a 14-year - old female reported to our clinic with the chief complaint of painless , hard swelling in the gums in relation to the upper front teeth .
but the patient did not notice any improvement after treatment . on clinical examination , a 1  1 cm .
gingiva over the swelling appeared normal and was clinically devoid of inflammation [ figure 1 ] .
intraoral periapical radiograph in relation to 21 and 11 was normal [ figure 2 ] .
since the clinical and radiographical pictures were inconclusive , it was decided to surgically explore the site .
after obtaining written consent for explorative surgery from the patient , a mucoperiosteal flap was elevated in relation to 11 , 21 and 22 .
we noticed excessive thickening of the labial cortex in relation to 21 extending from the mesial to the distal aspect of the tooth .
the thickened labial bone was elevated from the tooth surface , but the height of alveolar bone labially was not reduced .
the thickened and elevated labial cortex enclosed an intrabony defect which measured 10 mm on the william 's periodontal probe [ figure 3a ] .
the inner surface of the flap contained thick fibrous granulation tissue and that made the gingival over the swelling appear thick .
histopathological examination of the soft tissue and hard tissue was done and was reported as granulation tissue and as normal bone , respectively . therefore the clinical picture was suggestive of buttressing bone formation .
( a ) thickened labial cortex elevated from tooth surface , enclosing a bony defect , ( b ) thinned labial cortex with bone graft in place treatment involved osteoplasty in relation to 21 to reduce the thickened labial cortical bone .
prior to suturing , thick fibrous granulation tissue on the inner side of the flap was dissected and removed and the flap was sutured .
gingivectomy and gingivoplasty was done subsequently after about a month to enhance the aesthetics in relation to 21 .
the follow - up after 3 months and 1 year showed satisfactory esthetics and no evidence of any recurrence [ figure 4 ] .
three month post - op showing normal size and contour of gingiva in relation to 11 , 21 and 22
inflammation in bone triggers a positive and a negative response in the form of bone formation and resorption simultaneously . in periodontitis
, both these processes occur at the same time , but most often bone loss results due to predominance of bone destruction over formation . occasionally in periodontitis , bone formation can be robust and in an attempt to buttress bony trabeculae weakened by resorption , peripheral buttressing bone is formed .
this causes bulging of bone contour also termed lipping and may sometimes be accompanied by bony defects . in our patient ,
a similar inflammation due to local factors or foreign body must have triggered bone resorption in 21 resulting in the intrabony defect .
considering the young age of the patient , a robust host response might have triggered exuberant bone formation on the labial cortex resulting in buttressing bone formation that clinically presented as a gingival swelling .
literature search for reports of buttressing bone formation in periodontium and its management yielded few animal studies , an in vitro study analysing the prevalence and characteristics of bony exostoses using skull specimens by horning et al , and a report by glickman and smulow in 1962 .
hence , we would like to present this as a case report along with its management .
 the phenomenon of buttressing bone formation is relatively uncommon in the alveolar bone , more so in the anterior maxilla . in our case , peripheral buttressing bone formation presented as an isolated hard gingival swelling with relation to 21 in a 14-year - old girl . 
 radiographic presentation was normal with no evidence of bone loss or altered bone density . 
 therefore explorative surgery was planned . buttressing bone formation 
 could be appreciated , which also was the cause for swelling clinically . 
 osteoplasty was done and bone graft placed in the defect . on a subsequent recall visit gingivoplasty was done to reduce gingival thickness to improve esthetics . 
 we report the case for its unusual presentation , its management with follow - up . 
Case Report
Discussion