a 9-year - old female patient reported complaining of pain in the upper front tooth since 3 days .
there was a history of trauma to the same tooth due to fall about 4 days back . on clinical examination ,
periapical radiograph showed incomplete root formation with wide open apices for the same tooth [ figure 1 ] .
the working length was established within one mm of the radiographic apex by using size 30 hedstrom file .
next , pulp extirpation and complete debridement of the canal was done using h file number 40 followed by copious irrigation with normal saline . after drying of the canal using paper points ,
calcium hydroxide powder was mixed with normal saline and this mixture was placed into the canal and pushed to the short of apex using plugger .
, a periapical radiograph was taken , which showed complete formation of the root apex in maxillary right central incisor , without any signs and symptoms and periapical radiolucency .
clinically , apical barrier formation was confirmed by using a size 30 gutta - percha ( gp ) point to check for the presence of a resistant  stop  and absence of hemorrhage , exudates or sensitivity [ figure 3 ] . in the next visit ,
complete obturation was carried out with gp using lateral condensation technique [ figure 4 ] followed by composite restoration .
case 1 : periapical radiograph showing wide open apex in relation to 21 ( arrow ) case 1 : periapical radiograph showing placement of caoh dressing case 1 : periapical radiograph taken after 3 months shows confirmation of apical barrier with gutta - percha point case 1 : radiograph showing complete obturation of 21 an 11-year - old male patient reported with a chief complaint of discolored right maxillary central incisor with a history of trauma 1 year back .
the periapical radiograph revealed a large blunderbuss canal of the same tooth [ figure 5 ] . on clinical examination ,
pus was extruded from the root canal immediately after the access preparation ; irrigation was done with saline .
calcium hydroxide was placed in the root canal and patient recalled after 5 days . at subsequent appointment ,
the canal was dried with paper points and mta placed with pluggers until thickness of 6 mm [ figure 6 ] .
a wet cotton pellet was placed in the canal and access cavity was sealed with temporary cement . in next appointment ,
case 2 : periapical radiograph showing wide open apex in relation to 11 ( arrow ) case 2 : radiograph showing placement of mineral trioxide aggregate case 2 : radiograph showing complete obturation of 11
a 9-year - old female patient reported complaining of pain in the upper front tooth since 3 days .
there was a history of trauma to the same tooth due to fall about 4 days back . on clinical examination ,
periapical radiograph showed incomplete root formation with wide open apices for the same tooth [ figure 1 ] .
the working length was established within one mm of the radiographic apex by using size 30 hedstrom file .
next , pulp extirpation and complete debridement of the canal was done using h file number 40 followed by copious irrigation with normal saline . after drying of the canal using paper points ,
calcium hydroxide powder was mixed with normal saline and this mixture was placed into the canal and pushed to the short of apex using plugger .
, a periapical radiograph was taken , which showed complete formation of the root apex in maxillary right central incisor , without any signs and symptoms and periapical radiolucency .
clinically , apical barrier formation was confirmed by using a size 30 gutta - percha ( gp ) point to check for the presence of a resistant  stop  and absence of hemorrhage , exudates or sensitivity [ figure 3 ] . in the next visit ,
complete obturation was carried out with gp using lateral condensation technique [ figure 4 ] followed by composite restoration .
case 1 : periapical radiograph showing wide open apex in relation to 21 ( arrow ) case 1 : periapical radiograph showing placement of caoh dressing case 1 : periapical radiograph taken after 3 months shows confirmation of apical barrier with gutta - percha point case 1 : radiograph showing complete obturation of 21
an 11-year - old male patient reported with a chief complaint of discolored right maxillary central incisor with a history of trauma 1 year back .
the periapical radiograph revealed a large blunderbuss canal of the same tooth [ figure 5 ] . on clinical examination ,
pus was extruded from the root canal immediately after the access preparation ; irrigation was done with saline .
calcium hydroxide was placed in the root canal and patient recalled after 5 days . at subsequent appointment ,
the canal was dried with paper points and mta placed with pluggers until thickness of 6 mm [ figure 6 ] .
a wet cotton pellet was placed in the canal and access cavity was sealed with temporary cement . in next appointment ,
case 2 : periapical radiograph showing wide open apex in relation to 11 ( arrow ) case 2 : radiograph showing placement of mineral trioxide aggregate case 2 : radiograph showing complete obturation of 11
the goal of apexification is to obtain an apical barrier to prevent the passage of toxins and bacteria into periapical tissues from root canal . in the literature , many materials have been used for apexification , such as calcium hydroxide in combination with sterile water , saline , local anesthetic , cmcp , zinc oxide paste with cresol and iodoform , polyantibiotic paste and tricalcium phosphate .
calcium hydroxide is one of the most important medicaments used in treatments of pulp conditions and apical periodontitis .
the use of caoh in apical barrier formation has shown promising results . because of its enhanced success rate , easy availability for the clinician and affordability for patients
some of the postulated mechanisms of caoh are as follows : 
 presence of high calcium concentration increases the activity of calcium dependent pyrophosphatasedirect effect on the apical and periapical soft - tissuehigh ph , which may activate alkaline phosphatase activityantibacterial activity . 
 
presence of high calcium concentration increases the activity of calcium dependent pyrophosphatase direct effect on the apical and periapical soft - tissue high ph , which may activate alkaline phosphatase activity antibacterial activity .
sheehy and roberts reported that the use of calcium hydroxide for apical barrier formation was successful in 74 - 100% of cases and the average time for
apical barrier formation was ranging from 5 months to 20 months . in the present case ,
appetite like interfacial deposits form during the maturation of mta result in filling the gap induced during material shrinkage phase and improves the frictional resistance of mta to root canal walls .
mta has superior biocompatibility and it is less cytotoxic due to its alkaline ph and presence of calcium and phosphate ions in its formulation results in capacity to attract blastic cells and promote favorable environment for cementum deposition .
a total of 5 mm barrier is significantly stronger and shows less leakage than 2 mm barrier . in the present case , mta
based on the existing literature and our present cases , both mta and calcium hydroxide can be used efficiently for apexification procedure . considering the time duration for the apex closure mta has superior properties when compared with calcium hydroxide .
 the completion of root development and closure of the apex occurs up to 3 years after the eruption of the tooth . 
 the treatment of pulpal injury during this period provides a significant challenge for the clinician . 
 the importance of careful case assessment and accurate pulpal diagnosis in the treatment of immature teeth with pulpal injury can not be overemphasized . 
 the treatment of choice for necrotic teeth is apexification , which is induction of apical closure to produce more favorable conditions for conventional root canal filling . the most commonly advocated medicament is calcium hydroxide , although recently considerable interest has been expressed in the use of mineral trioxide aggregate ( mta ) . 
 we report a case series wherein calcium hydroxide and mta were used successfully for one step apexification in teeth with open apex . 
Case Reports
Case 1
Case 2
Discussion
Conclusion