomy due to their impaired
healing power.

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Management of teeth with open apices with vital or non-vital pulp:
For many years immature teeth with pulp and/or periapical involvement offered
dentists a difficult condition to treat. The open apex case occurs when trauma or
decay causes pulpal exposure and/or periapical involvement prior to the
completion of root development. Performing root canal treatment on such cases
is rather a difficult procedure due to absence of an apical stop rendering the
obturation of the canal with perfect seal physically impossible.

Problems of open apex:

1. Very thin dentinal walls.
2. In these canals the larger apical diameter vs.
smaller coronal canal diameter makes
debridement difficult.
3. C-high possibility of hypochlorite accident.
4. absence of apical constriction

Management of teeth with open apices with vital or non-vital pulp

Immature
(Open apex)

Vital
Non-vital
(APEXOGENESIS)

1.Apexification
PULPOTOMY PULP CAPPING 2.Regeneration

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 Treatment of open apex with non-vital pulp:
1. Apexification:
a. Calcium hydroxide apexification
b. MTA apical plug (single visit apexification)

a) Calcium hydroxide apexification:

old method of inducing a calcified barrier in a root with an open apex or the
continued apical development of an incompletely formed root in teeth with
necrotic pulp.
Procedure for Calcium hydroxide apexification:
The procedure for apexification requires at least two appointments:
 First appointment (aim: disinfection):

1. Tooth isolation by rubber dam.

2. Proper coronal access preparation and establishment of working length.
3. Light root canal instrumentation (because of thin dentinal walls) with
copious amounts of irrigants (NaOCl 0.5%).
4. The canal is dried with paper points and a creamy mix of calcium
hydroxide (toothpaste thickness) spun into the canal using a Lentulo
spiral instrument.
5. Coronal access cavity to be adequately sealed.

Second appointment (1-2 weeks later) (aim: hard tissue barrier formation):
1. Tooth isolation and removal of temporary dressing.
2. Thorough irrigation of the root canal and proper dryness.
3. Pure calcium hydroxide powder is mixed with sterile saline (or anesthetic
solution) to a thick (powdery) consistency
4. The mix can be applied by a special syringe (pressure syringe) or it is
packed apically using root canal pluggers.
5. This step is followed by backfilling with calcium hydroxide to completely
fill the canal.
6. A radiograph is taken; the canal should appear to have become calcified,
indicating that the entire canal has been filled with the calcium hydroxide.
7. Clean the access cavity from any calcium hydroxide remnants.
8. Place a sterile cotton pellet in the pulp chamber and seal the access
cavity with a final restoration.
9. Follow up the case where the patient should be recalled after three months
for radiographic examination. A radiograph is exposed to evaluate whether
a hard tissue barrier has formed and if the calcium hydroxide has washed
out of the canal. This is assessed to have occurred if the canal can be seen
again radiographically. If no washout is evident, the calcium hydroxide can
be left intact for another 3 months.

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Figure: Apexification: preoperative view of immature permanent tooth with large apical
foramen, (b) canal instrumentation, (c) placement of calcium hydroxide using Lentulo spiral
filler, (d) interim calcium hydroxide changed every 3 months until (e) apical hard tissue
barrier formation complete, and (f–h) obturation completed with gutta-percha root filling
material.

Prognosis of apexification:
The radiographic examination of the apexified tooth may reveal one of the
following five conditions:
1. No radiographic change is apparent but clinically, a definite apical stop can
be probed at the apex.
2. Radiographic evidence of a calcified material at or near the apex.
3. Apical closure without any change in the canal space.
4. Apical closure with closure of the canal space.
5. No radiographic change is apparent with evidence of periapical pathosis.

If any of the first four conditions occurred, routine endodontic treatment should
be continued and canal can be properly obturated. If the fifth condition
occurred, apexification should be reattempted.

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Radiographic evidence of a calcified material Apical closure with closure of the canal space.
at or near the apex

b. MTA apical plug (single visit apexification)

1. Root canal is cleaned & shaped.
2. Calcium sulfate is pushed in the canal
3. A 4mm MTA apical plug is placed at the apex
4. The body of the root canal is filled with root canal filling material
5. Bonded restoration is placed inside the root canal to strengthen the root

Step 1 Step 2 Step 3 Step 4 Step 5

MTA apical plug (single visit apexification)

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 Regeneration

 Definition: Biologically based Procedures designed to replace damaged

structures such as dentin structure and cells of the pulp-dentin complex.

 Regenerative strategies:
Regenerative Endodontics are dependent upon those elements associated with
normal tissue development and tissue engineering: (the triad of tissue
engineering):

1. Stem cells
2. Signaling molecules (Growth factors).
3. extracellular matrix/cellular scaffold (Hydrogel is the scaffold of choice)

Targeting these elements has been approached in a variety of ways (approaches)

A. Cell-based Approaches
Cell-based regenerative strategies include the transplantation of cells to the site
of injury in the tissue to promote regeneration.

B. Cell-free Approaches
Cellular synthesis and secretion of tissue components are imperative to the
formation of any tissue. However, its regeneration can also be achieved from
populations already present in the patient’s body that can be recruited to the site
of injury to stimulate self-healing mechanisms and unlock the innate powers of
regeneration, where localized areas of cellular necrosis exist within a tissue,
without the need to directly transplant cells to the injury site.

Stem Cells
Cells that are able to Proliferate, differentiate into Odontoblasts like cells to form
Pulp Tissue.
 The plasticity of the stem cell defines its ability to produce cells of different
tissues
 Stem cells are also commonly subdivided into
1. Pluripotent
2. Multipotent cells

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1. Pluripotent stem cells have the capacity of becoming specialized cells and belong
to all three germ layers. Embryonic stem cells are the best example of pluripotent
cells. BUT:
 ethical, legal, and medical (tissue-rejection) issues can render these cell types
unsuitable for clinical applications.
 True pluripotent stem cells can only be found in the developing embryo, and the
harvesting of these cells requires destruction of the embryo, hence the legal and
ethical concerns with such practice
2. Multipotent stem cells: These cells can be found compartmentalized within
tissues in “stem cell niches.” The mesenchymal tissues
Location:
These cells were first found in bone marrow decades ago and were characterized
as self-renewing but later received the now widely accepted name mesenchymal
stem cells (MSCs).

Most stem cells found in the orofacial region are MSCs.

1. SCAP (stem cells from apical papilla)

2. SHED (stem cells from human exfoliated deciduous teeth)
3. DPSC (dental pulp stem cells) from adult pulp
4. PLSC (periodontal ligament stem cells)

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 Dental stem cells:

a. SCAP stem cells:

 They are derived from the apical part of a developing tooth and have high
proliferation, migration and regeneration capabilities.
 They contain fibroblast-like and odontoblast like cells.
 The apical papilla is a dense reservoir of undifferentiated MSCs with great
proliferative and odontogenic differentiation capacity.
 the close proximity of the apical papilla to the apices of teeth in continuum with
the root canal space makes this rich source of stem cells readily available for
regenerative endodontic therapeutics through autologous cell transfer without
the necessity to harvest and manipulate these cells exogenously.
b. Dental pulp derived stem cells (DPSC):
 These are the most common source of dental tissue derived stem cells and are
obtained from the pulp of permanent teeth.
 DPSCs can be found throughout the dental pulp but are known to accumulate in
the perivascular region and the cell-rich zone adjacent to the odontoblastic
layer.
 can produce pulp dentin complex.
 These cells are recruited to the site of injury following a gradient of chemotactic
agents released by resident immune cells and from the damaged dentin.
 The reparative dentin formed by these cells is distinct from the primary,
secondary, and reactionary dentin that has been lost. It is often called
“osteodentin”.
c. Stem cells from human exfoliated deciduous teeth (SHED):
 They are derived from exfoliated teeth and are more proliferative than DPSC.
 They have high regenerative and renewal power, so they have high effect in
wound healing.
 With proteins on the dental pulp, they can differentiate into bone, PDL, nerve
cells, pulp and adipocytes.
 They differentiate into odontoblast-like cells able of forming dentin.
 The SHED are able of forming microvasculature and anastomosis to provide
blood supply to the generated pulp.
 They can differentiate into fibroblasts.
 They induce formation of osteoblasts, thus forming bone.
 (SHED, unlike DPSCs, cannot be differentiated into osteoblasts or osteocytes
but are able to induce the host cells to undergo osteogenic differentiation)
d. Periodontal ligament stem cells (PDLSC):
 They are derived from separated periodontal ligaments of third molars in
humans and contain progenitors for self-renewal of oral structures like
cementum and bone. - Its proliferation rate = DPSC proliferation rate.
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 Growth factors:
 They are proteins that bind to receptors on the cell and induce cellular
proliferation and differentiation or stimulating stem cells to synthesize and
secrete mineralized matrix
 Research on dentine structure and composition has highlighted that the matrix
contains some components that may be important in regulating tissue due to their
bioactive properties. For this reason, dentine is today considered a reservoir of
growth factors and cytokines.
Types of growth factors:
 Platelet derived growth factor (PDGF)
 Fibroblast growth factor (FGF)
 Insulin like growth factor (IGF)
 Colony stimulating factor (CSF)
 Epidermal growth factor (EGF)
Scaffolds:
An important component of tissue engineering is a physical scaffold.
Importance of scaffold:
1- provide a spatially correct position of cell location
2- regulate differentiation, proliferation, or metabolism while promoting nutrient
and gaseous exchanges.
Requirements:
 Permeable
 Allow Diffusion of growth factors and nutrients
 Resorbable “mimic tissue formation”
 Release Growth Factor
 Release Antibiotics
 easy delivery
 adequate mechanical properties
Classification:
1- natural scaffolds:
 Blood clot
 Platelet Rich Plasma (PRP)
 Platelet Rich Fibrin (PRF)
 collagen, glycosaminoglycans, hyaluronic acid (HA), demineralized or
native dentin matrix, and fibrin.
2- synthetic scaffolds
 Polymers
 Calcium phosphate
 poly-L-lactic acid (PLLA), polyglycolic acid (PGA), polylacticcoglycolic
acid (PLGA),
 bioceramics, and hydrogels

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 Revascularization: (cell free approach for regeneration of the pulp)
A conservative approach for management of immature non-vital teeth
cell-free strategies are dependent upon:
1. providing a conducive environment in which regeneration can take place
(disinfection).
2. providing cellular signaling (growth factors).
3. consider how the scaffold should be optimized.
Case selection:
The presence of radiolucency at the periradicular region can no longer be used
as a determining factor, nor is the vitality test. In both situation, vital pulp tissue
or apical papilla may still present in the canal and at the apex
First visit - Disinfection
1. Minimal or no instrumentation of the canal while relying on a gentle but thorough
irrigation of the canal system. The root canal systems are slowly irrigated first
with 1.5% NaOCl (20 ml/canal, 5 min) then the canals irrigated with 17% EDTA
(10 ml in2 min).
2. Canal are filled with calcium hydroxide or The antimicrobial past (triple-
antibiotic paste) (metronidazol, ciprofloxacin and minocycline) in R.C, the
access cavity is sealed.
Second visit (Bleeding)
After two weeks if the patient is asymptomatic:
1. adequate local anesthesia with 3% mepivacaine (no epinephrine), dental dam
isolation is obtained.
2. Irrigation: The root canal systems are accessed; the intra-canal medicament is
removed by irrigating with 17% EDTA (20 mL/canal, 5 min).
3. Induction of bleeding in the canal + MTA + Coronal seal
4. Periodical follow-ups will take place to observe any continued maturation of the
root.

Revascularization protocol

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 Clinical considerations for regenerative endodontic procedures

 Primary goal (essential): The elimination of symptoms and the evidence of

bony healing
 Secondary goal (desirable): Increased root wall thickness and/or increased root
length
 Tertiary goal: positive response to vitality testing

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