EQUINE

DENTISTRY THIRD EDITION

Edited by
Jack Easley
DVM MS Dipl ABVP (Equine)
Equine Practitioner, Shelbyville, KY, USA

Padraic M. Dixon
MVB PhD MRCVS
Professor of Equine Surgery, Division of Veterinary Clinical Studies,  
University of Edinburgh, UK

James Schumacher
DVM MS MRCVS Dipl ACVS
Professor, Department of Large Animal Clinical Sciences, College of Veterinary
Medicine, University of Tennessee, USA

Edinburgh  London  New York  Oxford  Philadelphia  St Louis  Sydney  Toronto  2010
First Edition © Saunders 1999
Second Edition © Elsevier Limited 2005
Third edition © 2011, Elsevier Limited. All rights reserved.

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changes in practice, treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most
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 Contributors

Safia Z. Barakzai BVSc MSc DESTS Dipl ECVS MRCVS Nicole du Toit BVSc MSc Cert EP PhD MRCVS
Senior Lecturer in Equine Surgery Veterinary Pathologist
Royal (Dick) School of Veterinary Studies Division of Veterinary Clinical Studies
University of Edinburgh University of Edinburgh
Easter Bush Veterinary Centre Easter Bush Veterinary Centre
Roslin Easter Bush
Midlothian EH25 9RG Roslin, Midlothian EH25 9RG
UK UK
Dwight G. Bennett DVM PhD Jack Easley DVM MS Dipl ABVP (Equine)
Professor Emeritus of Equine Medicine Equine Practitioner
2307 Tanglewood Drive Equine Veterinary Practice, LLC
Colorado State University PO Box 1075
Fort Collins, CO 80523 Shelbyville, KY 40066
USA USA
Alexandra Boehler Melanie S. Galloway DVM
University of Veterinary Medicine, Vienna Animal Care Hospital
Department IV, Clinical Department for Companion Animals 8565 Hwy 64
and Horses Somerville, TN 38068
Veterinaerplatz 1 USA
A-1210, Vienna
Stephen S. Galloway DVM Fellow, Academy of Veterinary
Austria
Dentistry (Equine)
James L. Carmalt MA VetMB MVetSc MRCVS Animal Care Hospital
Dipl ABVP(Eq) Dipl ACVS 8565 Hwy 64
Associate Professor – Equine Surgery Somerville, TN 38068
University of Saskatchewan USA
Western College of Veterinary Medicine
Tim Greet BVMS MVM Cert EO DESTS Dipl ECVS FRCVS
Saskatoon, SK, S7N 5B4
Senior Surgeon
Canada
Rossdales Equine Hospital
Ian T. Dacre PhD MRCVS Cotton End Road
Professor of Equine Surgery Exning
Division of Veterinary Clinical Sciences Newmarket
University of Edinburgh Suffolk CB8 7NN
Easter Bush Veterinary Centre UK
Roslin, Midlothian EH25 9RG
Jennifer Hatzel DVM
UK
1707 SW 35th Place
Padraic M. Dixon MVB PhD MRCVS Gainesville, FL 32608
Professor of Equine Surgery USA
Division of Veterinary Clinical Studies
Travis Henry DVM
University of Edinburgh
Midwest Equine Services
Easter Bush Veterinary Centre
N7188 Country Side Lane
Roslin, Midlothian EH25 9RG
Elkhorn, WI 53121-2916
UK
USA
Tom Doherty MVB MSc MRCVS Dipl ACVA
Donald F. Kelly MA BVSc PhD MRCVS
Department of Large Animal Clinical Sciences
FRCpath Dipl ECVP
College of Veterinary Medicine
Department of Veterinary Pathology
University of Tennessee
University of Liverpool
Knoxville, TN 77901-1071
Leahurst, Merseyside CH64 7TE
USA
UK

vii
 Contributors

Derek C. Knottenbelt OBE BVM&S DVM&S Bayard A. Rucker DVM

Dipl ECEIM MRCVS 309 Overlook Drive
European Specialist in Equine Internal Medicine Lebanon, VA 24266
RCVS Specialist in Equine Internal Medicine USA
Philip Leverhulme Hospital
James Schumacher DVM MS MRCVS Dipl ACVS
University of Liverpool
Professor
Leahurst, Merseyside CH64 7TE
Department of Large Animal Clinical Sciences
UK
College of Veterinary Medicine
Bruce J. MacFadden PhD BS University of Tennessee
Associate Director and Curator Knoxville, TN 77901-1071
Florida Museum of Natural History USA
University of Florida
Hubert Simhofer
Gainesville, FL 32611
Assistant Professor
USA
Clinic for Large Animal Surgery and Orthopaedics
Sofie Muylle DVM PhD Department IV, Clinical Department for Companion
Department of Morphology Animals and Horses
Faculty of Veterinary Medicine University for Veterinary Medicine
Ghent University Veterinaerplatz 1
Salisburylaan 133 A-1210, Vienna
B-9820 Merelbeke Austria
Belgium
Neil Townsend BSc BVSc Cert ES (Soft Tissue) MRCVS
Justin D. Perkins BVetMed MS MRCVS Dipl ECVS Royal (Dick) School of Veterinary Studies
Department of Veterinary Clinical Sciences University of Edinburgh
Royal Veterinary College Easter Bush Veterinary Centre
Hawkshead Lane Roslin, Midlothian EH25 9RG
North Mymms UK
Hatfield, Hertfordshire AL9 7TA
W. Henry Tremaine BVet Med MPhil Cert ES
UK
Dipl ECVS MRCVS
Dennis J. Rach DVM Senior Lecturer
Moore & Co. Veterinary Services Department of Clinical Veterinary Sciences
Box 460 University of Bristol
Balzac, Alberta, T0M-0E0 Langford House
Canada Langford
Bristol BS40 5DU
Peter H.L. Ramzan
UK
Rossdales and Partners
Beaufort Cottage Stables Renate Weller Dr.vet.med. PhD MRCVS
High Street Lecturer in Diagnostic Imaging
Newmarket Department of Veterinary Clinical Sciences
Suffolk CB8 8JS The Royal Veterinary College
UK Hawkshead Lane
North Mymms
Hatfield
Hertfordshire AL9 7TA
UK

viii
 Preface and Acknowledgments

Producing this textbook required the support, encourage- attract a diverse audience. We hope this information is useful
ment, and patience of our families and the contribution to veterinarians in clinical equine practice and research, vet-
of many colleagues – all experts in the various aspects of erinary students who have a particular interest in the health
equine dentistry. We are indebted to the editors and staff of and welfare of the horse, and equine dental technicians. If
Elsevier for helping us produce this book and, in particular, the information presented in this text benefits veterinarians,
to Louisa Welch for keeping us organized and on time with it will ultimately benefit their patients.
production. The number of illustrations found in the text has been
As editors, the three of us have had a keen interest in greatly expanded from the number found in previous edi-
equine dentistry from the beginning of our careers and have tions. The number of chapters has been expanded from 17
enlisted the help of many others who share this interest to to 23 to reflect the expansion of knowledge in this field.
produce this book. We believe this text to be a compilation References following each chapter can be used as a source
of a comprehensive range of topics discussed by the most for more in-depth study of topics covered within the chap-
world renowned experts in the field of equine dentistry. We ters. The DVD provides visual as well as vocal demonstration
thank many colleagues, who although are not contributing of techniques of equine dental examination and prophylac-
authors, have contributed to our knowledge as authors. We tic treatment.
also acknowledge the horses and their owners that provided The text represents the state-of-the-art of equine dentistry
the experiences contributing to our understanding of equine but it continues to be a work in progress for equine veterinar-
dentistry. ians. May the current enthusiasm of our profession continue
The first edition of Equine Dentistry was published ten to advance this specialty for the good of the horse.
years ago. Since that time, the field of equine dentistry has
undergone tremendous changes, with major advances in our Jack Easley
understanding of equine dental anatomy and disease and Shelbyville, Kentucky, USA
also more general advances in equine analgesia and anesthe-
sia, diagnostic imaging, and dental surgery. Additionally, the Padraic M. Dixon
expansion of equine dental research has allowed us to use
Royal (Dick) School of Veterinary Studies
scientific evidence in developing diagnostic, prophylactic,
and treatment options for our equine patients. Midlothian, UK
Publication of this present text now provides the most
up-to-date information about equine dentistry. This book is James Schumacher
comprised of chapters written by veterinarians with diverse University of Tennessee
interests in the field of equine dentistry and so, should Knoxville, Tennessee, USA

ix
 Section 1:  Introduction

C H A P TER  1 
Equine dental evolution:  
perspective from the fossil record
Bruce J. MacFadden PhD, BS
Florida Museum of Natural History, University of Florida, Gainesville, FL 32611, USA

Introduction adaptations than is seen in modern Equus. Fossil horses are

first known 55 million years ago during the early Eocene
It is generally believed that horses are native to the Old throughout the northern continents (Fig. 1.1).6 These are
World and were first brought to North America by the represented by Hyracotherium (or ‘eohippus,’ the dawn
Spanish explorers during the 16th century. While this is horse) and a solely Old World group, the palaeotheres
correct for historical times, the prehistoric fossil record of (family Palaeotheriidae).5 Horses persisted in North America
horses and their extinct relatives indicates that the Equidae after the Eocene, but this family and the horse-like palaeo­
underwent the majority of its evolutionary history in North theres became extinct in the Old World by the early Oli-
America from about 55 million years ago (early Eocene) gocene, 29 million years ago. During the Oligocene and later
until this family became extinct about 10 000 years ago at times, the major evolutionary diversification of horses
the end of the last Ice Age (Pleistocene). The fossil record of occurred in North America. Ancient dispersal events resulted
horses in North America is a classic and compelling example in three-toed (tridactyl) horses immigrating into the Old
of long-term (i.e., macro-) evolution.1,2 Fossil horses were World during the Miocene 23 million years ago (Anchith-
exceedingly widespread and abundant in North America. erium), 15 million years ago (Sinohippus), and after 12
Their teeth are highly durable and readily fossilize, and million years ago (hipparions; Fig. 1.1). Extinct species of
therefore figure prominently in our understanding of the one-toed (monodactyl) Equus, which first originated in
evolutionary history of this group. This chapter will review North America 4.5 million years ago during the Pliocene,
what is known about fossil horse teeth and related morpho- subsequently dispersed into the Old World across the Bering
logical adaptations from the rich time sequence in North Land Bridge 3.5 million years ago.7 During the Pleistocene
America to provide the framework within which teeth of after about 2 million years ago, Equus species also dispersed
modern Equus can be understood. into South America after the formation of the Isthmus of
Panama. The genus Equus subsequently became extinct
10 000 years ago throughout the New World at the end of
Equid interrelationships and phylogeny the last Ice Age (Pleistocene).
Extant equids (horses, zebras, and asses) and fossil horses
are classified in the family Equidae as part of the Order Peris- Fossil horse dental adaptations
sodactyla, or ‘odd-toed ungulates.’ Other perissodactyl fami-
lies include tapirs (Tapiridae), rhinoceroses (Rhinocerotidae), The earliest equid, Hyracotherium, is characterized by the
and several extinct families. So far as is known, all perisso- primitive placental mammalian dental formula of three inci-
dactyls are united by a suite of unique characters including sors, one canine, four premolars, and three molars (3 : 1 : 4 : 3),
a concave, saddle-shaped navicular (central tarsal) facet both upper and lower. The canine is large and sexually
on the astragalus (talus3), axis of symmetry through the dimorphic.8 The premolars are primitive in structure, and
central metapodial (III), hind-gut fermentation, and particu- roughly triangular in shape, whereas the molars are relatively
lar cheek tooth cusp morphology.2 Likewise, so far as is square and have a greater surface area for trituration. During
known, all perissodactyls living and extinct have been herb­ the Eocene and into the Oligocene, fossil horses in North
ivores. With the exception of the extinct clawed chalico­ America are characterized by progressive ‘molarization’ of
theres, all perissodactyls have a foot terminating with an the premolars (Fig. 1.2), resulting in a functional dental
ungual phalanx that is either padded or hooved. battery consisting of six principal teeth (P2/p2 through M3/
The 7–10 (i.e., depending upon classification) extant m3) for mastication of foodstuffs. The cheek teeth of Hyra-
equine species can all be conservatively classified within the cotherium and other early horses are short-crowned (brachy-
single modern genus Equus.4 In contrast to this single genus, dont). The preorbital cheek region is relatively unexpanded
about 32 extinct genera and more than 150 species of fossil and the mandible is shallow (Fig. 1.3). Studies of dental
horses are recognized over the past 55 million years,2,5 and structure and wear patterns suggest that these early horses
these also represent a far greater diversity of morphology and were browsers, probably feeding on soft leafy vegetation and

3
 1 Introduction

S. America N. America Old World

Plio. Quat.

Equus
Onohippidium

Old World Hipparion Clades

Hippidion
Astrohippus
5

Dinohippus

Nannippus
Pseudhipparion

Cormohipparion
Neohipparion
Calippus

Protohippus
10

Sinohippus
Hipparion
Pliohippus
Miocene

Merychippus I

Megahippus
Hypohippus
15

Archaeohippus
Parahippus

Anchitherium
Merychippus II

Kalobatippus
20
Million years ago

25

Miohippus
Oligocene

30
Mesohippus
Haplohippus

35

40
Epihippus
Eocene

45
Orohippus

Mostly grazers

50
Hyracothere Clades

Mixed feeders

55 Mostly browsers

Fig. 1.1  Phylogeny, geographic distribution, diet, and body sizes of the Equidae over the past 55 million years. (From ref.6 and reproduced with permission
of the American Association for the Advancement of Science.)

groundcover (e.g., including perhaps ferns) in ancient wood- accom­modating high-crowned (hypsodont) teeth. Miocene
lands.8 This overall dental bauplan and inferred diet contin- and later horses with hypsodont teeth are principally inter-
ued through the first half of equid evolution from 55 to 20 preted to have been grazers, although there are exceptions
million years ago. (It also should be noted that grasslands to this rule. Hypsodont teeth are well adapted to increased
had not yet evolved as principal biome types in North wear resulting from eating abrasive grasses (in contrast to
America.9) soft browse), as well as ingesting contaminant grit from
The major morphological evolution of the equid skull and plants growing close to the soil substrate. Evidence from the
dentition occurred during the middle Miocene, between fossil plant record indicates that grasslands became a domi-
20 and 15 million years ago.10–12 This evolution resulted in nant biome in North America during the middle Cenozoic9
a morphology adapted for grazing, including a relatively and horses soon thereafter exploited this newly available
longer cheek tooth row and deeper skull and jaws food resource as they invaded the ‘grazing adaptive zone,’1

4
 Equine dental evolution: perspective from the fossil record

0 2cm

5 cm Hyracotherium

5 cm Mesohippus
0 2cm

Fig. 1.2  Upper cheek tooth dentitions (excluding anterior-most P1) of

Eocene Hyracotherium (top) compared with Oligocene Mesohippus (bottom).
Note that relative to the triangular-shaped premolars (P2–P4; i.e., left three C
teeth in row) in Hyracotherium, those of Mesohippus are more square, or
‘molarized.’

i.e., this is when they became grazers (Fig. 1.4).13,14 The

maximum diversity of horses occurred during the middle
Miocene when some dozen genera coexisted at some North
American fossil localities.
The direct correlation between high-crowned teeth and
grazing in horses is not absolute.15 Recent studies of the
5 cm Merychippus
carbon content preserved in fossil hypsodont horse teeth
indicate that some coexisting equid species secondarily
acquired partial browsing diets.16 The extant genus Equus is
first known 4.5 million years ago during the Pliocene from D
North America. It has a hypsodont dental battery and elon-
gated and deepened skull and jaws, all of which are charac-
ters adapted for grazing (Fig. 1.3). Similar studies of the
carbon content in extinct Equus teeth indicate that these
horses were primarily grazers. However, depending upon
available food resources and competing species, extinct
Equus sometimes was a mixed feeder, incorporating some
browse into its diet.

Trends in dental evolution 5 cm Equus

Fig. 1.3  Changes in the cranial proportions of the family Equidae as

Number of teeth represented in Eocene Hyracotherium (top), Oligocene Mesohippus, Miocene
Merychippus, and Pliocene – modern Equus (bottom).10,11 (From ref.2 and
Primitive equids from the Eocene have a dental formula of
reproduced with permission of Cambridge University Press.)
3 I/i, 1 C/c, 4 P/p, and 3 M/m. The cheek teeth, consisting
of the premolars and molars, represent the functional
dental battery for post-cropping mastication. During equid absent.3,17 Like most other mammalian families in which
evolution the rostal-most cheek teeth, P1/p1, were there is little evolutionary variation in the dental formula,
either reduced to small, relatively functionless teeth, or lost other than the variable presence of the first premolar, equids
completely. In Equus the P1, or wolf tooth, is rudimentary, are relatively constant in the dental formula throughout
or often absent. The corresponding p1 is characteristically their phylogeny.

5
 1 Introduction

Fig. 1.4  Reconstruction of a Miocene savanna

grassland in North America showing a diversity  
of horse species, as they might have existed in a
local community. (From ref.13 and reproduced
with permission of the American Museum of
Natural History.)

Fig. 1.5  Left partial adult mandible of the

three-toed hypsodont horse Cormohipparion plicate
from the late Miocene (≈9 million years old) of
Florida showing the deposition of cement (above
arrow) on the erupted portion of p2 (above
alveolus) and p3–p4 (bone removed).

0 2in

0 5cm

hydroxyapatite, whereas dentin is about 75 % mineral, the

Histology remaining portion consisting of organic compounds, mostly
collagen.20 Minor chemical variations in fossil teeth result
The teeth of primitive horses demonstrate three primary primarily from changes in diet, difference in climate, and the
dental tissues: pulp, dentin, and enamel. The composition source elements available in the animals’ environments.
of each of these dental tissues is developmentally very con- Considerable infolding of the enamel occurs in later, hyp-
servative, i.e., there is little variation in mammals, including sodont horses, resulting in a more durable tooth surface.
equids.18 Composed of collagen, connective tissue, and reti- Cementum, the external dental tissue in extant horses, first
culin fibers, pulp is the relatively soft tissue located in the appeared during the Miocene in advanced species of Parahip-
center of the tooth,19 but is not normally exposed on the pus, and thereafter it was characteristically developed in hyp-
occlusal surface unless the tooth is heavily worn. Enamel sodont species (Fig. 1.5). Cementum is seen in numerous
and dentin are characterized by an inorganic component herbivorous mammalian groups and functions to provide an
consisting of the mineral hydroxyapatite (the primary con- additional occlusal surface for mastication of abrasive food-
stituent of vertebrate bone). Enamel is more than 95 % stuffs, i.e., principally grasses.21

6
 Equine dental evolution: perspective from the fossil record

Dental ontogeny and wear Miocene Parahippus leonensis

Most ungulates, including horses, are characterized by deter- 1 cm

A Wear-class 2
minant dental growth of two sets of premolars and one p2 p4
molar series. Likewise, the individual teeth are characterized
by growth that is completed during the lifetime of the indi-
vidual when crown enamel mineralization ends and the
m1 erupting
roots form. Despite the fact that some mammals, e.g., ele-
phants and manatees, have supernumerary tooth sets, and
other mammals, e.g., rodents and lagomorphs, possess teeth B Wear-class 5
that are ever-growing, the dental ontogeny in the family
Equidae is conservative. A fixed set of premolars and molars
and determinant tooth mineralization during an individu-
al’s lifetime is pervasive in fossil horses and Equus, with
one notable exception. One species of tiny three-toed
horse, Pseudhipparion simpsoni, from the 4.5-million-year- C Wear-class 7
old Pliocene of Florida, had teeth that were partially ever-
growing,22 thus providing an effective dental battery for
feeding on abrasive foodstuffs and potentially increasing
individual longevity.
Like modern horses, individuals of fossil equid species can
be aged by the relative wear on teeth as represented in large
quarry samples presumed to be ancient populations. It also
can be determined if breeding was synchronized, thus imply- D Wear-class 9
ing a relatively seasonal ancient environment, or occurred p2
year-round as in more equable climates. In seasonal cli-
mates, tooth wear was discontinuous within the population
because births occurred in annual cohorts, i.e., a group of
individuals that all started to wear their teeth about the same Fig. 1.6  Progressive dental wear on the lower cheek teeth of the
time (Fig. 1.6). In contrast, species that lived in equable three-toed horse Parahippus leonensis from the 18-million-year-old Thomas
climates will demonstrate continuous wear because indi- Farm locality, Miocene of Florida. The different wear stages shown are
viduals were born at different times during the year. interpreted to represent individuals that died at different ages within the
When horses are aged from fossil sites by the amount of same population. The top dentition (A) probably represents an individual
about 2 years old, whereas that at the bottom (D) was probably about 9–10
wear on their teeth, we can see that potential individual
years old when it died. The occlusal enamel pattern is indicated in black.
longevity has evolved since the Eocene (Fig. 1.7). Eocene and Pulp is exposed in the center of each tooth in Wear-class 9. (Modified from
Oligocene horses from 55 to 30 million years ago indicate ref.2 and reproduced with permission of Cambridge University Press.)
a maximum potential longevity of 4–5 years per individual
based on tooth wear and population analysis of Hyracoth-
erium and Mesohippus. Beginning about 20 million years ago
during the Miocene, cohort analyses indicate an increase in
25
potential longevity from 5–15 years depending upon taxon,2 Equus
and thereafter up to 20–25 years per individual during the
Pliocene and Pleistocene, as also has been reported for wild Pseudhipparion ?
20 simpsoni
populations of Equus.4 As longevity is generally correlated
with adult body size in modern mammals,23 it is not surpris-
Potential longevity (years)

ing that longevity increased in fossil horses over the past 20 Protohippus
15 cf. perditus
million years because this also was the time of dramatic
increases in body size.24 Neohipparion
cf. leptode
Merychippus primus
10
Sexual dimorphism Parahippus leonensis

Relative to certain modern mammalian species in which the 5 Hyracotherium Archaeohippus

males can be as much as 30–40 % larger than females within Mesohippus
a population,4 the degree and expression of sexual dimor-
phism as represented in skeletal hard parts is relatively 0
minor in living Equus. While male equids are generally 50 40 30 20 10 0
larger23 and have relatively more robust canines, these sexu- Million years ago
ally dimorphic characteristics are much less distinctive than
Fig. 1.7  Evolution of individual potential longevity in selected species of
in fossil equids. fossil Equidae based on analysis of the population dynamics of well-
A quarry sample of 24 individuals of Hyracotherium tapiri- preserved quarry samples. (From ref.2 and reproduced with permission of
num from a 53-million-year-old (early Eocene) locality from Cambridge University Press.)

7
 1 Introduction

Fig. 1.8  Dorsal, left lateral, and ventral views of female

(left: A, C, E) and male (right: B, D, F) crania of
Hyracotherium tapirinum from the 53-million-year-old
A B Huerfano Quarry, Eocene of Colorado. These are from
the same locality and therefore interpreted to represent
individuals within the same ancient population.  
Note the larger cranium and canine in the male.
Shading indicates reconstruction. (Modified from  
ref.8 and reproduced with permission of the
Paleontological Society.)

C D

E F

0 5 10 cm

Colorado gives insight into the sexual dimorphism in cranial 9

and tooth size in this early horse.8 The males are on average
15 % larger than females, and have markedly robust canines
relative to females (Fig. 1.8). Thereafter, during the Eocene 8
through early Miocene, size and canine dimorphism are
characteristic of more primitive species for which there are
sufficient samples for statistical discrimination. With the
Transverse canine width (mm)

7
evolution of open-country grazing forms during the Miocene,
cheek teeth are essentially monomorphic,25 but sexual dis-
crimination can be seen in the relative canine size (Fig. 1.9). 6
Likewise, in an extraordinary quarry accumulation inter-
preted to represent an ancient population of Equus (E. sim-
plicidens), the species close to the origin of the modern 5
genus, from 3.5-million-year-old Pliocene sediments of
Idaho,26 males and females can be distinguished based on
relative canine size. 4

Cranial adaptations 3

The 55-million-year evolutionary history of the family 5 6 7 8 9 10 11

Equidae is characterized by profound changes in cranial Anteroposterior canine length (mm)
morphology. Primitively, Hyracotherium had a skull in which
the orbit was centrally located, a postcanine diastema, and Fig. 1.9  Bivariate plot of canine length versus width in a late Miocene
quarry sample of the three-toed horse Hipparion tehonense from MacAdams
a relatively shallow mandible that accommodated short-
Quarry, Texas. The distinctly bimodal populations represent individuals
crowned teeth (Fig. 1.8). In contrast, Equus has a preorbital interpreted to represent females (lower left) and males (upper right).
region that is much longer than the postorbital region, a (Modified from ref.27 and reproduced with permission of the American
relatively more elongated diastema, and the mandible, Museum of Natural History.)
which accommodates high-crowned teeth, is very deep.
These trends all relate to the fundamental change in diet
that occurred from the morphology seen in Hyracotherium to Although not directly related to diet and feeding adapta-
that of Equus. This evolution, however, was not gradual, and tions, fossil horses show a fundamental evolution in the
a major morphological reorganization occurred in equid cheek region over the past 20 million years during the
skulls during the Miocene related to the adaptation to middle Cenozoic. Primitively, Hyracotherium has a smooth
grazing.10,11 preorbital cheek region (junction of nasal, maxillary, and

8
 Equine dental evolution: perspective from the fossil record

Fig. 1.10  Adult skull and mandible (left side) of

18-million-year-old, three-toed, short-crowned
Archaeohippus blackbergi from the Miocene of
Thomas Farm, Florida, showing dorsal preorbital
fossa (below finger). The orbit is to the right of  
the fossa.

lacrimal bones), but during the Miocene there was an adap- molarized cheek teeth, and deep mandible, represent an
tive radiation resulting in an elaboration of a pit, or multiple integrated character complex related to feeding on abrasive
pits, in the facial region. These are collectively termed pre- foodstuffs. These morphological adaptations are first seen 20
orbital fossae, of which the dorsal preorbital fossa is most million years ago during the Miocene when equids exploited
widespread (Fig. 1.10). Preorbital fossae are absent in living the grazing niche during the expansion of grasslands.
Equus, so the function of this structure cannot be based on The 55-million-year fossil record, particularly the ubiquitous
a modern closely related analog, and has, therefore, engen- and abundant horse teeth, provides fundamental evidence
dered much discussion in the literature. One theory suggests for macroevolution within the family Equidae in North
that preorbital fossae housed an organ complex that could America.
have been used for vocalization. The time of maximum mor-
phological diversity of facial fossae is seen at the time of
maximum equid diversity during the Miocene. During the
Acknowledgments
Pliocene and Pleistocene, when equid diversity declined,
facial fossae became reduced and were ultimately lost in Jeff Gage, Lee Seabrook, and Tammy Johnson for preparing
Equus.2 some of the graphic images in the text.
The US National Science Foundation supported aspects of
the research presented in this chapter.
Summary: modern Equus This is University of Florida Contribution to Paleobiology
number 631.
The cranial and dental adaptations of modern Equus, in
particular the elongated preorbital region, high-crowned

References
1. Simpson GG. Horses: the study of the 6. MacFadden BJ. Fossil horses–Evidence for 10. Radinsky LB. Allometry and
horse family in the modern world and evolution. Science 2005; 307: 1728– reorganization in horse skull proportions.
through sixty million years of history. 1730 Science 1983; 221: 1189–1191
Oxford University Press, Oxford, 1951 7. Lindsay EH, Opdyke ND, Johnson ND. 11. Radinsky LB. Ontogeny and phylogeny in
2. MacFadden BJ. Fossil horses: systematics, Pliocene dispersal of the horse Equus horse skull evolution. Evolution, 1984;
paleobiology, and evolution of the family and late Cenozoic mammalian dispersal 38: 1–15
Equidae. Cambridge University Press, events. Nature, 1980; 287: 135– 12. MacFadden BJ, Hulbert RC, Jr. Explosive
New York, 1992 138 speciation at the base of the adaptive
3. Getty R. Sisson and Grossman’s The 8. Gingerich PD. Variation, sexual radiation of Miocene grazing horses.
anatomy of domesticated animals. WB dimorphism, and social structure in the Nature, 1988; 336: 466–468
Saunders, Philadelphia, 1975 early Eocene horse Hyracotherium 13. MacFadden BJ. The heyday of horses.
4. Nowak RM. Walker’s Mammals of the (Mammalia, Perissodactyla). Natural History 1994; 103(4): 63–
world, 5.1. Online. Johns Hopkins, Paleobiology 1981; 7: 443–455 65
Baltimore, 1997 9. Jacobs BF, Kingston JD, Jacobs LL. The 14. MacFadden BJ. Origin and evolution of
5. McKenna MC, Bell SK. Classification of origin of grass-dominated ecosystems. the grazing guild in New World terrestrial
mammals above the species level. Annals Missouri Botanical Garden 1999; mammals. Trends in Ecology and
Columbia, New York, 1997 86: 590–643 Evolution 1997; 12: 182–187

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 1 Introduction

15. Janis CM. An estimation of tooth volume 20. Carlson S. Chapter 21. Vertebrate dental adaptation, and behavior. University of
and hypsodonty indices in ungulate structures. In: Carter JS, ed. Skeletal Chicago Press, Chicago, 1981
mammals, and the correlation of these biomineralization: patterns, processes 24. MacFadden BJ. Fossil horses from
factors with dietary preference. In: Russell and evolutionary trends. Vol 1. Van ‘Eohippus’ (Hyracotherium) to Equus:
DE, Santoro JP, Sigogneau-Russell D, eds. Nostrand Reinhold, New York, 1990, scaling, Cope’s Law, and the evolution of
Teeth revisited: Proceedings of the VIIth pp 531–556 body size. Paleobiology 1987; 12:
International Symposium on Dental 21. White TE. The endocrine glands and 355–369
Morphology, Paris 1986. Mémoires evolution, no. 3: os cementum, 25. MacFadden BJ. Dental character variation
Musée National Histoire Naturelle, Paris hypsodonty, and diet. Contributions in paleopopulations and morphospecies
(série C). 1988; 53: 367–387 from the Museum of Paleontology, of fossil horses and extant analogues.
16. MacFadden BJ, Solounias N, Cerling TE. University of Michigan 1959; 13: In: Prothero DR, Schoch RM, eds. The
Ancient diets, ecology, and extinction of 211–265 evolution of perissodactyls. Clarendon
5-million-year-old horses from Florida. 22. Webb SD, Hulbert RC, Jr. Systematics and Press, Oxford, 1989, pp 128–141
Science 1999; 283: 824–827 evolution of Pseudhipparion (Mammalia, 26. Gazin CL. A study of the fossil horse
17. Sach WO, Habel RE. Rooney’s Guide to Equidae) from the late Neogene of the remains from the Upper Pliocene of
the dissection of the horse. Veterinary Gulf Coastal Plain and the Great Plains. Idaho. Proceedings US National Museum
Textbooks, Ithaca, 1976 In: Vertebrates, phylogeny, and 1936; 83: 281–319
18. Janis CM, Fortelius M. On the means philosophy, eds. KM Flanagan and JA 27. MacFadden BJ. Systematics and
whereby mammals achieve increased Lillegraven, Contributions to Geology, phylogeny of Hipparion, Neohipparion,
functional durability of their dentitions, University Nannippus, and Cormohipparion
with special reference to limiting factors. of Wyoming, Special Paper 3, 1986, (Mammalia, Equidae) from the Miocene
Biological Reviews 1988; 63: 197–230 pp 237–272 and Pliocene of the New World. Bulletin
19. Dixon PM. Dental anatomy. In: Baker GJ, 23. Eisenberg JF. The mammalian radiations: of the American Museum of Natural
Easley J, eds. Equine dentistry. WB an analysis of trends in evolution, History 1984; 179: 1–196
Saunders, Philadelphia, 1999, pp 3–28

10
 Section 1:  Introduction

C H A P TER   2 
The history of equine dentistry
Jack Easley† DVM, MS, Dipl ABVP (Equine), Jennifer Hatzel* DVM
†
Equine Veterinary Practice, LLC, Shelbyville, KY 40066, USA
*Gainesville, FL 32608, USA

Introduction until recently with the development of the web and other
internet services.4,5 Through careful scrutiny of available texts
and other sources, the intriguing history of equine dentistry
Diseases of teeth; this is a subject which I have little to
may be pieced together.
offer.
William Percivall, 18241
Ancient roots
Of the diseases of the teeth in the horse we know little.
Hyracotherium was a prehistoric rabbit-sized creature that
William Youatt, 18312
was the precursor to our modern horse, Equus caballus. As
evolution progressed, this animal went from consuming
The diseases of the teeth attracting attention are but leaves and having brachydont (simple low-crowned) teeth
few. to chewing on grass and adjusting with hypsodont (high-
William Dick, 18623 crowned) teeth. This, along with enamel folding and the
coronal cement, created a grinding surface appropriate for
These quotes from three prominent 19th century European the spicules of silica within the grass as discussed in detail
veterinarians and scholars are accurate but ironic introduc- in Chapter 1.6
tions to the history of equine dentistry. Accurate, because As humans began to domesticate animals, responsibility
only recently has the equine veterinary profession taken steps for their medical care and well-being fell into the hands of
to embrace dentistry as a legitimate medical practice best caregivers. Written records from 2200 BCE within the Codex
served by the licensed and well-trained practitioner. Ironic, of Hammurabi in Babylon show the establishment of a code
because although significant advancements have been made of ethics allowing for medical practice on both humans and
associated with equine dentistry, similar quotes are heard animals. Other instructions included fees allowed to be
from today’s graduating veterinary students and seasoned charged for medical services as well as those which barbers
practitioners. In many cases these concerns are justified since (ancient beard trimmers and medicine men) charged for
veterinary schools still do not spend a great deal of time pulling teeth.4 The Kahane papyrus from 1850 BCE Egypt
teaching equine dental procedures. However, veterinary stu- makes no reference to horses. However, Egyptian carvings
dents and equine practitioners spend hundreds of hours and paintings dated from 2000 BCE portray individuals per-
learning the anatomical, biological, physiological, histologi- forming what appear to be oral examinations on various
cal, medical, and surgical information necessary to practice poultry and livestock. None appear to depict any equine
sound equine dentistry. Philosopher and poet Georges San- species simply due to the fact that the ancient Egyptians did
tayana stated, ‘Those who do not study history are doomed not extensively use horses or donkeys. However, the Codex
to repeat it.’ Perhaps by turning to the history of equine of Hammurabi does provide proof that donkeys were used in
dentistry, we may benefit from its ancient roots and devote Asia Minor and the Orient during this time period.4
its future to development, not repetition of failures. The domestication, riding, and breeding of horses can
Expressions from historical folklore such as, ‘long in the be traced back prior to 1000 BCE in Asia. Archeological
tooth’ or ‘don’t look a gift horse in the mouth,’ reference and paleontological evidence indicated that the horse was
horses’ teeth. Much of this history is buried in hand-made domesticated about 5000 years ago, substantially later than
materials such as manuscripts, folios, tablets, and paintings other farm animals. By that time (approximately 3000 BCE)
utilizing ancient characters, or languages. Before the inven- the dog had been our companion for 9000 years and we had
tion of printing, these documents were transferred through- herded goats, sheep, and cattle for upwards of 5000 years.
out the ages by scribes, leaving much room for error, The horse came late but lost no time in transforming our
superstition, and quackery. Most of this history of the horse lives. Sequentially, as horse selling became more popular,
is located in European libraries and was not readily available the ancient Chinese practice of ‘aging’ by examining teeth

11
 2 Introduction

became an invaluable tool.7 As the art of riding and selling

horses spread from Asia to Europe it became engrained
within the Greek and Roman societies. From 430–354 BCE
Xenophon, a student of Socrates, collected his experiences
on the art of riding in the document, Peri hippikes (On
horsemanship). This text makes reference to the art of
riding being restricted to the upper class who kept ‘heads of
stables’, ‘equerries’, and ‘masters of the horse’, to care for
their horses. It also references the use of a ‘machina’, Latin
for mouth-gag, used to administer medicinal drenches or to
aid with the clearing of esophageal obstructions while utiliz-
ing a stick.8
Several other important documents were also created
throughout this period as the use of horses in transport,
agriculture, and military work became increasingly more
important. The Veterinary Art, Inspection of Horses by Simon
of Athens and the History of Animals by Aristotle were pro-
duced in 430 BCE and 333 BCE, respectively. Both manu-
Fig. 2.1  A farrier’s shop (1648) by Paulus Potter, a famous Flemish animal
scripts contain information regarding the aging of horses by painter (1625–1654). Potter shows a farrier (horse doctor) wearing a red
examination of their teeth. Simon’s text discusses eruption jacket and leather apron, examining the mouth and teeth of a restrained
patterns and Aristotle’s includes information on periodontal horse.
disease. It is suspected that additional collections of valuable
equine text were lost during the fire in Alexandria in 391 AD
that destroyed the largest library of the ancient world with
at least 700 000 volumes consumed.4 Stablemasters
As the Roman Empire flourished, a few significant medical
documents were created with additions of personal observa- The horse’s role in work and transportation gained impor-
tions and local superstitions. In 400 AD, Chiron, a Roman tance throughout Europe during the medieval era, but
writer often confused with the Centurion god and son of medical advancements in Europe were few and far between.
Apollo, created manuscripts including Book VI that con- As the value of horses increased with upper-class showman-
tained information on tumors of the jaw, diseases of the ship, the importance of having a well-shod animal fell into
teeth, and management of jaw fractures. In addition, Book the hands of farriers (Fig. 2.1). Consequently, a revival in
VIII contained a description of dentition. Another major the advancement of veterinary medicine began in the late
Roman contributor to early veterinary medicine was Vege- 13th century. From 1212–1250 AD Emperor Friedrich II of
tius who recorded The Veterinary Art between 450 and 500 Hohenstaufen held court in Naples, Italy, and commis-
AD. This document included not only works on aging, but sioned Giordano Rosso from Calabria and Master Albrant,
also a description of the ‘pain of sockets of the teeth,’ the a farrier of German descent, to manage all of his equine care.
only reference to periodontal disease from that time. The Both men detailed their experiences including ancient Arabic
treatment of choice for this affliction was to rub vinegar and prescriptions in various manuscripts which Rosso, a noble
chalk to the outside of the jawbone. Much of Vegetius’ work man by birth, published in Latin. Albrant, a less formally
relied upon the previous writings of Apsyrtus, the senior educated man, published his experiences, including aging
veterinarian of Constantine the Great’s army in 333 AD. (utilizing previous texts) and the use of herbal medicines to
However, Vegetius’ text is still considered a cornerstone of heal oral mucosal wounds. Published in German, the more
ancient equine literature and was translated into English and common people were able to read and understand Albrant’s
reprinted in 1528, making it one of the first veterinary texts text but much of his knowledge was passed on by word of
to be printed. Apsyrtus’ work may also be found in mouth, leading to large discrepancies and regional supersti-
the Hippiatrica, a manuscript compiled by order of Emperor tions (Fig. 2.2).
Constantine VII. This text also contained a section on denti- In 1250 AD, with the Renaissance occurring in Europe,
tion by Hierocles from 350–400 AD.4,9 Johanes Ruffus, the chief veterinarian to Frederick II of
As the Dark Ages enveloped Europe, learning shifted east Sicily, created Equine Medicine. This detailed text included a
as Arabic equine education benefited from the magic within description on cutting a horse’s lip to accommodate the bit,
Hippiatrica and the widespread military use of horses. Con- dental extraction techniques, as well as reference to false
tributors included the author Ibn al Awam from Seville, incisor alterations created by horse owners to make horses
Spain, whose manuscript (1100 AD) contained a section on for sale appear younger. ‘Bishoping,’ named after a scoun-
dentition. Around 1200 AD Abou Bekr created the Naceri drel who utilized the practice, became popular in England
which displayed a section on dentition, operations, a sketch throughout the 16th century and beyond, as horse sellers
of early hand-held mouth gags used for the extraction of increased profits by making their horses appear younger or
teeth, and the cutting/breaking of long molars. His work also older, whichever proved more valuable and to their benefit.
included recommendations for using files and floats for A reference to this behavior is found as late as in Jacques L.
trimming unequal teeth. Hassan Ibn al Ahnaf’s manuscript de Solleysel’s 1664 text, Le parfait mareschal. Solleysel ‘com-
in 1209 AD contained a drawing of a tooth extraction using plained bitterly’, describing a German’s practice of changing
forceps.8,9 horses’ teeth appearance as inappropriate.8

12
 The history of equine dentistry

Fig. 2.3  Large and brutal bits used by the Italians necessitated cutting the
commissures of the lips and removing the lower tushes. The Turkish figure
suggests an Eastern origin for these monstrosities, and perhaps symbolizes
the burden borne by the hapless horse. (Feraro 1560 Cure of horses,
Fig. 2.2  Farriers and horsemen inflicted many painful and barbaric reproduced from Smithcors 1957,10 p. 150, with permission from Veterinary
treatments on their horses during the Middle Ages and beyond. An 18th Medicine Publishing Company.)
century complaint against the existing order. (Reproduced from Bracken
1737 Farriery improved.)

leeches, farriers, and quacks. Often, the barbaric treatments

During the crusades and the Moors’ invasion of Spain,
utilized were based on superstitions handed down from
European and Arabian cultures crossed. Much of the Arabian
previous generations. In England the agriculture writer, John
knowledge previously compiled influenced Europe, and
Fitzherbert, whose text Boke of Husbandrie (1523) provided
more specifically Spain. Juan Alvarez Salmiellas translated
expert advice, was an important influence on agriculture
some 96 chapters of ancient Arabian horse knowledge into
practices for several centuries. His work helped perpetuate a
Spanish which comprised the most complete manuscript of
number of imaginary equine diseases, three affecting the
equine knowledge available at the time. Manuel Diaz, major
mouth: ‘lampas’ or swelling of the palate, ‘barbs’, the papil-
domo of King Alphonso of Aragon, compiled his text Libro
lated openings of the salivary ducts, and ‘vives’, which
de Albeiteria of equine diseases utilizing Arabian influences.
appears to be a non-pathological enlargement of the parotid
In 1492, Queen Isabella of Castilla in Spain defeated the
salivary gland. Fitzherbert insisted the vives must be ‘killed’
Arabian conquerors in the Battle of Granada. Realizing the
before it can ‘eat the roots of the ears’. ‘Vives’ had also been
importance of horses in warfare, she devoted time and some
mentioned by Ruffus two centuries earlier.10 From the
of her treasure to the development of equine science. By
middle ages until the 19th century, wolf teeth were also
1500, laws had been established calling for albietares, or
blamed for various ailments including blindness and
horse doctors, to be properly trained through apprentice-
‘madness’ with their removal apparently relieving the symp-
ships.8 Despite advances in the field of equine dentistry,
toms. While lacking proof, the chosen methods to remove
many discrepancies remained. In 1566, Blunderville stated
wolf teeth with a carpenter’s gouge, chisel and mallet or by
that horses only have 16 teeth, due to the fact that only the
filing them, appeared in the literature of this time period and
12 incisors and 4 canine teeth could be easily examined. It
beyond.
was evident from his work that he was unaware that horses
M. LaFoose in 1749 used a trephine to open the sinuses,
have cheek teeth. Millennia earlier, Aristotle correctly placed
as a means of treating nasal ‘gleet’ caused by glanders or
the number of equine teeth at 44. Blunderville also addressed
sometimes dental disease.4 Reports of farriers using a chisel
that horses with small mouths have the angles of their lips
and hammer to remove focal dental overgrowths (‘hooks’)
cut by an ‘expert horse-leech’ and cauterized to prevent
and sharp edges, tall teeth reduced with saws, and teeth
healing over. As an additional means of making room for
extracted with a long fixed iron instrument called a ‘key’,
the ornate bits of the time, he recommended that the lower
without the aid of a speculum, often resulted in damage such
tushes (canine teeth) be extracted (Fig. 2.3).4
as jaw fractures and even death. Designs of a scissor type
instrument invented to cut the difficult distal hook on the
Barbary last molar and various patterns of sliding chisels and screw-
type molar cutters are found in textbooks published during
Throughout the 16th, 17th and 18th centuries medical pro- this era.8 Most of these tools were still manufactured and
cedures were most commonly performed by owners, horse sold into the 20th century (Fig. 2.4).

13
 2 Introduction

Fig. 2.5  Burning for lampus. A red hot iron was placed in the roof of the
young horse’s mouth to relieve the symptom of this imaginary disease.
(Edward Mayhew, 1888 The illustrated horse doctor, p. 66.)

associated with this disease is often the result of a simple

feed change. Stablemasters would move a young horse off
pasture and into the stable, altering the diet with dry feed-
stuff. Veterinarians found it more difficult to convince the
stablemaster, the affliction was physiological, and found it
easier to simply ‘treat’ the problem. Veterinarians still treat
imaginary diseases today, regardless of scientific evidence, as
client pressure still dictates many actions.
Although the majority of veterinary medical treatments
were documented, a large percentage of them contained
errors and misinterpretation due to mistakes in translation.
Fig. 2.4  Equine Dental Instruments, Plate IV, John Reynolds & Co, New York, Martin Boehme, a horse smith serving in the armies of
from Clark (1893). Price list and descriptions: 25. Bow tooth saw with two Germany, Holland, and Hungary in 1618, was called to
blades … $6.00, 26. Tooth key with hooks of assorted sizes … $35.00, 27. court by Johann Georg of Brandenburg to establish the first
Plain tooth saw … $1.50, 28. Chain tooth saw … $12.50, 29. Fine ferruled
tooth saw … $1.75, 30. Narrow tooth chisel, length 6 inches … $1.25, 31.
pre-university veterinary education and formalize a learning
Hurlburt’s gum knife and tooth pick … $2.00. environment leading to organized academia. He was also
attributed with publishing the first exact prints (woodcuts)
of various equine dental instruments in his text, ‘Ein nett
Buch von bewehrter Ross Artzeneyen.’8
Another commonly performed, barbaric, and unscientific
procedure involving the mouth of the horse was the treat-
ment of ‘lampas.’ This ‘defect’ occurs as the palatal epithe- The Age of Enlightenment and the
lium physiologically begins to bulge, resulting from erupting introduction of formal education
incisors in younger horses. Included in almost all farriery
texts prior to the 1900s, the treatment of choice was to cau- During the 18th century, scientific, rational, and evidence-
terize the region with a hot iron, allow the horse to rest a based thought began to displace the previously held
day or two, and repeat if necessary (Fig. 2.5). religion-centered philosophies. The Age of Enlightenment
Solleysel, as early as 1664, was the first to document this produced a wave of writers and thinkers with scientific back-
change in young horses as entirely normal and advised grounds who used their ideas and authority to establish
against the cauterization process and much debate ensued.4 scientific societies and academies throughout Europe and
This practice was still being performed when William Per- North America. These societies became the backbone of the
civall wrote in 1823 that the treatment of the imaginary scientific profession during the time and ushered in signifi-
lampas by cautery be considered to be a ‘stigma on our cant advancements in biology, chemistry, and in the practice
national character and a disgrace to veterinary science.’1 of medicine. Consequently, the advancement of science and
Youatt in his 1846 publication states, ‘a few slight incisions medicine spilled over to the veterinary community. In 1762,
across the bars with a lancet or penknife will relieve the the first veterinary school was established in Lyon, France,
inflammation.’2 Although addressing this ‘affliction’ Youatt and the second followed quickly in 1766 in Alfort, France,
found himself in a common predicament. The inflammation near Paris. Disorders of the horse were the pre-eminent

14
 The history of equine dentistry

subjects in all veterinary schools for almost the next two

centuries. Although advancements in equine veterinary
practice were being made through formal education, den-
tistry was not a priority of the curriculum. Farriers were
still responsible for conducting the majority of veterinary
treatments but were beginning to be considered as ‘a car­
penter compared to the architect: both having to do with
the same thing, with only the architect understanding the
underlying principles.’11
As veterinary education began to flourish, so did the
amount of technology and literature created by experts. Sur-
gical techniques initially gained attention due to the mystery
shrouding many medical ailments affiliated with then undis-
covered bacterial and viral infections. In 1805, Professor
Hayemann from the Hannover veterinary school described
a procedure where the skin is incised crosswise under the
apex of a diseased tooth, then flapped in order to chisel the
bone away, thus exposing the root of the tooth. He then
described using an iron punch to hammer it out. Jaw and
tooth fractures were common consequences but this repul-
sion procedure is still in part used today. In 1835, Jean-
Baptiste Girard, as director of the Veterinary School of Paris
Fig. 2.6  French World War I military veterinarian working on a horse’s teeth.
Maison Alfort, published the Traité de l’age du cheval for his The mouth is held open with a Gunther speculum.
son who was an anatomy professor at the same institution.
Girard was the first to describe the inconsistent nature and
shedding of the wolf teeth at 2.5 years when the deciduous
first cheek tooth (Triadan 06) displaces it. He also made clear October of 1915 to the Journal of the American Veterinary
that the presence of canine teeth has nothing to do with Medical Association, to accompany the association’s new
sterility, another common misconception at the time.12 name, the American Veterinary Medical Association. The
New surgical techniques such as the previously described name change took place in 1898 in order to recognize vet-
cheek teeth extraction, created a demand for appropriate erinarians in both Canada and the United States.11,13
instrumentation and an opportunity for new companies. The doorway for advancement in equine veterinary medi-
Arnold & Sons of England met this demand by making cine and equine dentistry had been opened as scientific
dental floats and other instruments in 1817. J.H. Friedrich experimentation led the way for significant published
Guenther and his son Karl W.A. Guenther, both also famous advances in knowledge, improved instrumentation, and col-
professors at the Hannover veterinary school, were influen- lections of data. Robert Jennings, a Philadelphia veterinar-
tial in advancing the tools used for equine dentistry. In ian, stated in 1865 that the ‘horse was subject to caries’
1859, they published Die Beurtheilungslehre des Pferdes which (tooth decay) and collected 350 well-defined specimens of
included a 164 page chapter on teeth, a chapter on aging, caries in horses’ teeth. He later published his findings in an
descriptions of 36 innovative instruments used for dental article entitled Diseases of the Horses Teeth, which may be
surgery accommodating the different shapes and positions found in the Archives of Comparative Medicine of 1883.11
of all teeth, and a diagram of a mouth gag utilizing a screw Another important textbook, Veterinary Dental Surgery, pub-
spindle (Fig. 2.6).8 lished in 1889 by T.D. Hinebach, a Professor at Purdue
University in Lafayette, Indiana, described dental anatomy,
physiology, pathology, and therapy complete with illustra-
The origins of organized veterinary dentistry tions. He illustrated the use of instruments by Sharp & Smith
along with a mechanical drill borrowed from human den-
The American Civil War and westward expansion of settlers tists (Figs 2.7, 2.8). In the text he described techniques for
cemented the popularity and utility of the horse in American filling in decayed incisors and molars.14 The Exterior of the
culture during the mid to late 1800s. With formal veterinary Horse, penned originally by Goubaux and Barrier and
education established throughout Europe, the youthful later translated from French in 1892 by Simon J.J. Harger,
United States opened its first veterinary school in 1875. The contained over 900 pages including 360 figures of which
majority of early American veterinary practitioners were 120 were of horses’ teeth with detailed anatomical
migrant European veterinarians such as John Haslam, a illustrations.11
1799 or 1801 graduate of the Royal Veterinary College of In the late 19th century major improvements in equine
London, who most likely practiced in Baltimore. The 7th dental instrumentation began to appear in uniquely designed
United States Census reported 46 practicing veterinarians in tools such as the ‘Frick/Hauptner Universal Forceps’ created
1850 but this number had increased to 392 by 1860. With by a professor of surgery in Hannover, Germany in 1889.
the establishment of formal veterinary education, the United His cheek teeth forceps contained two adjacent bars which
States Veterinary Medical Association published their first rotated in two joints, thus closing the jaws in a parallel
scientific journal, The American Veterinary Review in 1877. fashion allowing for proper application (Figs 2.9–2.11). Pre-
The title of this often referenced ‘Review’ was changed in vious forceps had jaws that rotated around a riveted joint

15
 2 Introduction

Fig. 2.7  Simons mouth speculum with a screw mechanism to aid in

opening the mouth of the unsedated horse. The speculum put pressure on
the bars of the mouth. Sharp and Smith manufacturers and importers of
superior surgical veterinary instruments, Chicago. (Hinebauch, 1889, p. 235.)

B
Fig. 2.8  A mouth gag that rests on the horse’s bars. (Merillat 1905.)
Fig. 2.10  Equine extraction forceps designed by Gunther. (A) Extractor
forceps, breaking forceps, first lower molar forceps, first upper molar forceps.
(B) Upper molar forceps and lower molar forceps. (Regional Veterinary
Surgery 1904, pp 48–49.)

behind the jaws (similar to scissors). His model sold unmodi-

fied from 1889 until the 1970s and is still often used in
Europe today. In 1895, Chicago veterinarian Herman Hauss-
mann invented and patented the first mouth speculum fea-
turing interchangeable incisor and gum plates as well as poll
straps and upper and lower jaw straps. Previous mouth
Fig. 2.9  Frick and Hauptner’s ‘Universal’ forceps. The clamping head is speculums utilized plates which rested on the bars of the
shown with and without the fulcrum. (Regional Veterinary Surgery 1904, mouth. J. Gordon McPherson of Toronto, Canada, patented
p. 49.) a speculum in 1901, which provided improved holding of
interchangeable incisor plates and secured ratchets used for
adjusting the speculum.8
Scientific explanation did not always dominate advance-
ments in actual dental practice during the late 1800s. Many

16
 The history of equine dentistry

Fig. 2.12  Inside cover of Galvayne’s text on dental aging, first published in
the early 1880s.
A

any horse to within one year of its true age’ (Fig. 2.12).15 He
traveled throughout Europe and Australia during the 1880s.
Galvayne’s Groove is still used today to aid in equine aging.16
Many of Galvayne’s materials were plagiarized from previ-
ous authors. Girard gives a detailed explanation of the
changes in equine dentition from birth through eight years
of age.12 In 1832, Delabere Blaine described the art of aging
a horse by its teeth (Fig. 2.13). He was the first to explain
that the disappearance of the ‘cups’ or ‘marks’ on the occlu-
sal surfaces of the incisors in the 3–10-year-old horse was
not from ‘filling up from the bottom’ but in fact from the
incisor teeth wearing down.17 Edward Mayhew, an early
member of the Royal College of Veterinary Surgeons, pub-
lished a text in 1848, The Horse’s Mouth and Showing the Age
by Teeth. This book contained many fine color plates showing
the teeth of various aged horses (Fig. 2.14). He also described
several dental wear abnormalities and how to correct them
with ‘chisel and mallet.’18 J. N. Navin, author of an 1867
American text, stated in the chapter on aging, ‘the back
teeth or grinders, may indeed be referred to and with
considerable accuracy, but they are too far from view and
so difficult to expose as to render their examination imprac-
tical.’19 About this period of time, an American veterinarian,
Professor Oscar R. Gleason, published a ‘new method’
and poem to help horsemen age horses by their dentition
B (Fig. 2.15).20
In 1879, William H. Clarke wrote an extensive, well
Fig. 2.11  (A and B) Moller’s shears were introduced to reduce tall teeth. researched text, Horses’ Teeth: a treatise on their mode of devel-
The central screw ensures great power without disturbing the position of opment, anatomy, microscopy, pathology, and dentistry; compared
the instrument. It was recommended to cast the horse and insert a rather
large mouth gag before trying to cut the tooth. If the shears slide off the
with the teeth of many other land and marine animals, both living
sides of the back molar, Moller’s tooth screw may preferably be employed. and extinct; with a vocabulary and copious extracts from works of
(Moller & Dollar 1904, pp 36–37.) odontologists and veterinarians. This text devoted a full chapter
to dental cysts and supernumerary teeth (Fig. 2.16). Clarke
dental practitioners retained the information passed down gives detailed descriptions of over 60 cases of dental tempo-
from previous generations, yet still managed to leave their ral cysts reported since this condition was first accurately
mark on history. One example of this was Fredrick Osbourne, described by Mage Grouille in 1811.21
known then as Sydney Galvayne, an Australian veterinary L. A. Merillat, author of the popular Animal Dentistry and
surgeon and horse breaker, who arrogantly claimed to ‘age Diseases of the Mouth, first published in 1906, pioneered

17
 2 Introduction

Fig. 2.13  Aging by the teeth. (D.B. Blaine, 1832.)

many unique dental surgical procedures. He was highly 1. The cutting and floating of the enamel points of the
regarded and considered to be ‘one of the foremost veteri- horse and ox
nary surgeons in this country,’ who ‘has in the intervals of 2. The removal of projections which prevent perfect
active practice given his colleagues the benefit of his close apposition of the dental arcades of the horse, ox and
study and large experience in the treatment of the organs hog
concerned in the mastication.’11 His advanced publication 3. The treatment of secondary nasal catarrh resulting from
was the first to summarize dental procedures into nine diseased teeth
categories: 4. The extraction of all diseased teeth of all animals

18
 The history of equine dentistry

Fig. 2.14  Color plate, aging by the teeth. (Mayhew, 1850, The horses’
mouth, The teeth.)

Fig. 2.16  1905 ear tooth diagram (Merillat).

5. The removal of tumors related to the teeth in all

animals
6. The treatment of stomatitis caused by the bit or by
dental projections
7. The amelioration of driving defects resulting from
dental irregularities in the horse
8. The treatment of faulty eruptions of the permanent or
temporary dentures in the dog, the horse, the ox and
the cat
9. Improving the appearance of the incisors of the horse.
Interestingly, in another example of history repeating itself,
Merillat is also quoted as saying, ‘the veterinarian consigned
dental operations to others because it is rather beneath the
dignity of the learned veterinarian to float the teeth of horse,
not because it is difficult, tedious, or dangerous but because
animal dentistry is regarded as a trifling accomplishment
that the uneducated can master.’22
Toward the end of the 19th century in the USA, bogus
veterinarians such as ‘hoss doctors,’ ‘cow-leeches,’ and ‘quack
doctors’ appeared to dominate the medical field, outnum-
bering licensed veterinarians.23 By 1900, 14 of approximately
30 veterinary schools in the USA, most of which were private
institutions, closed their doors. From 1901 to 1930, of an
Fig. 2.15  Gleason’s poem for aging horses by their teeth (1892).
additional 13, seven failed, including a state veterinary
college. Before the beginning of WWI, 14 veterinary schools,

19
 2 Introduction

all of which were private, remained in the USA but many as unqualified but as having improved some operations in
closed as students and faculty left to fight. By 1921, there horses’ mouths without the use of a speculum. House was
were only three private veterinary schools left, with the also praised for developing new instruments which have
last closing its doors in 1927. Although short-lived, these remained unaltered since William Hope’s in 1596. However,
private institutions provided North America with over Sayre did mention the danger House posed by possibly
10 000 veterinarians. Some of these institutions offered a tempting other ‘lay-people’ into equine dentistry and
correspondence-earned diploma, leading to fraudulent edu- potentially leading to disastrous results. House was also
cation and a few arrests. The Detroit Veterinary College, Inc., mentioned in texts by William H. Clarke, the well-known
formed in 1905, offered correspondence courses in veteri- veterinarian and author who questioned ‘skill versus brutal-
nary dentistry which were described in an elaborate adver- ity’ in his first book, Horse’s Teeth, in 1879. Clarke’s book
tisement (Fig. 2.17). Another veterinary dental college in St references House often, commenting that he was an Ameri-
Louis was created in 1905. Neither school kept their doors can equine dentist practicing mainly in Connecticut and
open for long.12 Massachusetts. Apparently, House earned a graduate degree
C. D. House was an unqualified non-veterinarian, who is sometime between the 1st and 3rd editions (1879–1886)
often referred to as one of the founders of American equine of Clarke’s book and was mentioned to have obtained a
dentistry. In 1891 C.E. Sayre described House in the Review diploma.21
American equine veterinary dentistry soon became a
politically complicated profession. In 1896, a French-
educated veterinarian, Professor Alexandre Liautard claimed
Dr House led to the ‘cause of much mischief and harm
and injury.’ Liautard went on to compliment Professor J.A.
Ryder of New York, who when asked to examine the mouth
of a horse having problems pulling on the bit, found that
‘the anterior borders of the first two lower molars were
worn and notchy,’ and decided to file them obliquely so
that ‘they would not touch each other by their front part, but
form a V shape, with the base turned forward, the apex
backwards.’ The results were so favorable that he was asked
to apply this technique to many other horses throughout the
years. Liautard expressed his concern for the future of equine
veterinary medicine in the American Veterinary Review,
referencing the increased interest in technology such as the
horseless carriage and bicycle.11 In 1900, another American
veterinarian, W.L. Williams of the New York Veterinary
College, contributed his Surgical Operations. This text was in
part a translation of works by W. Pfeiffer of the Berlin Vet-
erinary High School with distinctly American surgical tech-
niques of molar extractions, repulsions, and trephining the
nasomaxillary sinuses being added.24,25 In 1906, Williams
contributed his six points, dispelling American veterinary
dentistry in the Review by addressing it as a recent trend
towards urging horse owners to seek out those who interfere
with the teeth of horses and an attempt has been made to
dignify the practice by appellation of veterinary dentistry.

1. More has been written upon this subject in America

than in all other countries combined, we have two
pretentious volumes under the title veterinary dentistry,
besides much current literature…
2. American veterinary colleges have attached to their
faculties a professor of veterinary dentistry and
presumably give a special course in that subject. Great
stress is laid upon this feature in the announcement of
some of the shorter course veterinary colleges…
3. A perusal of the catalogues of the manufacturers of
veterinary instruments shows a special emphasis upon
dental apparatus by American firms as compared with
foreign houses…
Fig. 2.17  How to approach and examine a horse’s mouth. Fig. 1 Illustrated
4. Graduates of American veterinary colleges largely
Lectures, Part II, Detroit Veterinary College, Inc., Detroit, Michigan. This mail advertise themselves as specialists in dental work…
order correspondence course advertised that veterinary dentists with a 5. American horse owners, trainers, coachmen, and
diploma could make from $1500 to $3000 a year in 1900. stablemen have been firmly led to believe that a very

20
 The history of equine dentistry

Fig. 2.18  An explanation of equine dental

practice given by Louis Merillat 30 years after
publication of his original text on equine
dentistry. (Veterinary Military History, Vol 1, 1935.)

large proportion of the diseases and vices of horses are convinced his nephew to pursue a career in veterinary medi-
referable to defective teeth and the veterinary dentist is cine. Becker was the first to promote the importance of
sought as a universal panacea…’11 performing dental examinations on every patient seen in his
These general thoughts continued to cause problems in the uncle’s practice using a set of stocks which he constructed
equine industry for many years and were addressed again in (Fig. 2.20). In 1937, Becker created an improved mouth
1935 by Louis Merillat in his review on the military history speculum with a panic bolt, interchangeable bite plates, and
of veterinary medicine (Fig. 2.18).26 upholstered round bars that could be positioned over the
incisors and edentulous parts of the jaws. During the period
before the use of sedation, this improved speculum was
Education during four decades of war helpful, working with two threaded spindles to aid in
opening. Becker also worked on production of the first
The introduction of automobiles, trucks, and tractors (thus, mechanical motor-driven float system to improve arcade
the reduced need for horses) and a better understanding of corrections and consequently reduce treatment time. This
infectious diseases at the turn of the 20th century prompted power grinding equipment also featured the use of water-
a change in veterinary textbooks as emphasis was shifted cooling during some procedures, thus preventing pulpar
from equine to food animals and pets. Many of the overall thermal insult to an area. This potentially pathological
advancements in veterinary medicine arrived through the process still receives research attention today.8
discovery of bacteria by Pasteur, Fleming, and McFayden Summaries of Becker’s work, instrumentation, and experi-
during the late 1800s and early 1900s. Other applications ence with pathological findings were published in Neuzeitli-
such as the use of barbiturates in veterinary patients in 1902, che Zahnbehandlung beim Pferd in 1938. Research by G. Leue
flexible endotracheal tubes in 1914, and anesthesia in the (cited by Becker), measured the lateral jaw excursion of
form of pentobarbital and penthal in 1931 and 1934 encour- horses fed different types of forages and grain.27 Becker
aged veterinary surgery to take on new challenges.4 Equine claimed that a study of 50 000 Cavalry horses showed that
veterinary interest shifted back to Europe as WWI ended and regular dental care saved 1.5 kg of oats per horse, per day,
WWII began (Fig. 2.19). By this time the United States Army which was a desirable concept due to food shortages in
Calvary contained only 50 000 horses whereas the German Germany at the time.
army utilized 2.5 million. Becker was conscripted into military work before WWII
Erwin Becker (1898–1978), a cornerstone in the advance- and moved to military headquarters at Salzburg. This estab-
ment of dentistry techniques, served in the German army lishment was taken over by American troops and Becker
during WWI. Initially interested in pursuing an advanced maintained a prisoner of war status until June 16, 1945,
engineering education, his veterinarian uncle, Helmar Dun, following which he stayed on at the equine hospital to train

21
 2 Introduction

Fig. 2.19  A complete set of United States Army

equine dental instruments manufactured by
Sharp and Smith Co., Chicago, 1915–1945. This
set of steel chrome plated instruments came with
interchangeable handles and was packaged in a
canvas roll for ease of inventory control and
reduced weight for shipping.

Fig. 2.20  The stocks and motorized equine

dental system developed by Erwin Becker in the
1930s. A high quality black and white movie
shows the dental tools in use and other Becker
innovations such as the taking of dental
impressions and making plaster models of dental
abnormalities. (Einmal im jahr, Ein Lehrfilm von
Prof. Dr Erwin Becker, Equivet, Kruuse, Denmark.)

American veterinary students serving in the army. Eventu- of which are equine.28 Professor Hugo Triadan, a human
ally, Becker returned to Berlin to continue his career at the dentist, opened a dentistry suite in a veterinary facility in
American Cavalry and Riding Center, until 1959. The largest Bern, Switzerland in 1970. His experience led to the develop-
collection of Becker’s equine dental findings may be found ment of the Modified Triadan system and dental charting
in Joest’s Handbook on Pathological Anatomy published used today.29
in 1970.8 The second half of the 20th century brought the revival of
interest in horses for sport and recreational purposes. With
the increase in horse numbers, equine veterinary practition-
A new interest is born ers began to realize the importance of forming a unified
In 1931, the Dental Board of the UK published a text con- group with which to share knowledge. The American Asso-
taining four lectures by Sir Frank Colyer regarding Abnormal ciation of Equine Practitioners was formed in 1954 and the
Conditions of the Teeth in Their Relationship to Similar Condi- British Equine Veterinary Association in 1961. Despite the
tions in Man, which was based on observations of museum renaissance of equine veterinary work at the time, little
specimens from Europe and the USA. In 1936, Colyer pub- emphasis was given to equine dentistry in the 1960s with
lished what is considered the preeminent text on animal the exception of Hofmeyer’s South African publication of
dentistry, Variations and Diseases of the Teeth of Animals which comparative dental pathology and Honma’s Japanese study
included over 1000 pictures of dental abnormalities, many of dental caries in domestic animals.30,31

22
 The history of equine dentistry

Throughout the 1970s and 1980s, with the increased knowledge for many current trends and practices that were
encouragement of horse trainers and owners, interest was born out of fiction and superstition. Many of these tradi-
spurred regarding dentistry affecting performance and tional techniques, including incisor reduction and wolf teeth
dietary supplementation. This consequently led to the devel- extraction continue to be used in modern times.36
opment of new dental instrumentation such as advanced One such previously unquestioned practice was the use of
power floats. Improved methods and drugs for standing aging from dental appearance which can be traced back to
sedation allowed veterinarians the ability to perform safe China in 600 BCE. In 1993, Walmsley’s studies initially
and effective oral examinations and procedures. With the questioned the accuracy of aging horses through dentition,
advancement of technology and technique, research on and from 1994–1995 the work of Richardson, Cripps, and
equine dental disorders should have followed, but it was Lane further confirmed the inaccuracy of aging by denti-
difficult to prioritize dollars for graduate study and training tion.37,38 With an increase in evidence-based medicine and
devoted to equine dentistry. Following the formation of the research the field of equine dentistry continued to develop.
American Veterinary Dental Society in the United States in During 1996–1998, Muylle and colleagues conducted exten-
1976, the Academy of Veterinary Dentistry, and American sive research on the gross histology of age-related changes in
Veterinary Dental College in 1987, awareness increased, but equine incisors.39,40 In 1998, an equine dentistry issue of
books with texts on equine dentistry contained no new the Veterinary Clinics of North America edited by Gaughan
scientifically-based knowledge. Many veterinary dental texts and deBowes was released. Along with the 1999 first edition
of that time mainly contained information on small animal of Equine Dentistry by Baker and Easley, these texts repre-
dentistry, with a few containing limited chapters referencing sented the only two professional veterinary publications on
equine dentistry: Zetner 1982, Harvey 1985, d’Autheville & equine dentistry since Becker’s 1938 book.8 Not only did
Barrairon 1985, and Kertez 1993.8 research take on new challenges, but the opportunities
Several important modern technological improvements in within clinical practice began to expand as ideas flourished
equine dentistry were developed in the 1980s and 1990s. and prospects for new procedures grew. The first decade of
Soon after the interchangeable carbide chip blade replaced the 21st century saw the introduction of endodontics, ortho-
the steel Dick float blade, Don Matlock introduced the solid dontics, periodontology, and restorative dentistry into the
carbide float blade. During this time three breakthroughs in equine field. Diagnostic capabilities also provided new areas
motorized dental equipment occurred with the introduction of interest and created innovative avenues through which
of the rotary disk power tool in Europe by Eisenhut, the
guarded flexible shaft grinder in Argentina by Estrada, and
the short stroke oscillating float by Stubbs (Figs 2.21 & 2.22).
Original evidence-based scientific research on equine den-
tistry finally began in the late 1970s. In 1979, Dr Gordon
Baker completed his PhD thesis on equine dental anatomy
and development in health and disease.32 He continued to
teach this topic throughout his professional veterinary surgi-
cal career. In 1989, Larry Moriarity started a discussion on
the evaluation of incisor alignment and occlusal contact
during lateral jaw movements which was later modified by
Drs Scrutchfield, Rucker, and DeLorey.33,34,35 During the mid-
1990s Professor Paddy Dixon and his associates began what
is considered the ‘renaissance’ of equine dentistry through
research conducted at Edinburgh University, Scotland. He
not only promoted the general practice of equine dentistry Fig. 2.21  Estrada’s flexible shaft rotary tooth grinder with a guarded burr.
but emphasized the need for advanced species-specific This tool was patented in the 1960s and distributed in the United States by
research to be performed in order to provide scientific Jorgenson, Co.

Fig. 2.22  The Makita rechargeable battery

powered oscillating dental float with an
adjustable head was introduced in the 1980s.

23
 2 Introduction

dental problems were addressed and treated. Contemporary Forty-nine scientific equine dental papers were presented to
digital radiograph systems including intraoral radiography over 400 international veterinarians in attendance (see
allowed for detailed studies of dental tissues and computed ‘Focus on Dentistry’; http://www.ivis.org).43
tomography imaging increased the imaging capabilities of Although veterinarians’ interests in adding or expanding
the head and assisted with planning intricate treatment equine dentistry within their practices are escalating, the old
modalities.41,42 struggle between lay tooth floaters and veterinarians con­
As interest through research, clinical capabilities, and tinues to be a heated and debated topic. In 2000, BEVA
advanced diagnostics reached new horizons, the need for and the British Agriculture Ministry developed a program to
specialized groups focusing on the care and challenges asso- train and test for licensure, equine dental technicians to
ciated with equine dentistry emerged. AAEP president Dr perform basic oral examinations and carry out minor dental
Clyde Johnson in 1996 appointed Drs Lowell Smalley, Leon corrections.
Scrutchfield, and Dean Scoggins as the equine dental com- The results of the 2005 AAEP survey showed that 79 %
mittee chairs for a group involved with the promotion of of veterinarians provided some dental service to their
good equine dental care through advanced education, wet clients with 30 % examining at least 200 horses per year.
laboratories, and programs involving equine practitioners, However, of the 21 % of veterinarians who did not see
veterinary students, and clients. Since that time, the com- any dental cases, 48 % admitted referring their clients to
bined efforts of veterinary associations, universities, and non-veterinarians for dental care.44 This is not a new issue,
national organizations, in particular the American Associa- as evidenced throughout the rich pages of history regarding
tion of Equine Practitioners (AAEP), the British Equine Vet- the care of horses’ teeth. Equine dental technicians have
erinary Association (BEVA), the Canadian Veterinary Medical historically and currently blurred the line between veterinar-
Association, and the Australian Association of Equine Prac- ian and lay person, but it is important to recognize the
titioners have held over 200 short courses and wet laborato- limitations of all parties. Ultimately, the goal should be
ries to train thousands of equine veterinarians in basic and improvement of the quality of care for the horse. If this goal
advanced dental techniques. is diminished or lost, our patients suffer and we as profes-
In 2001, the Academy of Veterinary Dentistry established sionals risk being doomed to repeat history’s mistakes.
an equine credentialing tract where two fellows eventually
became recognized. The American Veterinary Dental College Acknowledgments
has since formed a committee to establish the criteria neces-
sary to obtain equine dentistry diplomates. The most recent Special thanks go to Daniel J. Easley for research and edito-
and significant collaboration of equine veterinarians practic- rial assistance with this chapter. Additionally, Dr Mike
ing the art of dentistry occurred in 2006 when the AAEP and Lowder provided some of the antiquarian text references
BEVA held a joint conference titled ‘Focus on Dentistry’. used in the research of this chapter.

References
1. Percivall W. Part second of a series of the North Am Vet Conf, Orlando 2005, 17. Blaine D. Veterinary art, diseases of
elementary lectures on the veterinary art: pp 51–154 the horse, 4th edn. Boosey, Longman,
wherein the anatomy, physiology, and 9. Easley K. Veterinary dentistry: its origin Rees, Brown and Green, London, 1832,
the pathology of the horse are essayed on and recent history. J Hist Dent 1999; pp 29–40
the general principles of medical science. 47(2): 83–85 18. Mayhew E. The horse’s mouth, the
Longman, Hurst, Rees, Orme, Brown and 10. Smithcors JF. Evolution of the veterinary teeth, 3rd edn. Fores, London, 1850,
Green, London, 1824, p 20 art. Vet Med Pub Co, Kansas City, 1957, pp 69–115, 181–194
2. Youtt W. The horse, with a treatise of pp 161–171 19. Navin JN. Navin’s veterinary practice or
draught, 1st edn. Baldwin and Cradock, 11. Bierer BW. American veterinary history, explanatory horse doctor. Roach,
London, 1846, 31: 146, 202 1st edn. Olson C, Fort Dodge, Iowa, Indianapolis, 1867, p 443
3. Dick W. Manual of veterinary science. 1980, pp 6, 8, 43, 54, 118–120, 128, 20. Gleason OR. Gleason’s horse book and
Adam and Charles Black, Edinburgh, 131–133, 143 veterinary advisor.: Donohue, Chicago,
1862, p 76 12. Girard J. Traité de l’age du cheval, 3rd 1892, pp 224–240
4. Harvey CE. The history of veterinary edn. Béchet Jeune, Paris, 1835, 21. Clarke WH. Horses’ teeth, 3rd edn
dentistry, part one: from the earliest pp 8–37 rev.: WK Jenkins, New York, 1886,
record to the end of the 18th century. 13. Lopez T. One hundred years as the pp 113–129, 198–202
J Vet Dent 1994; 11(4): 135–139 AVMA. J Am Vet Med Assoc 1998; 22. Merillat LC. Veterinary surgery, Vol 1.
5. The Literary Encyclopedia. Online. 212(1): 9 Animal dentistry and diseases of the
Ancient texts translations. Available: 14. Hinebauch TD. Veterinary dental mouth: Aberouder Eger, Chicago, 1916,
http://www.litencyc.com/index.php surgery. LaFayette, Indiana, 1889, pp 16–17
6. Bennett D. The evolution of the horse. pp 224–239 23. Lemonds LL. A century of veterinary
Horse breeding and management. 15. McCarthy PH. Galvayne: the mystery medicine in Nebraska, 1st edn.
Elsevier, Amsterdam 1992, pp 1– surrounding the man and the eponym. Service Press, Henderson, 1982,
29 Anat Histol Embryol 1987; (16): pp 13–17
7. Kertesz P. Color atlas of veterinary 330–336 24. Williams WL. Surgical and obstetrical
dentistry and oral surgery. Wolfe Publ., 16. Galvayne S. Horse dentition, showing operations. Ithaca, New York, 1900,
Aylesbury, UK, 1993 how to tell exactly the age of a horse up pp 1–41
8. Fahrenkrug P. The history and future of to thirty years, 3rd edn. Thomas Murray, 25. Moller H, Dollar JAW. The practice of
equine dental care. In: Proceedings from Glasgow, 1886, pp 17–27 veterinary surgery Vol. III. Regional

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Surgery, Jenkins, New York, 1904, pp occurrence of dental caries in domestic model be accurate? Vet Rec 1995; 137(6):
1–74 animals. In: The Horse. Jpn J Vet Res 139–140
26. Merillat L, Campbell D. Veterinary 1962; 10: 31–36 39. Muylle S, Simoens P, Lauwers H. Ageing
military history of the United States, 32. Baker GJ. A study of dental disease in the horses by examination of their incisor
Vol 1. Haver-Glover Laboratories, horse. PhD thesis, University of Glasgow, teeth: an (im)possible task? Vet Rec
Kansas City, 1935, p 295 Glasgow, 1979, pp 42–56 1996; 138: 295–301
27. Leue G. Cited by Becker E. 1962. 33. Scrutchfield WL. Incisors and canines. 40. Muylle S, Simoens P, Lauwers H,
Zahne. In: Dobberstein J, Pallaske G, Proc Am Assoc Eq Pract 1991; 37: 117– Van Loon G. Ageing Arabian horses by
et al. Handbuch der speziellen 121 their dentition. Vet Rec 1998; 142:
pathologischem, Anatomie der Haustiere, 34. Rucker BA. Modified procedure for 659–662
Vol V, 3rd edn. Paul Porey, Berlin, 1941, incisor reduction. Proc Am Assoc Eq Pract 41. Klugh DO. Intraoral radiology in equine
pp 131–132 1995; 41: 42–44 dental disease. Clin Tech Eq Pract 2005;
28. Miles AEW, Grigson C. Colyer’s variations 35. DeLorey M. A retrospective evaluation 4: 162–170
and diseases of the teeth of animals. of 204 diagonal incisor malocclusion 42. Pulchalski S. Computer tomographic and
Cambridge University Press, Cambridge, corrections in the horse. J Vet Dent 2007; ultrasonographic examination of equine
1990, p ix 24(3): 145–149 dental structures: normal and abnormal
29. Floyd MR. The modified triadan system: 36. Dixon PM. Equine dental disease: a findings. Proc Am Assoc Eq Pract, Focus
nomenclature for veterinary dentistry. neglected field of study. Eq Vet Edu 1993; on Dentistry. Indianapolis, Indiana,
J Vet Dent 1991; 8(4): 18 6: 285–286 2006
30. Hofmeyer CFB. Comparative dental 37. Walmsley JP. Some observations on the 43. Galloway S, Easley J. Establishing a
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31. Honma K, Yamalawa M, Yamauchi S, evaluation of the accuracy of ageing Equine Practitioners, Lexington, KY,
Hosoya S. Statistical study on the horses by their dentition: can a computer 2005

25
 Section 1:  Introduction

C H A P TER  3 
Bits, bridles and accessories
Dwight G. Bennett DVM, PhD
Colorado State University, Fort Collins, CO 80523, USA

Introduction Of course, for the driver of the horse in harness, commu-

nication via the seat and legs is not an option. Discounting
A veterinarian must understand the action and purpose of the relatively minor role of the whip, the bridle and reins or
bridles, bits, and accessories (e.g., nosebands and martin- lines (the proper name for the reins of a draft horse) are the
gales) not only to provide optimal health care to horses’ only nonverbal means of communication and thus assume
mouths but also to effectively communicate with owners even more importance than they do in the ridden horse.1
and trainers and to address their concerns about their horses’ As with all methods of training and communicating with
performance.1 We must be aware of what a horse does for a the horse, the key to the proper use of bits and bridles is the
living, become familiar with what is expected, and provide principle of pressure and release.6–9 A horse does not intui-
the kind of dental care required to help horses perform most tively move away from pressure. Rather, he learns to seek a
comfortably and at their best.2 position of comfort to relieve the pressure applied by the
Refinements in the way that teeth should be floated bit in his mouth. Consequently, the rein pressure must be
depend both upon the job of the horse and the type of released the instant that the horse complies (or even tries to
bit used. The bitting requirements are different for western comply) with the request sent to him via the bit. If the pres-
performance, English pleasure, polo, jumping, dressage, sure is not released, the horse has no way of knowing that
racing, equitation, driving, etc. For example, the D-ring his response was correct and becomes confused.6–9 When a
snaffle is a popular bit for Thoroughbred racing, in which rider or driver applies rein pressure, he is asking the horse
the jockey’s hands are above the horse’s neck, but this bit is for a response; when he releases the pressure, he is thanking
seldom used in Standardbred racing because the angle of the horse for complying.6,9
pull on the reins of a driving horse is straight back towards Bits, bridles, and accessories can exert pressure on a horse’s
the driver. mouth bars (the horseman’s term for the lower interdental
The second premolars of a racing Thoroughbred, whose space), lips, tongue, hard palate, chin, nose, and poll. Of
chin must extend to achieve maximum speed, require more these, the tongue and the hard palate are the most sensitive
rounding than those of a pleasure horse who performs in a and the most responsive to subtle rein pressure. Depending
nearly vertical head set (compare Fig. 3.1E with Fig. 3.1A and upon the type of headgear used, however, commands sent
Fig. 3.3C with Fig. 3.3A). The removal of wolf teeth is of to the horse via the bars, lips, chin, or nose can be more
more obvious advantage for harness horses with overcheck important than those transmitted via the tongue and palate.
bits than it is for pleasure horses.1,3,4,5 (Compare Fig. 3.3A An important concept in bitting is signal, which is defined
with Fig. 3.19.) A barrel-racing horse in a gag bit requires a as the time between when the rider or driver begins to pull
deeper bit seat than a cutting horse in a grazer curb bit on the reins and the time when the bit begins to exert pres-
(compare Fig.3.7B with Fig. 3.9D). sure in the horse’s mouth. As a horse becomes schooled, he
learns to recognize the initial increase in rein pressure and
Proper use of bits and bridles to respond before significant pressure is applied.7

Bits and bridles are for communication. They are not handles Signs of bitting problems
to stabilize the rider in the saddle or instruments for punish-
ing the horse.6–8 The western horse is ridden with slack in Although cut tongues are the most obvious injuries associ-
the rein while the English horse is generally ridden with ated with the improper use of bits, less spectacular injuries
more contact with the bit, but in either case the accom- to the bars and other tissues are also signs of bitting prob-
plished rider uses his seat and legs before his bit to com- lems. Tissue trapped by a bit may bunch between the bit and
municate his wishes to his mount. Indeed, the most the first lower cheek teeth where it is pinched or cut. The
important factor in having soft, sensitive hands on the reins damaged area may then be irritated every time the bit
is developing a good seat.9 moves.1 Trauma to the lower interdental space frequently

27
 3 Introduction

Fig. 3.1  The proper head carriage when a horse is ‘on

the bit’ varies depending upon the function of the
horse. (A) The pleasure horse with a nearly vertical head
set is collected, that is, his weight is shifted to the rear.
(B) The draft horse pulling a heavy load may carry his
head more vertically. (C) This horse is ‘behind the bit,’
overflexing his chin to his chest to evade bit pressure.
(D) The racing Standardbred needs to extend his nose to
achieve speed but his head position must be controlled
to keep him on gait. (E) The racing Thoroughbred, in
A B C order to achieve maximum speed, must be able to fully
extend his nose and shift his center of gravity forward.
(F) This horse is ‘ahead of the bit,’ overextending his chin
to evade bit pressure.

D E F

penetrates to the mandible with resulting mandibular Even in the absence of an obvious injury, a change to a
periostitis.8,10,11–15 All types of headgear can press the lips gentler bit will often lead to an improvement in a horse’s
and cheeks against points or premolar caps on the upper performance.8,11,13,16
cheek teeth.1
Most bit-induced wounds are superficial, heal rapidly due
to the extensive blood supply to the mouth and the antibac- Mouthpieces
terial action of saliva, and seldom require treatment.11,16 A
severely lacerated tongue, however, often heals with a per- The mouthpiece of a bit may be solid or may have one or
manent defect, and mandibular periostitis, in severe cases, more joints. A mouthpiece made up of two or more pieces
can lead to the formation of osseous sequestra.10–13,17,18 is referred to as a jointed or broken mouthpiece (Fig. 3.2A).
A horse with a sore mouth or improperly fitting bit will The two halves of a simple jointed mouthpiece are called the
often gape his mouth and pin his ears. He may nod his head ‘cannons.’ One purpose of the joint is to form a roof over
excessively or toss his head. He may extend his neck (get the tongue, which gives the tongue some relief from the
ahead of the bit) or tuck his chin against his chest (get pressure of the bit. Another purpose is to change the angle
behind the bit; Fig. 3.1).9 Bitting problems can be mistaken of pull. As the cannons collapse, pressure is transferred from
for lameness, as when a horse fails to travel straight. the tongue to the bars and lips. Some jointed mouthpieces
It is a common misconception that a horse with a painful (e.g., Dr Bristol and French snaffle) have an extra link
mouth will be especially sensitive to bit cues. In fact horses between the cannons. The center link creates more room for
tend to push into pain.2,8,9 A horse with bilaterally tender the tongue, but changes the angle at which the pressure is
bars may root into the bit. A horse which is sore on one side applied to the tongue, bars and corners of the lips. There is
of his mouth may lean on the bit on the tender side. A more pressure on the tongue and less leverage on the bars
vicious cycle can result from attempts to gain such a horse’s and lips8 (Fig. 3.3). Of course, the position of the horse’s
respect by changing to increasingly severe bits.6 Oral discom- head, which varies depending upon the horse’s use, will have
fort causes horses to focus on pain rather than on perform- a profound effect upon the bit’s action (Figs 3.1 & 3.3).
ance. They may fail to respond to the bit cues, may evade A solid mouthpiece may be straight, curved or ported. One
the action of the bit or may ignore the bit completely.2 of the most common misconceptions in bitting is that a low
When you are consulted about a horse that has perform- port makes a mouthpiece mild and that a high port makes
ance problems, you should always inquire about the type of it severe.6 The error in such a conception becomes evident
bit used and carefully examine the tongue, lips, bars, palate, when we consider that the tongue is the most sensitive part
chin and nose for subtle signs of injury.19 It is important to of the horse’s mouth and that the purpose of the port is to
compare the left and right interdental spaces to detect subtle prevent the bit from applying the majority of its force directly
differences.10,17 to the tongue6,20 (Fig. 3.4). A high port is severe only if it
A localized soft and thickened raised area may indicate comes into contact with the horse’s palate (Fig. 3.7D). For
mandibular periostitis, especially if the horse reacts violently most horses, the port must be at least 2–2.5 inches (5.1–
when pressure is applied to it. Techniques such as mental 6.4 cm) high to contact the palate.6,9
nerve blocks, radiographs, scintigraphy, and computed tom- A straight, solid mouthpiece can be severe because the
ography may be necessary to confirm the presence of this tongue takes almost the full force of the pull. The mullen
condition in living horses. A simple surgical procedure has mouthpiece (Figs 3.2E & 3.12A), with its gentle curve from
been described for removing the periostitis and making the one side to the other, still lies largely on the tongue and gives
horse more comfortable with his bit.10 only a small margin of tongue relief. When using a bit with

28
 Bits, bridles and accessories

Fig. 3.2  Examples of snaffle bits. (A) O-ring with

broken mouthpiece. (B) Egg butt with center link  
in mouthpiece. (C) D-ring with rubber covered
mouthpiece. (D) Fixed ring with double twisted wire
A E mouthpiece. (E) O-ring with solid mullen mouthpiece.
(F) Half cheek with leather covered mouthpiece. (G) Full
cheek with cricket in mouthpiece.

B
F

D G

Fig. 3.3  Lateral radiographs of snaffle bits under rein

pressure. (A) Broken mouthpiece, poll flexed. (B) Center
linked mouthpiece, poll flexed. The extra link transfers
pressure from the bars to the tongue. (C) Broken
mouthpiece, nose extended. The more a horse’s nose is
extended, the more likely that his lips will be pinched
against his teeth and his tongue will be punished by
the bit.
B

C
A

Fig. 3.4  (A) Standard curb bit. (B) The lower the port,
the greater the chance that the tongue will be
damaged by a curb bit.

A B

29
 3 Introduction

Fig. 3.5  Examples of leverage bits. (A) Straight shanked

pleasure horse bit. (B) Grazer bit. (C) Loose cheeks.  
(D) Myler bit with fixed cheeks and independently
rotating shanks. (E) Loose cheeks, broken mouthpiece.
(F) Correction bit.
A C E

B D F

a straight or mullen mouthpiece, a hard jerk on the reins can mouthpiece which causes the horse to worry or fret is
easily cut the tongue.8 unlikely to promote a wet mouth regardless of its chemical
A mouthpiece’s severity is inversely related to its diameter. make-up. Some mouthpieces incorporate rollers, commonly
Mouthpiece diameter is measured one inch in from the called ‘crickets,’ or danglers, commonly called ‘keys,’ to stim-
attachment of the bit rings or shanks, because this is the ulate tongue movement and thus enhance salivation. Such
portion of the mouthpiece that ordinarily comes into contact tongue toys also have a pacifying effect on nervous horses.
with the bars of a horse’s mouth. A standard mouthpiece is Some horsemen cover their mouthpieces with latex in the
8 inch (9.5 mm) in diameter. Most horse show associations
3
early stages of training or use rubber or leather-covered
prohibit a 1 4 inch (6.4 mm) (or smaller) mouthpiece covered mouthpieces on very soft-mouthed horses to protect
because it is considered too severe.8 Although a 1 2 inch the bars and tongues.23 Plastic and synthetic mouthpieces
(1.27 cm) mouthpiece is generally mild, some horses may are gradually coming into greater acceptance.24
be uncomfortable carrying so thick a mouthpiece.17,21 Some The more complicated the mouthpiece of a bit and the
horses, especially Thoroughbred types, have relatively more contact used by the rider, the greater the risk of oral
narrow, sharp bars which are easily damaged by pressure.22 discomfort and/or injuries. Smooth mouthpieces are obvi-
Such horses require thicker and/or softer mouthpieces ously gentler than those with edges, ridges, teeth or chains.
than do horses with thicker bars. One should always look
into a horse’s mouth to assure that a mouthpiece fits
comfortably.8 Snaffle bits (Fig. 3.2)
Mouthpieces are constructed of many different materials
and combinations of materials (Figs 3.2, 3.5 & 3.12). In Regardless of the bit they will ultimately wear, the great
order for a bit to function properly, the horse’s mouth must majority of today’s horses are started in snaffle bits. Snaffle
be wet.8,9 Copper is frequently incorporated into mouth- bits are used on 2–5-year-old western performance horses as
pieces because it is reputed to promote salivation. Cold- well as on all classes of English riding for younger horses.
rolled steel, sometimes called ‘sweet iron’, is second to Nearly all racehorses, both ridden and driven, spend their
copper in stimulating salivation. Sweet iron will rust and, entire careers in snaffle bits.
while it may be unattractive, rust seems to taste good to A snaffle bit is any bit, whether it has a jointed or solid
many horses and may further stimulate salivation. Rust- mouthpiece, in which the cheeks of the bridle and the reins
proof stainless steel, however, will also promote salivation attach to the same or adjacent rings on the bit.6,9,25 There is
to some degree and has the advantages of being hard, staying a direct line of pull from the rider’s hands to the horse’s
smooth and cleaning easily. Some bitmakers assert that mouth with no mechanical advantage. Tightening of the
mouthpieces which combine two different metals are supe- reins causes all types of snaffle bits to relocate caudally, to
rior for saliva production to mouthpieces made with a rotate on their long axis and to press on the horse’s tongue,
single metal. Aluminum, chrome-plated, rubber and leather bars and lip corners.18
covered mouthpieces are thought to produce dry mouths. Snaffle bits often are identified by the shape of their rings
Of course the metal used in the mouthpiece is not the only (e.g., O-ring, D-ring, half-cheeked, full-cheeked) and by how
factor involved in producing a wet mouth. A dry mouth, their cannons attach to the rings (e.g., loose-ring, fixed ring,
usually a result of excessive epinephrine secretion, is a sign egg butt). All ring shapes and attachments have their advan-
of a stressed, unhappy horse. When it comes to generating tages and disadvantages. A loose ring snaffle, in which
a wet mouth, the horse’s mental state is probably more O-shaped rings run through holes in the ends of the mouth-
important than the metal used in the bit. A severe piece (Fig. 3.2A), affords the maximum signal. The rings

30
 Bits, bridles and accessories

revolve freely and tend to rotate slightly when the reins are Although the severity of a bit increases with the length of
picked up but before the bit engages. However, the rotating the shanks, this severity is partially offset by the fact that the
rings can pinch the corners of a horse’s mouth. signal provided to the horse increases as well.8 A long-
In egg butt and D-ring snaffles (Fig. 3.2B & 3.2C) a metal shanked bit must rotate more than shorter-shanked bit
cylinder connects the mouthpiece to the cheek rings and before it exerts significant pressure in the horse’s mouth.
prevents pinching at the corners of the mouth. The well- Leverage bits are called curb bits because to exert their
defined corners of the D-ring snaffle (the straight line of the leverage they depend upon a curb chain or strap that passes
D) increase the pressure on the horse’s cheeks and thus the beneath the horse’s chin groove and attaches to the rings on
control over the horse. However, this same pressure increases the cheeks of the bit. The bit rotates in the horse’s mouth
the chances that the horse’s cheeks will be pressed against until the curb strap stops (curbs) the rotation and the lever-
points on the upper premolars. age action of the bit takes effect (Fig. 3.6). The leverage bit
Some snaffles have prongs or ‘cheeks’ attached to the rings exerts pressure primarily on the chin groove, the tongue and
(Fig. 3.2F & 3.2G). ‘Full cheek’ snaffles have prongs both the bars (Fig. 3.4 and 3.7).6,9
above and below the mouthpiece, while half-cheek snaffles The adjustment of the curb strap determines the point at
have prongs below the mouthpiece. Like the D-ring or cyl- which it snugs up into the chin groove, how quickly and
inder type snaffles, the cheeks encourage the horse to turn where the bit makes contact with the mouth, and how far
in the desired direction by increasing the pressure on the the mouthpiece will rotate (Fig. 3.6). The tighter the setting,
corners of the mouth and sides of the face. The cheeks also the less the pull required to activate the bit. The more the
prevent the bit from being pulled through the mouth. bit rotates before the chin strap engages, the more the pres-
Because their rings do not rotate, all cheeked, D-ring and sure is transferred to the corners of the lips and to the poll
egg-butt snaffles provide less signal than loose ringed and the less to the tongue, bars and chin groove. Of course,
snaffles.8 if the bit has a high port or spoon, and the curb strap is
loose, the rotation may be halted by contact with the palate,
which then must bear part of the pressure.
Leverage bits (Figs 3.4 & 3.5) Typically, the more moving parts within a leverage bit, the
more signal it will provide to the horse.6,8 For example, a
Leverage, or curb, bits provide a mechanical advantage to the loose-jawed bit, one that attaches to the mouthpiece via
rider. There are two sets of bit rings: the upper rings attach hinges or swivels, will provide a certain degree of rotation
to the headstall, and the lower rings attach to the reins. The before the bit engages. Add a loose rein ring to the loose jaw,
ratio of the length of the shanks of the bit (the portion below and the bit will provide even more signal. Install a broken
the mouthpiece) to the cheeks of the bit determines the mouthpiece in those shanks and you amplify the signal even
amount of leverage. The severity of a bit increases as the ratio more.9 The downside of a broken mouthpiece in this type
increases.9 For example, in a standard curb bit with 4.5 inch of bit is that it increases the potential severity of the bit. In
shanks and 1 1 2 inch cheeks (a 3 : 1 ratio), one pound of a swivel ported bit, often called a ‘correction’ bit, there are
pressure on the reins translates into 3 pounds of pressure in joints on each side of the port where it joins the bars
the horse’s mouth. When using a bit with 8-inch shanks and (Fig. 3.5F). Such bits are capable of exerting tremendous bar
2-inch cheeks, one pound of pull results in four pounds of and tongue pressure.
pressure. However, regardless of the ratio, the longer the The angle between the shanks and the cheeks affects the
shanks, the less the force on the reins required to exert a speed of communication. The straighter the line, the less
given pressure in the mouth.8 signal the bit provides. In the so-called grazer bit (Fig. 3.5B),

Fig. 3.6  (A) A curb strap’s adjustment is often based

upon the number of fingers that can be slipped under
it. (B) A better way is to determine how much rotation
of the bit is desired and to set the curb strap
accordingly.

A B

31
 3 Introduction

Fig. 3.7  Lateral radiographs of curb bits. (A) No rein

pressure. (B) Rotation under rein pressure. (C) Rein
pressure on a bit with loose cheeks and a broken
mouthpiece can force the mouthpiece against the
palate. (D) A bit with a high port or spoon can contact
the palate, and a lateral pull of the reins can force the
bit against the cheek teeth.

B D

Fig. 3.8  Three types of gag bits. (A, B) Basic gag bit, in
A C this example with a link in the mouthpiece. (C, D) Gag
snaffle with half-O-rings. (E, F) Gag with full rings for
attachment of snaffle rein.

D E

with swept back shanks, the mouthpiece tends to rotate less poll. But head carriage is more a factor of where the horse
than in a bit with straighter shanks (Fig. 3.5A) and provides finds relief from bit pressure. Since the horse’s mouth is
more signal to the horse.8,9 Also, a grazer bit releases its pres- much more sensitive to pressure than his poll, if the gag is
sure more quickly than a straight-shanked bit when the reins used with no auxiliary aids, its net effect is to accentuate the
pressure is relaxed. Of course, a tight curb strap reduces the basic head-raising action of a snaffle bit.8 If strong rein pres-
signal of any leverage bit. sure is applied to a gag bridle, the bit is pulled relatively far
caudally and can severely punish the horse’s tongue, lips and
cheeks (Fig. 3.9).
Gag bits (Figs 3.8 & 3.9)
In the basic gag bridle, the reins and the cheekpieces of the Full bridle
headstall are one continuous unit.6,9,25 When the reins are
pulled, the mouthpiece slides upwards in the horse’s mouth The full bridle or double bridle (Fig. 3.10) has two sets of
and transfers much of the pressure from the tongue and bars cheek pieces and two sets of reins. One set is attached to a
to the lips and poll. A gag bit, when used properly, provides curb bit; other set is attached to a snaffle bit. The snaffle,
a rider more control than a standard snaffle without propor- which is generally relatively small, is called a bridoon or
tionally providing more punishment to the horse’s tongue bradoon and is placed above and behind the curb.22,26
and bars.6,8 The double bridle with its combination of bits, employing
It might be thought that the gag functions to lower the a number of forces to achieve its ends, is an extremely sensi-
head because tension on the reins places pressure on the tive instrument. When used by a skilled rider on a schooled

32
 Bits, bridles and accessories

Fig. 3.9  Radiographs of gag bits. (A) Ventrodorsal with

no rein pressure. (B) Ventrodorsal under rein pressure.
(C) Lateral with no rein pressure. (D) Lateral under rein
pressure.

A
C

B D

Fig. 3.10  (A) Full bridle on dressage horse. (B) Full

A B bridle on English pleasure horse. (Inset) The snaffle and
curb bits on a dressage bridle.

horse, it can place the head with greater finesse than is pos- Pelhams (Figs 3.12 & 3.13)
sible with any other bridle in current use. But the rider needs
a considerable amount of skill for this bridle to be effective A Pelham bit is basically an attempt to gain the advantages
and humane. of a double bridle with only a single bit in the horse’s
It is often stated that, with the double bridle, the rider uses mouth. The Pelham bit is really just a curb bit with an extra
the snaffle bit to raise the head and turn the horse and the set of rings at the level of the mouthpiece to which an extra
curb bit to lower the head and stop the horse. When the set of reins is attached. Tension on the lower rein gives the
double bridle is used properly, however, nearly all com- effect of a curb bit and tension on the upper rein gives the
mands for head position, moving and stopping are given via effect of a snaffle bit.
the snaffle.22 The role of the curb is the basically passive one Pelham bits come in a wide variety of forms (Fig. 3.12).
of promoting poll flexion, collection and balance.8,26 Exces- The mouthpiece may be straight, curved, jointed, or ported.
sive tension on the curb rein is the most common cause of The shanks may be long or short, fixed or loose. Some have
problems with full bridles.8 very short shanks and thick rubber mouthpieces and are very
The use of the double bridle when the horse is not suffi- mild. Others have ports and long shanks and are more severe.
ciently schooled or the rider is not sufficiently skilled can One type, the Kimberwicke (Figs 3.12C & 3.13B), uses only
damage the horse’s psyche as well as his mouth. The double one rein with the hand position, or rein setting, determining
bridle puts a lot of hardware in the horse’s mouth (Fig. whether the bit functions as a snaffle or as a curb.
3.11), and the chances of injury are arguably doubled as Critics of Pelhams say that both reins come into
compared to bridles with a single bit. play at the same time and confuse a horse. Certainly

33
 3 Introduction

Fig. 3.11  Radiographs of bits on full bridles.

A (A) Ventrodorsal. (B) Lateral without rein pressure.  
C
(C) Lateral under rein pressure.

Fig. 3.12  Examples of Pelham bits. (A) Mullen

mouthpiece with moderate shanks. (B) Rubber covered
mouthpiece with short shanks. (C) Kimberwicke with
ported mouthpiece. (D) Long shanked bit with lip strap.
A
(E) Western Pelham with center link, loose cheeks, and
D
long shanks.

E
C

Fig. 3.13  (A) Standard Pelham. (B) Kimberwicke with

rein set to lower level in Uxeter cheeks. (C) Proper
adjustment of curb chain (upper arrow) and lip strap
(lower arrow).

A B C

34
 Bits, bridles and accessories

Fig. 3.14  Driving bits. (A) O ring snaffle. (B) Half cheek
snaffle. (C) Liverpool. (D) Ashleigh Elbow. (E) Buxton.

A
B

C D E

Fig. 3.15  Teams with common driving bits

(A) O-ring Snaffle. (B) Liverpool: the line on the
A B horse on the left is attached to the snaffle ring.
The line on the horse on the right is attached  
to the lowest curb ring for greater control.  
(C) Ashleigh Elbow. (D) Buxton.

C D

the Pelham does not work well in a horse with very Driving bits (Figs 3.14 & 3.15)
long narrow jaws or an exceptionally long interdental
space. In such a horse, it is essentially impossible simul­ In riding horses, we have stressed the importance of ‘getting
taneously to have the curb chain in the chin groove and off of the horse’s mouth.’ In other words, the rider should
the mouthpiece in its proper position against the lip cue the horse first with his legs and seat and only secondarily
corners. The curb chain, under such circumstances, tends via the bit. However, disregarding the relatively minor role
to pull backwards until it is beneath the branches of of the whip, the driving horse receives non-verbal commu-
the mandible, and pressure on these is quite painful to the nication only through the reins (harness horses) or lines
horse and may result in severe bruising. The use of a lip (draft horse) and the bit. Communication with the driving
strap (Figs 3.12D & 3.13C) can help to counteract this horse is further complicated by the fact that, although the
disadvantage. distance between the bit and a rider’s hands is seldom more
Despite all of the criticisms, some horses perform better than 30 inches, the distance between the bits of a horse or
in the Pelham bit than in any other. In the horse with short a pair of horses in harness and a driver’s hands is approxi-
jaws and a relatively small interdental space, the single mately 12 feet.1,27 The remoteness of contact is increased to
mouthpiece of the Pelham may fit better than the double 24 feet or more when horses are driven in tandems or larger
mouthpiece of the full bridle. teams.1,3,22,27,28

35
 3 Introduction

Driving bits for racing trotters and pacers are essentially balance is closer to that of the Liverpool bit than to that of
always snaffle bits with solid or, more commonly, jointed the Ashleigh Elbow bit. The Buxton is a large, ornate bit that
mouthpieces. Such bits are often used on other types of is used for most ceremonial and formal occasions through-
driving horses as well. Driving snaffles often have half cheeks out the world.1,3,25 The horses in many of the fancy, multiple
to provide extra lateral control.1 horse hitches used for advertising or for parades are driven
The Liverpool, Ashleigh Elbow, and Buxton (Figs 3.14 & in Buxton bits.
3.15) are curb bits commonly used for driving. The mouth-
pieces of these bits are most commonly straight with a
smooth and a corrugated side. However, these bits are also Overchecks and sidechecks (Figs 3.16–3.19)
available with a variety of ported and jointed mouthpieces.
The reins are attached to rings at the level of the mouthpiece For most driving horses, a single overcheck rein or two side-
or to one of the two or three slots which are progressively check reins are added to the bridle to prevent the horse from
lower in the shanks – the lower the attachment, the more lowering his head. The overcheck rein runs from the back
severe the curb action. With the reins at the top position (i.e., pad of the harness up between the horse’s ears, passes down
through the ring at the level of the mouthpiece), the curb the front of the horse’s face and divides into two straps
chain does not operate and the effect is that of a plain bar which fasten to either side of a separate overcheck bit that
(unjointed) snaffle.1 All three bits commonly have swiveling presses upwards in the horse’s mouth (Fig. 3.17). Less
(loose) cheeks that can be adjusted so that either the smooth commonly, the straps attach directly to the driving bit or to
(Fig. 3.14E) or the corrugated side (Fig. 3.14D) of the straight a chin strap.1
bar mouthpiece is in contact with the horse’s tongue The sidecheck is a variation on the overcheck in which two
and bars.1,24 check reins, rather than joining and running over the top of
The Liverpool bit has cheeks that form complete rings the horse’s head, run through loops on either side of the
around the ends of its mouthpiece with straight flat bars bridle and back along the sides of his neck to come together
projecting below them (Figs 3.14C & 3.15B). Because it is at his withers (Fig. 3.18). The practice of some drivers of
symmetrical, the cheeks of a Liverpool bit need not be loose attaching check reins directly to a leverage driving bit is not
to allow the use of either the smooth or corrugated side recommended, because such an arrangement pulls the bit
of the mouthpiece. It is probably the most widely used uncomfortably up into the corners of the horse’s mouth and
driving bit.3 interferes with curb action and driver contact.1,3
The shanks of the Ashleigh Elbow bit (sometimes referred Most draft horse bridles are set up with either an overcheck
to as the military bit) extend backward at right angles to the or a sidecheck to prevent the horse from lowering his head
cheeks before extending straight vertically (Figs 3.14D & to graze or rub and to keep his head in the optimal position
3.15C).25 This rearward placement of the shanks prevents a for pulling. A check rein is nearly always required for light
horse from seizing them with his lips. Perhaps more impor- horses shown in pleasure driving classes or in fine harness
tantly, the angle of the shanks alters the balance of the bit classes. Harness racing horses wear overchecks because their
making the elbow bit more forgiving, i.e., requiring more heads must be held in an exact position to keep them
pull on the reins to exert pressure in the mouth and releasing balanced and on their gait.1,23
pressure more quickly when the reins are slackened, than the The plain overcheck bit (Figs 3.16G, 3.17A & 3.19A) is a
straight-shanked Liverpool bit.1 very small straight bar bit. However, there are many other
The Buxton bit (Figs 3.14E and 3.15D), with its S-shaped types, varying widely in severity (Fig. 3.16). Some racing
shanks, prevents a horse from seizing the shanks, but its overchecks, like the McKerron (Figs 3.16A & 3.17B), Crit

Fig. 3.16  Overcheck bits. (A) McKerron with check rein

and nose strap. (B) Burch. (C) Crit Davis. (D) Crabb.  
(E) Hutton. (F) Speedway. (G) Plain. (H) O’Mara leverage.

B C D E

F G

A
H

36
 Bits, bridles and accessories

Fig. 3.17  Four overcheck systems used on racing

A B Standardbreds. (A) Plain overcheck bit. (B) McKerron
overcheck bit. (C) Crit Davis overcheck bit. (D) O’Mara
leverage overcheck. All four driving bits are half-cheek
snaffles.

Fig. 3.18  (A) Driving bridle with Ashleigh Elbow and

sidecheck bits. (B) Horse bridled with Buxton and
A
sidecheck bits. (C) Sidecheck rein attached to O ring
C snaffle driving bit.

Fig. 3.19  Lateral radiographs of overcheck bits

A B in horses’ mouths. (A) Plain overcheck bit. (B) Crit
Davis overcheck bit. (C) Crabb overcheck bit.  
(D) Burch overcheck bit. All four driving bits are
half-cheek snaffles.

C D

37
 3 Introduction

Fig. 3.20  A mule team prior to hitching to show

the coupling lines (arrows) and driving lines (D)
from the front and rear. The coupling lines attach
to the inside rings of the bits, cross each other,
pass through rings on the hamess of the
opposite horse’s collar and buckle into the
driving lines (D). When the team is hitched and
traveling straight ahead, the coupling and driving
lines join over the mules’ backs.

Davis (Figs 3.16C, 3.17C & 3.19B), and Crabb (Figs 3.16D a coupling or stub line1,3,22,27,28 (Fig. 3.20). The draft and
& 3.19C), listed in increasing order of severity, are used in coupling lines are connected so that only one left line and
combination with nose straps to prevent horses from leaning one right line for each pair of horses finally reaches the
into their check reins.1,29 Potentially even more severe is the driver’s hand.1,3,22 In a team of two horses the draft line of
Burch overcheck (Figs 3.16B & 3.19D), which is shaped so each horse extends from the driver’s hand to the outside ring
as to press directly into the hard palate. of the horse’s bit. The coupling line of each horse is attached
The cumbersome appearing, but reasonably humane and to his draft line as it passes over the horse’s back, passes
effective, Raymond and O’Mara (the so-called leverage over- through a ring at his withers and crosses over to the inside
checks) involve no bit at all. (Figs 3.16H & 3.17D) When a ring of the bit of the opposite horse3,27,28 (Fig. 3.20). Thus,
horse leans into a leverage overcheck, a strap over his face when the left line is pulled, both horses turn left, and when
presses down onto his nose and the U- or V-shaped lower the right line is pulled, both horses turn right. This provision
portion of the overcheck lifts up on his chin.1,29 is a practical necessity to make accurate line handling pos-
The combination of forces applied by the driving and sible, but it does not allow constant even contact to be
check reins can place marked stress on a horse’s mouth, and maintained with each horse’s mouth.1,3
one must be aware of the type of overcheck used when caring The exact adjustment of the coupling lines, which may be
for a horse’s teeth and mouth. For example, the hard palate buckled at varying distances along the draft or outside line,
should be examined carefully for injury in a harness-racing is a critical factor in team driving in assuring that both horses
horse who performs poorly when checked with a McKerron, are moving with their heads held straight to the front.3,28 The
Hutton, Burch, Crit Davis, or Crabb bit. If the palate is sore, coupling lines must both be adjusted at the same time,
one should consider recommending a change to a chin chain because when only one line is adjusted, the other will pull
or leverage overcheck.1 one horse’s head to one side or the other.22,28 Moving cou-
Removal of wolf teeth, careful floating and rounding of pling lines further forward on the draft line spreads the team
the upper premolars and removing sharp edges from upper apart, and moving the coupling lines back brings the team
canine teeth are of special importance whenever overchecks closer together.28
are used.1,30 The upper canines are placed more caudally than Proper alignment of the horses in a team is critical for
the lower canines thus providing less space for the overcheck correct bit function. If one horse is ahead of the other, or if
bit than for the driving bit. The overcheck bit may be forced the horses are too far apart or too close together, the bit will
backwards, especially if the horse’s head is checked very be off-center in one or both horses’ mouths.28 Sores at the
high, pinching the gums against the teeth. Even leverage corners of the lips of one or both horses may be a clue that
overchecks can force a horse’s cheeks against upper points the alignment of the horses is improper.1 Fortunately, to
or caps. prevent the chafing or injury that would otherwise occur,
horses tend to place their heads so as to center the bits in
their mouths.1,28 However, this compensation results in one
Team driving or both horses’ heads being turned to one side, making
straight traveling and turning difficult.28
The previously mentioned remoteness of control in driving If one horse is ahead of the other and thus pulling more
horses is compounded in the case of a pair or larger team, than his share of the load, his bit should be made more
in which each horse is controlled by a draft line (rein) and severe, while that of his partner should be made less severe

38
 Bits, bridles and accessories

Fig. 3.21  (A) Bridles are often adjusted so that the

bit causes a wrinkle at the commissures of the lips.  
(B) Bridle adjusted so that bit hangs loosely.  
(C) Bridle adjusted too tight.

(Fig. 3.15B).1,28 The different slots for attachment of the lines providing more tongue relief than the bit required by the
to Liverpool, Ashleigh Elbow, and Buxton bits are ideal for deeper-mouthed horse.
the quick changes in bit pressure that sometimes become An older horse may have less space for a bit in his
necessary in the middle of an event. mouth. As a horse ages, his incisors slope further forward
while the cheek teeth wear down, causing the palate to sink
closer to the tongue. A bit that was comfortable for a horse
Fitting the bit when he was 5 may no longer be comfortable when he
is 20.
The variation in size, shape, and degree of sensitivity of
One must consider more than the external dimensions of
horses’ mouths should be considered when selecting and
a horse’s head and his age in choosing an appropriate bit.
fitting bits and bridles.9,17,18 The width of the mouthpiece
The size and shape of a horse’s oral cavity often correlate
should accommodate the width of the mouth. If the mouth-
poorly with the size and shape of its head, its age or its sex.17
piece is too short, it will pinch the corners of the lips against
In selecting and properly fitting a bit, there is no substitute
the cheek teeth. Too long, and the bit can shift sideways,
for careful manual and digital examination of a horse’s
sawing on the lips, tongue and bars. An oversized mouth-
mouth. Periodic reexaminations are indicated because
piece also puts the port or joint out of position and makes
wearing of the teeth, or even dentistry, can change the shape
the bit ineffective and possibly painful. Ideally the mouth-
of the oral cavity.17
piece should not project more than 1 2 inch or less than 1 4
inch beyond the corners of the lips on either side.8
The position where the bit fits in the bar space is also Bitless bridles
important. However, this adjustment varies from horse to
horse and bit to bit. A popular rule-of-thumb for adjusting Some horses that don’t respond well to a bit perform quite
snaffles has been to adjust the bit so that the commissures well with bitless bridles. Bitless bridles can be especially
of the horse’s lips are pulled into one or two wrinkles (Fig. useful in preventing mouth injuries caused by the overzeal-
3.21A).The problem with such a fit is that releasing the pres- ous hands of a beginning rider or in allowing a mouth injury
sure on the reins gives the horse no relief at the corners of to heal.13,31
his mouth.6,8,9 A better method is to first hang the bit rela- When choosing bitless headgear, horse owners should
tively loosely until the horse learns to pick it up and carry it consider the same factors that they would when choosing
and then adjust the headstall to position the bit where the any other bridle. Otherwise, they risk dulling the horse’s
horse has determined it is most comfortable (Fig. 3.21B). A sensitivity and responsiveness to rein signals.13
driving horse’s bit should rest squarely against the corners
of the mouth without wrinkling them.1
A horse with a short or shallow mouth (from lips to
Traditional hackamore (Fig. 3.22A)
corners) carries the bit forward in his mouth where his The hackamore provides a means of promoting poll flexion,
tongue rides highest. A horse with a deep mouth holds the collection, and balance along with optimal stopping power
bit farther back in his mouth where his tongue sits lower in and directional control while staying out of the horse’s
his jaw space and his palate is more concave.9 Consequently, mouth. It is used with a light bumping action, initiated
there is less space between the tongue and hard palate in the by gently tugging on one rein at a time. Alternating pulls
shallow-mouthed horse and, everything else being equal, he and releases can be used to ask the horse to flex at the poll
requires a bit with a thinner mouthpiece and a port and stop.32

39
 3 Introduction

Fig. 3.22  Bitless bridles. (A) Traditional bosal

A B hackamore. (B) Cross-under bitless bridle. (C) Side pull.
(D) Mechanical hackamore.

C D

The heart of the hackamore is the bosal, a braided rawhide The Cross Under Bitless Bridle (Fig. 3.22B) distributes pres-
or leather noseband that is fashioned around a rawhide sure across the poll, behind the ears, down the side of the
core. An 18- to 22-foot hair rope, the mecate, is wrapped face, behind the chin and across the nose.33 The bridle con-
above the heel knot of the bosal to form a continuous rein sists of two loops, one located over the poll and the other
and lead rope.9 Bosals vary greatly in diameter, with the located over the nose, with both crossing under the horse’s
appropriate size depending upon the horse’s sensitivity and chin. The reins run from the rider’s hands through two rings
stage of training. Generally one moves from thicker, heavier on either side of a noseband and then cross beneath the
bosals to thinner, lighter ones as the hackamore horse horse’s jaw and loop over the poll. With this figure-eight
progresses.31 configuration, simultaneous pressure can be applied to the
The bosal should rest on the bridge of the nose, or just poll, nose, chin, and cheeks. Pressure on one rein pushes the
slightly above, where it is supported by the nasal bones. horse’s head in the desired direction rather than pulling on
When placed too low, it exerts excessive pressure on the its mouth with a bit.31,34
horse’s nasal cartilages and interferes with his breathing. The side pull and the cross-under are gentle bridles that
Obviously, a hackamore does not damage a horse’s tongue minimize the stress on a horse’s mouth and work exception-
and bars, but the bosal contacts some very sensitive points ally well on some horses.
on his face. Rein pressure presses the bosal into the top of
the face and into contact with the cheeks and lower jaw all
at the same time. Heavy hands on the reins or an ill-fitting Accessories
bosal can abrade the horse’s nose and jaw and press his
cheeks against the upper premolars. Some bitting problems can be alleviated and a horse’s per-
formance improved by adding bitting accessories, such as
nosebands and martingales. We must be familiar with the
Mechanical hackamore (Fig. 3.22D) functions of such accessories in caring for horses’ mouths
While mechanical hackamores are indeed bitless bridles, because they alter the function of, or the direction of pull
they function more like curb bits than like true hack- on, the bit.
amores.9,31 Mechanical hackamores have metal shanks that
attach to a noseband and curb chain. While there is no
mouthpiece, the shanks amplify force to the nose, chin and
Nosebands
poll in the same way that a leverage bit works on the mouth, The simplest noseband, the cavesson, functions merely to
chin and poll. Because of the wide variety of mechanical stabilize the bridle (Figs 3.10A &B) or as a point of attach-
hackamores, it is possible to vary the severity as required. ment for a martingale (Fig. 3.24A). Other types of nosebands
are used to aid or modify the action of the bit.
Drop, flash, and figure-8 nosebands (Figs 3.23A, 3.23B
Other bitless bridles and 3.23C) are used to hold the bit in the proper position
The Side Pull (Fig. 3.22C) is little more than a hybrid halter.9 and to keep horses from gaping their mouths. The top of the
Rein rings are placed on each side of the noseband in line drop noseband is fitted just at the lower end of the nasal
with the commisures of the lips. A chin strap beneath the bones while the lower portion passes below the bit and lies
rein rings allows the noseband to be snugged into position. in the chin groove. A drop noseband is fairly restrictive and
The side pull promotes lateral control with pressure on the can cause problems if not properly adjusted.35 If it is too long
reins leading the horse’s nose in the desired direction.9 on top and too short below, it will hang too close to the

40
 Bits, bridles and accessories

Fig. 3.23  Nose bands. (A) Drop. (B) Flash. (C) Figure-8.
(D) Cheeker. (E) Shadow roll.

A C

E
B D

Fig. 3.24  Martingales. (A) Standing. (B) Running.

A
B

nostrils, interfering with breathing, and the bottom will Sheepskin-covered cavessons or shadow rolls (Fig. 3.23E)
press the bit into the corners of the lips and hold the mouth are used to prevent a horse from seeing the ground in front
too tightly closed. of him, and thus to prevent his shying at shadows or other
The flash noseband attaches to the center of a simple potentially frightening sights. Cheekers and shadow rolls are
cavesson above the nose. The lower end passes below the bit used mainly on racehorses.
and lies in the chin groove. The figure-8 or grackle noseband
has a top strap that fastens above the bit and a lower strap
that fastens under the bit and lies in the chin groove. The
Martingales
two straps intersect in the middle of the face at about the There are two basic kinds of martingales: standing (known
level where a cavesson would be located. Both the flash and in western circles as tie-downs) and running (Fig. 3.24).
the figure-8 nosebands have actions similar to the drop nose- Both types of martingales promote balance and the
band but are less severe and are not as likely to interfere with proper action of a bit by discouraging, or physically
breathing.31 preventing, the horse from raising his head too high or
The so-called ‘cheeker’ (Fig. 3.23D) is not really a nose- extending his nose too far.9,31 Both types begin with a
band but rather is a rubber strap that runs from the crown- strap running from the saddle girth up the front of the
piece of the bridle down the middle of the horse’s face where horse’s chest. The standing martingale, which exerts its
it separates to attach on either side of a snaffle bit. Like the pressure on the horse’s nose, continues as a single strap
drop, flash, and figure-8 nosebands, the cheeker holds the that attaches to the bottom of a noseband. The running
bit up in the horse’s mouth.31 martingale, which exerts its pressure on the bit, forks

41
 3 Introduction

into two straps with rings at their upper ends through which mechanical and surgical skills and the possession of the
the reins run. best equipment available is not always sufficient to provide
A martingale should not be adjusted so tightly as to pull optimal dental care to horses. One must consider the age,
the horse’s head down into an unnatural or uncomfortable performance discipline, ability, and level of competition of
position. The martingale should become active only when the horse, not to mention the level of skill and the experi-
the horse raises his head, thus preventing him from evading ence of his rider or driver. The more the veterinarian knows
the bit and becoming unbalanced.31 about bits, bridles and accessories as they relate to the above
factors, the better he can fulfill the needs of his clients and
the more rewarding his dentistry practice will be.
Conclusion
The knowledge of anatomy, physiology, pharmacology and
nutrition, even when coupled with high levels of diagnostic,

References
1. Bennett DG. Bitting and dentistry for 12. Tremaine WH. Management of Equine 23. Riegle G. Training the pacer. In: Greene
the driving horse. In: Proceedings of the Mandibular Injuries. Equine Vet Educ C, ed. The new care and training of the
53rd Annual Meeting of the American 1998; 10: 146–154 trotter and pacer. U. S. Trotting
Association of Equine Practitioners, 2007; 13. Hague BA, Honnas CM. Traumatic dental Association, Columbus, OH, 1996,
53: 451–459 disease and soft tissue injuries of the oral p. 337
2. Scoggins RD. Bits, bitting and dentistry. cavity. Vet Clin North Am 1998; 14: 24. McBane S. The illustrated guide to horse
In: Proceedings of the 47th Annual 333–347 tack. David and Charles, Newton Abbot,
Meeting of the American Association of 14. Van Lancker S, Van Den Broeck W, 1992, pp 49–91
Equine Practitioners, 2001; 47: 138– Simoens P. Incidence and morphology 25. Malm GA. Bits and bridles, an
141 of bone irregularities of the equine encyclopedia. Grasshopper, Valley Falls,
3. Coombs T. Bits for harness horses. In: interdental spaces (bars of the mouth). 1996
McBane S, ed. The horse and the bit. Equine Vet Educ 2007; 19: 103–106 26. Crossley A. The double bridle. In:
Howell Book House, New York, 1988, 15. Dixon PM, Tremaine WH, Pickles K, et al. McBane S, ed. The horse and the bit.
pp 127–131 Equine dental disease Part 3: a long-term Howell, New York, 1988, pp 60–78
4. Scrutchfield WL. Wolf teeth: how to study of 400 cases: disorders of wear, 27. Telleen M. The draft horse primer. Rodale
safely and effectively extract and is it traumatic damage and idiopathic Press, Emmaus, PA, 1977, p 256
necessary. In: Workbook: American fractures, tumors and miscellaneous 28. Bowers S, Steward M. Farming with
Association of Equine Practitioners Focus disorders of the cheek teeth. Equine Vet J horses. MBI, St Paul, 2006
on Dentistry 2006, pp 56–60 2007; 2: 9–18
29. Haughton T. Choosing the right
5. Dixon PM, Gerard MP. Oral Cavity and 16. Jansson N, Hesselholt M, Falmer-Hanson equipment. In: Greene C, ed. The new
Salivary Glands. In: Auer JA, Stick JA, J. Extirpation of a mandibular canine care and training of the trotter and pacer.
eds. Equine Surgery, 3rd edn. Elsevier, tooth in a horse as a treatment for severe U S Trotting Association, Columbus,
St Louis, 2006, pp 321–351 bit-induced trauma to the bar. Equine 1996, pp 184–214
6. Bennett DG. Bits and bitting: form and Veterinary Education 1980; 10: 143–145
30. Caldwell LA. Canine teeth in the equine
function. In: Proceedings of the 47th 17. Engelke E, Gasse H. An anatomical study patient – the guide to eruption,
Annual Meeting of the American of the rostral part of the equine oral extraction, reduction and other things
Association of Equine Practitioners. 2001; cavity with respect to position and size of you need to know. In: Workbook:
47: 130–137 a snaffle bit. Equine Veterinary Education American Association of Equine
7. Young JR. The schooling of the horse. 2003; 15: 158–163 Practitioners Focus on Dentistry. 2006,
University of Oklahoma Press, Norman, 18. Engelke E, Gasse H. Position of different pp 47–55
OK, 1982, pp 235–263 snaffle bits inside the equine oral cavity. 31. Bennett DG. Bitting accessories and
8. Bennett DG. An overview of bits and Pferdeheilkunde 2002; 18(4): 367–376 bitless bridles. In: Workbook: American
bitting. In: Workbook: American 19. Easley J. Dental and oral examination. In: Association of Equine Practitioners Focus
Association of Equine Practitioners Focus Baker GJ, Easley J, eds. Equine dentistry, on Dentistry. 2006, pp 237–242
on Dentistry. 2006, pp 181–195 2nd edn. Elsevier, London, 2005, 32. Connell E. Hackamore reinsman.
9. Lynch B, Bennett DG. Bits and bridles: pp 151–169 Lennoche, Katy, TX, 1952
power tools for thinking riders. 20. Sutton A. The bridle and the bit. In: The 33. Cook WR. Pathophysiology of bit control
EquiMedia, Austin, 2000 injury-free horse. David and Charles, in the horse. J Equine Vet Sci 1999; 19:
10. Johnson TJ. Surgical removal of Newton Abbott, 2001, pp 59–60 196–204
mandibular periostitis (bone spurs) 21. Clayton HM, Lee RA. Fluoroscopic study 34. Cook R. Tradition and status quo, or
caused by bit damage. In: Proceedings of of the position and action of the jointed science and advance? Vet Times 2007; 37:
the 48th Annual Meeting of the American snaffle bit in the horse’s mouth. Journal 16–18
Association of Equine Practitioners 2002; of Equine Veterinary Science 1984; 4:
35. Loriston-Clarke J. The Complete Guide to
48: 458–462 193–196
Dressage. Courage Books, Philadelphia,
11. Smith JC. Osteitis and sequestrum 22. Edwards EH. The complete book of bits 1987, pp 130–131
formation of the interdental region of the and bitting. David and Charles, Newton
mandible in 11 polo ponies. Vet Rec Abbot, 2000
1993; 133: 188–189

42
 Section 1:  Introduction

C H A P TER   4 
The business of equine dentistry
Travis Henry† DVM, Dennis J. Rach* DVM
†
Midwest Equine Services, N7188 Country Side Lane, Elkhorn, WI 53121-2916, USA
*Moore & Co. Veterinary Services, Box 460, Balzac, Alberta, Canada T0M-0E0

Customers are the most important visitors on our general equine veterinary practice. To perform this much
premises. They are not dependent on us. We are dentistry effectively, a veterinarian must incorporate an
dependent on them. They are not an interruption in our appropriate business model into the practice.
work. They are the purpose of it. They are not an
outsider in our business. They are part of it. We are not Major contributing business factors
doing them a favor by serving them. They are doing us a
favor by giving us an opportunity to do so. Three major factors are required for a business model to
function, and a deficit in any of the three decreases the likeli-
Mahatma Gandhi hood of success.

Horse owners expect dental care to be high quality and • Structures: the availability of necessary physical and
delivered with expertise. Enthusiasm is a crucial component human resources.
of high quality veterinary service. Delivering exceptional • Processes: the use of efficient resources.
levels of dental care with enthusiasm creates a positive • Systems: the provision of useful information to
atmosphere, making a dental procedure a satisfying experi- management so that business decisions can be made.
ence for both the owner and practitioner. The client’s
needs are fulfilled, and the client develops trust in the prac- Structures
titioner, which is a cornerstone of a successful dental prac-
tice. Enthusiasm is often the key ingredient that separates a Expertise develops a trusting relationship
successful equine dental practice from a practice that is less Equine dentistry is the one common service that the entire
successful. spectrum of equine clients need throughout all four seasons
Dentistry has become an important sub-discipline of of the year. This type of service, when expertly offered, can
veterinary practice. In the recent past, equine dentistry was become the cornerstone of a stable’s herd health program.
a discipline overlooked by many veterinarians, perhaps If the veterinarian is able to expertly perform an oral exami-
because the economic value of the horses used for agricul- nation and provide for the horse’s dental needs efficiently
tural work was low. When horses became valued because of and competently, the owner is satisfied. After a relationship
emotional attachment or because of their worth as a sport of mutual trust between the veterinarian and client is estab-
horse, their economic value increased, and dental care lished, the client is likely to accept the advice of the veteri-
became more important to owners. Many of today’s clients narian in other matters of health. During these discussions,
compete in various kinds of sporting events for horses, and dental care strategies for various age groups of horses can
the horse’s interaction with the bit and bridle is a critical part be outlined, and the importance of dentistry for the per­
of the interaction between horse and rider during these formance and long-term well-being of the horses can be
events. Clients recognize that equine dentistry is essential in illustrated. When the managers or owners realize how
maintaining a good interaction between the horse and bit. important dental care is for their horses, they become ardent
When a practice is not willing to provide high-quality equine supporters of a herd health strategy scheduled around dental
dental care, clients seek dental care elsewhere. In many parts appointments.
of the world, horses are still used in agriculture, and for these It is incumbent upon veterinary graduates to receive extra
horses, dental maintenance is vital for their overall health instruction and to develop skills in the practice of equine
and welfare. dentistry to achieve an acceptable level of judgment and
As drugs for sedation, instrument design and dental tech- competence in this discipline. Dental procedures must be
niques have improved, the activity in equine dentistry at performed in a competent, efficient manner that is safe
modern veterinary practices has increased markedly. Den- for the patient, practitioner, and handler. Like surgery, the
tistry can easily comprise 10–15 % and sometimes up to practice of equine dentistry requires skill, knowledge,
30 % of the total workload and revenue produced in a and experience.

43
 4 Introduction

Fig. 4.2  Clinic logos and signage on practice vehicles to promote services
offered are ideal methods of advertising. (Contributed by Christopher Pearce
MRCVS.)

The practice team must collectively agree on the level of

service to provide and then devise strategies to deliver these
levels of service. Dental education and services provided to
clients in a pleasant and courteous manner, with enthusiasm
and skill, produce referrals given confidently by satisfied
clients, and these referrals promote the growth of the
practice.

Referral of complex cases

Fig. 4.1  Creative signs direct clients to your business and publicize various
types of services. A practice does not have to provide all levels of equine
dental care, but members of the practice should have a good
knowledge of current standards of dental care. They should
Advanced educational programs are readily available for be able to accurately diagnose dental problems and if neces-
veterinarians seeking to improve their knowledge about sary, be willing to refer a horse with a complex dental condi-
equine dentistry and their skills in performing dental proce- tion to a more experienced veterinarian. Clients are satisfied
dures. Practitioners must continue to educate themselves to if a proper presumptive diagnosis is made and a referral to
stay current in this rapidly developing discipline. Continu- a veterinarian com­petent to resolve the condition is pro-
ing education in dentistry has never been more accessible. vided. They become dissatisfied if they receive an inaccurate
Many organizations and institutions provide avenues for diagnosis or feel that ample effort was not provided to
equine dental education taught by leaders in the profession. resolve the dental condition.
Interested veterinarians can enroll in module courses to
learn more about current techniques in diagnosis of dental
diseases and treatment of affected horses. In addition, Health management
seminars provide a venue for practitioners interested in The health needs of the entire horse should be addressed
improving their knowledge about equine dentistry to meet because comprehensive dental care involves much more
veterinarians providing high quality dental services who are than just floating teeth. A dental examination should include
willing to share their knowledge. Applying knowledge a cursory general physical examination before a sedative/
obtained by attending courses dealing with equine dentistry analgesic is administered. Queries from the owner about the
promotes business for a practice. horse’s nutritional and prophylactic health needs, reproduc-
tive health, training strategies, and behavioral problems can
Total practice commitment be answered during the examination. The ‘value-added’
service builds the owner’s trust and confidence in the
A totally committed staff sends a message to clients that veterinarian.
equine dentistry is a priority of the practice. ‘Visual effects’
around the office, clinic, or ambulatory vehicle create a dis-
tinctive corporate image (Figs 4.1 & 4.2). Dental posters, Equipment
audiovisual aids, anatomical specimens, and dental logos on When developing a dental specialty within a practice, basic
clothing, caps, stationery, and pens provide a special image sets of instruments are required to diagnose dental condi-
and a positive atmosphere for the practice. tions and perform routine dental procedures. Equipment
When equine dentistry becomes a focus for a practice, a needed to conduct an ambulatory dental practice may differ
dental procedure is no longer just a procedure to ‘fit in’ from that needed in a hospital, and may depend on climatic
between vaccinations and the next emergency. To maintain conditions and the type of infrastructure available at farms
this focus, ample time must be allotted for dental proce- and stables. The cost of equipment required to perform
dures, so that the procedures are performed to a high basic, good quality dentistry is within the budget of most
standard. practices.

44
 The business of equine dentistry

As caseload and economic rewards increase, individuals Convenience

within the practice may develop interests in sub-specialties
Efficient and convenient delivery of dental services should
of dentistry. As individuals develop expertise in advanced
always be a goal. In some jurisdictions, supervised, licensed,
dental procedures, investment in more education and addi-
veterinary technicians can assist in providing some aspects
tional dental equipment becomes economical. Much of the
of dental care. Using technical personnel to assist with dental
equipment and instrumentation can be purchased in stages,
procedures, charting medical records, caring for equipment,
and selecting equipment to purchase is an important part
educating clients, immunizations, and invoicing can greatly
of business planning. New equipment needed during the
increase the efficiency of a practitioner. Clients value a task
growth phase of a dental practice might include exodontic
completed in a timely fashion because it allows them to plan
and endodontic instrumentation, restraint devices, imag­
their own day. Clients who have horses that are not easily
ing modalities, medical record systems, and technical
transported appreciate the convenience of having dental pro-
assistance.
cedures performed on their premises. For others, transport-
ing their horse to a facility that has all the amenities may be
Processes more attractive.
From the client’s perspective, there are four Cs to good Client communication
veterinary care:
Mailed notices and electronic mail are important modes of
• Client solution: does the service meet the client’s communication to remind clients that their horse is due for
needs? physical and dental examinations. Educational brochures for
• Cost: is the economic and emotional justification better clients can be custom-designed or purchased through veteri-
than that of other competitors? nary organizations, such as the American Association of
• Convenience: is the service easily accessible and Equine Practitioners. Clients appreciate a reminder because
convenient? scheduling an examination becomes one less thing they have
• Communication: did the veterinarian provide adequate to remember, and the reminder shows that the practice cares
information? about their horse’s well-being. By organizing ‘dental days’ at
various venues, a practice can make dental care more eco-
Client awareness (seeing is believing) nomical and convenient for clients. Information notices can
In our fast-moving society, giving customers what they be tailored to clients’ needs based on their horse’s age, occu-
expect is no longer enough. To gain an edge on competitors, pation, or location. Reminders allow a practice to schedule
a practice must help clients learn what they need.1 To do dental procedures months in advance, and this assists man-
this, a practice should integrate marketing into other agement in planning growth of the practice. Scheduling
activities. permits work to be distributed evenly throughout the day
Each veterinarian in the practice can increase the client’s and among members of the practice.
awareness of the importance (i.e., the need) of dental care
Absentee clients
by incorporating an oral examination into other routine,
physical examinations, such as a lameness examination. The portion of the equine population that is under the care
Incorporating an oral examination into other examinations of trainers, and not the owner, presents a special challenge
adds to the client’s knowledge of the status of their horse’s to the veterinarian.2 The owner, trainer, and veterinarian are
health. all members of a business relationship, and good rapport
Many clients, including experienced horse owners, have between all members, especially between the veterinarian
never viewed the inside of a horse’s mouth, and when they and the trainer, is fundamental to the success of this relation-
can see the dentition, they begin to appreciate the horse’s ship. If the owner must receive medical information about
need for regular dental care. Many horse owners are shocked his or her horse directly from the veterinarian, the trainer
to see buccal lacerations and large hooks. Seeing is believing, must also receive the same information so that the trainer
and from that moment on, horse owners understand the does not feel threatened.
importance of dental care. On site, cellular communication with an absent owner is
convenient and effective, but the billing statement is the best
means of documenting to the owner the health care that his
Cost of service or her horse has received. A billing statement can be used as
The value of dental services is determined by the quality of an opportunity to send the owner a medical record of each
service delivered, the skill of the person delivering the service, horse, along with an additional statement that details the
the regional cost of living, and business costs. One method charges for each horse and the total payment that is due. A
of determining a fee schedule for dental services is to consult well-designed billing statement/dental record becomes an
with local practices to determine what the average charges advertisement for the practice because it can be used to
for the dental services are in the area. Fees for dental proce- illustrate the veterinarian’s expertise (Fig. 4.3). Clients appre-
dures can also be compared to fees charged for similar types ciate receiving this dental record and share the information
of veterinary procedures or to fees charged by other equine contained within it with other horse owners. The dental
businesses, such as farrier work. After these guidelines are record should be easy for an owner to understand, it should
determined, the practice can calculate expenses required to accurately describe findings of the dental examination, and
deliver dental services, and based on these expenses, a fee it should outline procedures done to correct dental abnor-
that produces a suitable profit can be generated. malities. The invoice and dental record can be generated at

45
 4 Introduction

Fig. 4.3  A dental record form can be a valuable aid in communicating with the owner/trainer. The form should clearly show what dental problems
the horse has, what treatments were given and when the next follow-up visit is scheduled. (Contributed by Rob Pascoe BVSc MRCVS.)

the time of service using a laptop computer, which greatly request throughout the year. Procedures such as blood
improves efficiency, and collections, and decreases mistakes testing for equine infectious anemia, annual vaccinations,
in the billing process. insurance examinations, reproductive work, and preparation
for competitions, can be scheduled with dental work.
All horses involved in competition need regular dental
Grouping with scheduled procedures care, and the office staff can use the computer to predict
Opportunities can be found to schedule dental procedures when this regular dental care can be provided to a group of
by auditing common veterinary procedures that clients clients.

46
 The business of equine dentistry

Table 4.1  Number of dental cases that practices treated in the Table 4.2  Practices polled by the authors
year 2004 (among only those practices who said they provide
dental services) (AAEP Poll of 2005 Concerning Dentistry) Percentage of dentistry to practice’s total gross income 7.78 %
Percentage of dentistry to equine infectious anemia tests 81.0 %
31 % More than 200 dental cases
Percentage of dentistry to influenza and rhinopneumonitis 51.0 %
21 % 101–200 dental cases
vaccine
21 % 51–100 dental cases
17 % 26–50 dental cases
10 % 1–25 dental cases
1 % No dental cases practice activity can be quantified to allow comparisons with
the overall amount of dental work performed.
Often, more dental care could be performed but the prac-
tice lacks the personnel to perform it. The information
system can predict if hiring a new associate and purchasing
Systems new instrumentation to fill the void are economically
feasible. Because the cost of basic dental instrumentation is
Well-organized offices with state-of-the-art information moderate, compared with equipment needed for other sub-
systems report on the resources and processes of the busi- specialties, deciding whether or not to expand equine den-
ness. The record-keeping system for inventory, invoicing, tistry within the practice is usually easy.
payroll, medical records, statistics, and research generates
reports that allow the managing veterinarian to determine
how well the business plan is functioning. Accounting state- Summary
ments from these records also give valuable information that
can be used to plan business strategies. Information systems Veterinarians with an interest in equine dentistry have the
can also identify potential areas for growth in dentistry. opportunity to make dentistry a significant part of their prac-
Software tools can be used to monitor client and veterinary tice. The practitioner who is enthusiastic can acquire the
activity. A high number of dental procedures performed by requisite knowledge and skills to efficiently and effectively
some members of the practice can be identified as a goal for perform dentistry. With the advent of sedative/analgesia
others in the practice (Table 4.1). agents and motorized instrumentation, equine dental prac-
Numbers of various types of veterinary procedures can tice is no longer laborious, and anyone who has interest in
also be compared with numbers of dental procedures. For equine dentistry can include it in his or her practice. Veteri-
example, horses being tested for equine infectious anemia narians who become competent in equine dentistry find it
or immunized so that they can attend an equestrian event to be one of the most rewarding and interesting aspects of
are likely to also need dental care (Table 4.2). Many areas of equine veterinary practice.

References
1. Kotler P. Marketing management. Pearson
Education, New Jersey 2000, p 21
2. Mitchell JS. Absentee owner
communication: an equine practitioner’s
challenge. Equine Veterinary Education
2007; 19(4): 111

47
 Section 2:  Morphology

C H A P TER  5 
Dental anatomy
Padraic M. Dixon MVB, PhD, MRCVS, Nicole du Toit BVSc, MSc, PhD, MRCVS
Division of Veterinary Clinical Studies, University of Edinburgh, Easter Bush Veterinary Centre, Roslin, Midlothian EH25 9RG, UK

Introduction interproximal or interdental refer to the area of teeth that

face the adjoining teeth in the same arcade (incisors) or row
(cheek teeth). The terms mesial and distal, which refer,
Equine dental nomenclature respectively, to the surfaces of teeth that face towards and
Adult mammals have four types of teeth, termed incisors, away from an imaginary line between the central incisors,
canines, premolars (PM) and molars (M), in a rostrocaudal are satisfactory for equine incisors – that form a true arch.
order.1 Teeth embedded in the incisive (premaxillary) bone However, these terms are unsatisfactory for the equine cheek
are by definition termed incisors. The most rostral teeth in teeth, because they do not form part of a continuous dental
the maxillary bone are the canines. In horses, the main three arch as they are separated from the incisors by the ‘interden-
premolars have evolved to become more complex and mor- tal space (‘physiological diastema’, ‘bars of mouth’). The
phologically identical to the molars (i.e., molarization of term cheek teeth row is a more appropriate term to describe
premolars) to facilitate grinding of foodstuffs. Consequently, the straight rows of six cheek teeth.
in horses, premolars 2–4 (Triadan 06–08) and the three
molars (Triadan 09–11) can be collectively termed cheek
teeth. Each type of tooth has certain morphological charac- Equine dental evolution
teristics and specific functions. Incisor teeth are specialized
for the prehension and cutting of food, and the canine teeth The evolution of equine dentition is comprehensively
are for defence and offence (for capture of prey in carni- covered in Chapter 1, and the functional consequences of
vores). Equine cheek teeth function as grinders for mastica- this dental evolution are discussed in Chapter 6; neverthe-
tion. The occlusal or masticatory surface is the area of tooth less, some salient anatomical aspects of the differentiation
in contact with the opposing teeth; the term coronal refers of brachydont into hypsodont teeth are briefly discussed
to the crown. The anatomical crown is that part of the tooth here. Following ingestion of their coarse forage diet, the
covered by enamel and in brachydont (short crowned) necessary grinding down of this foodstuff to a small particle
teeth, such as in humans, is usually the same as the clinical size (the average length of fibers in equine feces is just
(erupted) crown, i.e., the erupted part of the tooth. However, 3.7 mm)3 to allow more efficient endogenous and microbial
in equine teeth (hypsodont – long crowned), especially digestion, causes a high degree of wear on their cheek teeth.
young teeth, most of the crown is unerupted and is termed However, unlike ruminants that can later regurgitate their
unerupted or reserve crown, and a smaller proportion (circa food to allow further mastication, horses have only one
10–15% in young adult horses) of crown is clinical crown. opportunity to effectively grind their foodstuffs.
The term occlusal (‘coronal’ is a much less satisfactory term Brachydont teeth (permanent dentition) fully erupt prior
for hypsodont teeth) is used when referring to direction to maturity and are normally long and hard enough to
towards the occlusal surface. The reserve crown can be sub- survive for the life of the individual because they are not
divided into alveolar crown (i.e., that part lying in the alveo- subjected to the prolonged and high levels of dietary abra-
lus) and the gingival crown, i.e., that part which has erupted sive forces that herbivore teeth must contend with. In con-
from the alveolus, but which is still lying sub-gingivally.2 trast, hypsodont teeth slowly erupt over most of the horse’s
Apical refers to the area of tooth furthest away from the life at a rate of 2–3 mm/year,4,5 which is similar to the rate
occlusal surface, i.e., the area where the roots later develop of attrition (wear) on the occlusal surface of the tooth, pro-
and is the opposite of occlusal. Lingual refers to the medial vided that the horse is on a grass (or some alternative fibrous
aspect (area closest to the tongue) of all the lower teeth, diet, e.g., hay or silage) rather than being fed high levels of
whilst palatal refers to the same aspect of the upper cheek concentrate food. The latter type of diet reduces the rate of
teeth. Buccal (aspect closest to cheeks) refers to the lateral occlusal wear and also restricts the range of lateral chewing
aspect of both upper and lower (cheek) teeth, whilst labial actions6 and thus dental overgrowths can occur. Both brachy­
refers to the rostral and rostrolateral aspect of teeth (incisors dont and hypsodont teeth have a limited growth period
and canines only in horses) close to lips. The terms (although this period is very prolonged in the latter group)

51
 5 Morphology

and thus are termed anelodont teeth. A further evolutionary the underlying mesenchymal tissue to form two distinct
progression to cope with highly abrasive diets, as has ridges, the vestibular lamina, and (caudal to it) the dental
occurred in some rodents such as rabbits (and some extinct lamina. The dental lamina produces a series of epithelial
equid lineages), is the presence of teeth that continually swellings called tooth buds along its buccal margin. This
grow throughout all of the animal’s life, that are termed stage is known as the bud stage of tooth development (Fig.
elodont teeth. 5.1). At this stage, a mesenchymal cell proliferation develops
Many brachydont teeth have a distinct neck between beneath the hollow ectodermal tooth buds and invaginates
the crown and root, a feature that could not be present into these tooth buds, which then develops into inverted
in permanent hypsodont teeth that have a prolonged erup- cap-shaped structures called the enamel organs. This is
tion period. At eruption, hypsodont teeth have no true termed the cap stage of dental development (Fig. 5.1).
roots and in this text the term root specifically refers to the All deciduous teeth and the permanent molars develop
apical area which is enamel free.7,8 The formation of roots from the enamel organ of the dental laminae. However,
in equine teeth permits further dental growth for some year permanent incisors, permanent canines, and permanent
or so after these teeth erupt, in addition to the very pro- premolars are formed from separate enamel organs that are
longed eruption of these teeth for most of the horse’s life. derived from lingual (medial) extensions of the dental
The terms apical or periapical are much more appropriate to laminae of the deciduous teeth (Fig. 5.1). Consequently, the
describe this area of equine teeth that, for example, com- deciduous incisors are normally displaced labially (towards
monly develop apical infections of the mandibular 07s the lips) by the erupting permanent incisors.
and 08s (2nd and 3rd cheek teeth) even prior to the develop- After formation of the enamel organ, the mesenchymal
ment of any roots. About 25 % of equine mandibular cheek cells continue to proliferate within the concave aspect of
teeth still have no root development even 12 months fol- the enamel organ, and are then termed the dental papilla,
lowing eruption.9 a structure that is later responsible for dentin and pulp
Because of the marked physiological wear (attrition) on formation. These cells now also extend peripherally, as a
the surface of hypsodont teeth, exposure on the occlusal structure termed the dental sac (follicle), which surrounds
surface of enamel ridges, and also of dentin and cement and protects the enamel organ and dental papilla until
(cementum) is inevitable and leads to the presence of alter- tooth eruption occurs (Fig. 5.2).1,15 The enamel organ,
nate layers of these three calcified dental tissues on the occlu- dental papilla and dental sac are together termed the
sal surface. This is in contrast to the sole presence of enamel tooth germ, with each germ responsible for an individual
on the occlusal surface of brachydont teeth. The presence tooth.
of infolding of the peripheral enamel, and also of enamel The enamel organ proliferates further, and in brachydont
cup-like infoldings (infundibula) in the upper cheek teeth teeth now assumes a concave, bell-like shape, which is
and all incisors also increases the amount and irregularity termed the bell stage of dental development. At this stage,
of exposed enamel ridges on the occlusal surface. This the concavity of the enamel organ increases, while the mes-
peripheral enamel infolding is greater in mandibular cheek enchymal cells of the dental papilla invaginate further into
teeth to compensate for the lack of enamel infundibulae its hollow aspect (Fig. 5.1). Additionally, in some equine
that are present in the maxillary cheek teeth.10 This feature teeth (all incisors and maxillary cheek teeth), invaginations
confers additional advantages to hypsodont teeth, as the of enamel epithelium that will later become infundibula
different calcified tissues wear at different rates (enamel develop from the convex aspect of the ‘bell’ into the papilla
slowest, dentin and cementum fastest) and therefore a per- (one per incisor and two per upper cheek teeth). Equine
manently irregular occlusal surface that is advantageous in cheek teeth have multiple cusps (raised occlusal areas) that
the grinding of coarse fibrous foodstuffs is created by a self- arise from protrusions on the convex aspect of the bell. The
sharpening mechanism. enamel organ in equine incisors and in all brachydont teeth
is circular on transverse section; however, the enamel organ
of equine cheek teeth (which are rectangular to square on
Embryology of teeth transverse section) develops peripheral infoldings16 that later
produce the infolded peripheral enamel.
Dental development (dentogenesis) involves several sequen- Most cytodifferentiative events in the tooth germs occur
tial processes, including epithelial-mesenchymal interaction, during the transitional period between the cap and bell
growth, remodeling and calcification of tissues until a tooth stages. The ectodermal cells lining the concave aspect of the
is fully developed.11,12,13 During dental development, the enamel organ become the internal enamel epithelium, and
tooth germ undergoes a series of distinct, consecutive events the cells lining the convex aspect of the enamel organ form
termed the initiating, morphogenetic and cytodifferentiative the external enamel epithelium.12 Between them lies a third
phases. These phases occur in all types of mammalian denti- layer containing star-shaped cells with large intracellular
tion;14 however, their timing and termination vary, i.e., com- spaces, termed the stellate reticulum (Fig. 5.1), which has
pared to brachydont teeth, hypsodont teeth have a delayed nutritive and mechanical functions in enamel development.
termination of the morphogenetic and cytodifferentiative The cells of the internal dental epithelium develop into tall
stages (at their apical region), whilst in elodont teeth (such columnar cells with large, proximally located nuclei. This
as in some rodents), these stages continue throughout all of development induces alterations at the molecular level in
the animal’s life. Tooth formation begins by the develop- the underlying dental papilla whose uppermost cells now
ment of a horseshoe-shaped, epithelial thickening along the rapidly enlarge, becoming odonto­blasts. The first layer of
lateral margin of the fetal oral cavity. This epithelial thicken- dentin is now laid down along the basal membrane, which
ing (termed the primary epithelial band) invaginates into then disintegrates. These events reciprocally induce the

52
 Dental anatomy

Bud stage Dental sac

Buccal Lingual
Dental sac vasculature
Oral epithelium
Developing cusp

Peripheral cement
of crown
Enamel organ
Enamel

Dentin
Mesenchymal MEDIAL
cell condensation Predentin
A
Odontoblasts
Cap stage
Pulp
Oral epithelium
External enamel epithelium
(of reserve crown)
Dental lamina
A Stellate reticulum Internal enamel layer
External enamel
epithelium

Stellate reticulum
Dental sac
Dental follicle Dental sac vasculature

Internal enamel Developing cusp

epithelium
Peripheral cement
of crown
Dental papilla
Enamel
B Mesenchyme
Dentin

Bell stage MEDIAL

Predentin
Oral epithelium Odontoblasts
Degenerating
Pulp
dental lamina
Enamel organ of External enamel epithelium
permanent tooth

External enamel Internal enamel epithelium

B
epithelium

Stellate Fig. 5.2  Two stages of the development of a multicusped hypsodont tooth
reticulum without an infundibulum (i.e., a lower cheek tooth) showing the presence of
coronal cement and enamel that are covered by the dental sac. The large
Dental follicle common pulp chamber (A) later develops separate pulp horns (B) due to
Enamel
deposition of dentin by the odontoblasts within the common pulp
chamber.
Dentin and
predentin
Odontoblasts distal aspect. Secretions from the proximal aspect of Tome’s
Ameloblasts process form interprismatic enamel, and secretions from the
surface of Tome’s process form the enamel prisms. The
Dental papilla development of enamel and dentin (and later, also of
cement) occurs in two consecutive phases, the secretion of
Cervical loop
extra cellular matrix of mucopolysaccha­rides and organic
C
Mesenchyme fibers, which is then followed by its mineralization.18,19
Odontoblasts, like ameloblasts and cementoblasts (that
Fig. 5.1  The three early stages of development of a brachydont or
produce cement), are end cells, meaning that they cannot
hypsodont tooth. (Reproduced from Kilic72 with permission.)
further differentiate into other cell types. During dentin
deposition, the basal aspects of odontoblasts gradually
overlying internal enamel epithelial cells to differentiate into become thinner and form long fine cytoplasmic exten-
ameloblasts which now begin to produce enamel.17 sions termed odontoblast processes, that remain within the
The ameloblasts initially deposit a structureless enamel dental tubule, whilst the odontoblast cell body gradually
layer and then migrate away from the enamel-dentinal inter- moves centrally on the peripheral of the pulp horn, remain-
face, and form a projection termed Tome’s process at their ing on the surface of the developing dentin.13

53
 5 Morphology

Enamel organ and

developing enamel

Pulp cavity
Odontoblasts and
predentin layers
Hypoplastic
cement
Infundibular enamel
Primary dentin

Pulp cavity (horn) Peripheral enamel

Infundibular
cement
Dentin

Coronal enamel

Coronal enamel Coronal Central

cement vasculature
Coronal cement channel
Infundibular vasculature
from dental sac

Dental sac
A B

Predentin/Odontoblasts

Pulp cavity

Infundibular cement
MEDIAL
Infundibular enamel

Primary dentin

Peripheral enamel

Central vascular channel

Secondary dentin
(beginning to be deposited)

Fig. 5.3  The crown and occlusal surface of a multicusped hypsodont tooth with an infundibulum (i.e., an upper cheek tooth) (a) immediately prior to
eruption (b) immediately following eruption, showing loss of the dental sac over the occlusal surface and (c) following wear of the primary occlusal surface
to expose the secondary occlusal surface which is the permanent occlusal surface in hypsodont teeth. Note the additional apical blood supply to the
infundibulum.

In multi-cusped teeth (such as equine cheek teeth) miner- buds (three in each quadrant) to be underway by the 120th
alization begins independently at each cusp tip (Figs 5.2 & day of fetal life and to be completed by 240 days.20 The
5.3) and then merges, as calcification progresses down deciduous 06 (PM2) germs are largest, indicating that they
towards the amelodentinal (enamel-dentin) junction.1 As develop first. Calcification of the first permanent tooth bud
dentin and enamel deposition continues, odontoblasts and (09s) begins about 6 months later.20
ameloblasts move in opposite directions and thus avoid In brachydont teeth, vascularization begins at the periph-
becoming entrapped in their own secretions. Radiography ery of the tooth germs at the early cap stage, and blood
has shown the calcification of equine deciduous cheek teeth vessels then grow into the dental sac and dental papilla.13

54
 Dental anatomy

IP
P

IP

Fig. 5.5  Scanning electron micrograph of Equine Type-1 enamel.

Fig. 5.4  Dissected hemimandible of a yearling Thoroughbred showing This shows parallel rows of enamel prisms (P) lying on flat plates of
the tooth germs of the permanent 06 and 07 mandibular cheek teeth interprismatic enamel (IP). The enamel crystals within the enamel prisms are
developing beneath and causing resorption of their overlying temporary oriented parallel to the long axes of the prisms while the enamel crystals of
counterparts. Some calcified developing cusps can be seen on the the interprismatic enamel plates are oriented at right angles to the prisms
developing teeth through the semi-transparent dental sac. Note the (×3860).
resorption of the apices of the overlying deciduous teeth by the developing
permanent teeth.

advocated for this feature22 as discussed further in the cemen-

tum section.
Until this stage, the enamel epithelium is supplied by small
mesenchymal capillaries. Once dentinal and enamel miner-
alization begins, the connection between the enamel epithe- Dental structures
lium and the dental papilla is completely lost. The developing
enamel is now solely nourished by the vasculature of the
surrounding dental sac (Figs 5.3 & 5.4).
Enamel
After crown formation is completed in brachydont teeth, Enamel is the hardest and most dense substance in the body.
the external and internal enamel epithelial cells at the cervi- Due to its high (96–98 %) mineral content, it is almost
cal region proliferate down over the dental papilla as a translucent, and gains its color from that of the underlying
double layer of cells that (at this site) is termed Hertwig’s dentin. Being ectodermal in origin, much of its limited
epithelial root sheath (Fig. 5.2). This epithelium induces the organic component is composed of the keratin family of
underlying mesenchymal cells to differentiate into odonto- proteins, in contrast to the largely collagenous proteins of
blasts, which produce dentin.13 With the progressive distal dentin and cement (i.e., connective tissue – reflecting their
disintegration of Hertwig’s epithelial root sheath, the dental mesodermal origin). In equine teeth, enamel (except on the
sac cells come into direct contact with dentin. Interaction occlusal surface) is usually covered by dull, chalk-like periph-
between these two tissues now induces the cells of the dental eral cement. However, at the rostral aspect of the incisors,
sac (mesenchymal cells) to convert into cementoblasts and and more occlusally on the cheek teeth, this peripheral
then to lay down cement (cementum).11,15 In equine teeth cement is usually worn away, thus exposing the shiny under-
cement deposition occurs over the entire crown, including lying enamel. The deciduous incisors often have little overly-
over the future occlusal surface just prior to eruption16 (Fig. ing cementum and thus appear whiter and shinier than their
5.3). When the equine tooth has reached its full length, the permanent successors. Enamel, with its high mineral content
epithelial root sheath disintegrates, and no further enamel and absence of cellular inclusions (unlike dentin or cement)
can be formed. can be regarded as almost an inert or ‘dead’ tissue. Therefore,
In the infundibula (two in all upper cheek teeth and one as the ameloblasts die off once the tooth is fully formed,
in all incisors), cement deposition proceeds by cemento­ enamel has no ability to repair itself. Enamel is almost fully
blasts, that are nourished by vasculature from the dental sac composed of impure hydroxyapatite crystals (Fig. 5.5) which
(Fig. 5.3) and also via openings in the apical aspects of the are larger than the hydroxyapatite crystals of dentin, cement,
infundibula.21 Immediately after eruption (or following loss or bone. Enamel hydroxyapatite crystals are arranged both
of the overlying deciduous tooth), the soft tissue of the into structured prisms which may be contained in a prism
dental sac is quickly destroyed by mastication and conse- sheath, and also into less structured, interprismatic enamel.
quently infundibular cement no longer has any occlusal Different species, different teeth within a species and even
blood supply (Fig. 5.3). The cement at the occlusal aspect of different areas of teeth in an individual can have differently
the infundibulum can now be regarded as an inert or ‘dead’ shaped enamel prisms or different arrangements of pris-
tissue, but cement deposition can continue more apically, matic and interprismatic enamel, which form the basis for
possibly for some years if an apical infundibular blood enamel classification in equidae.23
supply is present. Because of the frequent absence of com- Equine enamel is composed of two main types termed
plete filling of more central areas of the cheek teeth infundib- Equine Types-1 and -2 enamel, with smaller amounts of a
ula, the term central infundibular cemental hypoplasia has been third enamel, i.e., Equine Type-3 enamel sometimes

55
 5 Morphology

S Pc Pr
PE

IE
Cl MI
IA
Ch C

Fig. 5.6  Scanning electron micrograph of Equine Type-1 enamel showing

interprismatic plates (IP) alternating with rows of prisms (P). Note the
convergence and branching of some of the interprismatic enamel plates Fig. 5.8  Transverse subocclusal section of a methyl methacrylate
(×3700). embedded upper 09 of an 18-year-old horse. The rostral (mesial)
infundibulum (MI) and the caudal (distal) infundibulum (CI) are surrounded
by infundibular enamel (IE), and the infundibular cement has a central
channel (Ch). Five pulp cavities (Pc) are present and are surrounded by areas
of secondary dentin (S) that in turn are surrounded by primary dentin (Pr).
D Both the peripheral enamel (PE) and infundibular enamel (IE) are thicker at
3 1 the palatal (Pa) and buccal (B) aspects than at the interdental aspects (IA).
2
IP Additionally, the enamel is thicker in ridges (↑↑) than in invaginations (↑)
(×4). (Reproduced from Kilic72 with permission.)
P

D
PC
PC

C
Fig. 5.7  Scanning electron micrograph of a section of an equine tooth
showing dentin (D) enamel and cement (C). A thin layer of Equine Type-3
enamel (3) is visible on the left at the amelodentinal junction. Adjacent to
this area is a wider layer of Equine Type-1 enamel (1) showing interprismatic
enamel (IP) that is contiguous with Type-3 enamel and enamel prisms (P).
To the right is a wider layer of Equine Type-2 enamel (2) that in this area has
horseshoe-shaped prisms (↑) (×482). (Reproduced from Kilic et al23 courtesy L
of the Editor of Equine Veterinary Journal.)

Fig. 5.9  Transverse section 2 cm beneath the occlusal surface of a methyl
methacrylate embedded lower fourth cheek tooth of an 8-year-old horse.
detected.23 Equine Type-1 enamel is present on the medial The enamel (peripheral only) is thickest (↑↑) in regions that are parallel to
aspect of the enamel folds, i.e., at the amelodentinal junc- the long axis of the mandible and thinnest (↑) in invaginations of enamel.
tion. It is composed of prisms that are rounded or oval on One peripheral infolding is apparent on the buccal (B) aspect while two
deeper infoldings are present on the lingual (L) aspect. PC, peripheral
cross section and lie in parallel rows between flat plates of
cementum; D, dentin (×4). (Reproduced from Kilic70 with permission.)
dense interprismatic enamel (Figs 5.5 & 5.6). Equine Type-2
enamel is present on the periphery of the enamel layer, i.e.,
at the amelocemental (enamel to cement) junction, and is
composed solely of enamel prisms ranging from horseshoe The distributions of Equine Type-1 and -2 enamels vary
to keyhole in shape (Fig. 5.7) with no interprismatic enamel throughout the teeth, with Equine Type-2 enamel increasing
present. Equine Type-3 enamel is composed of prisms com- in thickness in the peripheral enamel folds (ridges) and
pletely surrounded by large quantities of interprismatic decreasing where these folds invaginate towards the center
enamel in a honeycomb-like structure and is inconsistently of the tooth (Figs 5.8 & 5.9). Almost all enamel folds contain
present as a thin layer at both the amelodentinal and amelo­ both Type-1 and Type-2 enamel; however, increased amounts
cemental junctions (Fig. 5.7). of Equine Type-1 enamel are present in the upper cheek

56
 Dental anatomy

IE

h IC
PD
OP ID
o

1 v 2

Fig. 5.10  Scanning electron micrograph of a section of an equine incisor Fig. 5.11  Scanning electron micrograph of partially decalcified dentin.
tooth showing dentin (D) infundibular enamel (IE) and infundibular cement The hexagonal shaped intertubular dentin (ID) has a compact appearance.  
(IC). A thin layer of Equine Type-1 enamel is present on the left (1). The bulk A network of collagenous fibers is apparent in the fully decalcified
of the enamel is Equine Type-2 (2) and this is oriented at a wide variety of intratubular dentin (formerly termed peritubular dentin) (PD) that are
angles including horizontal (h) obliquely (o) and vertically (v) relative to the attached to the odontoblast processes (OP) (×2020). (Reproduced from
occlusal surface. The bands of enamel oriented obliquely and vertically form Kilic72 with permission.)
alternating bands that are oriented perpendicular to the amelodentinal and
amelocemental junctions with the changes in direction of the enamel
bands are demarcated by grooves (∇∇∇∇) (×131). (Reproduced from Kilic
et al23 courtesy of the Editor of Equine Veterinary Journal.)
exposure and thus to apical infection.25,26 Donkeys have
similar enamel types and distribution of enamel types to
horses except that their maxillary cheek teeth have similar
teeth. Similar quantities of Equine Type-1 and-2 enamel proportions of Equine Type-1 and Type-2 enamels.27
occur in the lower cheek teeth, whereas incisor enamel is In equine cheek teeth, both peripheral and infundibular
composed almost solely of Equine Type-2 enamel. Equine enamel are about three times thicker in areas where they are
Type-1 prisms are oriented at angles of approximately 45° parallel to the long axis of the maxillae or mandible, than
to both the amelodentinal junction and the occlusal surface, where perpendicular to this axis, i.e., are invaginated into
but bundles of Equine Type-2 enamel prisms are oriented at the tooth.23 It appears that enamel may have evolved to
a very wide variety of oblique angles.23 become thinner or thicker in certain regions of the tooth in
Although enamel is the hardest substance in the mam- response to the level of localized masticatory forces.
malian body, it is brittle. The closely packed prisms of However, enamel thickness remains constant throughout
Equine Type-1 enamel form a composite structure including the length of the tooth, therefore, as the animal ages the
dense interprismatic plates that confer very strong wear enamel thickness remains constant at the different sites in
resistance. However, these often-parallel rows of enamel the transverse plane.
prisms and interprismatic enamel are susceptible to cracking
along prismatic and interprismatic lines. One adaptive
process to prevent such cracks, which is particularly notice-
Dentin
able in Equine Type-2 enamel, is the presence of enamel The bulk of the tooth is composed of dentin, a cream colored,
decussation (which means interweaving, with changes of calcified tissue composed of approximately 70 % minerals
direction of bundles of enamel prisms that run in three- (mainly hydroxyapatite crystals) and 30 % organic compo-
dimensions) (Fig. 5.10). In contrast, Equine Type-1 enamel nents (including collagen fibers and mucopolysaccharides)
has no decussation. Equine incisors are smaller and flatter and water. The latter content is obvious in dried equine teeth
than cheek teeth, have less support from adjacent teeth and specimens where the dentin (and also cement) develop arte-
yet undergo great mechanical stresses during prehension factual cracks following loss of their water content. The
that could readily cause enamel cracks. Therefore, it is not mechanical properties of dentin, including its tensile strength
surprising that they are largely composed of Equine Type-2 and compressibility, are highly influenced by the arrange-
enamel prisms. Cheek teeth primarily have a grinding func- ments and relationships of its matrix collagen fibers
tion, and so the presence of enamel that confers high wear (Fig. 5.11), other organic components, water content and its
resistance is more essential, and this requirement is fulfilled calcified components, with the heterogeneity of its structure
by the high proportion of Equine Type-1 enamel present in contributing to its overall strength.28 Electron microscopic
cheek teeth.23 Close examination of cheek teeth enamel examination of equine dentin shows that it contains both
sometimes shows the presence of fine transverse fissures calcified fibers and calcospherites. In equine teeth, the pres-
(micro fractures) through the peripheral enamel,24 which ence of dentin (and also cement) interspersed between the
does not appear to be clinically significant, as the progres- hard but brittle enamel layers forms an elegant laminated
sion of these cracks through the remaining part of the tooth structure (a biological ‘safety glass’) allowing the two softer
often appears to be prevented by the adjacent cementum and calcified tissues (dentin and cementum) to act as ‘crack stop-
dentin, but some fissure fractures can lead to pulpar pers’ for the enamel28 as well as creating an irregular occlusal

57
 5 Morphology

RL
PD 1D

O
2iD
2rD
p

RL

1D
pd

Fig. 5.12  Odontoblast cells (O) withdrawing toward the center of the pulp Fig. 5.13  Decalcified transverse histological section through a mandibular
(p) laying down a secretory matrix i.e., a paler staining layer of predentin CT pulp horn that has become completely filled with dentin. Primary equine
(pd) adjacent to the primary dentin (PD). dentin (1D) is peripheral to regular secondary dentin (2rD) and irregular
secondary dentin (2iD) with a resting line (RL) present between them  
(H and E).

surface, due to the differential wear between the hard enamel

and the softer cementum and dentin. Lateral (Buccal) Aspect
Dentin can be divided into three main types: primary
dentin; secondary dentin that can be subdivided into regular
E C E
and irregular secondary dentin;27,29,30 and tertiary dentin that C E
forms in response to local insults that in turn can be sub­ SD
divided into reactionary tertiary dentin if formed by pre- C1 R1
C
existing odontoblasts or reparative tertiary dentin if formed PD
by previously undifferentiated mesenchymal cells.31,32 Even C E E
in a morphological resting phase, odontoblasts remain PD
PD SD C
capable of synthesizing dentin throughout their lives if A B
appropriately stimulated.13,33 Similarly undifferentiated con-
nective tissue cells of the pulp can also be stimulated to Medial Aspect
differentiate into odontoblasts. In equine teeth, odontob- Fig. 5.14  A Triadan 11 maxillary cheek tooth (Triadan 211) showing 7 pulp
lasts (Fig. 5.12) synthesize regular secondary dentin and horns and a Triadan 08 mandibular cheek tooth with (the standard) 5 pulp
also irregular secondary dentin on the periphery of the pulp horns. The cheek tooth pulp numbering system is presented in Fig. 5.20.
horn throughout most of the life of the tooth, which gradu- C, cementum; E, enamel; PD, primary dentin; SD, secondary dentin.
ally reduces the size of the pulp cavity and thus of the pulp
and eventually fully occludes the pulp horn (Fig. 5.13). In
equids, irregular secondary dentin is a physiological dentin exposure of the pulp horns and vital pulp, due to normal
that is laid down last, subocclusally in the centre of the pulp attrition on the occlusal aspect and normal eruption. Follow-
cavity and, along with regular secondary dentin, it prevents ing insults to teeth, such as traumatic injury, dental caries,
pulpal exposure with normal wear (attrition). The physio- or excessive attrition, primary dentin can respond by devel-
logical nature of irregular secondary dentin has been shown oping sclerosis of the primary dentinal tubules to prevent
in horse and donkey teeth, when irregular secondary dentin microorganisms or their molecular products gaining access
was present sub-occlusally in every normal cheek tooth to the pulp, a defensive feature that is additional to the
examined histologically (Fig. 5.13).27,32 A recent study exam- deposition of tertiary dentin.
ining cheek teeth from 17 skulls (age range 4–30) showed As noted, the cream color of dentin largely contributes to
the median depth of occlusal secondary dentin in mandibu- the color of brachydont teeth. Because equine primary
lar and maxillary cheek teeth to be 10.8 and 9.0 mm, respec- dentin contains very high levels of heavily mineralized
tively, and does not appear to increase in thickness with intratubular dentin, it too has an almost translucent appear-
age.34 These values are similar to the mean occlusal second- ance, similar to enamel. In contrast, the less mineralized
ary dentin depth determined (by CAT examinations) in regular secondary dentin (produced at the site of the former
donkeys of 14.6 and 13.4 mm in mandibular and maxillary pulp cavity) has a dull opaque appearance. Secondary dentin
cheek teeth, respectively.10 However, the donkey study also absorbs pigments from foods such as grass (but little
showed a trend towards thicker secondary dentin in older from grains), which give it a dark brown color that is obvious
donkeys.10 in the so-called ‘dental star’ of incisors35 or in the brown
This process has great practical significance because the linear areas of secondary dentin that develop on the occlusal
occlusal surface of equine teeth would otherwise develop surface of cheek teeth that are in wear (Fig. 5.14).

58
 Dental anatomy

OP

ID

Fig. 5.15  Scanning electron micrograph of an untreated dentinal section Fig. 5.16  Scanning electron micrograph of the occlusal surface of an
showing a longitudinal profile of dentinal tubules containing odontoblast equine cheek tooth showing regular secondary dentin that has been etched
processes (OP) that are attached to the intertubular dentin (ID) by calcified to remove the organic pellicle. Almost all the dentinal tubules contain
fibrils (↑) (×1010). (Reproduced from Kilic et al36 courtesy of the Editor of protruding odontoblast processes (OP) which may be calcified and many
Equine Veterinary Journal.) are hollow (×1010). (Reproduced from Kilic72 with permission.)

Dentin is composed of several distinct structures, includ- termed laminae limitantes, that are the un-mineralized inner
ing dentinal tubules, which are its characteristic histological layer of intratubular dentin.39 However, even if microorgan-
feature, intratubular dentin (which lines the tubule walls), isms could enter patent dentinal tubules on the occlusal
intertubular dentin (which lies between the tubules) and surface, they may not reach the pulp cavity because the den-
odontoblast processes. Dentinal tubules extend from the tinal tubules are sealed by a smear layer of ground dental
pulp cavity across the width of the tooth to the enamel at tissue and additionally, retrograde flow of fluid from the
the amelodentinal junction. The odontoblasts reside in the pulp through the dentinal tubules to the occlusal surface40
predentin at the periphery of the pulp cavity, but their odon- may also prevent descent of microorganisms down these
toblast processes extend through the dental tubules (Figs tubules. Irregular (reparative) secondary dentin is less organ-
5.11, 5.12 & 5.15) as far as the enamel, sometimes subdivid- ized than primary dentin and contains no odontoblast
ing into two or three tubules and displaying a sharp curva- processes as its dentinal tubules are fully obliterated. This
ture just before reaching the amelodentinal junction. There type of dentin can fully seal off the pulp from the oral
is a debate on whether the odontoblast processes reach as environment.
far as the amelodentinal junction in other species, but in the Intratubular dentin (Fig. 5.11) has a higher mineral
horse it appears that the odontoblast processes do reach this content than intertubular dentin and therefore has a higher
far.36 Because there is an intimate association between the resistance to wear. A transitional region exists between
pulp and dentin that act as a single functional unit, the term equine primary and secondary dentin where intratubular
pulpodentinal complex is appropriately used for these two dentin is absent, and is sometimes very distinct histologi-
tissues.30 Because its tubules contain odontoblast processes, cally.32 Because regular secondary dentin contains no (dense)
dentin is considered to be a sensitive living tissue and thus intratubular dentin, it is more susceptible to attrition
mechanical interference with dentin, e.g., reducing larger than primary dentin. Likewise, the dentin near the ame-
overgrowths that contain dentin, can damage sensitive lodentinal junction contains the lowest amounts of intratu-
odontoblast processes and can thus potentially cause pain.37 bular dentin and would theoretically be expected to wear
In brachydont species, odontoblast processes or their sur- faster; however, it is protected from excessive wear by the
rounding fluid can convey pain signals from insulted (e.g., adjacent enamel.
by excessive heat or cold, trauma, infection) dentin to the
pulp, by incompletely understood mechanisms. In horses,
where exposed dentin constitutes a major part of the occlusal
Pulp
surface, it is most unlikely that such a pain-producing mech- The histology of equine teeth pulp has been poorly evalu-
anism exist on the normal occlusal surface. It is interesting ated to date, with most information derived from studies on
that on the occlusal surface of normal equine teeth, appar- brachydont teeth pulp. Pulp is a soft tissue within the dental
ently intact, odontoblast-like processes are visible protrud- pulp cavities that contains a connective tissue skeleton,
ing from the dentinal tubules of primary and regular including fibroblasts, thick collagen fibers and a network of
secondary dentin (Fig. 5.16), even though this area is con- fine reticulin fibers, connective tissue cells (that, as previ-
stantly exposed to oral microbial and biochemical insults38 ously noted, can differentiate into odontoblasts if appropri-
and pulpar infection is rare. A possible explanation for their ately stimulated), extensive vasculature (to allow active
apparently undamaged morphology is that they have become continuous secondary dentin deposition), lymphatics, and
calcified. Some studies have suggested that these structures nerves (sensory and vasoregulatory). In mature teeth, pulp
are not odontoblast processes, but are in fact collagen fibrils, is contiguous with the periodontal connective tissue at the

59
 5 Morphology

Fig. 5.17  Transverse section of a young equine maxillary cheek tooth

sectioned just above the apex showing the common pulp chamber that
later will become divided into separate pulp horns. A thick vascular
periodontal membrane surrounds a thin layer (not apparent in some areas)
of cementum that overlies the almost translucent layer of enamel that, in
turn, overlies a layer of thicker cream-colored dentin.

apical foramen. A thin layer of predentin (that becomes

thinner in older brachydont teeth) lies between the formed
dentin and pulp periphery that contains the odontoblasts
(Fig. 5.12) whose cytoplasmic processes extend into the den-
tinal tubules.
At eruption, equine permanent teeth possess a large Fig. 5.18  Transverse section of the skull of a 3.5-year-old horse at the level
common pulp (Fig. 5.17) that is contiguous with the pri- of the 207 (second right maxillary cheek tooth) and between 107 and 108
mordial pulp that surrounds the developing apices (Figs. on the left with part of 108 lying within the rostral maxillary sinus. Note the
5.18 & 5.19). At the apex of these young teeth, a thin layer remnants of the deciduous teeth (‘caps’), the angulation of the occlusal
of enamel surrounds this pulp. Later, following deposition surfaces, and the anisognathia. There are wide common pulp chambers of
the apices of the permanent teeth and absence of roots. The infundibula of
of apical dentin and cement, roots are developing well in all the temporary maxillary teeth have cemental hypoplasia.
equine cheek teeth by circa 2 years after eruption. One study
suggested that separate pulp canals may not develop in man-
dibular cheek tooth until 5–6 years following eruption,9 but
more extensive studies of both mandibular and maxillary CT
have shown separate pulp horn development 1 year follow- reduction in foramen size does occur with age.43 The apical
ing cheek teeth eruption.32 The distinct anatomical features foramina also become displaced more occlusally by contin-
of equine cheek teeth pulps have significant implications for ued cement deposition at the apical aspect of the teeth
endodontic therapy. The 07s to the 10s all contain 5 pulp with age. Kirkland et al found constricted (‘closed’) apical
horns but the fully-developed 06s and mandibular 11s foramina in equine mandibular cheek by 5–8 years after
usually contain 6 and the maxillary 11s have 7 pulp horns.32,41 their eruption, with development of two apical foramina in
Whilst the original pulp horn classification of Dacre32,41,42 the rostral root.9 This is in contrast to the apical foramina of
was a major step forward, its use of differing pulp number- brachydont teeth which become more rapidly and exten-
ings for upper and lower CT has caused some confusion. sively constricted (‘closed’) by deposition of secondary
Consequently, a modified pulp classification10 is used in this dentin within the pulp canal1 and also by cement deposition
text (Fig. 5.20). Equine incisors are similar to brachydont externally.
incisors in having just a single pulp. A practical result of these features is that pulp exposure in
Unlike brachydont teeth, hypsodont teeth need to con- mature brachydont teeth causes pulpitis due to pH changes,
tinue to lay down secondary dentin over a prolonged period irritation from molecules in saliva and foodstuffs, and an
(most of their life) in order to prevent occlusal pulp expo- inevitable bacterial infection. The resultant pulpar inflam-
sure. Consequently, in order to supply the metabolically mation within the totally rigid confines of the pulp chamber
active odontoblasts, the apical foramina through which the compresses the limited pulpar vasculature, usually leading
tooth vasculature passes into the pulp must remain relatively to pulpar ischemia and necrosis, resulting in the death of the
dilated (‘open’) for a prolonged period, although progressive tooth. However, in hypsodont teeth, especially when young,

60
 Dental anatomy

Buccal
1 2 1 2
1 2
7

6
8
3 3
4 4 3
5 5 4
5
Palatal
Buccal
1 2 2
1
1 2
6
7
5
3 5
4 3 4 5
3
4
Lingual
Fig. 5.20  A revised cheek teeth pulp numbering system (maxillary cheek
teeth on top row and mandibular cheek teeth on bottom row) as described
by du Toit et al.10

dentin, and thus are somewhat shell-like. These teeth are

readily rasped but may fracture if cut with shears (whose use
is no longer advocated – as mechanical burrs are much
safer). In contrast, the teeth of older horses contain large
amounts of secondary dentin, which makes them more solid
and less likely to shatter when cut, but more difficult to rasp
(float) than young teeth. With age, the pulp of brachydont
teeth loses much of its vasculature, fibroblasts, and odonto-
Fig. 5.19  Transverse section of the skull of a 3.5-year-old horse at the level blasts, while its collagen content increases. This process
of the 110 and 210 (with overlying infra-orbital canals) that lie at the should be delayed in equine teeth due to the prolonged,
junction of the rostral and caudal maxillary sinuses. Due to their curvature, higher metabolic requirements of their pulp to allow pro-
parts of the mandibular 10s and 11s are shown. The mandibular canal lies longed secondary dentin deposition (Fig. 5.12).
on the ventromedial aspect of the mandible. The wide common pulp cavity
of 210 has pulp horns that extend to within 1 cm of the occlusal surface.
Cement
Cement (cementum) is a white or cream-colored, calcified
the dilated apices and good blood supply often allows the dental tissue with mechanical characteristics and a histologi-
pulp to withstand such inflammation by maintaining its cal appearance similar to bone. It contains circa 65%
blood supply. Local macrophages within the pulp, along inorganic (again mainly impure hydroxyapatite crystals)
with extravasated white blood cells and their molecules can and 35% organic and water components. Similar to dentin,
then control pulpar infection. Additionally, the odonto­ its high organic and water content give it flexi­bility.
blasts laying down secondary dentin can also lay down The organic component of cement is comprised mainly
reactionary tertiary dentin in response to infection of the of extensive collagen fibers, which include small intrinsic
overlying dentin or following traumatic pulp exposure. In fibrils (produced by cementoblasts) and larger extrinsic
the absence of sufficient local odontoblasts as noted, adja- fibers (produced by fibroblasts of the periodontal mem-
cent undifferentiated connective tissue cells or fibroblasts in brane), some of which form tight bundles termed Sharpey’s
the pulp can transform into odontoblasts and lay down terti- fibers (median 2.5 microns in diameter in horses) that cross
ary reparative dentin to seal off the exposed pulp from the the periodontal space to become anchored in the alveolar
healthy more apically situated pulp. bone3 (Fig. 5.21), thus indirectly attaching the cement and
In addition to progressive, complete occlusion of the pulp alveolar bone. Cementum may be variously classified by its
horn beneath their occlusal aspect with secondary dentin, a cellular content, i.e., cellular or acellular; its anatomical loca-
continuous, but slower deposition of secondary dentin over tion, i.e., peripheral or infundibular; or coronal or root. A
all of the pulp horn walls causes the overall pulp size to recent study examining cell proliferation within the equine
reduce with age, as the surrounding dentin becomes thicker. periodontium demonstrated that a dynamic process of cell
A practical consequence of this is that the cheek teeth in proliferation and migration is involved in the periodontal
younger (e.g. <7–8 year old) horses contain a high propor- ligament remodeling associated with continued eruption.44
tion of hard but brittle enamel with minimal secondary The recent successful culture of equine periodontal

61
 5 Morphology

la

Fig. 5.21  Light microscopy of the periphery of an upper cheek tooth

showing the periodontal ligament (PL) containing fibroblast-like cells (↑). Fig. 5.22  Light micrograph of the peripheral cement of the deep reserve
The adjacent peripheral cement contains lacunae (La) of the cementoblasts crown (adjacent to the apex) of a recently erupted cheek tooth. This
(↑↑). Projections of the periodontal ligament into the cementum contains wavy incremental lines (arrowhead) between successive
(arrowhead) probably represent Sharpey’s fibers (×1000). (Reproduced from depositions of cement that have occurred even at this early stage of tooth
Kilic et al22 courtesy of the Editor of Equine Veterinary Journal.) growth. Cementoblast lacunae (la) are present at all levels of the cement
(×44). (Reproduced from Kilic72 with permission.)

fibro­blasts and equine dental cementoblasts will result in

better elucidation of the process of continued eruption.45
Under polarized light, undecalcified (ground) transverse la
sections of equine CT show two distinct regions. Adjacent to
the peripheral amelocemental junction, the crystalloid
nature of the cementum has irregular orientation of its
hydroxyapatite crystal similar to those of maxillary CT
infundibular cement. More peripherally, the crystal orienta-
tion changes to a more regular pattern, with the crystals
having a similar concentric orientation. ‘Peripheral lines’
may be observed in decalcified transverse sections in this Sh cn
more peripheral zone. These two zones of regular and irregu-
lar peripheral cementum are most obvious in sections of
older teeth near the occlusal surface.
Like dentin, cement (of the subgingival area and a few
millimeters more occlusally, i.e., of reserve crown and roots) Sh
is a living tissue with its cells (cementoblasts) nourished by
the vasculature of the periodontal ligament.2 Peripheral la
cement and the adjacent periodontal membrane can be con-
sidered as a single functional unit29 (as are dentin and pulp).
After eruption onto the clinical crown, cementoblasts lose
their blood supply from the periodontium and, in general,
cement on the clinical (erupted) crown can be regarded as
an inert tissue. However, recent work has shown active vas-
culature extending from the gingival margin beneath the
surface of cementum on the clinical crown.2,27 Cement is
the most adaptable of the calcified dental tissues and can
be quickly deposited (within the alveolus or subgingivally)
in response to insults such as infection or trauma,46 as
commonly observed in some teeth with chronic apical
infections.25,26 As noted earlier, hypsodont teeth have cemen-
tum covering all of the crown at eruption (including the
occlusal surface) but the latter is soon worn away after erup-
tion. Cement also fills the infundibula, usually incompletely Fig. 5.23  Transmission electron micrograph of peripheral cement of a
at eruption.21 cheek tooth. This shows irregularly shaped lacunae (la) and their canaliculae
(cn) but the cementoblasts have been lost during sample preparation.  
In hypsodont teeth, cement deposition continues through-
The dense Sharpey’s fibers (Sh) have been transversely sectioned.  
out the life of the tooth, both around the roots (root cement) The intrinsic fibrils of the cement (↑) are also apparent (×2150).
and also on the reserve crown (coronal cement) (Fig. 5.22). (Reproduced from Kilic et al,22 courtesy of the Editor of Equine Veterinary
The latter allows new Sharpey’s fibers (Fig. 5.23) to be laid Journal.)

62
 Dental anatomy

Infraorbital canal

'Open' apex
MS VCS

Pulp cavity Alveolar bone

Peridontium

Peripheral cementum

Pulp
Gingiva Fig. 5.25  Occlusal view of a maxillary cheek teeth row of an aged horse.
Just the roots (with the rostral roots separated) remain of the 109 and 111
that have heavy peripheral cement deposits. These remnants contain little
Thicker peripheral Infundibulum
cementum enamel (‘smooth mouth’) and consequently are ineffective at grinding
forage and will soon fully wear out. The infundibula of some of the
remaining teeth have fully worn out, and diastemata are present between
some teeth.
Fig. 5.24  Longitudinal section of a young maxillary cheek tooth lying in
the maxillary sinus (MS) and ventral conchal sinus (VCS). Note the very
extensive common pulp chamber and large pulp horns and thus a limited
amount of (secondary) dentin present, which is characteristic of young
equine teeth. Localized (clinically insignificant) central cemental caries is
present in the transected infundibulum. The alveolar bone and periodontal
membrane can be identified adjacent to the cement at the periphery of the
tooth. Note the increase in thickness of the peripheral cement (of the D
‘gingival reserve crown’) immediately following eruption of the tooth from ADJ
the alveolus.
IE

down, a process required to allow the necessary prolonged IC

eruption of hypsodont teeth and also to allow additional
cement deposition to mechanically contribute to the clinical
crown. However, further cement cannot be deposited in the
more occlusal aspect of the infundibulum that has lost its
blood supply following tooth eruption, or more apically in
the infundibulum unless some apical vasculature remains;21
Fig. 5.26  Scanning electron micrograph of a mid tooth transverse section
likewise on the cement of the clinical crown once it moves of the infundibular area of a maxillary cheek tooth of a 14-year-old horse.
a few millimetres away from the gingival vasculature.10 The This contains dentin (D), an amelodentinal junction (ADJ), infundibular
main functions of cement are to provide anchorage for fibers enamel (IE), and infundibular cement (IC). The infundibular cement shows
of the periodontal ligament that support (with some flexibil- extensive hypoplasia and areas of porous cementum with the large central
ity) the tooth in the alveolus, and to protect the underlying defect partially lined by shrunken organic tissue (arrowheads). The
dentin at the dental apex, and these two features of cement infundibular enamel is exposed in several areas (×10.6). (Reproduced from
Kilic et al,31 courtesy of the Editor of Equine Veterinary Journal.)
are present in both brachydont and hypsodont teeth.
However, in hypsodont teeth, cement has major additional
roles by contributing significantly to the bulk and thus A thin layer of peripheral cement covers the incisors and
mechanical strength of the clinical crown (especially in the canine teeth, but much greater amounts overlie the cheek
lower cheek teeth), protecting the coronal enamel from teeth, where its thickness varies greatly, largely depending
cracking and helping form the protruding enamel ridges on on the degree of infolding of peripheral enamel. Peripheral
the occlusal surface.2,43 The mandibular cheek teeth have a cement is thickest in deeply infolded areas, especially in the
greater amount of peripheral cementum than maxillary two deep infoldings on the medial aspect of the lower cheek
cheek teeth.10 teeth (Fig. 5.9). At these sites, especially towards the tooth
To provide additional cement on the clinical crown, there apex, this thick peripheral cement can be fully enclosed by
is a large increase in cement deposition, once the tooth exits these deep enamel folds, and these areas of cement can
from the rigid spatial restrictions of the alveolus2 (Fig. 5.24). resemble infundibula.
In some aged horses, the dental remnants exposed at the As noted, the infundibula (in all incisors and the upper
occlusal surface may eventually be composed only of roots cheek teeth) are usually incompletely filled by (infundibu-
(dentin and cement) with surrounding heavy cemental lar) cement. Kilic et al22 found that in addition to the 24 %
deposits. As this dental remnant contains no enamel, it of (upper) cheek teeth that had gross caries (mineralized
becomes smooth on its occlusal surface (smooth mouth) dental tissue dissolution) of their infundibular cement (Fig.
and wears away quickly (Fig. 5.25). 5.26), a further 65 % of horses had one or more small

63
 5 Morphology

central vascular channels in this cement.22,38 These channels

extended from the occlusal surface to a variable depth and
contained smaller lateral channels extending as far as the
infundibular enamel. This type of cement hypoplasia was
termed central infundibular cemental hypoplasia. In addition,
some infundibula had linear areas of cement hypoplasia at
the enamel junction termed junctional cemental hypoplasia.22
As this latter cemental hypoplasia was commonly found in
incisor infundibula, that show little evidence of caries (albeit
they are much shallower infundibula than those of cheek
teeth), consequently junctional cemental hypoplasia is not
believed to be clinically significant.22 A more recent study
showed infundibular cemental hypoplasia present in 22 %
of 786 maxillary cheek teeth infundibula, with discoloration
of an often porous-appearing infundibular cement present
in 72 % of infundibula and true cemental caries present in
8 % of infundibula (Figs 5.27 & 5.28). The most marked
cemental hypoplasia was present in the apical third of the
infundibula.21 As only 15 % of the infundibula were com-
pletely filled with normal cementum, the hypoplasia (Figs
5.27–5.29) and discoloration so commonly observed in this
study further supports the theory that cemental hypoplasia
and discoloration could almost be considered as normal
anatomical variations. Viable cementocytes and an active
local blood supply were found in the more apical aspects of
infundibula in one study (Figs 5.28 & 5.29).21

The occlusal surface

At eruption, the crown, including the occlusal surface of
equine teeth, is fully covered by coronal cement, which in
turn covers a thin layer of coronal enamel. With normal Fig. 5.27  Longitudinal section of a young maxillary cheek tooth circa
occlusal wear, the coronal cement and coronal enamel are 10 cm long with an infundibulum of 90 % of that length. Note the central
very soon worn away thus exposing the secondary occlusal area of discolored darker staining infundibular cementum that represents
the site of the central vascular channel. Two pulp horns derived from the
surface of these teeth, which is the permanent occlusal common pulp chamber are partially visible except at their occlusal aspects.
surface of hypsodont teeth (Fig. 5.3). The normal wear Enamel extends to the full extent of the immature apex indicating absence
process, i.e., attrition on the occlusal surface of hypsodont of root development. Note the extensive peridontal attachments
teeth is a complex phenomenon depending on many factors, peripherally.

Fig. 5.28  Longitudinal section of a

recently erupted maxillary cheek tooth
with both infundibula partly exposed.
The outlines of both infundibula are
curved and irregular with a dilation of
one infundibulum near its apex that
additionally contains some vascular
cementum with a blood supply from
the apical area. This infundibulum  
also has a central cemental defect
running through almost all of the
infundibulum with more marked dark
food-staining present 2–3 cm
subocclusally. Note that one pulp horn
contains viable pulp circa 5 mm
sub-occlusally.

64
 Dental anatomy

Depression Pulpar
exposure

Peripheral
enamel

Fig. 5.30  Occlusal aspect of two aged mandibular cheek teeth with the
tooth on the left showing limited peripheral cement infolding of its caudal
aspect – with consequent excessive wear of the adjacent dentin causing a
depression in this area of the occlusal surface (‘cupping’ ‘senile excavation’).
The adjacent cheek tooth has normal enamel infolding but has occlusal
exposure of one of its pulps.

Additionally, some shorter striations are present on the

occlusal surface of equine teeth perpendicular to the buc-
Fig. 5.29  Decalcified histological section of infundibular cementum from a
colingual/palatal plane (at right angles to the normal
109 in a 3-year-old horse showing viable cementocytes within the lacunae chewing direction), and it is suggested that these striations
(×100). Inset picture shows a viable infundibular cemental blood vessel with are caused by ingested phytoliths during the crushing phase
red blood cells (×400). of chewing.38
The softer dentin on the occlusal surface wears faster than
the surrounding enamel, and therefore the dentinal surface
becomes depressed, relative to the adjacent enamel. The
including the type of diet, e.g., in the winter outdoor horses depth of these depressions is directly related to the area of
may be forced to graze lower and thus ingest more soil- occlusal dentin, with larger exposed areas more deeply
covered roots and leaves, or even eat the roots of plants such recessed.38 In contrast, smaller areas of occlusal dentin are
as nettles (M. Booth 1996, personal communications), thus better protected from wear by the adjacent enamel folds and
greatly increasing the amount of silicates that are ingested. so undergo less wear and have shallower depressions on
When grazing is scarce, they may also eat coarser food, their surface. Therefore, the orientation and invaginations of
including bushes, such as gorse. The duration of eating the enamel folds (peripheral and infundibular) play an
also varies according to the season from up to 13 hours/day important role in dividing the occlusal surface of dentin into
in summer to 16.5 hours/day in winter in outdoor smaller areas and thus protecting it from excessive attrition.
horses, in some environments (M Booth 1996, personal The lower cheek teeth have three very deep infoldings of
communications). While eating hay, horses and ponies have enamel, two on the medial (lingual) aspect and one on the
58–66 chews a minute, with 4200 chews /Kg of dry matter,47 buccal aspect. The upper cheek teeth have less marked
whilst at grass they have 100–105 chewing movements per peripheral enamel infoldings; however, they contain two
minute.48 Dental attrition also depends on the force and the enamel-containing infundibula, which further subdivides
direction of the chewing action, the sizes, shapes, and angles and compartmentalize their occlusal dentin, thus protecting
of the opposing occlusal surfaces, and the relationship of it from excessive wear centrally in the teeth.38 The ratio of
opposing cusps and crest patterns to the occlusal motion. peripheral enamel length to tooth perimeter on sub-occlusal
Horses eating roughage exhibit a more lateral masticatory transverse sections is greater in maxillary cheek teeth with
action compared with horses eating a concentrate/pelleted infundibular enamel (1.87) compared to mandibular cheek
diet, which have a more vertical crushing stroke.49,50 Conse- teeth (1.48) despite the greater peripheral enamel infolding
quently, painful oral disorders can cause changes in the present in mandibular cheek teeth.10 There is usually less
direction and forces of mastication and thus affect the wear infolding of peripheral enamel folds more apically in teeth,
patterns of cheek teeth, as further discussed in Chapters 6 and therefore some older teeth may show excessive dentinal
and 9. wear at such unprotected areas (Fig. 5.30). Similarly, if
The occlusal surfaces of equine teeth are covered by an infundibula (in upper cheek teeth) are absent or are short
organic pellicle38 containing microorganisms, small food and wear away prematurely, excessive local dentinal wear
particles, and a smear layer of finely ground dental particles also occurs centrally in such teeth (Fig. 5.31). A study of
formed by masticatory actions. The underlying enamel con- normal infundibula has shown lengths (depths) from
tains differing wear patterns, including polished areas, small 89 mm (in a 4-year-old horse) to 2 mm (in a 30-year-old
local fractures, pit striations, and depressions. Most large horse), with infundibular length being a mean of 82 % of
striations are at right angles to the long axis of the cheek the total dental crown length.21
teeth rows (i.e., in the buccolingual/palatal plane) and
appear to be caused by the normal side-to-side chewing Gross Anatomy of Equine Teeth
motion of the cheek teeth when grinding down small
ingested phytoliths (calcified plant particles). Scanning
electron microscopy of such deep grooves shows that pris-
Incisors
matic enamel is more deeply worn than interprismatic The deciduous 01s (central incisors), 02s (middle-
enamel, confirming that the former structures are softer. intermediate) and 03s (corner) incisors erupt within a few

65
 5 Morphology

days of birth, 4–6 weeks, and 6–9 months of age, respec- depending on the presence and number of canine teeth or
tively.51 Deciduous incisors are whiter and contain wider and 1st premolar (wolf teeth).54
shallower infundibula than their permanent successors, The Triadan System of dental nomenclature utilizes three
which erupt on their lingual aspect. As noted, the eruption digits to identify each tooth. The first digit refers to the
of both deciduous and permanent teeth can be used to esti- quadrant, with 1 for upper right, 2 for upper left, 3 for lower
mate the age of horses up to 5 years old with a reasonable left, and 4 for lower right (Fig. 5.32).55 The deciduous teeth
degree of accuracy52,53 (see Ch. 7). are similarly identified using the prefix 5–8 for the four
quadrants.
The dental formula of deciduous and permanent Adult horses also have 12 incisors in total, six in each
arcade. The upper incisor teeth are embedded in the premax-
teeth in horses
illary (incisive) bone, and the lower incisors in the rostral
Deciduous teeth: 2 (Di 3 3 , Dc 0 0 , Dm 3 3) = 24 teeth mandible, with the reserve crowns and apices of incisors
Permanent teeth: converging towards each other. Incisor teeth are curved con-
2 ( I 3 3 , C 1 1 or 0 0 , PM 3 3 or 4 4 , M 3 3) vexly on their labial aspect (concavely on their lingual
= 36 to 44 teeth aspect) and taper in uniformly from the occlusal surface
toward the apex (unlike equine deciduous incisors, and all
brachydont incisors that have a distinct neck). Therefore
with age, spaces eventually develop between equine perma-
nent incisors, but the development of these spaces is delayed
by the medial (mesial) pressure of the 03s on the remaining
incisors. The fully developed incisor arcade in a young adult
horse has an almost semicircular appearance, which gradu-
ally becomes shallower with age, due to alteration of teeth
shape caused by progressive wear.56 The occlusal angle of
incisors also changes from almost vertical apposition in the
young horse (Fig. 5.33) to an increasing angle of incidence
with age.
Infundibular
Infundibular cementum Equine incisors also develop certain wear-related macro-
enamel scopic features that have been traditionally (if not very accu-
rately) utilized for estimating age52–54 as discussed in detail
in Chapter 7. The infundibulum present in all incisors is
Excessively termed the incisal cup (‘cup’). This funnel-like enamel struc-
worn
dentin ture is oval in shape and circa 10 mm deep when the tooth
first erupts. However, variations in its depth may cause the
Peripheral infundibulum to wear away more rapidly or slower
enamel than ‘normal’ and thus make aging difficult. The incisor
infundibulum is usually incompletely filled with cement
and consequently later becomes filled with food material
Fig. 5.31  Occlusal surface of a maxillary cheek tooth that is missing one of
its infundibula with resultant excessive wear causing a deep depression
and appears dark.52 When the infundibular cavity is worn
(‘cupping’ ‘senile excavation’) in the occlusal surface at this site. Such away, it leaves behind a small ring of the remaining apical
‘cupping’ may predispose to sharp overgowths on the lateral and medial aspect of the infundibular enamel, located on the lingual
aspects of upper and lower cheek teeth in older horses. Unusually the aspect of the tooth, which is called the enamel spot (enamel
remaining infundibulum appears to consist of two separate smaller ring or mark).52 Due to the slower wear of enamel as
infundibula.

111 110 109 108 107 106 105 104 103 102 101 201 202 203 204 205 207 208 209 210 211

411 410 409 408 407 406 405 404 403 402 401 301 302 303 304 305 306 307 308 309 310 311

Fig. 5.32  The Triadan classification of equine teeth.

66
 Dental anatomy

Coronoid process

Caudal maxillary sinus

Rostral maxillary sinus

Infraorbital foramen

First premolar (105)

Zygomatic process
of temporal bone Canine tooth (104)

Curved occlusal
surface

Mental foramen
True root Immature Thin ventral
apex mandibular border

Fig. 5.33  Diagram of a skull of a 5-year-old horse demonstrating ventral deviation of the mandible associated with eruption of 408. Note the shape and
apposition of the incisors of this young horse. The angulation of the rostral and caudal cheek teeth and the curvature of the sixth teeth maintain tight
apposition of all six cheek teeth at the occlusal surface. The TMJ is high (approximately 15 cm higher in an adult Thoroughbred) above the level of the cheek
teeth occlusal surface. Note the small coronoid process and the large area of muscle attachment of the mandible.

compared to dentin, the enamel spot becomes elevated and then oval in shape. These changes are more apparent in
above the occlusal surface. The dental star represents expo- the lower 01s and 02s than in the lower 03s.53,54
sure of secondary (regular and irregular) dentin on the occlu-
sal surface of incisor teeth that was deposited in the former
pulp cavity. It appears sequentially in the 01s, 02s and 03s
Canine teeth
(see Ch. 7). This secondary dentin initially appears as a dark The deciduous canine teeth (Triadan 504, 604, 704 and 804)
yellow (due to food staining), transverse line on the labial are vestigial spicule-like structures, 0.5–1.0 cm long, that do
aspect of the infundibulum. With further tooth wear, it grad- not erupt above gum level. The lower deciduous canine is
ually becomes oval in shape and moves toward the centre situated caudal to the 03s (corner incisor).51 Male horses
of the occlusal surface. normally have four permanent canine teeth, two maxillary
Galvayne’s groove is a longitudinal groove that appears (104, 204) and two mandibular (304, 404), that erupt
on the labial aspect of the permanent upper 03s (corner between 4 and 6 years of age in the interdental space (physi-
incisors), and is traditionally stated to first appear at about ological diastema).54 They are often stated to be simple teeth,
10 years of age, reaching halfway down the tooth by 15 years but while they have no enamel infolding, their clinical
of age and extending to the occlusal surface by 20 years of crown is covered in peripheral cementum, and some degree
age. However, recent critical studies, as reviewed in Chapter of prolonged eruption can occur. Canine teeth have a pointed
7, have shown much variation in the time that these features occlusal surface, are convex on their buccal border, and
develop. Another, variable anatomical feature is the develop- slightly concave on their medial (lingual and buccal) aspect,
ment of a ‘hook’ (a colloquial term for a localized dental with a slight caudal facing curvature. The lower canines are
overgrowth) on the caudolabial aspect of the occlusal surface more rostrally positioned than the upper, and thus there is
of 103 and 203 after circa 6 years of age, due to incomplete no occlusal contact between them. This is alleged to be a
occlusal contact between the upper and lower 03s. It is often reason why canine teeth (especially the lowers) are prone to
termed a ‘7 year notch or hook’ because it was traditionally develop calculus. Canine teeth are usually absent or rudi-
(but erroneously) believed to always appear at 7 years of mentary in female horses, with a reported prevalence of
age.7,56 Variations in incisor teeth appearance can also be due 7.8–28 % in horses57 and 17.3–30 % in donkeys.59 Canines
to individual and breed variation, differences in diets, envi- do not continually erupt like cheek teeth, and thus long
ronmental conditions, eruption times, mineralization rates, reserve crowns can be present in older horses. In the young
depth of enamel infundibulum, amount of infundibular adult Thoroughbred, canine teeth are 5–7 cm long with
cement and the presence of certain stereotypic behaviors, most present as unerupted crown. In some horses, just 10–
such as crib-biting and wind sucking.57,58 The occlusal surface 20 % of the crown is erupted and consequently, due to the
of individual incisors is elliptical in recently erupted incisors, great length and size of the reserve crown and roots, extrac-
but, with wear, they successively become round, triangular, tion of these teeth is a major undertaking. Canine teeth have

67
 5 Morphology

a wide pulp cavity that in young adult horses may extend to

within 5 mm of the occlusal surface; consequently, the
reduction (grinding down) of canines in horses (usually for
non-scientifically validated reasons) risks causing pulpar
exposure.

1st premolar (‘wolf tooth’)

One or both of the upper 05s (1st premolar), and less com-
monly, the lower 05s, can be present as the small, vestigial
‘wolf teeth’. These should normally lie immediately in
front of the 06s. They are simple brachydont teeth whose
clinical crown can vary from 1 to 2 cm in length. Their roots
can vary from being non-existent (with loose attachments of
the teeth to the gingiva), to being > 30 mm in length. These
teeth are sometimes rostrally or rostrolaterally displaced and
also may be angulated (i.e., not vertically aligned in relation
to the hard palate). The (permanent) 05s usually erupt at
6–12 months of age, and they do not have a deciduous Fig. 5.34  Occlusal view of the five maxillary cheek teeth of a 3-year-old
precursor. Wolf teeth have a reported prevalence of 24.4 % horse. Note the absence of spaces between these teeth, the pronounced
in females and 14.9 % in males;60 and of 13 %20 to 31.9 %61 vertical ridges on the buccal aspects of these teeth, and the triangular
in horses of both sexes. This wide range of prevalence is shape of the 06s (as will be the case for the 11s when they erupt).
likely due to loss of some wolf teeth at circa 2.5 years of age,
when the adjacent deciduous 06s are shed (J. Easley, per-
sonal communications). the (10), whose clinical crowns tilt rostrally (reserve crowns
tilt caudally; Fig. 5.33). The purpose of these angulations is
to compress all six cheek teeth together at the occlusal surface
Cheek teeth to prevent the development of diastemata. The buccal aspects
The 12 temporary premolars (506–508, 606–608, 706–708 of the upper cheek teeth have two prominent vertical (long­
and 806–808) are erupted at birth or do so within a week itudinal) ridges (cingula, styles) rostrally and a less promi-
or so. These deciduous teeth are replaced by the larger, nent caudal ridge with two deep grooves between them,
permanent premolars at circa 2.5, 3, and 4 years of age for except the 06s which can have 3–4 small grooves and ridges.
the 06s, 07s and 08s, respectively. In contrast to brachydont These ridges can decrease with age; they vary in size between
teeth and to equine incisors (where the deciduous teeth individual horses and different breeds. Dental overgrowths
are much smaller than the permanent teeth) the transverse (enamel ‘points’) can often be sharp and prominent on the
(cross sectional) area of equine deciduous cheek teeth lateral and medial aspects of these occlusal ridges (especially
can be similar to those of adult teeth,43 and thus a retained on larger ridges such as 10s and 11s), even in horses on a
remnant of a deciduous cheek tooth remnant (‘cap’) can permanent forage diet. In contrast, horses with less promi-
be difficult to identify from the underlying permanent nent vertical ridges appear to be less likely to develop enamel
tooth. The three deciduous cheek teeth in each row have a overgrowths on their maxillary cheek teeth. The palatal
distinct neck between the crown and roots, unlike their per- aspect of the upper, and both lingual and buccal aspects of
manent successors.62 Latterly, these deciduous cheek teeth the mandibular cheek teeth contain much less distinct verti-
erupt into the oral cavity due to traction by their periodontal cal grooves and ridges.
ligaments and pressure from the underlying permanent In younger horses, the permanent cheek teeth possess long
tooth. They are simultaneously resorbed at their apices by crowns, most of which is un-erupted reserve crown, that are
immunologically-mediated mechanisms until eventually embedded in deep alveoli (Figs 5.18, 5.19, 5.35). In Thor-
just a thin ‘cap’ of the temporary tooth remains lying on the oughbreds, the 06 cheek tooth is the shortest (circa 5–6 cm
occlusal aspect of the permanent cheek tooth (Fig. 5.18). maximum length), with the remaining cheek teeth being up
An adult equine mouth normally contains 24 cheek teeth to 9 cm long at eruption. Dental eruption proceeds through-
(06s–11s, i.e., 2nd – 4th premolars and 1st – 3rd molars), out the life of equine teeth, and normally the eruption rate
forming four rows of six teeth that are accommodated in the corresponds with tooth wear (attrition) and has been calcu-
maxillary and mandibular bones. The molars erupt at lated as 2–3 mm per year;4,5 therefore a 75-mm long perma-
approximately 1, 2, and 3.5 years of age, respectively. On nent 08 cheek tooth that comes into wear at 4 years of age
transverse section, equine cheek teeth are rectangular shaped, should be fully worn by 30 years of age.4
except the first (06) and last (11), which are somewhat tri- Once their roots have clearly developed (circa 2 years fol-
angular shaped (Figs 5.14, 5.34). The maxillary cheek teeth lowing eruption), the upper cheek teeth usually have three
are about 50 % wider and so are squarer in comparison with roots, two small lateral roots and a large, flat medial root,
the mandibular cheek teeth, which are narrower and more but occasionally the medial root will form two separate roots
rectangular in outline. The long axes of all cheek teeth are giving a total of four roots.63 The lower cheek teeth (except
relatively vertical, except the first cheek tooth (06) whose the 11s, which have three roots) usually have two equally
clinical crown tilts caudally (reserve crown tilts rostrally) and sized roots, one rostral and one caudal, that tend to become
the last cheek tooth (11) and to a lesser and variable extent longer than those of their maxillary counterparts.

68
 Dental anatomy

Fig. 5.36  Skull of an aged horse with the lateral maxillary and mandibular
walls removed to expose the cheek teeth. Minimal reserve crowns now
remain, with most teeth just having alveolar attachment to their (cemental)
roots (R) that are very elongated in all teeth. The mandibular teeth in
Fig. 5.35  Skull of young horse (circa 7 years) with the lateral maxillary and particular still have good angulation of their remnants, that is compressing
mandibular walls removed to expose the cheek teeth. Note the long reserve their occlusal aspects together. There is a ‘step-like’ overgrowth of the
crowns – with the mandibular 408 tooth almost touching the ventral cortex caudal three mandibular cheek teeth. Note the larger rostral maxillary sinus
of the mandible. The rostral maxillary sinus (RMS) and caudal maxillary sinus (RMS) and caudal maxillary sinus (CMS) in this older skull as compared to
(CMS) overlie the apical aspects of 408–411. Note the angulation of the the skull in Fig. 5.35. (Image courtesy of Istvan Gere.)
reserve crowns that keeps the occlusal surface of all 6 teeth tightly
compressed together. Root development is present in all teeth. Image
courtesy of Istvan Gere.

embedded in maxillary bones: for example, in young Thor-

oughbreds, the apices of the 08s often lie 2–3 cm rostral to
The alveoli of the first two upper cheek teeth (06s and 07s) the rostral aspect of the facial crest, the 07s lie 2–3 cm rostral
and often the rostral aspect of the 08, and usually all of this to this site, and the apices of the 06s lie a further 2–3 cm
tooth in older horses62 are embedded in the maxillary bone rostrally. In many young horses, eruption cysts occur at these
(Fig. 5.18). The caudal aspect of the 08 and the 09 alveoli sites during dental eruption, but due to the presence of the
usually lie in the rostral maxillary sinus, and the alveoli of overlying levator nasolabialis and levator labii superioris
the 10s and 11s usually lie in the caudal maxillary sinus (Fig. muscles, these swellings may not be detected.
5.19). However, there can be much variation in this finding, The six maxillary and six mandibular cheek teeth form
with the rostral aspect of the rostral maxillary sinus varying slightly curved rows (more pronounced in the maxillary
in position from overlying the 07s to the 09s, and the shell- cheek teeth), with their concavity facing buccally (laterally)
like, bony transverse maxillary septum (separating the rostral and lingually (medially), respectively.52 This convex curva-
and caudal maxillary sinuses) varying in position from the ture of the lateral aspect of the maxillary cheek teeth can be
caudal aspect of the 08s to the caudal aspect of the 09s.64,65 marked in some horses and a practical consequence is that
In young horses, the alveoli of the large cheek teeth reserve it renders effective dental rasping impossible, unless a selec-
crowns occupy much of these maxillary sinuses, but with tion of angulated rasps are available. A common feature of
age and subsequent eruption of their reserve crowns and all ungulates (mammals with hooves), including horses, is
remodelling and retraction of their alveoli, the sinus cavities the presence of an interdental space (‘bars of mouth’)
increase in volume, as their floor lowers due to cheek teeth between the incisors and the premolars, that is likely due to
eruption (Fig. 5.36). In younger horses, the infraorbital canal the evolutionary increase in face length (dolicephalic) to
lies directly over the apices of the caudal maxillary cheek allow these long-legged animals to more comfortably graze
teeth, and is often curved dorsally at this site, whereas in the off the ground66 whilst being able to view potential preda-
older horse a thin plate of bone (that divides the sinuses tors. Its presence, however, necessitates the clinical crown of
sagittally) attaches the alveoli to the infraorbital canal. the rostral cheek tooth (06) facing caudally to help compress
Additionally, the cheek teeth migrate rostrally in the the occlusal aspect of each row of cheek teeth, as noted
sinuses as they erupt.5 For example, the apex of the curved earlier (Fig. 5.33). In contrast, the complete arch of teeth of
upper 11s (caudal maxillary cheek tooth) drifts rostrally omnivores and many carnivores needs to be compressed in
from its site beneath the orbit in the young adult, to become just a single direction with the rostrally (mesially) facing
sited rostral to the orbit in the aged horse. The intimate rela- caudal tooth (‘wisdom tooth’) to promote compression of
tion between the caudal cheek teeth and sinuses can allow teeth.66
periapical infections of the caudal cheek teeth to cause max- Continued eruption of the angulated rostral and caudal
illary sinus empyema, as discussed in Chapters 13 (imaging) cheek teeth usually maintains the tight occlusal contact
and 14 (ancillary techniques). The rostral maxillary teeth are between the six cheek teeth until late in life in normal horses,

69
 5 Morphology

despite the fact that equine teeth slightly taper in towards more vertical and lead to a higher degree of occlusal surface
their apex and so, with age, would otherwise develop spaces angulation (e.g., >45 degrees in the caudal mandibular
between the teeth (interdentally–interproximally) that is cheek teeth), which is termed shear mouth if severe.
termed diastema(ta) (Fig. 5.25).67,68 Many very old horses The terminology concerning the irregularities present on
(>20 years) do develop diastemata between their incisors, the occlusal surface of the cheek teeth can be confusing. A
which is usually of little consequence in these teeth, unlike cusp is a pronounced elevation on the occlusal surface of a
the situation with cheek teeth, where diastemata can cause cheek tooth and is an area with thicker enamel. A ridge (or
food to accumulate between the teeth and in the adjacent style) is a linear elevation on the surface (peripheral or
periodontal space, possibly leading to severe dental disease,65 occlusal) of a tooth, and on the occlusal surface may be
and this situation is even more pronounced where cheek formed by interconnecting cusps. Horses usually have about
teeth diastemata are widespread and cause severe clinical 12 such ridges running transversely across the occlusal
disease.69 surface of their cheek teeth that are commonly termed trans-
The occlusal surfaces of the rows of cheek teeth are not verse ridges, two on the occlusal surface of each tooth,
level in the longitudinal plane as occurs in some other except the first and last, which can contain one to three
species, but instead the surfaces of the caudal 2–3 cheek ridges. These ridges can be quite tall, especially over the
teeth curve dorsally to a variable degree in the caudal direc- caudal cheek teeth in younger horses of certain breeds. Diet
tion that is termed the Curve of Spee 6 (Fig. 5.33). This and age may also influence their size. These normal ana-
curvature is often marked in Arabian-type horse breeds that tomical structures that increase the masticatory surface (and
often have a similar curvature on their (dished) facial bones, efficiency) of cheek teeth should not be confused with nar-
but can also be marked in other breeds of horses, even in rower acquired transverse overgrowths (usually just a lesser
larger draught horses with convex faces (i.e., ‘rams head’ or number) often termed ‘exaggerated or accentuated trans-
‘Roman nose’). Some horses also have a marked upward verse ridges’ due, for example, to being opposite a wide
curvature of the rostral aspect of their cheek teeth rows, with diastema or some other area of reduced contact with their
the lower 06 becoming quite tall (dominant) and little clini- occlusal counterpart.
cal crown present on the upper 06s. This anatomical configu- Because equine cusps contain sharp ridges of exposed
ration is likely be a normal anatomical variation in such occlusal enamel adjacent to hollows (craters) of dentin (and
horses, that causes no clinical problems, whereas misguided cementum at some sites) they are classified as lophs and
attempts to create a standard appearance of equine teeth thus the cusp pattern of equine teeth is termed lophodont.
certainly can have deleterious clinical consequences. If both A fossa is a rounded depression, and a fissure is a linear
a Curve of Spee and a rostral curvature are present, this gives depression between cusps or ridges.1,71 The latter physiologi-
the lower cheek teeth row occlusal surface a concave appear- cal fissures should be distinguished from pathological fissure
ance in the rostrocaudal plane, i.e., raised at the 06s and fractures (cracks) in cheek teeth24 that can lead to pulpar
the 11s. exposure.25,26 The opposing ridges and (physiological) fis-
In normal horses, the distance between the maxillary sures of the upper and lower equine cheek teeth interdigitate
cheek teeth rows is approximately 23 % wider than the dis- when the mouth is shut. Other variations in cusp number,
tance between the mandibular rows,70 a feature which is size and distribution are used for paleontological research
termed anisognathia. Anisognathia is even more marked and for taxonomic classification of different species.71
(27 % difference between upper and lower CT) in donkeys.10
This is in contrast to many brachydont arcades, such as
human upper and lower dental arcades, that are equally
Nerve supply of teeth
spaced (isognathic). As noted, the maxillary cheek teeth are Because of its great importance in human dentistry, the
also wider than their lower counterparts. Consequently, innervation of teeth has been well studied in brachydont
when the equine mouth is closed, approximately one-third teeth. Pulpar nerves enter through the apical foramen and
of the occlusal surface of the upper cheek teeth is in contact include sensory nerves derived from the trigeminal (5th
with about half of the lower cheek teeth’s occlusal surface. cranial) nerve, which are most extensive in the coronal
Additionally, the occlusal surfaces of the cheek teeth are not (occlusal) region of the pulp where they form the plexus of
level in the transverse (bucco-lingual) plane as is usually the Raschkow,13 and sympathetic fibers from the cervical gan-
case in brachydont species, but are angled between 15 and glion that supply the vascular smooth muscles to regulate
35 degrees [angled from dorsal on their lingual (buccal) blood flow in the pulp.72,73 The latter are also believed to
aspect to ventral on their buccal aspect] (Figs 5.18 & 5.19). control the differentiation and function of odontoblasts,
The maxillary cheek teeth have a lower angulation than the including their circadian rhythm of activity.30
mandibular cheek teeth, varying from circa 19.2 degrees at The type and duration of pain caused by stimulation
the 06s and decreasing to 9.2 degrees at the 11s. In contrast, of dentin are different from those of pulp. In brachydont
the mandibular cheek teeth occlusal angulation increases teeth, dentin responds to various stimuli, including excessive
from 15.3 degrees on the 06s to up to 31.5 degrees on the heat and cold, and to therapeutic procedures, such
11s.71 Cheek teeth angulation is also influenced by mastica- as drilling, with a sharp pain which stops when these
tory activity.50 For example, on a normal forage diet where stimuli cease. In contrast, stimulation of the pulpal nerves
horses have a wide range of lateral masticatory movement, produces dull pain (sometimes a throbbing pain synch­
the angle is believed to remain within the normal range. In ronous with the heartbeat caused by the effect of arterial
contrast, on a diet high in concentrates, e.g., processed pulsations within the inflamed pulp) which continues for
grains, or with an intercurrent painful dental disorder that some time after the stimulus is removed.30 Nerves are also
causes pain on mastication, the masticatory action will be present in the pulp of hypsodont teeth, although the role of

70
 Dental anatomy

sensory nerves is unclear, as these teeth have dentin, includ- Supporting bones and muscles of
ing open dentinal tubules, and odontoblast processes con- prehension and mastication
stantly exposed on the occlusal surface,38 a situation that
would cause marked pain in brachydont teeth. Following
significant dental overgrowth reductions, some horses do Alveolar bone
not masticate properly for days to weeks, and this is without Alveolar bone is very flexible and constantly remodels to
any evidence, attributed to temporomandibular joint (TMJ) accommodate the changing shape and size of the dental
pain caused by prolonged opening of the mouth with a structures it contains. Alveolar bone can be divided into two
speculum during the dental procedures. However, the recent main parts: a thin layer of compact (radiodense) bone (the
work showing exposed, apparently viable dentinal processes ‘cortex’ of alveolus) that lines the alveolus proper, in which
following dental rasping37 makes it more likely that in Sharpey’s fibers insert, that is radiographically termed the
fact pain from damaged sensitive dentin, or in some lamina dura (lamina dura denta). This area is radiographi-
cases from actual pulp exposure, is the cause of such cally detectable (but not on computed tomography) as a
post-treatment pain.74 thin radiodense line in brachydont teeth but due to irregu-
larities of the periphery of some normal equine cheek teeth,
Blood supply of teeth this feature is not always obvious on lateral radiographs of
equine teeth (Fig. 5.37). Secondly, the main alveolar bone
In brachydont teeth, the blood vessels enter pulp through surrounding the lamina dura denta cannot be morphologi-
the apical foramen and form an extensive capillary network, cally differentiated from the main bone of the mandible or
particularly in the coronal region of the pulp.30 These capil- maxilla in adult brachydont teeth.1 However, recent studies
laries drain into an extensive venous network that has a have shown that in horses, the alveolar bone beneath the
more tortuous course than the arterioles and also exits via lamina dura remains spongy and porous throughout life –
the apical foramen.30 Due to difficulties in microscopically similar to the alveolar bone of developing children’s
distinguishing lymphatics from vascular capillaries it remains teeth – probably a reflection of its constant remodeling as
unclear if lymph vessels are actually present in pulp.30 the equine teeth constantly erupt.2 This presents an area of
However, other authors believe that pulp tissues (like all anatomical weakness, which may explain why sequestration
other connective tissues), contain lymph vessels that in of the alveolar cortical bone can occur following oral extrac-
human beings drain into the submandibular and deep cervi- tion of cheek teeth. The most prominent aspect of the alveo-
cal lymph nodes. As previously noted, the good blood lar bone beneath the gingival margin (occlusally) is termed
supply and wide apical foramina of even adult equine teeth the alveolar crest.
can allow them to retain a blood supply following pulpar
exposure and then allow them to seal off the exposed pulp
with tertiary dentin. Although not involved in dental blood Mandible
supply, the greater palatine artery can be iatrogenically The mandible, the largest bone of the equine face, is com-
damaged during dental procedures and awareness of its site posed of two component hemimandibles that fuse together
and size is necessary. This artery runs around the periphery at the symphysis at 2–3 months of age.51 The mandible
of the hard palate and is not an end-artery as it adjoins its articulates with the squamous temporal bone at the TMJ and
counterpart rostrally and thus receives a blood supply from contains the alveoli of the mandibular incisors; canines; wolf
both internal maxillary arteries. It can be damaged if a dental teeth (if present) and lower cheek teeth. The ventral border
elevator slips medially when extracting wolf teeth, especially of the horizontal ramus of the mandible is wide and rounded
if they are medially displaced. It can also be damaged when in the young horse because of the length and size of the
orally extracting maxillary cheek teeth – which usually have reserve crowns of the cheek teeth it contains (Figs 5.18 &
short erupted crowns on their medial (palatal) aspect – if 5.19) and, conversely, becomes thinner and sharper in older
the extraction forceps is placed too high on the gingiva above horses as the cheek teeth erupt – a feature used to age horses
these teeth. in some Eastern countries. Some breeds, especially those that

Fig. 5.37  Radiographs of the apical aspects of

Infundibular enamel a young mandibular (left) and an inverted
aged maxillary cheek tooth (right). Note the
Lamina dura denta Peripheral enamel wide periodontal space of the younger tooth
Periodontal space that merges with soft tissue of the apical area
Peripheral cementum
and into the large apical foramen (of such
younger teeth) and on into wide pulp cavities.
Apical foramen The peripheral enamel folds reach to the apex
of this tooth i.e., it has no enamel-free apical
Root
Peripheral enamel area or true roots. In contrast, the older tooth
Sclerotic alveolar bone (right) has long true roots composed of
cementum with no radiographically obvious
apical foramen or pulp horns. The peripheral
(and infundibular enamel) folds are positioned
high above the alveolus on this old tooth due
Ventral mandibular to prolonged root cementum deposition.
border

71
 5 Morphology

are descendants of the Arabian horse (which in turn are their most highly developed masticatory muscles and are
descendants of Equus cracoviensis – Type IV horse), have innervated (like most muscles of mastication) by the man-
shallow mandibles and maxillae and commensurately dibular branch of the 5th cranial nerve. The facial (7th)
short reserve crowns, whereas most other breeds, e.g., derived nerve just innervates the superficial facial muscles (i.e.,
from E. muniensis (Types I or Mountain Pony) or E. muscles of expression). The powerful masseter muscle origi-
mosbachensis (Type III – Forest or Marshland Horse) such as nates along the full length of the facial crest and zygomatic
the North European Draught and native British pony types arch and has wide insertions along the caudo-lateral aspect
(such as Exmoor ponies) have deep alveoli and long reserve of the mandible, with its deeper fibers running ventrocau-
crowns.75,76 dally and its more superficial fibers running almost verti-
It has been proposed that crosses between these two types cally. Its elevated rostral border is caudal to the site where
of horses can develop pronounced ventral swellings under the facial artery, facial vein and parotid duct cross the ventral
the developing apices of the 2nd and 3rd cheek teeth,75 due border of the mandible and ascend vertically. In horses,
to an imbalance between mandibular depth and tooth the TMJ lies circa 15 cm above the level of the cheek
length. These mandibular eruption cysts (‘osseous tuber- teeth occlusal surface, and thus the movement arm of the
cles’) (Fig. 5.33) usually occur at 3–5 years of age and excep- masseter is longer. The powerful pterygoideus medialis and
tionally, unless they become infected (usually by blood lateralis muscles lie on the medial aspect of the mandible,
borne mechanisms, i.e., anachoresis), they usually regress and have similar attachments and orientation to the mas-
over the following 1–2 years.43 Other authors suggest seter, and can move the jaw sideways almost continually
that some breeds of horses are predisposed to retention with a strong power stroke.5 In some horses the pterygoideus
of deciduous cheek teeth remnants (‘caps’), which causes muscles are larger than the more obvious masseters. The
these mandibular swellings,67 but clinical studies have not relatively small digastricus muscle, which attaches from the
verified this.77 occipital bone to the caudal aspect of the mandible, func-
The mental nerve (branch of Cranial Nerve V) enters the tions to open the mouth – a gravity-assisted process that
mandibular foramen on the medial aspect of the vertical takes little mechanical effort, hence the small muscle size.
ramus, level with the occlusal surface of the cheek teeth. The Horses can generate massive occlusal pressure (up to 875N
mental nerve can be locally anesthetized at the mandibular during the power stroke) during mastication, that is highest
foramen to facilitate painful dental procedures (e.g., oral between the caudal cheek teeth, i.e., closest to the fulcrum
extraction of a mandibular tooth) in the standing horse. The (TMJ).79 Further details on masticatory function and on the
nerve then continues rostroventrally in the mandibular canal TMJ are presented in Chapter 6 (physiology) and Chapter
until it reaches the ventral aspect of the horizontal ramus, 23 (TMJ).
where it then continues rostrally within the mandible below The articular extremities of the mandible are composed of
the apices of the cheek teeth. However, in recently erupted the condyle that lies caudally and the coronoid process,
teeth whose apices reach the ventral border of the mandible, rostrally. The latter is poorly developed in the horse (Fig.
the nerve usually lies on the medial aspect of the developing 5.33) because it has smaller temporalis muscles (which close
tooth (Fig. 5.18). The main part of the mental nerve emerges the jaw) compared to carnivores, where the power stroke of
through the mental foramen on the rostrolateral aspect of the jaws is vertical (to catch and crush prey), consequently
the horizontal ramus, approximately halfway between the both the temporalis muscle and coronoid process are larger
lower 06 and the incisors, while a smaller branch continues in carnivores. Between the articular surfaces of the mandible
rostrally in a smaller canal along with the vasculature of the and the squamous temporal bone lies an articular disc that
lower incisors. The nerve supply to the lower incisors and divides the TMJ cavity in two. The joint capsule is tight and
lower canine tooth can be anesthetized within the rostral reinforced by an indistinct lateral ligament, and an elastic
aspect of the mandibular canal. posterior ligament.51
Immediately caudal to the alveoli of the lower 11s (6th Although it allows just limited opening of the jaws, the
cheek teeth), the mandible becomes a very thin sheet of equine TMJ has a wide range of lateral movements to
bone. This flattened, thin area progressively increases in size permit the cheek teeth to effectively grind coarse foodstuffs,
with eruption of the caudal mandibular cheek teeth and utilizing a side to side movement that is combined with
subsequent contraction of their alveoli. More caudally, at the a slight rostrocaudal movement of the TMJ, with one
angle of the jaw, this thin plate of bone expands medially side gliding rostrally and the other caudally. This rostro­
and laterally into two thick bony protrusions that are rough- caudal movement can vary greatly between horses and can
ened to allow muscle attachment (Fig. 5.33). These protru- be demonstrated in some sedated horses by gentle pushing
sions reduce in size towards the dorsal border of the vertical and pulling of the mandible rostrocaudally relative to the
ramus. These normal roughened mandibular areas may TMJ. More clinically significantly, this rostrocaudal man-
be radiologically confused with pathological mandibular dibular movement can be demonstrated by closing the
changes. mouth and then elevating the head – which causes caudal
movement of the mandible relative to the maxilla. Lowering
the head causes the opposite (rostral) mandibular move-
TMJ and muscles of mastication ment. This maneuver can cause a horse with mild overjet to
In contrast to carnivores that have a vertical power stroke, have normal occlusion on lowering the head. Horses with
horses also have a transverse power stroke in a lingual large focal dental overgrowths may have restriction of their
(medial) direction that is termed a lingual power stroke,78 rostrocaudal mandibular movement – but due to individual
as described in detail in Chapter 6 (physiology) and conse- variation between horses this parameter is difficult to
quently, their masseter and medial pterygoideus muscles are quantify.

72
 Dental anatomy

Maxillary bones connective tissue that limit its mobility. Most of the gingiva
is firmly attached to the supporting bone, with a slightly
The upper jaws are largely formed by the paired maxillary more mobile (usually non-keratinized) area, termed the free
bones that contain the alveoli of the upper cheek teeth, wolf (marginal) gingiva, which is the prominent area close to the
teeth and canine teeth (if present). The relationship of the tooth. Between the free gingiva and the tooth lies a depres-
cheek teeth to the maxillary bones and maxillary sinuses has sion termed the gingival sulcus, which is lined by non-
been discussed earlier. As noted, the rostral maxillary area in keratinized epithelium. In the deepest area of the gingival
younger horses may become focally swollen because of the sulcus lies the junctional epithelium, which is attached to
presence of the underlying eruption cysts of the 06s–08s. the peripheral cementum of the tooth, with the perio­dontal
The overlying bone may become thin and distended, with a ligament lying directly below this layer. In the horse, with
temporary and even focal loss of bone over the developing its prolonged dental eruption, this area is constantly remod-
apices occurring, but as noted these features are usually eling and reforming new periodontal ligaments and new
masked by the overlying muscles. Some 3–4-year-old equids gingival-dental attachments. In other species, interdental
(mainly ponies) develop marked bilateral firm swellings of papillae of gingiva are present between teeth to prevent food
the rostral maxillary bones during eruption of these teeth, trapping and subsequent periodontal disease, but as noted,
giving their face a ‘box-like’ appearance. These are the equiv- most equine teeth are tightly compressed at the occlusual
alent of the mandibular eruption cysts (‘osseous tubercles’, surface and so have no interproximal spaces occlusally.
‘3 or 4-year-old bumps’) of this same age group.
The facial crest is a lateral protrusion of the maxilla that
continues caudally as the zygomatic process and then joins The salivary glands
the zygomatic parts of the malar and temporal bones to form The (paired) main equine salivary glands are the parotid,
the zygomatic arch (Fig. 5.33). After giving off a small branch mandibular, and sublingual glands whose ducts drain
that runs rostrally to innervate the maxillary incisor teeth, directly into the mouth. Minor salivary glandular tissue is
the infraorbital nerve (a sensory branch of cranial nerve V) also present in the lips, tongue, palate, and buccal regions.
emerges through the infraorbital foramen, circa 5 cm dorsal The largest salivary gland is the parotid, which is circa 20–
to the rostral aspect of the facial crest. Its point of exit is 25 cm long, 2–3 cm thick, and weighs circa 200g in Thor-
covered by the pencil-like levator labii superiorus muscle, oughbreds, producing up to 50 ml of saliva/min. This
that can be dorsally displaced to allow local anesthesia of salivary gland lies behind the horizontal ramus of the man-
this nerve within the canal to anesthetise the upper 06 (pos- dible, ventral to the base of the ear, rostral to the wing of
sibly the 07), wolf teeth, canines, and incisors. atlas, extending ventrally just caudal to the mandible as far
The dorsal and caudal borders of the maxillary bone are as the tendon of origin of the sternomandibularis muscle
attached to the nasal and lacrimal bones respectively, whilst and the external maxillary vein (Fig. 5.38).5,51 The lateral
rostrally, the maxillary bone is attached to the premaxilla aspect of the parotid salivary gland is usually level with the
(incisive bone). The thicker ventral border of the maxillary masseter muscle, except for a small flat area of this salivary
bones contains the alveoli. The individual cheek teeth alveoli gland which can protrude above the surface of the masseter
are fully separated by transverse, inter-alveolar bony septa. muscle at the level of the lateral canthus of the eye, and
As noted, the equine maxillary sinuses are uniquely divided which often overlies some of the parotid lymph nodes at this
into rostral and caudal compartments by a thin, transversely site. In some apparently normal horses, the parotid salivary
angulated bony septum that can vary greatly in position. The gland may swell and protrude 1–3 cm above the masseter
medial aspect of each maxillary bone forms a horizontal muscle level when they are turned out to grass, in the ill-
bony shelf (the palatine process) that joins mid-line with its defined condition termed idiopathic parotitis (colloquially
opposite counterpart to form the supporting bone of most termed ‘grass glands’).
of the hard palate; the remainder of the hard palate is sup- The jugular vein is often embedded in the parotid salivary
ported by similar flat bony extensions, caudally by the pala- gland and the medial aspect of this gland covers the stylo-
tine bone, and rostrally by the premaxilla (incisive bone). hyoid bone, carotid artery, facial nerve, guttural pouch and
the origins of the brachiocephalicus and sternocephalicus
Premaxillary (incisive) bone muscles – the latter separating the parotid and mandibular
The paired premaxillary (incisive) bones form the rostral salivary glands.5 The dorsal aspect of the parotid salivary
aspect of the upper jaw. Their thick rostral aspects contain gland contains lymphatic tissue within its substance or lying
the alveoli of the incisors, whilst their thinner caudal aspects beneath it, which can become focally distended following
form the rostral aspect of the hard palate. The almost trans- purulent infections (especially strangles) of that region. The
verse suture line between the premaxillae and maxillae is an parotid duct originates from an amalgamation of 3–4 large
anatomically weak site that is a common site of fractures, ducts that converge on the rostroventral aspect of the parotid
especially in young horses. The canine teeth (if present) lie gland and this large duct then initially runs on the medial
on the maxillary side of this suture. aspect of the pterygoideus muscles (and mandible), and
then crosses beneath the ventral aspect of the mandible, just
caudal to the facial artery and vein. The parotid duct then
Oral mucosa moves dorsally on the lateral aspect of the mandible, moving
The mucosa of the gingiva and hard palate is a specialized rostral to the accompanying vasculature, and it perforates
masticatory mucosa. It can be keratinized, orthokeratinized the cheek at the level of the upper 08s35 (Fig. 5.38). At its
or parakeratinized and has deep interdigitating rete pegs caudal sites, the parotid duct is vulnerable to injury during
extending into the underlying vascular, subcutaneous cheek teeth repulsion, whilst it can be damaged more

73
 5 Morphology

Fig. 5.38  Diagram outlining the three (paired)

equine salivary glands.

Parotid
salivary gland

Masseter muscle

Facial crest
Mandibular
salivary
gland

Maxillary
cheek teeth 6

5
4

3
Parotid duct
2

Sublingual
salivary gland

rostrally by cheek teeth extraction by the lateral buccotomy the oral cavity in the sublingual fold, running beside the
technique.80 sublingual salivary glands rostrally, and enters into the oral
The smaller, (20–25 cm long and 2–3 cm wide, circa 50 g cavity on the lateral aspect of the sublingual caruncle.5 The
weight in adult medium-sized horses) mandibular salivary long, thin sublingual salivary glands lie superficially in the
gland lies deep to the mandible and parotid salivary glands floor of the mouth beneath the sublingual fold of the oral
and so is not palpable. It curves around beneath the parotid mucosa. They lie between the tongue and mandible, extend-
salivary gland and mandible, extending from the base of ing from the mandibular symphysis to the level of the lower
the atlas as far ventrally as the basihyoid bone. Its duct arises 09 and then drain through multiple small ducts into the
on its concave aspect and travels almost the full length of oral cavity.51

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204–208 86–199
FA Davis, Philadelphia and London,
1891, pp 33–35 70. Taylor AC. An investigation of 79. Staszyk C, Lehmann F, Bienert A, et al.
mandibular width and related dental Measurement of masticatory forces in the
63. Bradley OC. The topographical anatomy
disorders in the equine oral cavity, thesis. horse. Pferdeheilkunde 2006; 22: 12–16
of the head and neck of the horse. W
Coventry University, Coventry, 2008
Green, Edinburgh, 1923, pp 85–92 80. Dixon PM, Gerard M. Oral cavity and
71. Kilic S. A light and electron microscopic salivary glands. In: Auer G, Stick JA, eds.
64. Perkins J. Quantitative and qualitative
study of the calcified dental tissues in Equine surgery, 3rd edn. Elsevier,
anatomy of the equine maxillary sinuses
normal horses. PhD Thesis. University of St Louis, 2008, pp 321–350
with particular reference to the
Edinburgh, Edinburgh, 1995
nasomaxillary aperture, MScThesis,
University of Edinburgh, Edinburgh, 72. Hayward AF. Human tissue: Pulp. In:
2001 Osborn JW, ed. Dental anatomy and

76
 Section 2:  Morphology

C H A P TER  6 
Dental physiology
James L. Carmalt MA, VetMB, MVetSc, MRCVS, Dipl ABVP(Eq),  
Dipl ACVS
University of Saskatchewan, Western College of Veterinary Medicine, Saskatoon, SK, S7N 5B4, Canada

Introduction Functional morphology

This chapter focuses on how the masticatory system manages Thomas Henry Huxley, an ardent evolutionist, gave a public
ingested feed and prepares it for digestion. There is a large lecture in New York City on September 22 1876 entitled ‘The
amount of published data on the effect of chewing in the demonstrative evidence of evolution’ in which he used, as
ruminant and other herbivorous species.1 In the former case, his subject matter, the evolution of the horse beginning with
fermentation within the rumen does not significantly reduce Eohippus (now termed Hyracotherium).9,10 This lecture was
particle size, and in the horse there is no significant reduc- given in support of the newly published work, On the origin
tion in ingesta particle size between stomach and anus, of species by means of natural selection, or the preservation of
leaving mastication as the most important determinant in favoured races in the struggle for life by Charles Darwin.
feed particle size reduction. The evolution of the modern horse (Equus caballus) from
The morphology of equid teeth and their role in effective- its Eocene ancestors was one of the first examples recognized
ness of mastication have not been widely studied. Human to support the work of Charles Darwin. Two remarkable
studies have used molar occlusal surface area (OSA) as an adaptive traits allowed the horse to take advantage of increas-
indicator of chewing effectiveness. The influence of this vari- ing areas of grassland: a rapid (by paleobiological standards)
able on a variety of nutritional parameters has been studied change in dental morphology in just over 1.5 million years
in red deer,2 where researchers found that animals with low (or 0.5 million generations) and secondly, the loss of extra-
OSA had a greater mean fecal particle size, but no difference neous digits in the support of a single, enlarged middle toe
in the mean retention time of gastrointestinal contents was adapted for speed.
found between groups. Additionally, animals in the low The basic mammalian dental formula is of 3 incisors, a
OSA group had a greater mean number of chews per gram canine, 4 premolars and 3 molar teeth. The significance of
of dry matter than high OSA animals. the cheek tooth arrangement is two-fold. Firstly, premolars
Because the primary masticatory movement of herbivo- have a deciduous (juvenile) counterpart, and secondly, they
rous animals is a lateral translocation of the mandible, the are generally smaller and less robust than the larger, perma-
enamel ridge perimeter distance (termed ‘length of occlusal nent molars. Thus, the importance of the molarization (or
enamel edge’, ERPD) has been used to assess mastication in the assimilation of molar tooth characteristics) of the 2nd –
some studies. This measurement has been used in studies of 4th equine premolars should not be underestimated.
Nubian ibex, red deer, possums, gliders, koalas, and horses.2–7 In the modern horse, the first premolar is vestigial and
In koalas, ERPD was found to be directly related to chewing is the only cheek tooth not to have evolved hypsodonty
effectiveness.6 and a complex root system in conjunction with the
Only recently has similar attention turned to studies of remaining teeth.
dental physiology and masticatory biomechanics of the The environmental drive forcing the ancestors of the horse
horse. This revival has been driven by the fact that a greater from browsing to grazing and to develop a greater body size,
number of horses are currently undergoing oral examina- selected individuals with a different dentition than previ-
tions on a routine basis, the findings of which are querying ously required. Grasses are high in abrasive silicates, which,
the etiopathogenesis of common dental malocclusions. The in addition to Cope’s Law (stating that within a lineage there
absence of dental malocclusions or dental abnormalities is a tendency or trend toward increasing body size), forced
should, in theory, result in a normal masticatory cycle, an increase in body size from the fox-terrier-sized Eohippus
which would generate the appropriate forces on the occlusal (estimated to be 3 hands, i.e., 12 inches tall ≈5 kg) to the
surfaces of teeth for effective mastication, as well as resulting modern 14–16 hand (56–68 inch tall, 500–1000 kg) horse.
in sufficient even wear of the entire occlusal surfaces of all A doubling of body mass requires an eight-fold increase in
teeth, thus preventing overgrowth. However, the patterns of the amount of ingested feed. Simply doubling the size of
jaw movement (masticatory biomechanics) are the result of teeth would result in only a 4-fold increase in the surface
a complex interrelationship between food consistency, par- area of the occlusal surface of the tooth, which would be
ticle size, and neural control of mastication.8 inadequate to support these evolutionary changes.

77
 6 Morphology

Thus, evolutionary strategies to overcome these problems support, which otherwise would have resulted in breakage
included an increase in the relative size of each tooth, a of the enamel crests and thus negation of the hypsodont
change in the type and complication of the relationship effect. Cement is also formed within the enamel infoldings
between dentin and enamel ridges, and an increase in (infundibula) of the maxillary cheek teeth as the teeth
crown height (hypsodonty). There was even a lineage (clade) develop within the dental sac. Cement is also produced
of late Miocene horses (Pseudohipparion) that developed around the developing roots as they are formed. In this way,
hypselodont (elodont) teeth (continually growing teeth, a cheek tooth with prolonged eruption is formed with a
like those of rodents), but these horses were ultimately crown height (including reserve height) of at least twice
unsuccessful. its width. Such a tooth usually erupts at a rate equal to the
Ancestors to Eohippus (Phenacodus) had premolar and rate of the wear of the crown by attrition; however, in some
molar teeth formed like those of the pig or bear.11 They were cases, where there is no opposing tooth, ‘super-eruption’
broad and bore many separate conical cusps on the occlusal may occur.
surface that evolved to deal with a varied diet of insects, Odontological evolution in the horse was thus a rapid,
fruits or vegetables. As with the modern horse, the lower sustained event encompassing the molarization of premolar
teeth were narrower than the uppers; however, the surface teeth, the development of hypsodonty and cemental protec-
variations were such that both sets of teeth meshed together tion, as well as amalgamation of enamel crests into linear
when the jaws were closed. Microscopic wear patterns on occlusal ridges to increase efficacy for shearing coarse forage.
these teeth have suggested that the predominant chewing These evolutionary advantages are thought to have allowed
motion was crushing (vertical), rather than the modern the horse to advance from a generalized browsing animal to
shearing (side-to-side) action.12 In Hyracotherium the ante- a specialized grazer, thus enabling it to take advantage of the
rior (towards the front) premolars of the upper jaw were still increasing grassland areas of the late Eocene, Oligocene, and
shaped as cutting blades and were triangular. The complete Miocene eras. By the time of the arrival of Merychippus and
row of cheek teeth in this animal was no more than 10 cm the subsequent radiation (encompassing 19 species in the
in length in a mesial-distal (rostrocaudal) direction, approxi- late Miocene), the dental revolution was effectively at an
mately the same length as two cheek teeth of the modern end. Some small variations in the degree of hypsodonty
Equus caballus. continued, notably in the form of Nannohippus; however, the
A later horse, Orohippus, developed a sub-triangular- dental pattern observed in the modern horse (Equus caballus)
shaped second premolar (from its initial cutting blade is essentially unchanged for 15 million years. (See Chapter
appearance), but the fourth premolar was already four- 1 for more detail.)
cusped and quadrate (square). Epihippus had a squarer
second premolar, but both the third and fourth premolars Anatomy
were now quadrate. The outer crest of the tooth (the ectol-
oph) became W-shaped at this stage and has remained so Molarization of the cheek teeth of the horse, as with most
since. Mesohippus emerges at 40 million years, and all teeth herbivores, resulted in a row of 6 cheek teeth (not including
except the first premolar are now molarized with the excep- the 1st premolar), which function as a single chewing unit.
tion of the first premolar, which (if present) remains a uni- The integrity of this unit is maintained due to a combination
cuspid tooth to the present day. of the initial caudal angulation of the clinical crown of
Thus molarization, the first defining moment in equine premolars 2 (Triadan 06) and to a variable extent of the 07
dental evolution, was complete within 20 million years. and the rostral (mesial) angulation of the clinical crowns of
However, these teeth were still brachydont (low crowned) molars 1 to 3 (Triadan 09–11), the ‘keystone effect’ of an
and not able to withstand the rigors of animals wholly com- almost vertical eruption of the 4th premolar (08, Fig. 6.1)
mitted to grazing. Hypsodonty did not make a determined
appearance in the fossil record until the evolution of Parahip-
pus (23 million years) and its descendent Merychippus, at
which time the predominant chewing direction was side-to-
side with a wide stroke action ensuring efficient shearing
forces applied over the chewing surface.13 Interestingly,
research also indicates a gradual increase in crown height
from Parahippus through Merychippus into the modern equine
lineage and also into the extinct Hipparion group of horses.14
Enamel crests became increasingly convoluted, with the
effect of increasing the surface area (or perimeter) of the
enamel. These changes were similar in both upper and lower
jaws, but the changes were less extreme in the lower teeth.15
The spaces between enamel ridges are filled by a softer mate-
rial (dentin) which is preferentially worn away to create
craters rimmed by sharp enamel edges over which the grass
is sheared. In conjunction with the infolding (pleating) of
enamel ridges, cementum appeared in late Parahippus and
Merychippus animals.16 This material is softer than enamel
but is firm, tough and less brittle. Cementum filled the areas Fig. 6.1  A lateral radiograph of a young horse (4 years old) showing
around the edges of the brittle enamel crests providing the relative angulation of the cheek teeth (lines).

78
 Dental physiology

Fig. 6.2  (A) A photograph of an

equine maxilla taken post mortem.
Note the curvilinear arrangement of
the cheek teeth and compare the
width of the interdental oral cavity
(IDOC) with that of the mandibular
teeth. (B) A photograph of an equine
mandible taken post mortem. Note
the relatively straight arrangement of
the cheek teeth and compare the
width of the interdental oral cavity
with that of the maxilla.

A B

and the rostral (mesial) drift of cheek teeth as the horse

ages.
The horse is anisognathic, i.e., the lower dental arcade is
straighter and 23–30 % narrower than that of the upper
arcade (Fig. 6.2), such that the maxillary teeth project later-
ally beyond the mandibular teeth (Fig. 6.3). There is a sig-
nificant difference in morphology between maxillary and
mandibular cheek teeth, with the former generally having a
greater surface area and containing more enamel in the form
of mesial and distal infundibula.17 Despite large differences
in body weight realized by Equus callabus, measurements of
total cheek tooth enamel ridge perimeter distance have been
found to be only 7 cm more in a 1000 kg horse when com-
pared with a 350 kg pony.18 More recently, a number of
dental morphological variables (including total, inner, and
outer enamel ridge perimeter distance as well as total, inner,
and outer surface area) were measured in horses of different
body size and further confirmed an absence of correlation
between body size and any measured variables.7
The mandible articulates with the maxilla at the temporo-
mandibular joint (TMJ). This is a synovial joint formed by Fig. 6.3  A schematic diagram of the equine head as it pertains to the teeth.
the condylar processes of the mandible and the articular The outline of the incisors is in black and the position of the cheek teeth
can be seen through them. Note that in centric occlusion (when interdental
tubercle of the temporal bone. The relative incongruity spaces 1/201 and 3/401, red arrows, are in alignment) the cheek teeth are
between these bones is accommodated by the presence of a not in occlusion. This is normal.
fibrocartilagenous disc. The joint capsule is reinforced by the
presence of rostral and caudal ligaments, the latter of which
is concurrently attached to the disc. The joint is divided by
the disc into a larger dorsal and a smaller ventral compart- bone. The mandibular condyles are angled at approximately
ment, which communicate on the axial aspect of the joint. 15°, in a ventromedial to dorsolateral plane as well as from
TMJ morphology has been described in-depth using a variety a mediocaudal to laterorostral direction (Fig. 6.4). These
of different imaging modalities,19,20–22 (and as described in angles are mirrored by those of the articular portion of the
Ch. 23) and while the relative shapes and sizes of the osseus temporal bone. Interestingly, this 15° angulation of the TMJ
components vary with the size of the head, there is a consist- is also reported to be reflected in cheek tooth occlusal angles,
ent angulation of the mandibular condyle and temporal as well as the angles of the palatine ridges.23 More recent

79
 6 Morphology

There is also controversy surrounding the effect cheek

tooth occlusal angle and cheek tooth occlusion percentage
have on crude protein and fiber digestion,30,35 with others
finding no discernable effect on the same outcome varia-
bles.26 Additionally, the study of Carmalt and Allan found
A B no correlation between any dental morphological variable
examined and feed digestibility or ingesta particle size.7
Fig. 6.4  (A) Mandibular condyles, caudal view –15° angles. (B) Mandibular
condyles, dorsal view –15° angles.
Mastication: the chewing cycle
studies do not support this association as closely. Cadaver
studies suggested that not all cheek teeth within an arcade Chewing is a repetitive, cyclical motion resulting from the
have the same angulation.24,25 Mean angulation in the former contraction of musculature. Other than in man, studies of
study was 10° (+/− 6 degrees SD) and was unaffected by chewing cycles in mammals indicate consistent chewing pat-
tooth position or tooth age,24 whereas in the latter study terns (individually and within the species). How the food is
mandibular angles ranged from 19.2 to 30° and were sig- broken down, however, in horses, depends on the integrity
nificantly different from their maxillary counterparts, with a of the cheek teeth. In the following description of the mas-
range from 12.5 to 18°.25 In a study using live horses, mean ticatory cycle, the start-point will be the ‘neutral position’,
molar cheek tooth occlusal angle was determined to be 9° when the incisors are in centric occlusion (i.e., the interden-
(+/−2 degrees) and 10.6 degrees (+/− 7°) using a photo- tal space of 1/201 and 3/401 are in vertical alignment,
graphic and single tooth method, respectively.26 Fig. 6.3) and the cheek teeth are not in occlusion. Other
Jaw closing is effected primarily by the paired masseter and methods of description use maximal incisor separation as
temporalis muscles with a contribution from the pterygoid the start-point.36
muscles. These muscles originate on the maxilla and cranium Herbivorous mammals have a masticatory cycle consisting
and insert on the mandible. of three phases: the opening stroke (O), the closing stroke
Jaw opening is effected by contraction of the anterior belly (C), and the power stroke (P), which are defined by the rela-
of digastricus combined with the contraction of geniohyoi- tive displacement of the mandible.37 Using isolated frames
deus, and the inferior fibers of genioglossus coupled with from a video recording of equine mastication (Fig. 6.5A), a
the sternohyoideus and omohyoideus. All of these muscles schematic diagram of mandibular motion was constructed
that open and close the jaw are innervated by the fifth cranial (Fig. 6.5B). Note that Points 1–4 represent the opening
(trigeminal) nerve. stroke, including a small but integral rostral movement of
The significant disparity in mass between jaw elevator and the mandible,31,38 Points 5–6 represent the closing stroke,
depressor musculature can be explained by understanding and Points 7–10 represent the power stroke. This analysis of
the movements of the equine jaw during prehension and the equine masticatory cycle suggests, in fact, the presence
mastication. The mandible is elevated (mouth closed) of a fourth stroke – a post power ‘recovery’ stroke. During
against resistance (gravity and feed), whereas opening is the opening stroke, the mandible is displaced (laterally
primarily effected by gravity. Prehended feed is crushed and translated) to the point that cheek teeth occlusion occurs, at
sheared during jaw closure, which requires forces exceeding which point further displacement (translation) necessitates
those generated simply by elevating the mass of the man- incisor separation (Fig. 6.6). The forces generated during the
dibular structures. Jaw muscles have faster contraction rates closing and power equine masticatory strokes have been
than most other striated muscles, with reported contraction reported to be 248N ± 117N (24.8kg) and 875N ± 278N
rates of 333–500 cycles/min in pygmy goats.27 (87.5 kg), respectively. Maximum chewing force recorded
The muscles of the cheeks and lips include the levator and was 1758N (175.8 kg).39
depressor labii maxillaris and mandibularis, the orbicularis Some observers have stated that horses appear to be either
oris, the incisivus mandibularis and maxillaris, the buccina- right-sided or left-sided chewers. While some horses consist-
tor and zygomaticus muscles. These muscles are innervated ently demonstrate major lateral mandibular excursion to
by the seventh cranial (facial) nerve and control lip closure, one side only, the belief that they are only applying crushing
elevation, retraction and depression, as well as the flattening force to one side of the mouth consistently is not accurate.
of the cheeks. In a study of the masticatory movements of 400 horses, 45
The role of dentition in post-masticatory feed digestibility horses (11 %) chewed on both sides, 163 horses (41 %)
in the horse has been extensively studied in recent years. moved the mandible to the right (i.e., clockwise as viewed
Three initial clinical trials examined the role of dentition in from the front) and 131 (32 %) chewed counterclockwise
equine nutrition.28–30 The former two pronounced a benefit (i.e., mandibular movement to the left), while 63 horses had
of dental floating on feed digestibility, whereas the latter did incomplete observations recorded.40
not. Further studies suggest that although occlusal equilibra- It has further been suggested that during the power stroke
tion (floating) increases the rostrocaudal mobility (RCM) of in ungulate mastication, there is only contact with one side
the mandible,31 and reduces the number of chews/kg DM of the arcade at a time.41,42 This may be the case in some
(hay and barley) it does not alter chew rate,32 or improve species, but in the horse, the extent of anisognathism would
feed digestibility, fecal particle size, or weight gain in the suggest that there has to be some contact with both sides.
pregnant mare.31,33,34 Examination of the control animal Despite this anatomical constraint, major pressure would
subset similarly did not find a correlation between oral first be applied to one side and then, as the surfaces slide
pathology score and weight gain. across each other, to the other side (frames 5–10). It might

80
 Dental physiology

4 3 2 1 10

3 1
6 8
9
5
2 10

4
5 6 7 8 9
A B 3

Fig. 6.5  (A) Isolated video frames during a single masticatory cycle in the horse. (B) Schematic diagram to explain mandibular movement during
the masticatory (chewing) cycle. The figure is drawn from an imaginary perspective, above and immediately ahead of the horse’s head.

A
B

Fig. 6.6  (A) A schematic diagram of the equine head as it pertains to the teeth during the opening cycle of mastication. In this view, the mandibular
movement is to the reader’s left and is arrested at the point of molar contact. To travel further laterally, incisor separation has to occur. (B) As above. Lateral
movement is complete. Cheek teeth are in maximal occlusion, and the incisors are separated.

be concluded from these observations that there is a ten- occlusal surfaces of the cheek teeth and its subsequent move-
dency for unequal dental attrition as a result of the variation ment caudally within the oral cavity can be likened to that
in masticatory physiology. Necropsy examination of the of an auger. It is important to remember at this stage that
occlusal surfaces of the cheek teeth of horses (including all six cheek teeth function as a single unit and feed material
those with routine dental care, as well as those with a known is processed by each portion of each tooth only once, as the
history of no dental care) does not support this. bolus is moved caudally. The cheeks keep the ingested, par-
When eating, the horse uses its lips to prehend food mate- tially masticated feed within the intradental oral cavity
rial and pull it between the incisor teeth. The incisors cut or (IDOC).
grasp the food material using a bite force of approximately As the feed material is crushed, it is directed into the IDOC
2 % of body weight.43 The rostral part of the mouth is thus by the food channels on the occlusal surfaces of the cheek
filled, and mastication begins. The passage of feed across the teeth (loph basins). There are also 18 pairs of incomplete

81
 6 Morphology

Table 6.1  Mean (±SD) values for mastication parameters for the four horses used in the food-processing experiment

Fiber diet
Mastication parameter Low Medium High
g/‘mouthful’ 12.1 ± 2.1 9.5 ± 2.4 8.1 ± 1.3
Chew rate/10 s 11.6 ± 0.6 11.5 ± 0.2 11.4 ± 0.2
Energy/g/chew 9.4 ± 4.8 ¥ 10–3 8.9 ± 6.4 ¥ 10–3 1.4 ± 1.4 ¥ 10–2
Duration of grind (s) 0.51 ± 0.08 0.53 ± 0.03 0.55 ± 0.02
Incisor displacement (cm) 4.4 ± 0.6 4.5 ± 0.6 4.4 ± 0.3
Premolar 4 velocity (cm/s) 10.4 ± 1.8 9.7 ± 2.4 8.5 ± 0.4

Collinson (1994)18 with permission.

palatine ridges, each of which is curved from caudolateral to when chewing hay than when chewing pellets. This increased
rostro-medial, and offset in the midline (Fig. 6.2A). Food lateral movement was sufficient to allow full occlusal contact
material is compacted in the IDOC, pressed against the pala- between upper and lower cheek teeth rows during the
tine ridges by the tongue and moved caudally by the rotatory chewing cycle. These scientific data lend support to clinical
action of mastication, tongue and cheek compression. Swal- observations that horses managed extensively may not
lowing is initiated when boluses of food collect in the develop significant cheek tooth malocclusions (specifically
oropharynx. sharp lateral edges to the maxillary cheek teeth and lingual
The auger analogy has been substantiated by descriptions edges to their mandibular counterparts) as frequently as
of feed-bolus shapes obtained from edentate horses. Pro- pellet fed, intensively managed stabled animals.33,48
vided that feed presentation (crushed or soaked) is accept- Mandibular motion is controlled by the muscular forces
able, edentate horses can survive and thrive, but if they are acting upon it; however, morphological changes in dentition
allowed access to long-stem fiber (such as grass or hay), (occlusal pathology or malocclusions such as a ‘shear
spiral boluses of unmasticated feed combined with copius mouth’) or TMJ pathology have the potential to dramatically
amounts of saliva are produced, which may represent a affect masticatory efficiency. Determining whether TMJ
choke (esophageal obstruction) hazard.40 disease leads to alterations in the biomechanical forces
Factors influencing masticatory movements include the during mastication that subsequently cause dental malocclu-
fiber and moisture content, and the physical structure (degree sions, or whether dental malocclusions lead to altered mas-
of processing) of the diet. Chew rates have been calculated tication, thereby leading to TMJ pathology, is very difficult.
from electromyographic data,37 and direct observations18,44 To date, other than cases of septic or traumatic joint disease
(Table 6.1, data recorded over 10 minutes). It was noted that of the TMJ, there are no published data (clinical case reports
horses were capable of attaining higher than 11 per second or otherwise) to support a diagnosis of degenerative
chew rates, particularly at the onset of feeding. In more joint disease of the TMJ, despite the fact that it clearly occurs
recent studies, rates of 8 +/−1 chew cycles per 10 seconds (see Ch. 23).
(0.8 cycles per second) have been recorded.39 The degree of
lateral excursion was originally documented in an innova-
tive study that produced ‘molographs’ of the chewing pattern Summary
(the extent of lateral excursion) in horses eating different
feeds.45 However, Collinson’s research18 did not confirm The design and function of the equine masticatory appara-
these earlier observations that higher fiber content and lower tus has been refined over millions of years to cope with the
moisture content reduced the extent of excursion of the feedstuffs necessary for survival. The development of hyp-
mandible.45 More recently, studies have documented the sodonty, prolonged eruption of teeth, and the balancing of
three-dimensional kinematics of the equine TMJ and associ- eruption and attrition have been finely tuned. The mastica-
ated movement of the equine mandible during mastica- tory cycle results in balanced dental attrition which, in the
tion.18,46 A further study used the same recording method absence of dental abnormalities, serves the horse well. The
(using markers attached to the maxilla and mandible) to process of domestication (intensive rather than extensive
determine the relative positions of these structures while management styles) and the advent of processed feedstuffs
horses chewed either hay or pellets.47 From these data, the significantly alter the duration and biomechanics of masti-
three-dimensional position, i.e., displacement and rotation cation. These factors, in combination with increased per-
(defined as yaw, pitch, and roll) of the mandible compared formance expectations, selective breeding that ignores the
to the maxilla could be calculated. There was no difference presence of inherent dental disorders, and the current lon-
in mean velocity of mandibular motion between hay and gevity of horses, have resulted in the appearance of dental
pelleted diets; however, chewing frequency was lower in hay malocclusions and diseases of the soft tissues of the mouth
compared to pellet diets. The study also found that there was upon which the science and art of equine dentistry are
greater lateral translation (movement) of the mandible based.

82
 Dental physiology

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(Phascolarctos cinereus) dentition and 21. May KA, Moll HD, Howard RD, et al. 34. Carmalt JL, Townsend HGG, et al. The
nutrition. I. Morphology and occlusion Arthroscopic anatomy of the equine effect of dental floating on weight gain,
of cheek teeth. J Zool Lond 1986; 209: temporomandibular joint. Vet Surg 2001; body condition score, feed digestibility
155–168 30: 564–571 and fecal particle size in the pregnant
6. Lanyon JM, Sanson GD. Koala mare. J Am Vet Med Assoc 2004; 225:
22. Rodriguez MJ, Latorre R, Lopez-Albors O,
(Phascolarctos cinereus) dentition and 1889–1893
et al. Computed tomographic anatomy of
nutrition. II. Implications of tooth wear the temporomandibular joint in the 35. Rucker BA. Modified procedure for
in nutrition. J Zool Lond 1986; 209: young horse. Equine Vet J 2008; 40: incisor reduction. In: Proceedings 41st
169–181 (fast track) Annual Meeting American Association
7. Carmalt JL, Allen A. The relationship of Equine Practitioners 1995, pp 41,
23. Baker GJ. Equine temporomandibular
between cheek tooth occlusal 42–44
joints (TMJ): Morphology, function and
morphology, apparent digestibility, and clinical disease. In: Proceedings American 36. Hiiemae KM. Mammalian mastication: a
ingesta particle size in the horse. J Am Association of Equine Practitioners 2002; review of the activity of the jaw muscles
Vet Med Assoc 2008; 223(3): 452–455 48: 442–447 and the movements they produce in
8. Hiiemae KM. Mammalian mastication: a chewing. In: Butler PM, Joysey KA, eds.
24. Carmalt JL. Observations of the cheek
review of the activity of the jaw muscles Development, function and evolution
tooth occlusal angle in the horse. J Vet
and the movements they produce in of teeth. Academic Press, London, 1978,
Dent 2004; 21: 70–75
chewing. In: Butler PM, Joysey KA, eds. pp 359–398
25. Brown SL, Arkins S, Shaw DJ, Dixon PM.
Development, function and evolution 37. Weijs WA, Dantuma R. Electromyography
Occlusal angles of cheek teeth in normal
of teeth. Academic Press, London, 1978, and mechanics of mastication in the
horses and horses with dental disease.
pp 359–398 albino rat. Journal of Morphology 1975;
Vet Rec 2008; 162: 807–810
9. MacFadden BJ. What’s the use? 146: 1–34
26. Carmalt JL, Townsend HGG, Cymbaluk
Functional morphology of feeding and 38. Bonin SJ. Three dimensional kinematics
NJ. The effect of cheek tooth occlusal
locomotion (pp 229–262). In: Fossil of the equine temporalmandibular joint.
angle and degree of occlusion on weight
horses. Systematics, paleobiology and MS Thesis, Michigan State University,
gain, feed digestibility and fecal particle
evolution of the family equidae, 2001
size in horses. J Am Vet Med Assoc 2005;
Cambridge University Press, Cambridge, 39. Staszyk C, Lehmann F, Bienert A, et al.
227: 110–113.
UK, 1992 Measurement of masticatory forces in the
27. Gans C, DeVree F. Correlation of
10. Anon. The theory of evolution. The New horse. Pferdeheilkunde 2006; 22: 12–16
accelerometers with electromyograph in
York Times. September 23rd 1876 40. Baker GJ. Dental Physiology. In: Equine
the mastication of pygmy goats (Capra
11. Bennett D. The evolution of the horse. In: hircus). Anatomical Record 1974; 306: dentistry, 2nd edn. Baker GJ, Easley J,
Evans JW, ed. Horse breeding and (Abst): 1342–1343 eds. Elsevier, London, 2005, pp 49–54
management. Elsevier Science, New York, 41. Fortelius M. Ecological aspects of dental
28. Gatta D, Krusic L, Casini L, et al.
1992, pp 21–29 functional morphology in the Pleistocene
Influence of corrected teeth on
12. Butler PM. Some functional aspects of digestibility of two types of diets in rhinoceroses of Europe. In: Kirsten B, ed.
molar evolution. Evolution 1972; 26: pregnant mares. In: Proceedings 14th Teeth, form, function and evolution.
474–483 Symposium Equine Nutrition and Columbia University Press, New York,
13. Rensberger JM, Forsten A, Fortelius M. Physiology Society. 1995, pp 326– 1982, pp 163–181
Functional evolution of the cheek tooth 331 42. Fortelius M. Ungulate cheek teeth:
pattern and chewing direction in Tertiary 29. Krusic L, Easley J, Pagan JD. Influence of developmental, functional and
horses. Paleobiology 1984; 10: 439– corrected teeth on daily food evolutionary interrelations. Acta
452 consumption and glucose availability in Zoologica Fennica (Helsinki) 1985; 180:
14. Stirton RA. Observations on evolutionary horses. In: Proceedings 1st Symposium 78
rates in hypsodonty. Evolution 1947; 1: on horse diseases. Radenci, Slovenia, 43. Hongo A, Akimoto M. The role of
32–41 1995, pp 53–68 incisors in selective grazing by cattle and

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horses. J Agric Science 2003; 140: Verdauungsstörungen beim Pferde unter 47. Bonin SJ, Clayton HM, Lanovaz JL,
469–477 Heranziehung von Kaubildern. Veterinary Johnson TJ. Comparison of mandibular
44. Brøkner C, Nørgaard P, Søland TM. The Medicine Dissertation, Hanover, 1941, motion in horses chewing hay and
effect of grain type and processing on pp 170–174 pellets. Equine Vet J 2007; 39: 258–262
equine chewing time. Pferdeheilkunde 46. Bonin SJ, Clayton HM, Lanovaz JL, 48. Carmalt KP, Carmalt JL. Equine dentistry:
2006; 22: 453–460 Johnson TJ. Kinematics of the equine what do we really know? J Vet Dent
45. Leue G. Beziehungen zwischen temporomandibular joint. Am J Vet Res 2007; 21: 134–135
Zahnanomalien und 2006; 67: 423–428

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 Section 2:  Morphology

C H A P TER  7 
Aging
Sofie Muylle DVM, PhD
Department of Morphology, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133,
B-9820 Merelbeke, Belgium

Introduction at the occlusal surface, whose continuously changing con-

figuration allows a macroscopic dental age estimation.4–15
The age of a horse can be an important consideration when The most appropriate teeth for aging horses are the (lower)
forecasting its useful working life, when purchasing the incisors. The premolars and molars can be used with con-
animal, for insurance policies and for the prognosis of dis- siderable accuracy to determine the horse’s age, but their
eases. Furthermore, as long as no indelible identification distal position has limited their use.16 Recent work has
methods for horses are imposed, age estimation contributes shown that cheek teeth morphology data can be used to
to the identification of an animal. predict age in horses that possess all permanent dentition.17
Why does the horse, of all animals, have teeth that lend Radiographic assessment of cheek teeth root morphology
themselves to age determination? Most domestic animals can also help in determining age, especially in the young
(cattle, carnivores, etc.) have brachydont incisor teeth, i.e., horse.8 Because contact between upper and lower canines is
low-crowned teeth that erupt fully prior to maturity and that seldom made, canines do not wear down in a regular way
are strong enough to survive for the life of the animal. and have no age-related occlusal surface.
Equine teeth, which are subjected to much higher levels of When estimating a horse’s age by its incisors, the eruption
dietary abrasive forces, are hypsodont, which means that dates and the changes in appearance of the occlusal surfaces
they erupt continuously over most of the horse’s life. It is are the main criteria. Neither is wholly dependable but the
important in this context to make a distinction between first is the more reliable, although limited in application to
tooth growth and tooth eruption. Tooth growth implies the younger animals. The second may be used throughout the
lengthening of the tooth in its apical part due to the deposi- life span but becomes increasingly inaccurate with age.18
tion of new layers of dentin and cement. Tooth eruption is Incisival characteristics that are frequently used for dental
the progressive protrusion of the tooth out of its alveolus. It aging in horses are summarized below.
is now generally assumed that tooth eruption is caused by a
continuous remodeling of the periodontal ligament fibers
and not by root lengthening as was claimed before. The Eruption
deposition of bone at the bottom of the alveolus should be
the result rather than the cause of tooth eruption.1 In this context, gingival emergence is used as a reference
Equine incisors erupt lifelong, whereas their intrinsic point for eruption.
growth ceases at the age of about 17.2 As the total length of
horse incisors remains unchanged from the age of six until Eruption of the deciduous incisors (Fig. 7.1)
the age of 17, the continuous loss of occlusal dental tissue
is compensated by an equal amount of newly formed dental The deciduous incisors are smaller than the permanent ones.
tissue at the apical end of the tooth. During this period of The surface of their crown is white and presents several small
time, tooth root growth makes up for occlusal wear, which longitudinal ridges and grooves. The occlusal tables of decid-
is estimated to occur at a rate of 2.5 mm a year.3 In horses uous incisors are oval in the mesiodistal direction.
aged over 17 years, occlusal wear is no longer compensated
by apical tooth growth, and the total incisival length dimin- Eruption of the permanent incisors
ishes progressively. In horses of this age category, continu-
ous tooth eruption is the only mechanism to provide
(Figs 7.2 & 7.3)
maintenance of occlusal contact between upper and lower Permanent incisor teeth are larger and more rectangular than
incisors. the deciduous incisors. Their crown surface is largely covered
Because of the marked wear on the surface of hypsodont with cement and has a yellowish aspect. The upper incisors
equine teeth, occlusal exposure of dentin and cement is generally present two distinct longitudinal grooves on their
inevitable after the protecting enamel is worn off. This leads labial surface; the lower incisors have only one clearly visible
to the presence of alternate layers of the three calcified tissues groove.

85
 7 Morphology

Fig. 7.1  Arabian horse, 2 years old. The deciduous incisors have small Fig. 7.4  Standardbred horse, 8 years old. Dark-colored dental stars are
ridges and grooves on their labial surface. present in all lower incisors. The characteristic white spot in the center of
the dental star appears in the centrals (arrows). Cups have disappeared from
the central incisors. The remaining marks are oval (arrowheads). Deep cups
are still present on the middle and the corner incisors.

tertiary dentin that occludes the pulpal chamber when it

risks being exposed by wear. In young animals the dental
star appears as a linear stripe because the occlusal end of the
original pulp cavity is not conical but elongated in a mesio-
distal direction. With age dental stars become oval and then
round and move towards the center of the occlusal table.
These progressive patterns reflect cross-sections through the
stuffed pulp cavity at various levels.

Disappearance of the cups

Fig. 7.2  Belgian draft horse, 2 years and 10 months. The right permanent The infundibulum is an enamel infolding in the occlusal
central incisor (401) is emerging through the gum. All other incisors are surface of the equine incisor. The superficial half of the
deciduous. infundibulum is empty or filled with food particles. This part
is called the ‘cup.’ The bottom of the infundibulum is filled
with cement. When wear has brought this infundibular
cement layer into the occlusal surface, the cup is filled in or
has disappeared. The exposed cement core and the sur-
rounding enamel ring are called the ‘mark.’

Disappearance of the marks

The shape of the mark generally corresponds to the contour
of the occlusal table of the incisor. In young horses marks
are oval in the mesiodistal direction. When wear progresses,
marks become smaller and rounder and move caudally (lin-
gually) on the occlusal surface. With age, the cement of the
infundibular bottom wears away and eventually the remain-
ing enamel spot disappears from the occlusal surface.

Fig. 7.3  Belgian draft horse, 5 years and 7 months. All incisors are Changes in shape of the incisors
permanent and have a yellowish appearance.

Changes in shape of the occlusal surfaces

Changes of the occlusal surface (Fig. 7.4) (Fig. 7.5)
Due to extensive wear, the sequential shapes of the occlusal
Appearance of the dental star tables represent the cross-sections of the incisor teeth at
The dental star is a yellow-brown structure on the occlusal various levels. The sequence ranges from oval in the mesio-
surface situated between the labial edge of the incisor and distal direction, to trapezoid and triangular, and finally to
the infundibular cavity or ‘cup.’ It consists of secondary and oval in the labiolingual direction.

86
 Aging

c d

a b c d
A
A

a b c d
B

Fig. 7.6  (A) Belgian draft horse, 6 years old. The upper and lower incisors
are positioned in a straight line with each other. The crown of the upper
a b c d corner (103) is wider than it is tall. Notice the presence of a hook on the
upper corner (arrow). (B) Standardbred horse, 16 years old. The angle
between upper and lower incisors is more acute. The crown of the upper
C
corner (103) is taller than it is wide. The upper corner presents a Galvayne’s
groove over the entire length of its labial surface.
Fig. 7.5  (A) Longitudinal section of the lower central incisor of a
Standardbred horse (4 years old). (B) Lower central incisor of a 5-year-old
Standardbred horse. Cross-sections at various levels as indicated in (A).  
In the sections c and d, the pulpal cavity is open. (C) Occlusal tables of   is generally wider than it is tall. At ages 9–10, the upper
the lower central incisor of Standardbreds aged: a, 5 years; b, 8 years;   corner appears square in most horses and then progresses to
c, 14 years; d, 20 years, respectively. In the occlusal tables c and d the pulpal taller than it is wide as age increases.
cavity is occluded by secondary dentin.

The hook on the upper corner incisor

Direction of upper and lower incisors (Fig. 7.6) (Fig. 7.6A)
When incisors are viewed in profile, the angle between the The caudal edge of the upper corner sometimes exceeds the
upper and lower incisors changes with age. In young horses, occlusal surface of the lower corner, especially when the
the upper and lower incisors are positioned in a straight line lower incisors have acquired their oblique position. If
(angle ±180°) with each other. With age, the occlusal por- the caudolateral portion of the upper corner is no longer in
tions of the crowns wear off, and we look at different cross- contact with its lower counterpart, it wears more slowly,
sections of the crown shape in profile. The angle between forming a hook in the occlusal surface. Later, when the
upper and lower incisors becomes, therefore, increasingly upper incisors obtain their oblique position and the caudal
acute. The lower incisors are the first to obtain an oblique edge of the upper corner is in contact with its lower coun-
position followed at a later date by the upper incisor teeth. terpart again, this notch can disappear.

Length versus width of the upper corner The Galvayne’s groove (Fig. 7.6B)
incisor (Fig. 7.6) The Galvayne’s groove is a shallow, longitudinal groove on
The shape of the upper corner incisor has been used recently the labial surface of the upper corner and is filled with dark
to categorize a horse’s age into three groups from 5–20 years stained cement. In the unworn tooth the groove starts
of age.8 Between 5 and 9 years of age the crown of this tooth halfway from occlusal surface to apex and continues

87
 7 Morphology

three-fourths of the distance to the apex. It is buried within from the ‘outside world’ rather than from the pulp as
the alveolus when the tooth first comes into wear.19 With suggested in older literature reports.3,24
age, and due to the prolonged eruption of the tooth, the 2. When incisors with pale dental stars are stored in a
Galvayne’s groove first appears at the gumline. As the tooth mush of crushed grasses, dental stars become darkly
continues to erupt, it extends down the labial surface to colored after a few days; when they are stored in a
reach the occlusal edge, then starts to disappear at the buffered (pH 6.8) solution of various diphenols
gumline and finally disappears completely. The appearance (caffeic acid, 3,4-dihydroxybenzoic acid and
of the groove and its usefulness in aging horses were men- 3,4-dihydrophenylalanine (10 mmol/l) together with
tioned for the first time in the early 1880s by an American thyrosinase, the dental stars obtain a deep brown color
horsetamer called Sample. Later, his theory was adopted by after 72 hours (Fig. 7.8).
Sidney Galvayne, an Australian horseman.20 It was in his first This suggests that food pigments are responsible for the dark
work, Horse dentition: showing how to tell exactly the age of a color of the dental star.
horse up to thirty years (published prior to March 1886) that Dental stars also present a topical coloration pattern. In
Galvayne described the groove, which now bears his name, young horses, the dental stars have a uniform color, whereas
on the vestibular surface of the permanent upper corner in older individuals they are composed of a darker periphery
incisor.21 The presence and length of the Galvayne’s groove that surrounds an uncolored central zone, the so-called
as an accurate guide to the age of the older horse became ‘white spot’ (Fig. 7.9). The reason why absorption of food
known throughout the English-speaking world. However, it pigments occurs only in the peripheral rim of the dental star
was not until World War I that several investigations were and not in the white spot nor in the surrounding primary
undertaken to validate his theory.20 Contrary to Galvayne’s dentin can be found by examining the diameter, extent and
statements, these investigations showed that the groove may orientation of the dentinal tubules.
be absent in more than 50 % of the horses between the ages Dentinal tubules are formed as the odontoblasts retreat
of 10 and 30 years. centripetally and leave behind a cytoplasmatic process
around which the dentin matrix is deposited and mineral-
Dental star morphology ized. The tubules can therefore be regarded as hollow cylin-
ders traversing the dentin. Each tubule starts peripherally at
The appearance of the dental star is, next to eruption times, the interface between the primary dentin and the enamel,
one of the more reliable dental features, and the correlation and extends centripetally toward the pulpal border. The first
between dental star morphology and age is stronger than for dentin produced by the odontoblasts is located peripherally
any other feature.22 in the tooth, i.e., underneath the enamel, and is called
Horses at pasture have obvious darkly colored dental stars, primary dentin. It surrounds the younger and more centrally
whereas individuals without access to pasture or grass fodder located secondary dentin, whereas tertiary dentin is only
usually have pale yellowish dental stars (Fig. 7.7). This formed in the restricted areas between the tip of the pulp
suggests that the coloration of the dental star is caused by chamber and the occlusal surface.
an impregnation of grass pigments. Two small experiments The only obvious feature characterizing the transition
support this theory:23 between primary and secondary dentin of equine teeth is
the presence of peritubular dentin (Fig. 7.10), which is
1. When equine incisors are sectioned longitudinally one
hypercalcified tissue, deposited as a collar inside the tubular
can observe that the brown color of the dental star
walls of primary dentin. The term peritubular dentin is
extends only a few millimeters beneath the occlusal
surface and that the color intensity fades towards the
pulpal chamber. This indicates that the color originates

Fig. 7.8  Lower central incisors of a 20-year-old Standardbred without

access to pasture. The right tooth (401) was stored in a buffered Ringer’s
Fig. 7.7  Standardbred horse, 12 years old, deprived of fresh grass. Dental lactate solution; and the left one (301) was immersed in a buffered solution
stars are yellowish (arrowheads). It is difficult to distinguish the white spot in of 3,4-dihydroxybenzoic acid (10 mmol/l) for 48 hours. In 301, the periphery
the center of the stars. of the dental star has obtained a brown color (arrows).

88
 Aging

TD
AB

SD

Fig. 7.11  SEM image of the occlusal surface at the center of the dental star.
The boundaries of the tertiary dentin are indicated by arrows. TD, tertiary
Fig. 7.9  Occlusal surface of the left lower central incisor (301) of a dentin; SD, secondary dentin (×250).
15-year-old draft horse. The dental star consists of a dark peripheral rim
(asterisk) and a central white spot (arrow). The white spot is composed of
secondary dentin (A) and a core of tertiary dentin (B).
food pigments in this zone of the dental star is prevented by
the small number of tubules, which are, for the most part,
discontinuous with those of the surrounding secondary
dentin, their irregular arrangement, and their small diameter
(Fig. 7.11). This explains the colorless aspect of the central
core of tertiary dentin inside the dental star.
The secondary dentin around the core of tertiary dentin
A consists of a pale inner zone and a brown peripheral zone.
B Both zones contain regularly arranged dentinal tubules that
C are continuous with those of the surrounding primary dentin
B
and are completely devoid of peritubular dentin. The high
numerical tubular density, the regular tubular arrangement,
and the large tubular diameters of the secondary dentin are
suggestive of an easy and uniform penetration of food pig-
ments in this area. The only difference between the pale
inner zone and the dark peripheral zone of secondary dentin
is the spatial arrangement of the dentinal tubules. In the
periphery of the dental star, tubules end perpendicularly into
the occlusal surface (Fig. 7.12). This orientation allows an
optimal inflow of food pigments, which is far superior to
Fig. 7.10  SEM image of longitudinally fractured dentinal tubules. A, tubular
lumen; B, peritubular dentin; C, intertubular dentin (×3500). the dye penetration in the more central, uncolored secondary
dentin, where tubules lie nearly parallel to the occlusal
surface (Fig. 7.13). Penetration of food pigments in the latter
anatomically incorrect because this dentin forms within the zone is nearly negligible because due to the horizontal
dentinal tubule (not around it) and narrows the tubular position of the tubules, the maximal penetration depth of
lumen. It is, therefore, sometimes (more accurately) referred food pigments in this zone cannot exceed the tubular diam-
to as intratubular dentin.25 Apart from the presence of peri­ eter, which is 3  µm. Even when the horizontally exposed
tubular dentin, the structure of dentinal tubules is identical tubules are filled with food pigments, this 3 µm-thick mass
in primary and secondary dentin. Peritubular dentin deposit of colored dentin is worn off in less than 1 day by the severe
is thickest at the outer end of the primary dentinal tubules occlusal attrition, which amounts to 2500 µm a year. Food
and disappears at the transition between primary and sec- pigments can, therefore, not be accumulated in the inner
ondary dentin.23 The presence of peritubular dentin gives the zone of the secondary dentin of the dental star. This contrasts
tubules a tapered shape with the wider lumen at the pulpal with the more peripheral zone of secondary dentin, where
side and the narrower luminal diameter near the enamel. food pigments can permeate a longer distance in the perpen-
The dental star consists of a central core of tertiary dentin dicularly debouching tubules. The pigments can accumulate
and a much broader ring of secondary dentin, in neither of within these tubules and thus cause the dark coloration of
which peritubular dentin is deposited. Tertiary dentin, situ- the dental star periphery. This mechanism is fully compatible
ated in the very center of the dental star, is formed between with the aforementioned preliminary experiments, showing
the tip of the pulp chamber and the occlusal surface and that secondary dentin acquires its dark color within 72 hours
protects the pulp from exposure to attrition. Penetration of after immersion in a pigmented solution.23

89
 7 Morphology

wider lumina in which plant pigments can penetrate more

easily and give the dentinal tissue a dark brown color.
O

Dental aging in different horse breeds

Many standard textbooks dealing with aging of horses
suggest that the above-mentioned characteristics give an
accurate indication of a horse’s true age. However, some
reports are inconsistent in their guidelines and show large
SD discrepancies in the dental features described at specific ages.
A possible explanation for the non-uniformity of existing
guidelines is the lack of evidence that any system was used
to validate an author’s recommendations for aging.27,28 A
study performed by Richardson et al29 casts serious doubts
on the belief that the age of a horse can be determined accu-
rately from an examination of its teeth. In this study a large
Fig. 7.12  SEM image of the etched occlusal surface (O) and the subjacent group of horses with documented evidence of birth were
secondary dentin (SD) at the dark peripheral rim of the dental star of a examined, and age was estimated both by experienced clini-
longitudinally fractured incisor. Dentinal tubules end perpendicular to the cians and by a computer model. There was little difference
occlusal surface (×400). between the accuracy of the computer model and the clinical
observers, but neither method was accurate when compared
with the actual age. In older horses, there was much greater
variability between the dental age and the actual age, which
means that the accuracy of dental aging declines markedly
with age. Most standard texts do not provide exact data
concerning breed, sex, and nutrition of the examined horses.
However, anatomical, physiological, environmental, and
behavioral differences between individuals ensure differ-
O ences in rate of equine dental wear.30 The concealment of
these data may explain the discrepancies between different
reports. Inaccuracies in the dental aging system of horses
may also result from differences between breed and type of
horse involved. Eisenmenger and Zetner stated that the teeth
of Thoroughbreds erupt earlier than those of Lipizzaners and
coldblood horses. Teeth of ponies may also have rates of
SD eruption and wear that differ from the teeth of horses.3 As
for donkeys, both ancient literature data31 and recent inves-
tigations32 have suggested that the degree of dental attrition
in donkeys is slower than in horses.
Fig. 7.13  SEM image of the etched occlusal surface (O) and the subjacent The nature of diet can also play a part in the abrasion of
secondary dentin (SD) at the pale inner zone of secondary dentin in the
dental star. The orientation of the tubules is almost parallel to the occlusal
horse incisors. Dental wear is caused not only by grinding
surface (×400). of opposing crowns against one another, but also by contact
with abrasive particles in food, such as silicate phytoliths
which form part of the skeleton of grasses. Other plant-
The microstructure and spatial arrangement of the dentinal borne abrasives include cellulose and lignin.30 In order to
tubules can also explain the color differences between preclude the influence of the quality of nutrition on the rate
primary and secondary dentin. Primary dentin has a smaller of dental wear, it is necessary that horses that are examined
number of tubules per area unit than secondary dentin and for breed variability are raised and kept under similar envi-
thus offers fewer pathways for food pigments to penetrate ronmental and nutritional conditions.
into the occlusal surface. In primary dentin, exposed onto Based on the suggestions that the degree of attritional
the occlusal surface peripheral to the dental star, tubules dental wear is correlated with the breed of horse, four unre-
debouch obliquely. For the reasons described above, pene- lated horse breeds have been subjected to a comparative
tration of food pigments into these tubular lumina is consid- study.33–35 All horses examined here were raised in Western
erably less than in the dark peripheral rim of the dental star, Europe, were given access to daily pasture, and were fed
where tubules end perpendicularly. Furthermore, primary concentrates and hay. None of the horses was a crib-biter
dentin contains high levels of peritubular dentin and has an nor suffered from other vices with a possible influence on
almost translucent appearance, which is similar to the com- dental wear. The incisor teeth had not been rasped in any
plexion of enamel, as both tissue types are highly mineral- individual. It is evident that in practice one has to be vigilant
ized.26 In contrast, the less mineralized secondary dentin has for these considerations. Factors that are difficult to control
a dull opaque appearance. Additionally, because tubules in and that could not be taken into consideration are the indi-
secondary dentin are devoid of peritubular dentin, they have vidual chewing habits and the amount of food intake.

90
 Aging

A critical evaluation of the dental aging technique revealed

that the rate of attritional dental wear is different in different
horse breeds. Indentation hardness tests, performed with a
Knoop diamond indenter, showed slight breed differences
in the hardness of equine enamel and dentin. These different
microhardness values seem to contribute to the differences
in the rate of attritional dental wear.36
The following text describes the appearance of lower
incisor teeth at various ages as generally seen in the Stand-
ardbred horse, the Belgian draft horse, the Arabian horse,
and the mini-Shetland pony population of Western Europe.
It must be emphasized that this text is not a truism. When
determining a horse’s age, one must register all dental fea-
tures together and take account of clinical factors that may A
have influenced the aspect of the horse’s teeth. The following
descriptions will therefore be accurate in many cases, but
may be incorrect for any individual.

Eruption of the deciduous incisors

The central incisors generally erupt during the first week of
life. The middle incisors emerge through the gums at 4–6
weeks, and the corners erupt between the sixth and the ninth
month of life. In the mini-Shetland pony, eruption of the
middle and the corner incisors is retarded. The middle
incisor starts erupting at the age of 4 months, whereas the
corner incisor breaks through the gums between 12 and 18
months of age.
B

Eruption of the permanent incisors

The upper and lower permanent incisors erupt almost simul-
taneously. In some horses shedding begins with the maxil-
lary, in others with the mandibular incisor teeth. Arabian
horses shed their central, middle, and corner incisors at 2.5,
3.5 and 4.5 years of age, respectively. In Standardbreds and
in Belgian draft horses, shedding generally occurs later,
namely at nearly 3, nearly 4, and nearly 5 years of age (Fig.
7.14). In mini-Shetland ponies, eruption of the permanent
incisors is still further delayed by 2 or 3 months. In male
horses, the canines erupt at about 4.5–5 years of age. Gener-
ally, these teeth are absent or rudimentary in mares.

C
Appearance of the dental star
Dental stars appear sequentially in the central, the middle Fig. 7.14  (A) Standardbred horse, 5 years old. The permanent central
and the corner incisors. In Standardbreds and in Arabian and middle incisors are in place, the corner incisor is emerging through  
horses they appear on the centrals at 5 years, on the middles the gums. The dental star is present on the centrals, absent on the middles
and the corners. All lower incisors have deep cups. (B) Belgian draft horse,  
at 6 years, and on the corners at 7–8 years. In Belgian draft 4 years and 8 months. The permanent central and middle incisors are  
horses and mini-Shetland ponies, stars appear somewhat in place. The corner incisors are still deciduous. Dental stars are present on
earlier, namely on the centrals at 4.5 years, on the middles the centrals (arrowheads) and appear also on the middles. Cups are present
at 5.5 years and on the corners at 6.5–7 years (Fig. 7.14). in the central and the middle incisors. (C) Arabian horse, 5 years old. All
With age, the characteristic white spot becomes visible in the lower incisors are permanent, the corners are not yet fully in wear. There are
center of the dental star (Figs 7.15–7.17). In Standardbreds no obvious dental stars. Deep cups are present on all lower incisors.
and in Arabian horses this white spot appears on the central
incisors from the age of 7–8 years onwards, and on the
middle incisors from the age of 9–11 years onwards. In
Disappearance of the cups
Belgian draft horses and in mini-Shetland ponies the white The disappearance of the cups is an unreliable feature for
spot becomes visible on the centrals at the age of 6–7 years age determination because it does not occur between narrow
and on the middles at the age of 8. In all breeds, the appear- age limits. In all breeds, cups on the central incisors disap-
ance of the white spot in the dental star of the corner incisors pear at the age of 6–7 years, whereas cups on the middle
is variable and occurs between 9 and 15 years. incisors are filled in variably between 7 and 11 years and

91
 7 Morphology

A A

B B

C
C

Fig. 7.15  (A) Standardbred horse, 8 years old. Dental stars are present on
Fig. 7.16  (A) Standardbred horse, 12 years old. Dental stars, consisting of a
all incisors. In the central incisor, the white spot in the dental star becomes
white spot and a dark periphery, are present on all lower incisors. Cups have
apparent (arrows). Cups are filled-in on the centrals. On the middles and  
disappeared, and the marks are small oval to rounded. The occlusal tables of
the corners, cups are still present. The occlusal tables of the central incisors
the central and the middle incisors are trapezoid. On the central incisor, the
are becoming trapezoid, those of the middles and the corners are still oval.
lingual apex is visible (arrows). The corner incisors have an apex on the labial
(B) Belgian draft horse, 8 years and 6 months. Dental stars are present on  
side (arrowheads). (B) Belgian draft horse, 12 years old. Dental stars,
all incisors. In the central and the middle incisors, the white spot in the
consisting of a white spot and a dark periphery, are present on all lower
dental star becomes apparent (arrows). Cups are filled-in on all lower
incisors. Marks are rounded, and on the central incisors they have almost
incisors. The remaining marks are oval. The occlusal tables of the centrals
disappeared. The occlusal tables of the centrals and the middles are
and the middles are becoming trapezoid. (C) Arabian horse, 8 years and 6
trapezoid. On the corner incisor, the labial apex is obvious (arrowheads).  
months. Dental stars are present on the central and the middle incisors.  
(C) Arabian horse, 12 years old. Dental stars are present on all lower incisors.
The white spot in the dental star is appearing in the central incisor. Cups  
On the central and the middle incisors, the white spot in the dental star is
on the centrals and the middles have nearly disappeared; the remaining
visible. Cups have disappeared. The remaining marks are oval and still clearly
marks are oval (middles) to triangular (centrals). Deep cups are still present
visible. The occlusal tables of the centrals and the middles are trapezoid. The
on the corner incisors. The occlusal tables of the centrals become trapezoid.
corner incisor presents a labial apex.

92
 Aging

Changes in shape of the marks

On the central incisors, big oval marks are visible until the
age of 6–7 years. These marks become oval to triangular
from the age of 7–8 years onwards in Belgian draft horses,
from the age of 8–10 years onwards in Standardbreds and
Arabian horses, and from the age of 10 years onwards in
mini-Shetlands. Round marks on the central incisors are
visible at 9–10 years in Belgian draft horses, at 13–14 years
in Standardbreds and mini-Shetlands, and at 15–17 years in
Arabian horses (Fig. 7.17).

Disappearance of the marks (Fig. 7.17)

A
From all age-related dental characteristics, the disappearance
of the marks is the one with the highest interbreed variabil-
ity. In draft horses, marks on the central incisors disappear
from the age of 12–15 years, and those on the middles and
the corners from the age 14–15 years onwards. In mini-
Shetland ponies, marks on the central, the middle, and the
corner incisors disappear at the age of 15, 16, and 17 years,
respectively. In Standardbred horses, marks disappear some
years later. On the centrals, they vanish in 18-year-old horses
while disappearing on the middle and the corner incisors in
19- to 20-year-olds. In Arabian horses, marks on the lower
incisors may persist for a very long time. They start disap-
pearing at the age of 20 but exhibit considerable individual
variations.
B

Changes in shape of the occlusal surfaces

Changes in shape of the occlusal surfaces of the lower inci-
sors are useful but inaccurate indicators of age. The changes
are difficult to judge objectively because successive shapes
shade off into one another and are not easily distinguisha-
ble. The sequential shapes of the tables of the central and
the middle incisors are oval, trapezoid, triangular with the
apex pointing to the lingual side, and biangular. A survey of
the most important changes is given in Tables 7.1–7.4. It is
striking that the shape of the lower corner incisor does not
conform to the sequential changes described above. The
lower corners remain oval for a long time and gradually
develop an apex at the labial side. In Belgian draft horses
C and mini-Shetland ponies, a labial apex appears at the age
of 9, and in Standardbreds at the age of 11. In Arabian
Fig. 7.17  (A) Standardbred horse, 18 years old. Marks are small and horses, the apex is a constant characteristic in individuals
rounded. On the central incisors, they have almost disappeared (arrow). The aged over 12 years (Figs 7.16 & 7.17).
occlusal tables of the centrals and the middles are trapezoid, those of the
corner incisors are triangular with an apex to the labial side. (B) Belgian draft
horse, 18 years old. Marks have disappeared from all lower incisors. The Direction of upper and lower incisors
occlusal surfaces are triangular; those of the central and the middle incisors
have a lingual apex, and those of the corners have a labial apex. (C) Arabian The arch formed by the incisors of the opposing jaws as they
horse, 18 years old. Round marks are still clearly visible on all lower incisors. meet, when viewed in profile, changes as the teeth advance
The occlusal surfaces of the centrals and the middles are trapezoid with a from their alveoli and undergo attrition (Fig. 7.6). In young
lingual apex (arrows); those of the corner incisors are oval with a labial apex
(arrowheads).
horses, the upper and lower incisors are positioned in a
straight line (±180°). From the age of approximately 10
years onwards, the angle between upper and lower incisors
becomes more acute. Because exact measurements of the
those on the corners between 9 and 15 years. The variations age-related incisival angle are not available, the evaluation
in the age at which the cups disappear may be due to a dif- of the angle provides only a rough estimate of an animal’s
ference in the depth of the cup. The accumulation of cement age. The same applies for the curvature of the dental arch
in the infundibulum is variable, i.e., superabundant in some formed by the lower incisive tables. In young horses this arch
individuals and almost non-existent in others. is a semicircle, whereas in older individuals it forms a straight

93
 7 Morphology

Table 7.1  Aging Belgian draft horses Table 7.3  Aging Arabian horses

I1 I2 I3 I. I1 I2 I3
Shedding ±3 y ±4 y ±5 y Shedding ±2.5 y ±3.5 y ±4.5 y

Appearance of the dental star 4.5 y 5.5 y 6.5 y–7 y Appearance of the dental star 5 y 6 y 7 y–8 y

Appearance of the white spot 6–7 y 7–8 y 11–13 y Appearance of the white spot 7–8 y 9–11 y 13–15 y
in the dental star in the dental star

Disappearance of the cup 5–8 y 7–11 y 9–15 y Disappearance of the cup 7 y 7–11 y 9–15 y

Shape of the mark: Shape of the mark:

  oval until 6 y   oval until 7 y
  oval-triangular ≥7 y–8 y   oval-triangular ≥8–10 y
  round ≥9 y–10 y   round ≥15–17 y

Disappearance of the mark 12–15 y 14–15 y 14–15 y Disappearance of the mark ≥20 y ≥20 y ≥20 y

Shape of the occlusal table: Shape of the occlusal table:

  oval until 6 y until 7 y until 10 y   oval until 6 y until 7 y until 12 y
  trapezoid ≥7 y ≥8–9 y –   trapezoid ≥8–9 y ≥9–11 y –
  trapezoid with lingual apex ≥7 y ≥9 y –   trapezoid with lingual apex ≥10–11 y ≥14 y –
  labial apex on 303 or 403 ≥9–10 y   labial apex on 303 or 403 ≥12 y

Hook on 103 or 203 ≥5 y Hook on I03 or 203 ≥5 y

Galvayne’s groove ≥11 y Galvayne’s groove ≥11 y

Table 7.2  Aging Standardbred horses Table 7.4  Aging mini-Shetland ponies

I1 I2 I3 I1 I2 I3
Shedding ±3 y ±4 y ±5 y Shedding ≥3 y ±4 y ±5 y
Appearance of the dental star 5 y 6 y 7 y–8 y Appearance of the dental star 4.5 y 5.5 y 6.5–7 y
Appearance of the white spot 7–8y 9–11 y 11–13 y Appearance of the white spot 6–7 y 8 y 10–12 y
in the dental star in the dental star
Disappearance of the cup 6–7 y 7–11 y 9–15 y Disappearance of the cup 7–8 y 8–12 y 9 y–13 y
Shape of the mark: Shape of the mark:
  oval until 6 y   oval until 8 y
  oval-triangular 8 y–10 y   oval-triangular ≥10 y
  round ≥13 y   round ≥13 y
Disappearance of the mark 18 y 19–20 y 19–20 y Disappearance of the mark 15 y 16 y 17 y
Shape of the occlusal table: Shape of the occlusal table:
  oval until 6 y until 7 y until 12 y   oval until 6 y until 7 y until 10 y
  trapezoid ≥7 y ≥8 y–9 y –   trapezoid ≥7 y ≥8–9y –
  trapezoid with lingual apex ≥ 9 y ≥10 y –   trapezoid with lingual apex ≥11–12 y ≥14 y –
  labial apex on 303 or 403 ≥10–11 y   labial apex on 303 or 403 ≥9–10 y
Hook on 103 or 203 ≥5 y Hook on 103 or 203 ≥5 y
Galvayne’s groove ≥11 y Galvayne’s groove ≥11 y

94
 Aging

line. In view of the gradual character of this change in direc- however, is a complex process and all above-mentioned fea-
tion, however, it is impossible to determine the exact age at tures should be carefully examined. It must be emphasized
which it occurs. that dental aging in horses can only provide an approximate
guess rather than an exact evaluation. In older horses, most
of the so-called characteristic features can only be judged
The hook on the upper corner subjectively. It is obvious that the accuracy of the dental age
The hook on the caudal edge of the upper corner incisor has determination declines markedly with age.
long been considered as the typical characteristic for a 7- or An important factor that can interfere with an accurate
13-year-old horse. However, hooks on 103 and 203 are seen dental age determination in horses is the breed-dependence
in a minority of horses and occur at practically any age over of the attritional dental wear. A comparison of the dental
5 years. Only 13 % of all 7-year-olds and 8 % of all 13-year- criteria in different breeds revealed that, in general, the
olds that were examined for this study presented a hook on incisor teeth of draft horses and mini-Shetland ponies are
one or both upper corners. On the other hand, hooks were more liable to attrition, whereas the incisors of Arabian
also seen in 14 % of the 5- and 6-year-old horses, in 22 % of horses wear more slowly than those of Standardbred horses.
the horses aged between 8 and 12, and in 13 % of all horses A variety of other factors such as nature and quality of
aged over 13 years. As the presence of hooks on 103 and 203 food, environmental conditions, heredity, injury, and disease
cannot be related to any specific age category, it is considered can also influence dental wear. It is, therefore, important that
irrelevant for the estimation of age in horses. equine clinicians do not claim levels of accuracy that are
unjustifiable. As it is impossible to assign specific ages to
each dental feature, accuracy of age estimation in certain
The Galvayne’s groove individuals can be very low.
The Galvayne’s groove is a feature that is most often observed Therefore, it is advisable to make written records at the
in horses aged over 11 years. However, as its presence, length time of examination to show the dental features upon which
and bilateral symmetry are variable and inconsistent, the the age estimate was made. In some countries, there have
groove is considered to be of little value for age determina- been legal guidelines established to distance veterinarians
tion in horses. from trying to state the age of a horse solely from dental
findings. In case of insurance policies or legal questions, the
veterinarian should indicate explicitly that he is providing
Conclusion an ‘estimate of age.’ It is also advisable that the incisor tables
are photographed. When necessary, the pictures can be sub-
Teeth provide a practical available tool for estimating age mitted to others for a second opinion and can be stored with
in horses. Aging an individual horse from its dentition, appropriate identification for further use as well.8

References
1. Ten Cate AR. Physiologic tooth 9. Barone R. Dents. In: Anatomie comparée teeth as an indicator of age in the horse.
movement, eruption and shedding. des mammifères domestiques. Tome 3, J Vet Dent 2008; 25(3): 182–188
In: Ten Cate AR, ed. Oral histology, 3rd edn. Vigot, Paris, 1997, p 91 18. Dyce KM, Sack WO, Wensing CJ.
development, structure and function, 10. Dyce KM, Wensing CJ. Anatomie van het Textbook of veterinary anatomy, 2nd
5th edn. CV Mosby, St Louis, 1998, paard. Scheltema-Holkema, Utrecht, edn. W B Saunders, Philadelphia, 1996,
pp 289–314 1980, p 14 p 491
2. Muylle S, Simoens P, Lauwers H. 11. Willems A. Ouderdomsbepaling van het 19. St Clair LE. Teeth. In: Sisson and
Age-related morphometry of equine Paard, 5th edn. Van de Sompele, Grossman’s The anatomy of the domestic
incisors. Journal of Veterinary Medicine A Oud-Heverlee, 1980, p 14 animals, 5th edn. W B Saunders,
1999; 46: 633-643 12. Habermehl KH. Wie sicher ist die Philadelphia, 1975, p. 460
3. Eisenmenger E, Zetner K, eds. Veterinary Altersbestimmung beim Pferd? Berliner 20. McCarthy PH. Galvayne: the mystery
dentistry. Lea & Febiger, Philadelphia, und Münchener Tierärztliche surrounding the man and the eponym.
1985, pp 2–26 Wochenschrift 1981; 94: 167 Anatomia Histologia Embryologia 1987;
4. Kertesz P. In search of Mr Bishop. 13. McMullan WC. Dental criteria for 16: 330
Veterinary Record 1993; 133: 608 estimating age in the horse. Equine 21. Galvayne S. Horse dentition: showing
5. Zipperlen W. Over de ouderdomskennis Practice 1983; 5: 10, 36 how to tell exactly the age of a horse up
van het paard of de tandleer. In: 14. Walmsley JP. Some observations on the to thirty years. Thomas Murray, Glasgow,
Geïllustreerd veeartsenijkundig value of ageing 5–7-year-old horses by 1886
handboek. B. Dekema, Utrecht, 1871, examination of their incisor teeth. 22. CD Equus – Vetstream Ltd, Three Hills
p. 171 Equine Veterinary Education 1993; 5: Farm, Bartlow, Cambridge CB1 6EN, UK
6. Dupont M. L’âge du cheval. Librairie J B 295 23. Muylle S, Simoens P, Lauwers H. A study
Baillière, Paris, 1901 15. Sack WO. Rooney’s Guide to the of the ultrastructure and staining
7. Frateur JL. De Ouderdomsbepaling van dissection of the horse, 6th edn. characteristics of the dental star of equine
het Paard door het Gebit. E Marette, Veterinary Textbooks, Ithaca, 1994, p 182 incisors. Equine Veterinary Journal 2002;
Brussel, 1922 16. Navin JN. The age. In: Navin’s Veterinary 34: 230–234
8. American Association of Equine practice. John B. Hann, Indianapolis, 24. Joest E, Becker E. Zähne. In: Handbuch
Practitioners. Official Guide for 1882, pp 431–446 der speziellen pathologischen Anatomie
Determining the Age of the Horse, 17. Carmalt JL, Allen AL. Morphology of the der Haustiere, 3rd edn. Verlag Paul Parey,
6th edn. Fort Dodge, Iowa, 2002 occlusal surfaces of premolar and molar Berlin, 1970, pp 83–315

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25. Torneck CD. Dentin-pulp complex. In: 28. Richardson JD, Lane JG, Waldron KR. Is 33. Muylle S, Simoens P, Lauwers H. Ageing
Ten Cate AR, ed. Oral histology, dentition an accurate indication of the horses by an examination of their incisor
development, structure and function, age of a horse? Veterinary Record 1994; teeth: an (im)possible task? Veterinary
5th edn. CV Mosby, St Louis, 1998, 135: 31 Record 1996; 138: 295–301
pp 150–196 29. Richardson JD, Cripps PJ, Lane JG. An 34. Muylle S, Simoens P, Lauwers H, van
26. Kilic S, Dixon PM, Kempson SA. A light evaluation of the accuracy of ageing Loon G. Ageing draft and trotter horses
microscopic and ultrastructural horses by their dentition: can a computer by their dentition. Veterinary Record
examination of calcified dental tissues of model be accurate? Veterinary Record 1997; 141: 17–20
horses: III Dentine. Equine Veterinary 1995; 137: 139 35. Muylle S, Simoens P, Lauwers H, van
Journal 1997; 29: 206–212 30. Hillson S. Teeth. Cambridge University Loon G. Ageing Arab horses by their
27. Richardson JD, Cripps PJ, Hillyer MH, Press, Cambridge, 1986, p. 183 dentition. Veterinary Record 1998;
et al. An evaluation of the accuracy of 31. Marcq J, Lahaye J. Extérieur du cheval. 142: 659
ageing horses by their dentition: a matter J Duculot, Gembloux, 1943, p. 11 36. Muylle S, Simoens P, Verbeeck R, et al.
of experience? Veterinary Record 1995; 32. Misk NA. Radiographic studies on the Dental wear related to the microhardness
137: 88 development of incisors and canine teeth of enamel and dentine. Veterinary Record
in donkeys. Equine Practice 1997; 19: 23 1998; 144: 558–561

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 Section 3:  Dental disease and pathology

C H A P TER  8 
Disorders of development  
and eruption of the teeth  
and developmental  
craniofacial abnormalities
Padraic M. Dixon MVB, PhD, MRCVS
Division of Veterinary Clinical Studies, University of Edinburgh, Easter Bush Veterinary Centre, Roslin, Midlothian EH25 9RG, UK

Craniofacial abnormalities horses greatly resent incisor teeth floating and require seda-
tion for this procedure.
Foals can develop a variety of growth abnormalities of their The main clinical significance of incisor overjet or overbite
craniofacial bones that cause malocclusion of their teeth is that affected horses usually have concurrent CT disorders,
and possible permanent changes to their dental function. due to the upper CT row being rostrally positioned in rela-
Although some of these abnormalities, such as overbite tion to its lower counterpart.3 This leads to focal overgrowths
(‘parrot mouth’), are often regarded as being primary dental on the rostral aspects of the upper 06s and the caudal aspects
abnormalities, it must be remembered that the observed of the lower 11s, as discussed below. The treatment of overjet
dental abnormality is just a manifestation of a significant and overbite are discussed in Chapter 19, and of CT over-
skeletal abnormality and correction of the dental abnormali- growths in Chapter 17.
ties, such as reduction of dental overgrowths, will not correct
the underlying craniofacial abnormality.
Underjet
Underjet (prognathism, ‘sow mouth,’ ‘undershot jaw’; Fig.
Overjet and overbite 8.3) is rare in horses and is usually of little clinical signifi-
Many horses have some degree of overjet (‘overshot jaw’), cance unless there is total lack of occlusion between incisors.
i.e., where the occlusal aspects of the upper incisors project In contrast to horses with overjet, those with underjet usually
rostral to the occlusal aspects of the lower incisors (Fig. 8.1). develop focal CT overgrowths on the caudal aspects of the
Untreated cases of severe overjet generally develop overbite, upper 11s and the rostral aspects of the lower 06s. Due to
where the upper incisors lie rostral to the lower incisors as preferential overgrowth of the lower 01s, such cases develop
above but additionally now lie directly in front of the lower a concave occlusal surface of their upper incisor occlusal
incisors (‘parrot mouth’; Fig. 8.2). These disorders are com- surface (termed a ‘frown’). Similar to overbite, major incisor
monly termed brachygnathism (indicating shortness of overgrowths and concurrent CT focal overgrowths are the
mandible), but in horses they may actually be due to over- main consequences of underjet, and such overgrowths
growth of the upper jaw.1 With overbite, the upper incisors should be reduced at 6-month intervals.
may mechanically trap the lower incisors behind them and
so restrict mandibular growth; this in turn further exagger-
ates the disparity in length between the upper and lower Rostral positioning of the upper CT rows
jaws. Overjet, and more so overbite, are esthetically undesir- Rostral positioning of the upper CT rows relative to their
able, especially in show horses, but unless contact between mandibular counterparts is caused by an imbalance in
opposing incisors is totally absent, these problems rarely craniofacial bone growth and as noted earlier, is usually
cause difficulty in prehension.2 As the more rostral incisors associated with incisor overjet/overbite. This abnormality
(01s, central incisors) have the least occlusal contact, they can rarely occur independent of incisor malocclusions.
overgrow most and so affected horses develop a convex Because the upper and lower CT rows are not in full contact
appearance of their upper incisor occlusal surface (termed a in this disorder, localized dental overgrowths (colloquially
‘smile’), which should be reduced if pronounced.2,3 This termed ‘beaks’, ‘hooks’, and ‘ramps’) develop on the rostral
reduction should be performed in stages in order to prevent aspect of the upper 06s, and these overgrowths may be
pulpar exposure. In contrast to having their CT floated, many pressed against the lips and cheeks by the bit and so cause

99
 8 Dental disease and pathology

mucosal ulceration and bitting problems. If large, these over-

growths can also restrict the normal, but variable, rostrocau-
dal mandibular movement, relative to the maxilla, while
lowering and raising the head.4 Feeding affected horses fully
from the ground rather than from a height may also promote
normal rostrocaudal mandibular movement and so help
reduce the development of such overgrowths. Smaller 06
overgrowths can be fully reduced manually, but if large,
then motorized dental instruments are required, and such
overgrowths should be removed in stages, as described in
Chapter 17.
Similar overgrowths may also develop on the caudal aspect
of the lower 11s, but due to the later eruption of the 11s in
comparison to the 06s, mandibular 11 overgrowths may not
develop until affected horses are 5–6 years of age. These
lower 11 overgrowths may remain undetected unless a full
Fig. 8.1  Mild overjet in a 3-month-old Thoroughbred foal.
dental examination is performed.2,3 True lower 11 caudal
overgrowths must be differentiated (e.g., by visually or digit-
ally assessing crown height above gingival margin) from an
anatomically normal, upward sloping caudal CT occlusal
surface (‘curve of Spee’), which can be especially marked
in some smaller equine breeds (e.g., Arabian and Welsh
ponies). Lower 11 overgrowths can traumatize the adjacent
oral mucosa during mastication, and if large enough, can
even lacerate the hard palate and the greater palatine artery
or cause an oromaxillary fistula. Because there is very little
room between the caudal aspect of the lower 11s and the
vertical ramus of the mandible and the soft tissue protrusion
caudal to the lower 11s, the mandible and adjacent soft
tissue can be readily traumatized when manually reducing
(floating, rasping) overgrown lower 11s. Consequently,
sedation is usually necessary to both fully evaluate and if
necessary, carefully and in stages, reduce larger lower 11
overgrowths.
If lower 11s are very overgrown, they are best reduced in
stages from their medial aspects using motorized dental
instruments2,5,6 as described in Chapter 17, whilst maintain-
ing the normal high occlusal angulation of caudal mandibu-
Fig. 8.2  This foal has both marked overjet and overbite, with ventral lar CT.7 The use of ‘molar cutters’, cold chisels, or percussion
deviation of the premaxilla (incisive bone).
guillotines (that encircle these caudal 11 overgrowths),
risks fracturing the tooth and causing pulpar exposure,
which can lead to cellulitis of the mandibular, oral, and
pharyngeal areas.

Wry nose (campylorrhinis lateralis)

Wry nose is a syndrome involving shortening and/or devia-
tion of the premaxillary (incisive) and maxillary bones that
can also involve the nasal and vomer bones.8 In addition
to possible disturbances to nasal airflow, malocclusions of
the incisors (Fig. 8.4) and of teeth on the extremities of
one of the CT rows can occur. Milder cases later develop a
diagonal incisor occlusal plane (‘diagonal bite’, ‘slope
mouth’, ‘slant mouth’) and unilateral upper 06, and lower
11 CT overgrowths. All cases of diagonal occlusal bite should
be assessed for the presence of wry nose, which may be
subtle in some cases. Affected foals can have a variety of
surgical and orthodontic treatments for this disorder with
limited success.8 Affected horses should have 6-monthly
floating of excessively sloped incisors and also of any CT
Fig. 8.3  This adult donkey has underbite, i.e. the lower incisors lie directly overgrowths, bearing in mind that they cannot be perma-
in front of the upper incisors. (Image courtesy of Dr Nicole du Toit.) nently corrected.

100
 Disorders of development and eruption of the teeth and developmental craniofacial abnormalities

Fig. 8.4  This 8-week old foal has severe wry nose, with complete absence
of contact of some incisors.

Disorders of dental development

Hypodontia (anodontia) B
Hypodontia refers to reduced numbers of teeth, whilst
anodontia technically refers to total absence of teeth; Fig. 8.5  (A) This young horse has developmental absence of 202, with
however, the terms are sometimes interchangeably used. mesial (medial) drifting of 203 into its site, with consequent overgrowth of
Hypodontia is an abnormality of differentiation of the the unopposed opposite 302, that is more obvious when the mouth is open
(B). A diastema between 301 and 302 may be due to the overgrowth of 302
dental lamina and tooth germs (as are the presence of sup­ causing it to be laterally (distally) displaced.
ernumerary teeth).9 Developmental hypodontia is rela­
tively uncommon in horses, with absence of equine teeth
usually caused by loss due to trauma, disease or to wear.
Hypodontia generally affects the permanent equine denti- though not always in size. Consequently, it is often impos-
tion (Figs 8.5 & 8.6). This disorder is hereditary in humans sible to differentiate supplemental from normal teeth.1,9,11
and can be part of many generalized developmental syn- Haplodont supernumerary teeth are characterized by their
dromes.9 In many species (including the horse), multiple simple, usually conical crowns with single roots (Fig. 8.7).
hypodontia is often associated with the presence of other Tuberculate supernumerary teeth have complex crowns
dental abnormalities (such as dysplastic teeth) or even with several tubercles on the occlusal surface with deep
generalized ectodermal disorders including the ectodermal indentations between the raised tubercles.1,9 A connate
dysplasia syndrome.10 tooth is composed of two or more tooth elements, possibly
arising from fusion of multiple tooth germs or alternatively
from a partial splitting of an embryonic tooth.1,9 Connate
Supernumerary teeth teeth are not necessarily supernumerary teeth, but some
The presence of supernumerary (additional) teeth, also supernumerary equine cheek teeth are connated, including
termed polydontia or hyperdentition, is relatively uncom- 6 of the 10 supernumerary cheek teeth described by Dixon
mon in the horse, but the exact prevalence is unknown.11,12 et al.12 Connated supernumerary teeth have also been illus-
Colyer found a prevalence of 0.6 % supernumerary incisors trated by Miles and Grigson, including a connated incisor
and 2.4 % supernumerary cheek teeth in 484 museum with two fused crowns sharing separate roots.1 The relation-
skulls, whilst Wafa found a 0.3 % prevalence of incisors ship between connated and tuberculate supernumerary teeth
in an abattoir survey of 355 skulls.1,13 Canine teeth are is unclear.
uncommon in mares, but these teeth are not generally Supernumerary teeth are a developmental defect and may
considered as supernumerary teeth, but as atavism, i.e., arise due to localized excessive odontogenic capacity, or
the reappearance of a characteristic of a distant ancestor from the splitting of a tooth primordium.1,9 With supple-
that is not found in its immediate ancestors.1 Dentigerous mental supernumerary teeth, it is believed that the primor-
cysts are also not considered to be supernumerary teeth in dium divides into equal parts, each with the capacity to form
this review. a tooth of normal morphology. Haplodont and tuberculate
Supernumerary teeth can be categorized on their appear- supernumerary teeth may be due to division of the primor-
ance into three types, i.e., supplemental teeth which resem- dium into parts which do not have the capacity to form a
ble teeth of normal series in crown and root morphology, tooth of normal shape and size.9

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 8 Dental disease and pathology

Fig. 8.6  (A) This skull radiograph

A B shows absence of 306 (an intercurrent
sclerotic, eruption cyst lies beneath
the 307). (B) Intra-oral examination
shows marked overgrowth of the
opposing 206, with just a remnant of
the deciduous tooth (706) visible in
the intra-oral mirror. Such retention of
deciduous teeth remnants is common
in hypodontia, due to absence of
pressure from an underlying erupting
permanent CT to aid shedding.

A B

Fig. 8.7  (A) This horse has a haplodont supernumerary incisor lying between 302 and 303 that has caused caudal displacement of the 303. Despite having a
relatively small clinical crown, radiographs confirmed the great length and outlined the shape of the reserve crown and apex of this supernumerary tooth.  
(B) The 9 cm long supernumerary tooth was extracted by removal of the rostral alveolar wall, and the gingival wound was partially sutured.

Equine supernumerary teeth often occur at the peripheries Colyer (1906) recorded a 0.6 % prevalence of equine super-
of the different classes of teeth, especially at the caudal aspect numerary incisors whilst finding a 2.5 % prevalence of super-
of the molar teeth,1,14,15 and in particular, caudal to the upper numerary CT.1 Equine supernumerary incisors are usually
11s,12,16 and this is also a relatively common site for super- supplemental teeth, i.e., are morphologically similar to
numerary teeth development in other species, including normal incisors.11 Occasionally, a complete supplementary
humans, where a midline (pre)maxillary incisor is the most set of incisors (six) can occur,11,13,19 but more commonly,
common supernumerary tooth.17,18 Supernumerary equine only one or two supernumerary incisors develop, and pro-
cheek teeth can also occur lingually, buccally, and rostrally trude rostrally to the normal premaxillary (incisive) incisors
to the normal cheek teeth row.12,15,16 Supernumerary teeth (Fig. 8.8).16
are generally more common in permanent than in decidu- Because of their normal morphology, supplemental
ous teeth, in incisors than other classes of teeth, and are supernumerary incisors can readily be confused with
more common in maxillary in than mandibular teeth.9,17,18 retained deciduous incisors. This is particularly the case
Supernumerary teeth are present in 0.8 % of primary denti- with larger retained incisors, whose permanent successors
tion and in 2.1% of permanent dentition in humans.18 erupted beside, rather than beneath, the deciduous incisor,
and thus have not caused any resorption or mechanical
displacement of the apex or reserve crown. Radiography
Supernumerary incisors
usually distinguishes between a retained deciduous and
In contrast to human supernumerary incisors, equine super- supernumerary incisor, as a retained deciduous incisor is
numerary incisors have been said to only occur in the per- shorter and narrower than a supernumerary permanent
manent dentition,19 more commonly in the premaxillary incisor (see later), in contrast to supernumerary incisors that
incisors.11 Supernumerary incisors are believed to occur more are usually of similar size (Fig. 8.8). Supernumerary incisors
frequently in horses than supernumerary cheek teeth,14,15 as may cause overcrowding and displacement of the normal
is the case in humans where circa 90 % of all supernumerary permanent incisors, and diastemata often occur beside the
teeth are reported to be premaxillary incisors;17 however, displaced incisors. A rostrally displaced supernumerary

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 Disorders of development and eruption of the teeth and developmental craniofacial abnormalities

Fig. 8.8  (A) Intra-oral radiograph of a premaxilla

containing two bent, supplemental supernumerary
(permanent) incisors lying at oblique angles, that
have caused overcrowding and displacement  
of the remaining incisors. (B) One of these
supernumerary incisors is visible, abnormally
protruding at an oblique angle between 201  
and 202.

B
A

incisor may also develop between, and so cause separation Radio­graphy readily differentiates these teeth from canine
of the normal incisors (Fig. 8.7). teeth by the size and shape of their reserve crowns and roots.
If just one or two supernumerary incisors are present that Many suspected supernumerary ‘wolf teeth’ are retained frag-
lie rostral (labial) to the normal incisor arch, it is usually ments of the deciduous 06 that on closer inspection are seen
possible to extract them following infra-orbital (or mental) to be a flat structure lying relatively superficially in the
nerve block in the sedated horse, and removal of the rostral gingiva, as illustrated by Dixon and Dacre.20
alveolar wall with a curved osteotome, as described in detail
in Chapter 20. Long gingival incisions over the reserve crown
should be sutured more apically after repositioning rem- Supernumerary cheek teeth
nants of the alveolar wall. The occlusal aspect of the wound The most common site for supernumerary CT development
is left open for drainage (Fig. 8.7). If supernumerary incisors in horses is, as noted, the caudal aspect of the maxillary CT
are very rostrally displaced (especially in older horses) dental rows (Fig. 8.9) and less commonly, caudal to the mandibu-
elevators can be inserted progressively deeper into their lar 11s (Figs 8.10 & 8.11). These caudal CT have been termed
periodontal space to loosen them without removal of any Triadan 12s,16 but could also be termed Triadan 11b, if they
alveolar wall. originate from the same tooth bud as the normal 11. Super-
Supernumerary incisors and possibly displaced normal numerary CT may also develop medial, lateral, or rostral to
incisors can erupt in an overcrowded manner along the the upper or lower CT rows (Figs 8.12 & 8.13). Dixon et al
normal incisor arch, and caudal (palatal) to them on the illustrated a full-sized supernumerary maxillary CT lying
rostral aspect of the hard palate. In addition to the difficulty in the physiological diastema (between the incisors and
in clinically differentiating supplemental supernumerary the 06),12 and Wortley,21 and Dixon et al16 also reported
incisors from normal incisors, it is usually very difficult to supernumerary teeth developing in the hard palate, and
extract such displaced supernumerary incisors without further examples are shown in Figures 8.12 and 8.13. Usually
causing damage to the remaining incisors, the hard palate just one or two additional CT develop, but Wortley reported
and overlying soft tissues. Lateral and intra-oral radiographs a horse with four supernumerary maxillary CT.21 Many
generally demonstrate the great length of the reserve crowns supernumerary CT erupt when the normal CT are erupting,
of both the normal and the (indistinguishable) supernumer- but others may erupt in mature horses, and Dixon et al
ary incisors that are lying closely together, sometimes in reported supernumerary CT eruption at 12 years of age.16
an intertwined manner (Fig. 8.8). As the consequences of Connated supernumerary CT are very large and irregular in
leaving multiple supernumerary incisors in are usually shape and consequently can displace adjacent CT. Their
minimal, these teeth are, therefore, best not extracted. As the irregular interdental margins do not form tight seals with
supernumerary incisors erupt, their occlusal surfaces are adjacent normal CT and the resultant large interdental
usually worn down by attrition – due to contact with food (interproximal) space (i.e., diastema) leads to food pocket-
and intermittent contact with lower incisors due to the ing and often painful periodontal disease.
normal rostrocaudal movement of the mandible. If, how­ In other instances where a caudal supernumerary tooth
ever, supernumerary incisors are extremely displaced, indi- develops at the same time as the normal 11, overcrowding
vidual teeth lose occlusal contact and overgrow. Such teeth of the dental buds occurs prior to calcification. In these
should be reduced biannually, preferably using motorized cases, the 11 and the supernumerary cheek tooth are both
equipment. deformed and lie obliquely or possibly parallel to each other
in separate or a common alveolus. Following eruption of the
Supernumerary canine and 1st premolar supernumerary cheek tooth, diastemata between these two
distorted teeth allow food impaction also leading to painful
teeth (‘wolf teeth’) periodontal disease. Unopposed caudal supernumerary CT
Supernumerary canine or ‘wolf’ teeth are rarely recognized, will overgrow if not reduced (Fig. 8.11) and the overgrown
and most suspected supernumerary canine teeth are in fact teeth will become displaced caudally, causing diastema for-
rostrally displaced, large 1st premolar (‘wolf teeth’).16 mation (Fig. 8.9).

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 8 Dental disease and pathology

A B

Fig. 8.9  (A) The supernumerary CT present at the caudal aspect of this maxillary CT row is overgrown due to absence of occlusal contact. Contact of
the overgrowth with the caudal aspect of the lower 11 has caused it to displace caudally, causing a wide diastema (arrow) between it and the adjacent 11.
(B) Intra-oral view of a supernumerary 212 that has overgrown and caused a diastema (arrow) to develop between it and the 211. The flat occlusal surface
shows it has been reduced in the past.

A B

Fig. 8.12  (A) This supernumerary cheek tooth lies medial to 106/107 with
Fig. 8.10  Post mortem radiograph of a hemimandible with a caudal much periodontal pocketing of food on its rostral aspect (arrow). (B) The
supernumerary CT. In addition, there are focal, lytic areas in the sclerotic periodontal disease has caused the darkened area on the crown of the
mandibular bone under 311 associated with marked periodontal disease orally extracted tooth (arrow).
clinically evident around this tooth.

Fig. 8.13  A supernumerary maxillary CT lying medial (palatal) to 108 and

109 has caused some separation between these two normal teeth, with
resultant diastemata formation and periodontal disease development
between all three teeth. The subsequent marked and deep periodontal
disease necessitated extraction of all three CT.

Fig. 8.11  A marked (circa 5 cm long) overgrowth is present on this

caudally situated supernumerary mandibular CT (412) that has caused
In the rare cases where clinically significant diastemata do
marked ulceration of the adjacent cheeks (arrow). not occur adjacent to a supernumerary cheek tooth, continu-
ing eruption of the unopposed supernumerary tooth causes
an overgrowth (usually at the caudal aspect of the CT rows)
(Figs 8.9 & 8.11). Consequently, it is very worthwhile
in horses with caudal CT overgrowths, especially with

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 Disorders of development and eruption of the teeth and developmental craniofacial abnormalities

unexplained development of such overgrowths, not to just to the potential great depth of the diastema (e.g., up to 7 cm
assume that they are overgrowth of an 11, but to carefully deep), it may not be possible to clean them fully of impacted
count the teeth to assess if a supernumerary tooth is present. food, even with use of pressurized water or air systems.
If any doubt exists, latero-oblique radiograph can confirm As noted, diastema formation adjacent to a supernumerary
the presence of supernumerary teeth, but care must be taken Triadan 12 can lead to apical infection of the supernumerary
not to mistake two overlapping teeth for a single, wide tooth. and/or adjacent CT and to caudal maxillary sinusitis. Alter-
Very rarely, a second supernumerary tooth (e.g., Triadan natively, food tracking (between the upper 11s and 12s) into
113) will develop caudal to the initial supernumerary cheek the sinus may cause an oromaxillary fistula without apical
tooth as illustrated by Dixon et al.16 infection of adjacent CT.23 Unless advanced apical changes
Careful examination of a well-restrained horse using a are present in such teeth, it may be difficult to determine the
good light source and a dental mirror (or intra-oral camera) presence of apical infection by radiography alone because of
is needed to examine the poorly accessible caudal aspect of the superimposed radiodense sinus structures and contents.
the mouth where supernumerary CT most commonly Careful examination of each tooth for the presence of pulpar
develop. If significant periodontal disease is present, extrac- exposure is indicated in such cases and may indicate the
tion of the supernumerary tooth is the ideal solution, but presence of apical infection.26–28 Advanced imaging tech-
this can be a very difficult procedure, especially in a young niques, such as scintigraphy and computerized tomography,
horse.16,22 Extraction of an upper 12 can be particularly dif- can also be of great value. In the absence of conclusive evi-
ficult, as it will likely have a caudally facing reserve crown dence of apical infection of the upper 11, extraction of the
and apex that may partially lie beneath the orbit. Conse- supernumerary tooth prevents further food pocketing and
quently, it is impossible to apply adequate repulsive forces allows healing of the oromaxillary defect. In the presence of
directly behind the apex to repulse the supernumerary CT an oromaxillary sinus fistula, sinoscopy or sinusotomy is
into the oral cavity, but careful application of lateral pressure indicated with thorough lavage of food from the sinus and
may loosen the tooth. placement of a postoperative sinus lavage system. If the
For many reasons, oral extraction is preferable to repul- supernumerary CT is not apically infected, the placement of
sion, provided that enough clinical crown of a suitable acrylic into the cleaned and prepared diastema may prevent
shape is present, i.e., some supernumerary teeth may be further ingress of food into the sinus.23 Careful reduction of
conical – and very difficult to grip with extractors. Some- supernumerary CT also helps prevent its caudal displace-
times, caudal supernumerary CT may have been mechani- ment and reduces the likelihood of loss of diastema packing
cally reduced (Fig. 8.9) and possibly rounded off on their and re-development of oro-maxillary fistula.
occlusal surface, which may preclude oral extraction until
they erupt further. Caudal maxillary supernumerary teeth lie
beside and may be surrounded by the soft palate – whose
normal boundary with the hard palate usually lies at the Dental dysplasia
interdental space of the upper 10s and 11s. Consequently,
great care must be taken when orally extracting caudal maxil- Dysplasia or abnormal development of teeth can involve the
lary supernumerary CT to ensure that the soft palate is not crown, roots, or all of the tooth. Commonly recorded dis-
damaged. In particular, it is essential that the soft palate is turbances in the gross form of teeth include dilacerations
not perforated towards its midline (where there is no under- (abnormal bending of teeth), double teeth, abnormalities of
lying rim of bony palate), as such oropharyngeal fistulas size, and concrescence (roots of adjacent teeth joined by
show poor tendency to heal and are likely to cause perma- cementum) of teeth.1,9 Disturbances in the structure of teeth,
nent dysphagia in affected horses. Extraction of CT is com- including dysplasias (disturbances of development) of the
prehensively discussed in Chapter 20. individual calcified dental tissues or pulp, are well described
If oral extraction is not feasible, and clinical signs of apical in human dentistry, with disturbances in amelogenesis
infection are not present (e.g., sinusitis – with presence of particularly well described.29 There is a rapidly increasing
caudally situated supernumerary CT), a further option is to knowledge of the genetic defects that underlie some of these
remove any overgrown crown causing soft tissue trauma, dental dysplasias.30 However, very many human dental dys-
and, possibly, to attempt to widen the interproximal space plasias are secondary to systemic diseases that can occur in
between the supernumerary tooth and the normal 11s using utero, or during the neonatal or postnatal periods. Local
a diastema burr in order to prevent food impaction at this disturbances, including trauma, can also cause dental dys-
site. Alternatively, any diastema and periodontal pockets plasia; for example, the most common cause of enamel
present can be cleaned out and filled with acrylic or endo- hypoplasia of a single human permanent tooth (‘Turner
dontic restorative material.23 Due to poor access and com- tooth’) is damage to the developing ameloblasts by infection
monly also to tongue movements, diastema widening is a of the overlying deciduous tooth.9
relatively difficult procedure when the supernumerary tooth Amelogenesis imperfecta includes a range of hereditary
has erupted directly behind the 11, and great care must be disorders affecting enamel formation in both deciduous and
taken not to damage the soft palate with the burr during the permanent teeth and can be divided into two types, i.e.,
procedure.24,25 If the supernumerary and the Triadan 11 teeth defects in enamel matrix formation or in the mineralization
have an obliquely oriented interproximal space between of enamel. The genetics of this disorder in particular are well
them, it is even more difficult to safely widen this diastema studied in human dentistry, with AMELX gene mutations
and constant monitoring with an intra-oral mirror or endo- increasingly described.9,30 Amelogenesis imperfecta as part of
scope is necessary during the procedure to guide the diastema a generalized ectodermal syndrome has been described in a
burr along the irregular interdental space. Additionally, due horse (Fig. 8.14),10 and an amelogenesis defect is also the

105
 8 Dental disease and pathology

Fig. 8.16  This recently erupted dysplastic 403 has an abnormal protrusion
on its labial aspect.

Fig. 8.14  Severe dental dysplasia with some abnormally small

sized (microdontia) and misshapen CT, and concurrent hypodontia in  
a young Thoroughbred that suffered a generalized ectodermal dysplasia.
(From Ramzan et al10 with permission from Equine Veterinary Journal.)

Fig. 8.17  This young horse has displaced and abnormally shaped maxillary
incisors that additionally are suffering focal enamel caries – a rare feature at
this site, that is likely caused by structural developmental defects.

relatively common finding in apically infected CT, and to

predispose to the apical infection in a minority of cases, and
two examples are shown here (Figs 8.20 & 8.21).26–28 Some
dysplastic teeth are of normal morphological structure and
of normal shape but are excessively large i.e., macrodontia
or too small, i.e., microdontia, and an example of the former
is given in Figure 8.21.

Disparity in the length of the cheek teeth rows

Fig. 8.15  Lateral-oblique radiograph of a 3-year-old horse that initially

A disparity between the lengths of the upper and lower
presented with maxillary sinusitis. Gross dysplasias of multiple permanent CT rows, including due to the presence of a supernumerary
cheek teeth are present. (Image courtesy of Dr Scott Palmer.) cheek tooth in one row, or because of larger CT in one
opposing row, can result in overgrowths occurring unila­
likely cause of the widespread dental dysplasia present in the terally or bilaterally on the 06s or 11s (or supernumerary
horse shown in Figure 8.15. teeth) in upper or lower CT rows. Supernumerary CT prob-
A wide range of developmental defects of dentin has lems are dealt with separately later in this chapter. The CT
been described in humans including dentinogenesis overgrowths should be reduced biannually (as earlier
imperfecta and others caused by mineral and vitamin defi- described for the craniofacial disorder, rostral positioning
ciencies. Developmental cemental defects are less commonly of the maxillary CT row) using techniques outlined in
described in any species, and include root hypercementosis, Chapter 17.
a feature so commonly found in older equine teeth as to be
almost regarded as physiological. Marked hypercementosis Abnormalities of dental eruption
is present in some chronic equine CT apical infections.26–28
A dramatic hypercementosis of equine incisors has also been
described in many horses affected with the recently described
Maleruption of cheek teeth
equine odontoclastic tooth resorption and hypercementosis Some cases of ‘stepmouth’ and ‘wavemouth’ are caused
syndrome.31 by mismatched eruption of opposing permanent CT in
Examples of dysplastic incisors (Figs 8.16 & 8.17) and the maxillary or mandibular rows,19 causing an overgrowth
dysplastic cheek teeth (Figs 8.14, 8.15, 8.18 & 8.19) are also of the teeth that erupt first. Bilateral overgrowths of the
presented here. Recent studies have shown dysplasia to be a upper 10s are a common pattern of this disorder in some

106
 Disorders of development and eruption of the teeth and developmental craniofacial abnormalities

A B

Fig. 8.18  (A) Lateral-oblique radiograph of a miniature Shetland pony with dysplasia of 109, 110 and 111. The large, abnormally curved (dilacerated) 109 has
caused caudal displacement of the abnormally shaped 110 and 111, with resultant development occlusal abnormalities of both CT rows. (B) Dilacerated
dysplastic tooth following extraction. The clinical crown had a groove cut in it to aid its extraction.

2 1 2
1 3 C
3

4
4 5 5

A B

Fig. 8.19  (A) The occlusal surface of a 307 with multiple, branched subdivisions of pulp chambers 1 and 2 caused by dysplastic enamel. The dysplastic
enamel has altered the overall shape of the tooth, causing it to poorly fit its alveolus, resulting in some localized periodontal food pocketing and
periodontitis (site indicated by superimposed red lines). (From Dacre et al,26 with permission from The Veterinary Journal.) (B) The mid-tooth section shows
all pulp chambers to be empty. The enamel dysplasia has caused reduced dentinal thickness, and the peripheral cementum has become very infolded,
appearing like maxillary infundibula, i.e., completely surrounded by enamel. A new cheek teeth pulp horn numbering system is now in use (see Chapter 5).

A B

Fig. 8.20  (A) The caudal root of this dysplastic, apically infected mandibular CT is absent, and its site has a large apical opening leading into a wide necrotic
pulp chamber (arrow). Some extraction-induced loss of periodontal membrane has occurred. (B) The occlusal surface shows an additional dysplastic pulp
chamber (surrounded by a ring of enamel) that is occlusally exposed. (From Dacre et al,26 with permission from The Veterinary Journal.)

107
 8 Dental disease and pathology

breeds. These developmental overgrowths may remain for displaced (usually lingually), and if deciduous incisors are
life and even increase in magnitude with time, initiating retained for long enough (e.g., >1 year), they may cause
additional abnormalities of CT wear and diastemata. Recog- lasting changes to the position of the permanent incisors.33
nizing and removing such overgrowths at an early stage (in In some horses, the permanent incisor erupts beside its
stages if necessary) is the key to their successful manage- deciduous precursor, thus forming an expanded incisor
ment, as discussed in Chapter 17. arcade. In such cases, it may be difficult to clinically differ-
entiate between the normal permanent incisors and the
retained incisor(s), or indeed to assess if the additional tooth
Retention of deciduous teeth in the arcade is in fact a supernumerary incisor. Conse-
quently, radiographs should be taken prior to attempted
Retention of incisors extraction of any additional incisor, unless it can be posi-
Deciduous incisors are occasionally retained for a significant tively identified on morphological appearance as being a
period beyond their normal time of shedding, which is retained incisor.
approximately 2.5, 3.5, and 4.5 years of age, respectively, for Under sedation and appropriate regional nerve block,
the 01s, 02s and 03s. Because the permanent tooth buds firmly attached retained deciduous incisors with short reserve
normally develop lingual (on oral aspect) to their deciduous crowns can sometimes be extracted, using dental elevators
precursors, retained incisors usually lie labial (rostral) to the and forceps. However, retained incisors with very long
erupting permanent incisors,11 (Fig. 8.22) or lie between and reserve crowns need resection of their alveolar wall to allow
displace the permanent incisors (Figs 8.23, 8.24) but rarely extraction. Deciduous incisors that are retained on the
can develop on their lingual aspect (Fig. 8.25).32 Retained lingual aspect of the permanent teeth are more difficult to
incisors can cause the erupting permanent incisors to be extract, and their reserve crowns may need to be ground
(reamed) out.32 Details of incisor extractions are presented
in detail in Chapter 20.

Retention of cheek teeth

Abnormal retention of the remnants of the deciduous CT
(termed ‘caps’) can occur in horses between 2 and 4.5 years
of age. These deciduous teeth are normally shed at 2.5, 3 and
4 years of age respectively, for the 06s, 07s, and 08s, but
there can be much individual variation in the timing of
deciduous cheek tooth shedding.33,34 If the deciduous teeth
are loose, they may abnormally stretch or tear periodontal
ligaments or gingival attachments during mastication,
causing short-term oral discomfort. Affected horses may
display headshaking, quidding, resistance to the bit, and
occasionally loss of appetite for a couple of days, until the
loose teeth are shed. Such clinical signs of oral discomfort
in 2–4-year-old horses warrant careful oral examination for
Fig. 8.21  This macrodontic (enlarged) 110 (arrows) is of normal
evidence of deciduous teeth that are loose or have a distinct
appearance, but is about 50 % wider than the normal maxillary CT.   space between deciduous and permanent teeth (Fig. 8.26).
Due to its large size, it has overgrown and excessively worn down the If loose deciduous CT are found, they can be removed using
normal (but smaller) opposing 410. specialized ‘cap’ extractors or small CT forceps (Fig. 8.27).

A B

Fig. 8.22  (A) This retained 702 has caused caudal (distal) displacement of the permanent 302 and 303. (B) A ventrorostal view showing
the 6-cm long tooth being extracted.

108
 Disorders of development and eruption of the teeth and developmental craniofacial abnormalities

A B

Fig. 8.23  (A) The additional incisor present in this maxillary incisor arcade was believed to be the tooth with a small rounded clinical crown (arrow), rather
than the tooth with a normal sized crown medial (mesial) to it. (B) However, this radiograph showed a wide, short remnant of the 602 to be retained (arrow)
and the tooth with the small, rounded clinical crown to be a (slightly small) permanent incisor (302).

Fig. 8.24  Retention of the deciduous 702 (arrow) has caused caudal (distal)
displacement of the permanent 303 with subsequent abnormal wear of 303
and the opposing 203.

Even if not loose, some clinicians advise that temporary CT

should be extracted, if the corresponding contralateral ‘cap’
has already been shed.
It has been suggested that the prolonged retention of ‘caps’
may predispose to delayed eruption of the underlying per- B
manent cheek tooth and also to the development of enlarged
‘eruption cysts’ (‘3 y.o. or 4 y.o. bumps’) and thus to apical Fig. 8.25  (A) Initial examination of these incisors might suggest rostral
displacement of two retained deciduous incisors (501, 502). However,
infections.35 These swellings, beneath the developing apices
radiography showed the rostrally displaced incisors to be the permanent
of the permanent CT, occur more commonly on the mandi- teeth (101,102), with two short, retained deciduous incisors lying caudal
ble than maxilla. However, another study found no evidence (lingual) to them. (B) View of premaxilla following extraction of the two
of retained deciduous CT in horses with mandibular apical retained incisors.
infection – most of which developed within months of erup-
tion of affected teeth.36 Nevertheless, there is close temporal
relationship between dental eruption, and development of in some horses. Once the deciduous tooth is removed, the
apical infection in mandibular CT.36 The presence of very fleshy dental sac covering the underlying developing perma-
enlarged eruption cysts on a mandible or maxilla, especially nent cheek tooth is exposed and quickly destroyed by mas-
if unilateral, should prompt a thorough oral examination for tication. This leads to loss of blood supply to the occlusal
the presence of retained deciduous CT, or other dental aspect of the infundibula of the rostral three upper CT (06,
abnormalities. 07, 08), where active cement deposition may still be occur-
The practice of methodically removing deciduous teeth at ring. This may result in marked central infundibular cement
set ages results in the premature removal of deciduous CT hypoplasia and so predispose to the development of

109
 8 Dental disease and pathology

Fig. 8.28  This 4-year-old horse has bilateral eruption cysts beneath the
lower 07s and 08s.
Fig. 8.26  A distinct margin is apparent between the deciduous and
permanent mandibular CT in this skull, indicating the former is ready to be
shed, and is retained by periodontal attachments on one side only (arrow).
Overcrowding and vertical
impaction

11
06 10
07 09
08

Fig. 8.27  This loose deciduous tooth, which had a large space between it
and the underlying permanent CT with food entrapment, is being extracted
with a ‘cap extractor’. B

Fig. 8.29  (A) Diagrammatic representation of overcrowding and vertical

infundibular caries later in life. In conclusion, deciduous impaction of a mandibular 08. (B) Radiograph of a vertically impacted 307
teeth should not be removed until they become digitally that has become ankylosed to the ventral mandibular cortex. Additionally,
marked drifting of the two adjacent teeth (306, 308) more occlusally now
loose; have an obvious space between them and the erupting permanently prevents its eruption.
permanent CT; protrude above the remaining occlusal
surface; or the contralateral deciduous tooth has been shed.
mandibular CT with apical infection.36 With time, as the
Vertical impaction of cheek teeth (‘eruption mandible and maxillae lengthen, the impacted CT have
cysts’; ‘3 year-old and 4-year-old bumps’) room to erupt normally and the overlying bones then
remodel to a normal contour over the following year or so.
As noted in the previous section, many horses develop focal,
Occasionally, the impacted tooth may become ankylosed to
bilateral swellings of their mandible and also less obviously
the ventral mandibular cortex and never erupt (Fig 8.29).
(due to the presence of overlying muscles) of their maxillae
beneath the developing apices of the 07 and 08 CT
(Fig. 8.28). Certain breeds, especially lighter breeds and Developmental diastema(ta)
miniature breeds in particular, are more prone to develop
these bony swellings. These eruption cysts may be due to As noted earlier, the occlusal surfaces of the individual CT
vertical impaction of the CT that erupt last and a study rows are normally compressed tightly together so that the
showed increased angulation of the two adjacent CT onto occlusal surface of the 6 CT in each row function as a single

110
 Disorders of development and eruption of the teeth and developmental craniofacial abnormalities

the gingival margin (Fig. 8.30), especially between the caudal

mandibular cheek teeth (09s–10s; 10s–11s). Due to their
common position between the caudal mandibular CT where
they are hidden by the tongue, mandibular CT diastemata
are difficult to detect clinically unless these sites are carefully
examined with an intra-oral mirror24 or endoscope.38,39
Open-mouthed radiographic evaluation of diastemata
is a very useful method of assessment of this disorder,
both to evaluate the dimensions of diastemata and more
importantly, to assess the positions and angulations of the
CT.40,41 Cheek teeth with good angulation may grow together
over the following years, with closure of the diastemata,
whilst the prognosis is poorer for CT with inadequate
Fig. 8.30  View of medial aspect of the left hemimandible showing deep angulation.25
food impaction with periodontal disease in three interdental (interproximal) Cleaning out periodontal pockets with manual dental
spaces that has been caused by CT diastemata.
picks or long, right-angled forceps, or by using high pressure
water or air picks can allow short-term relief, and filling the
cleaned periodontal pockets with soft plastic impression
grinding unit. However, if spaces, i.e., diastema(ta) develop material may be of longer-term benefit for some cases. If
in the interdental (interproximal) space between the CT, present, removal of overgrown transverse ridges opposite
food impaction will occur in these spaces12,24,25 (Fig. 8.30). diastemata may reduce food impaction. Feeding mechani-
Developmental mechanisms that can allow CT diastemata cally chopped forage is also palliative because short (e.g.,
to develop24,25 include inadequate angulation of the rostral <5mm long) fibers do not become entrapped in diastemata.
(06s) and caudal (10s, 11s) CT that normally compress the In younger horses, this diet may allow time for further erup-
occlusal aspects of all 6 CT together occlusally. Alternatively, tion and compression of the CT row, provided the rostral and
CT may have normal angulation but develop too far apart caudal CT have sufficient angulation.24 Specialized burrs can
due to disparity between size of teeth and supporting bones be used to widen diastemata at the occlusal surface to help
or because the CT buds develop too far apart. limit food trapping and are best used after radiographic
Carmalt has proposed that the term valve diastema be used evaluation (open-mouth projections) of diastemata and
to differentiate these pathological diastemata from the careful examination of the occlusal surface to assess the
normal diastemata present between the incisors (or canine direction of the interproximal space (and diastema) between
teeth in males) and the CT (i.e., ‘bars of mouth’) or from a affected CT, as some (especially caudally situated) diastem-
wide interdental space, e.g., where a cheek tooth has been ata have a diagonal and/or wavy interproximal space. Great
lost.4 Such valve diastemata are more problematic than open care must be taken not to thermally damage or directly
diastemata – where the abnormal space has similar width expose the pulp of the CT being burred. A long-term study
from the occlusal surface to the gingiva. Du Toit et al have showed excellent clinical results with this treatment.25
shown that clinical examination of diastemata can accu-
rately differentiate between valve diastemata (narrower on Developmental displacement of teeth
occlusal than gingival aspect) or open diastemata (same
width from occlusal to gingival aspects) – with mean occlu-
sal to gingival diastema width ratios of 0.4 found in valve
Displacement of incisors
diastemata and of 1.07 in open diastemata.37 The presence In addition to displacements in the presence of supernumer-
of sharp transverse overgrowths or accentuated transverse ary incisors, occasionally gross displacement of permanent
ridges directly opposite wider diastemata can selectively incisors can occur in horses with a normal number of
widen such diastemata and compress food into them, but teeth (Fig. 8.31). Previous trauma can cause displacements
most problematic CT diastemata are valve diastemata with of the developing incisors, especially mandibular incisor(s),
narrow (<3 mm) spacing occlusally, that do not have linear but incisors may also be displaced because of intrinsic
occlusal overgrowths on the opposite CT. developmental reasons.
The massive and prolonged forces of mastication on
equine CT occlusal surfaces cause progressively deeper
impaction of long fibers into widened interdental spaces,
Displacement of cheek teeth
which can later spread sub-gingivally to the lateral and Displacements are extremely rare in deciduous equine CT,
medial aspects of the two affected teeth. This leads to a but are well recognized in permanent CT. Two different types
painful and usually progressive secondary periodontal of permanent CT displacement (i.e., developmental and
disease with remodeling and lysis of the alveolar bone – that acquired) are recognized in horses.12 Most severe CT dis-
occasionally may even lead to extensive osteomyelitis of placements, especially in younger horses, are developmental
the supporting mandibular or maxillary bones,12 or if and often appear to be caused by overcrowding of the dental
in­volving the upper 08s–11s, to sinusitis or an oro-maxillary rows during eruption and, less commonly, by developmen-
fistula – with the overlying maxillary sinuses becoming filled tal displacement of the developing CT bud. Developmental
with food and exudate.23 CT diastema can be recognized by CT displacement may be bilateral, and displaced CT may be
finding food fibers packed in between teeth and more sig- bent (dilaceration), suggesting that dental overcrowding
nificantly in periodontal pockets between the CT just above occurred prior to calcification of the developing tooth

111
 8 Dental disease and pathology

Fig. 8.31  This 4-year-old horse has a developmental displacement of 202 Fig. 8.33  Post mortem image of a marked developmental lateral (buccal)
that is rotated almost 90° and so is horizontally (rather than vertically) displacement of a 309 that has not been treated for years. The displaced
aligned to the long axis of the premaxilla. It was treated by repeated tooth has caused severe ulceration and deeper muscle damage to the
floating its occlusal surface. Extraction of the displaced incisor would be cheeks (arrow). Marked periodontal disease on both sides of the displaced
difficult and likely to damage the adjacent normal incisors. CT caused additional oral pain to this neglected horse. (From Dixon et al,12
with permission from Equine Veterinary Journal.)

have diastemata between the displaced and adjacent CT

(Fig. 8.31–8.33), which allows painful food pocketing.24,25
In some horses, very wide diastemata occur beside displaced
CT, which suggests that abnormal positioning of the devel-
oping tooth bud, rather than dental overcrowding, was the
initial cause of the displacement. Abnormally protruding
areas of displaced CT and, less commonly, secondary over-
growths on opposite teeth, can lacerate the cheeks and
tongue, causing bitting and quidding problems (Fig. 8.33).
However, deep and painful periodontal food pocketing due
to concurrent diastemata is the usual cause of quidding that
persists after the protruding areas of displaced (or opposing)
teeth are ground down.
Fig. 8.32  Developmental displacement is present in this 410 which is bent.
Marked displacements where CT lay horizontal in the
Diastema is present adjacent to the displaced tooth and also between 408
and 409. mandible or the maxilla and never erupted have been
reported.42,43
Abnormal protrusions or overgrowths of displaced CT (or
their misaligned opposing CT) can be removed with manual
(Fig. 8.32). Trauma to the jaws can also damage or displace or power instruments, and impacted food in diastemata
a developing CT bud, causing later maleruption. The perma- should be removed. If very extensive food pocketing is
nent 06, 07, and 08 positions are seldom affected with over- present, these diastemata can be mechanically widened
crowding or developmental displacements because they (removing most dental tissue from the displaced tooth), and
replace deciduous teeth of approximately the same size. overgrowths on the opposing teeth ground down. Finally,
The 09 and 10 positions are most commonly displaced, displaced teeth can be extracted, especially when markedly
and equine mandibular CT are three times more likely to be displaced or rotated, and this procedure is most readily per-
displaced than maxillary CT.12 Rotation of displaced CT is formed in older horses with shorter reserve crowns, espe-
occasionally present, especially with displaced maxillary CT. cially where the CT have been loosened by deep periodontal
Large and sharp overgrowths can develop on aspects of dis- disease. Such extractions can readily be performed per os in
placed teeth and their opposing teeth, that are not in full the standing, sedated horse, and an excellent clinical response
occlusal contact. Developmentally displaced CT invariably usually follows.

References
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Cambridge University Press, Cambridge, 2nd edn. Elsevier, Edinburgh, 2005, American Association of Equine
1990, pp 118–122, pp 249–266 Practitioners, Indianapolis, 2006,
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4. Carmalt JL, Townsend HGG, Allen AL. survey of 152 cases. International Journal understanding dental anomalies.
Effect of dental floating on the of Paediatric Dentistry 2002; 12: American Journal of Orthodontics and
rostrocaudal mobility of the mandible of 244–254 Craniofacial Orthopaedics 2000; 117:
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WB Saunders, London, 1999, Abnormalities of development. In: Incisor extraction in a horse by a
pp 173–184 O’Connor JJ, ed. Dollar’s Veterinary longitudinal forage technique. Equine
6. Easley J. Corrective dental procedures. In: Surgery, 4th edn. Alexander Eger, Veterinary Education 2001; 13: 179–182
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2nd edn. Elsevier Saunders, Edinburgh, 20. Dixon PM, Dacre I. A review of equine Examination of the oral cavity and
2005, pp 221–248 dental disorders. Vet J 2005; 169: routine dental care. Veterinary Clinics of
7. Brown SL, Shaw DJ, Dixon PM, Arkins S. 165–187 North America – Equine Practice 1993; 9:
Occlusal angles of cheek teeth in normal 21. Wortley AJ. Irregularities and diseases of 123–131
horses and horses with dental disease. the teeth. In: Wortley AJ, ed. The horse, 34. Sisson S, Grossman JD. In: The Anatomy
The Veterinary Record 2008; 162: its treatment in health and disease, Vol.2. of Domestic Animals, 4th edn. WB
807–810 Gresham Publishing, London, 1907, Saunders, Philadelphia, 1971,
8. Schumacher J, Dixon PM. Diseases p. 327 pp 396–405
of the Nasal Cavity. In: McGorum BC, 22. Dixon PM, Dacre I, Dacre K, et al. 35. Barrairon P, Blin PC, Molinier F.
Robinson NE, Dixon PM, Schumacher J, Standing oral extraction of cheek teeth in Contribution à l’etude du mechanisme
eds. Equine Respiratory Medicine and 100 horses (1998–2003). Equine Vet J de formation de fistule des premolaires
Surgery, Elsevier Oxford, 2005, 2005; 37: 105–112 chez le jeune cheval. Bulletin de l’
pp 369–392 23. Hawkes CS, Easley J, Barakzai SZ, Academie Veterinaire de France 1980; 53:
9. Soames JV, Southam JC. Disorders of Dixon PM. Treatment of oromaxillary 47–54
development of teeth and craniofacial fistulae in nine standing horses (2002– 36. Dixon PM, Tremaine WH, Pickles K, et al.
abnormalities. In: Oral Pathology, 4th 2006). Equine Vet J 2008; 40: Equine dental disease part 4: a long-term
edn. Oxford University Press, Oxford, 546–555 study of 400 cases: apical infections of
2006, pp 1–18 24. Collins N, Dixon PM. Diagnosis and cheek teeth. Equine Vet J 2000; 32:
10. Ramzan PHL, Dixon PM, Kempson SA, management of equine diastemata. 182–194
Rossdale PD. Dental dysplasia and Techniques in Equine Practice 2005; 4: 37. Du Toit N, Burden FA, Gosden L, Dixon
oligodontia in a Thoroughbred colt. 148–154 PM. A study of the dimensions of
Equine Vet J 2001; 33: 99–104 25. Dixon PM, Barakzai S, Collins N, Yates J. diastemata and associated periodontal
11. Dixon PM, Tremaine WH, Pickles K, et al. Treatment of equine cheek teeth by food pockets in donkey cheek teeth. J Vet
Equine dental disease part 1: a long-term mechanical widening of diastemata in 60 Dent 2009; 26: 10–14
study of 400 cases: disorders of incisor, horses (2000–2006). Equine Vet J 2008; 38. Tremaine WH. Dental endoscopy in the
canine and first premolar teeth. Equine 40: 22–28 horse. Clinical techniques in equine
Vet J 1999; 31: 369–377 26. Dacre IT, Kempson S, Dixon PM. practice 2005; 4: 181–187
12. Dixon PM, Tremaine WH, Pickles K, Pathological studies of cheek teeth apical 39. Simhofer H, Griss R, Zetner K. The use of
et al. Equine dental disease part 2: a infections in the horse Part 4: oral endoscopy for detection of cheek
long-term study of 400 cases: disorders of Aetiopathological findings in 41 apically teeth abnormalities in 300 horses. Vet J
development and eruption and variations infected mandibular cheek teeth. Vet J 2008; 178: 396–404
in position of the cheek teeth. Equine Vet 2008; 178: 341–351 40. Easley J. A new look at dental
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13. Wafa NSY. A study of dental disease in Pathological studies of cheek teeth Annual Convention of the American
the horse. MVM thesis, National apical infections in the horse. 5 Association of Equine Practitioners, 2002,
University of Ireland, Dublin, 1988, Aetiopathological findings in 57 apically pp 412–420
pp 91–173 infected maxillary cheek teeth and 41. Barakzai SZ, Dixon PM. A study of
14. Baker GJ. A study of equine dental histological and ultrastructural findings. open-mouthed oblique radiographic
disease. PhD Thesis, University of Vet J 2008; 178: 352–363 projections for evaluating lesions of the
Glasgow, 1979, pp 36–38 28. van den Enden MS, Dixon PM. erupted (clinical) crown. Equine
15. Orsini PG. Oral cavity. In: Auer JA, ed. Prevalence of occlusal pulpar exposure in Veterinary Education 2003; 15: 143–148
Equine Surgery, WB Saunders, 110 equine cheek teeth with apical 42. Edwards GB. Retention of permanent
Philadelphia, 1992, p. 300 infections and idiopathic fractures. Vet J cheek teeth in horses. Equine Veterinary
16. Dixon PM, Easley KJ, Ekmann A. 2008; 178: 364–371 Education 1993; 5: 399–402
Supernumerary teeth in the horse. 29. Aldred MJ, Crawford PJ. Amelogenesis 43. Becker E. Zahne. In: Dobberstein J,
Journal of Clinical Techniques in Equine imperfecta – towards a new classification. Pallaske G, Stunzi H, Band V, eds.
Practice 2005; 4: 155–161 Oral Diseases 1995; 1: 2–5 Handbuch der speziellen pathologischen
17. Rajab LD, Hamdan MAM. Supernumerary 30. Vastardis H. The genetics of human anatomie der haustiere, 3rd edn. Verlag
teeth: review of the literature and a tooth agenesis: new discoveries for Paul Parey, Berlin, 1962, pp 121–265

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 Section 3:  Dental disease and pathology

C H A P TER  9 
Head and dental trauma
Tim Greet† BVMS, MVM, Cert EO, DESTS, Dipl ECVS, FRCVS,
Peter H.L. Ramzan* BVSc, MRCVS
†
Rossdales Equine Hospital, Cotton End Road, Exning, Newmarket, Suffolk CB8 7NN, UK
*Rossdale and Partners, Beaufort Cottage Stables, High Street, Newmarket, Suffolk CB8 8JS, UK

A variety of injuries affecting the oral cavity may be encoun- Maintenance of a patent airway must be a priority and if
tered in equine practice. Many of these injuries arise from required, insertion of an emergency tracheotomy tube
inquisitive or playful interaction of the horse with objects in should be carried out without delay. Most nasal hemorrhage
its environment. Other injuries are the direct result of human (from nasal cavity and/or sinuses) associated with facial
action. Oral injuries may involve, in various combinations, injury ceases without need for particular action. Secondary
the soft tissues, osseous, and/or dental structures of the infection of the paranasal sinuses is common following
mouth. facial fracture and appropriate antibiotics should be admin-
istered. Sinus lavage may also be of benefit with an open
fracture of the sinus walls, or where there has been signifi-
The oral environment and healing cant intrasinus hemorrhage. In horses with major facial
of oral injuries wounds, the extent of osseous or dental injury and the pres-
ence of radiodense foreign bodies should be assessed using
Although wounds within the oral cavity are exposed to food multiple radiographic projections or, if available, computed
material and a large mixed resident population of obligate tomographic (CT) imaging, before any attempt is made to
and facultative anaerobic and aerobic bacteria, healing gen- repair the overlying soft tissues.
erally proceeds far more rapidly than with cutaneous
wounds. Even extensive intra-oral injuries to the cheeks or
tongue rapidly resolve providing the inciting cause (frac-
Management of specific intra-oral injuries
tured or displaced tooth, foreign body, or sequestrum) is no Lips and cheeks
longer present. One of the factors responsible for such effi-
One of the most commonly encountered injuries to the lips
cient healing and the limited subsequent formation of scar
is traumatic injury to the commisures of the lips arising from
tissue, is that oral mucosal wounds have a subdued inflam-
the use of a bit. Damage to the soft tissues may occur directly
matory response compared to external skin wounds.1,2 In
from inappropriate pressure on the bit or as a result of soft
addition, the constant bathing of oral wounds with saliva
tissue being trapped between the bit and the rostral cheek
(rich in protease inhibitors, cytokines and growth factors)
teeth. The appearance of these injuries is determined by
also speeds up wound healing. Furthermore, an excellent
severity and chronicity, ranging from a fresh wound to ulcer-
oral vascular supply ensures that tissue devitalization is
ation and eventually to scar tissue formation. To facilitate
minimal.
healing it is sensible to remove the inciting cause, which can
Given the intrinsic good healing characteristics of the oral
mean a period of time without using a bit. This is often
mucosa, there is generally little merit in attempting to assist
impractical and minimizing ongoing soft tissue trauma must
healing by using topical medications, and in any event, there
then be the primary goal. The use of a wide rounded bit such
is little objective support for the efficacy of most such treat-
as a rubber snaffle and removal of sharp cheek tooth edges,
ments. Oral lavage with a saline solution or water may tem-
can assist in the prevention of lip and cheek damage. Round-
porarily assist in reducing contamination with food material.
ing the profile of the rostral aspect of the 06s (first maxillary
Similarly, unless wounds are full-thickness or closure is nec-
and mandibular cheek teeth), known as ‘bit-seating’, may
essary to prevent food contamination of deeper defects,
also be employed. Any such profiling should be performed
suturing of intra-oral injuries is not generally indicated.
with awareness of the possibility of exposing the rostral
(6th) pulp and thus causing pulpitis if reductions are exces-
Management of horses with facial trauma sive. If large, displaced or sharp wolf teeth are present and
felt to be contributing to the problem, their extraction may
A horse with major facial trauma should be assessed imme- also be indicated.
diately for the presence of life-threatening respiratory Abrasions or lacerations of the cheeks within the oral
obstruction, epistaxis, and any indication of other major cavity can arise from direct trauma to the soft tissues by
dysfunction, such as neurological or ocular disturbance. sharp or prominent buccal enamel points/edges or displaced

115
 9 Dental disease and pathology

suture line by separating the adjacent musculature at the

edges of the wound, thus reducing the chance of dehiscence.
Should the sutured wound subsequently partly or fully
dehisce, it may be left to heal by second intention. If cos-
metic or functional outcome is poor, secondary repair of the
wound can be undertaken at a later date.

Tongue
There are two main types of direct injury to the tongue that
are encountered in practice. Lacerations of the lateral margins
of the tongue (Fig. 9.4) may be caused by the horse inadvert-
ently biting itself, trauma from displaced or fractured teeth
or from a foreign body. Injuries to the tongue arising from
Fig. 9.1  A small fresh buccal ulcer adjacent to a maxillary cheek tooth. inappropriate restraint may also be encountered. In the latter
case, aggressive use of a leading bit (typically a chifney) can
result in laceration of the dorsal or lateral margins of the
rostral portion of the tongue. These injuries can range from
small superficial cuts to near-total transaction of the tongue
(Fig. 9.6). Occasionally, a horse is examined that has previ-
ously sustained a severe laceration of the tongue that has
healed, leaving a large defect in its dorsum or lateral border
(Fig. 9.5). Grasping the tongue as a means of restraint can
also result in injury should the handler fail to release the
tongue if the horse pulls back; excessive traction can cause
laceration of the lingual frenulum. It is not usually necessary
to repair these injuries.
Horses that have sustained a laceration of the tongue due
to dental or foreign body trauma at the back of the mouth
typically present with acute signs of oral discomfort and
excessive salivation. A thorough examination of the oral
cavity, using a full-mouth speculum, is necessary to assess
these injuries. Due to their hidden location, some caudal
lacerations of the tongue may be more readily detectable by
digital examination, rather than by direct visualization.
However, oral endoscopy, if available, is the preferred tech-
nique to image the caudal tongue and a dental mirror may
also reveal some such lesions. Care should be taken to
Fig. 9.2  Chronic buccal abrasion of dental origin. palpate the dorsal and both lateral margins of the base of
the tongue, particularly at the level of the occlusal surface of
the mandibular cheek teeth. Once the inciting cause is
or fractured teeth. Injuries may be detected, when acute, as removed, these injuries tend to heal without further inter-
mucosal lacerations or fresh abrasions (Fig. 9.1) or when vention, although anti-inflammatory and/or antibiotic
chronic (characterized by ulceration with thickened mucosal therapy may be beneficial in some cases. On occasion, focal
edges or scar tissue; Fig. 9.2). The removal of the inciting abscess formation or more generalized infection of the
cause usually resolves the problem. tongue may occur following foreign body penetration (often
Trauma to the external lip or muzzle is usually the result with food material, wire fragments, or wood splinters). Such
of the horse biting or playing with a fixed object in its envi- cases may present with signs of oral discomfort and excessive
ronment. These injuries are typically full thickness, and salivation; however, early diagnosis is often more difficult
although wound breakdown often ensues, an attempt at than for the lacerations discussed above. In these cases, the
sutured repair is usually indicated to maximize the chance tongue is often grossly normal to visualisation without use
of a good cosmetic and functional outcome. Following of endoscopy, but palpation of the affected site may reveal
lavage of the wound and debridement of any obviously an area of firmness within the softer body of the tongue,
devitalized tissue, a multi-layer repair of the defect is usually which elicits a pain response on digital pressure and which
undertaken (Fig. 9.3) beginning with apposition of the oral may be associated with focal malodour. Depending on the
mucosa with simple interrupted or continuous absorbable severity of clinical signs, aggressive treatment with broad-
sutures. External closure of the skin wound using non- spectrum antibiotics or surgical drainage of a lingual abscess
absorbable suture material or staples then follows. However, may be necessary.
with more extensive defects, separate closure of the muscular In the case of a severe, bit-induced laceration of the tongue
layer should also be performed with absorbable sutures to (Fig. 9.6), assessment of the wound (and tongue viability)
afford the best chance of healing by primary intention. It is often best performed under general anesthesia. A gauze
may be beneficial to minimize excessive movement at the bandage tied around the tongue caudal to the wound can be

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 Head and dental trauma

Fig. 9.3  (A) An extensive laceration of the lower lip which also has a full-thickness defect
through the left cheek into the mouth. (B) Separating the skin from the underlying
musculature. (C) Repair of facial musculature using a continuous suture of 4 metric
B polydioxanone. (D) Although the lesion was repaired in layers, partial wound dehiscence
resulted in an orofacial fistula. This was successfully repaired by a second operation.

used as an effective tourniquet. Gentle traction to the alternately (Fig. 9.8). The latter should incorporate a signifi-
bandage also allows good exposure of the more caudal parts cant bulk of lingual musculature to take up some of the
of the tongue. Glossectomy may be necessary if the tongue tension and to ensure more satisfactory healing. All dead
tip is considered unviable (Fig. 9.7), and removal of tissue space should be obliterated if possible.
up to the level of rostral attachment of the frenulum is Multiple-layer closure of thicker areas of the tongue may
unlikely to affect function. Intravenous administration of be required. It should be remembered that the tongue is very
sodium fluorescein has been recommended as an aid to mobile, and the risk of wound dehiscence is significant
assess tongue viability. Oversewing the body of the tongue unless care is taken to align the tongue correctly and to repair
with simple interrupted or a continuous suture of polyglac- the injury accurately. If the injury is not dealt with immedi-
tin 910 or polydioxanone should be attempted after removal ately, some necrosis and a high level of wound contamina-
of the necrotic tip. Severe lacerations are repaired using tion may occur. In such circumstances, all devitalized tissue
simple interrupted and vertical mattress sutures applied must be debrided carefully to minimize the risk of wound

117
 9 Dental disease and pathology

Fig. 9.4  Large healing lingual laceration caused by self-trauma.

Fig. 9.7  (A) Amputation of severely lacerated tongue. (B) Stump of

amputated tongue.

Fig. 9.5  Healed lingual laceration involving all of dorsum.

Fig. 9.6  This severely lacerated tongue has been severed almost
completely. The injury was repaired using simple interrupted sutures of 4
metric polydioxanone alternated with vertical mattress sutures of the same
material. The wound healed by primary intention, and the horse regained
normal use of its tongue.
Fig. 9.8  Severely injured tongue repaired using polydioxanone sutures.

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 Head and dental trauma

Fig. 9.10  Close proximity of caudal soft tissue pillar to occlusal surface of
Fig. 9.9  Oropharyngeal foreign body. last mandibular cheek tooth (tooth 311).

dehiscence. When placing vertical mattress tension sutures

care must be taken to avoid damage to the lingual blood
supply. Although this blood supply is good, vascular com-
promise may result in necrosis of the more rostral aspects of
the tongue, particularly when the tip is involved. The dorsum
of the tongue has a much stronger mucosa than its ventral
aspect, and suture retention is better in this site. Tension
sutures should, therefore, be placed in this area.

Oropharynx
Lesions at the base of the tongue and in the oropharynx are
difficult to evaluate visually, by palption or imaging, and are
also difficult to surgically repair due to their inaccessibility.
Diagnosis is best achieved by oral endoscopy. Fortunately,
these inaccessible wounds usually heal well without the
Fig. 9.11  Oblique radiographic image showing mandibular sequestrum.
need for surgical repair. Daily lavage of the oral cavity with
a saline solution may be of value in reducing wound con-
tamination with food material. This site is also prone to Systemic antibiotic and anti-inflammatory therapy is indi-
damage by ingested foreign bodies, which are usually twigs cated with more severe injuries.
or pieces of wood. In most circumstances, affected horses
show a sudden onset of oral discomfort, dysphagia, inap­ Mandibular interdental space
petance, excessive salivation, and occasionally, epistaxis.
Foreign bodies within the oropharynx (Fig. 9.9) can often
(‘bar’ or ‘physiological diastema)
be detected by nasopharyngeal endoscopy as they frequently Injuries to the dorsal (intraoral) aspect of the mandibular
protrude through the intrapharyngeal ostium. Foreign interdental space (mandibular ‘bar’) are invariably caused
bodies can usually be retrieved manually with the horse by damage from a bit. Aggressive use of a bit, or indirect,
under heavy sedation or general anesthesia. Repair of any blunt, bit-related trauma, such as when a loose horse
mucosal injury is usually unnecessary. treads on trailing reins, may result in damage to one or
Ulceration of a caudal pharyngeal soft tissue pillar is a not both mandibular bars. In the most severe cases, the
uncommon sequel of dental ‘floating’. The soft tissues at this injury may cause a mandibular fracture (see Fig. 13.47 in
site are in very close proximity to the occlusal surface of the Chapter 13). However, more often with recent injuries there
caudal mandibular cheek teeth (Fig. 9.10). Trauma may is ulceration/laceration of the overlying gingiva that is
occur if excessive caudal movement of the rasp blade occurs painful to pressure, and the horse resents further bitting. If
during manual rasping of the last mandibular cheek tooth the damage is superficial, these injuries will heal unaided,
(311, 411), or if soft tissue becomes trapped between the providing time is allowed without bit contact. In a small
tooth and rasp blade or motorized burr. Ulceration can vary proportion of cases, the dorsal cortex of the bone underlying
in severity, and although clinical signs are generally self- the damaged mucosa may become devitalized and subse-
limiting, affected horses may demonstrate oral dysphagia quent sequestrum formation (Figs 9.11 & 9.12) can result in
until healing occurs, which can be days or even weeks later. a chronically discharging and painful focus. Radiographic

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 9 Dental disease and pathology

Fig. 9.13  This horse sustained severe trauma to the maxilla which resulted
in a fracture of the premaxillary bone and laceration of the hard palate.
There was direct continuity between the oral and nasal cavities.

Fig. 9.12  This is an oral ulcer in the interdental space of the right mandible
of a horse which suffered an injury following restraint with a chiffney.  
A large sequestrum can be seen, which was removed. The horse made  
a complete recovery.

examination (oblique lateral projections) and/or ultrasono-

graphic examination may be necessary to confirm the pres-
ence of a sequestrum. If a sequestrum is identified, surgical
removal is necessary if healing is to be expected, and this can
be performed satisfactorily with the horse sedated and using Fig. 9.14  This is the surgical repair of the injury illustrated in Fig. 9.13. The
regional (subgingival) analgesia. A longitudinal incision of fracture has been reduced with cerclage wire after radical debridement of
the site. The palate has been sutured partially using simple interrupted and
the gingiva overlying the affected area permits the introduc-
vertical mattress sutures of 4 metric polydioxanone. The horse made an
tion of a bone curette which is used to elevate the seques- uneventful recovery, and the cerclage wire was subsequently removed.
trum. Primary closure of such surgical sites is unnecessary
and ridden work using a bit may resume once the mucosa
has healed completely. repaired adequately in this manner, it may be possible to
close the defect by creating a mucoperiosteal flap, or by
making tension-relieving incisions in adjacent portions of
Hard and soft palates the palate and then suturing the defect. Care should be taken
Injuries to the hard palate are rare but may accompany to avoid damaging the palatine blood supply. Post-repair
severe head trauma (Fig. 9.13). In some circumstances, there feeding should be carried out by nasogastric intubation for
may be an underlying fracture of the palatine processes of the first 4 or 5 days to reduce the risk of suture dehiscence.
the premaxillary and/or the maxillary bones. In general, If the rostral portion of the skull is grossly unstable following
these injuries can be left as open wounds, to heal by second a maxillary or premaxillary injury, the fractures may require
intention. However, if the hard palate injury has caused an surgical repair. However, it is surprising how frequently
oronasal fistula, such lesions should always be repaired sur- horses with such major injuries respond successfully to con-
gically. A suspected oronasal fistula may be confirmed by a servative management.
combination of thorough clinical and endoscopic examina- Iatrogenic injuries to the hard palate are uncommon
tions, and by radiography after oral administration of barium but usually arise from dental intervention. The greater pala-
sulfate. While such a fistula may heal by second intention, tine artery courses close to the palatal margin of the maxil-
surgical repair should be attempted if the site is accessible. lary cheek teeth. Inadvertent laceration may occur during
It may be possible to repair the defect by debriding the ‘wolf’ tooth removal or intra-oral extraction of a cheek tooth,
wound and curetting any area of oronasal mucosal continu- and profuse hemorrhage ensues. This hemorrhage is dra-
ity and simply suturing the palatal mucosa with interrupted, matic but rarely life-threatening and is usually effectively
polydioxanone sutures (Fig. 9.14). If the injury cannot be controlled by pressure. If the defect is large enough it may

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 Head and dental trauma

be possible to insert and suture in place some gauze bandage

packing. The affected horse should be kept in a quiet envi-
ronment until bleeding subsides. If the horse is sedated, it
is useful to keep its head very elevated on a headstand. Lac-
erations of the hard palate mucosa may also arise iatrogeni-
cally from the use of dental extraction forceps during oral
extraction procedures, but such injuries typically heal by
second intention without intervention.
Injuries to the soft palate are uncommon but may result
iatrogenically from surgical procedures involving the soft
palate or adjacent structures, such as surgical correction of
epiglottal entrapment. When attempting to axially divide the
displaced mucosa using a curved bistoury, the soft palate
Fig. 9.15  This horse developed a salivary fistula, which caused saliva to
may become inadvertently damaged. However, there are flow out under pressure during eating (arrow) following damage to the
new safer knives available to avoid such risks. Injuries may parotid duct during surgical treatment of a chronic mandibular infection.
also arise from the use of motorized dental instrumentation,
particularly during procedures to reduce overgrowths of the
caudal mandibular or maxillary cheek teeth. In the case of
Salivary tissue
large overgrowths (such as with supernumerary maxillary Injuries to the salivary glands usually occur as a result of
cheek teeth), the soft palate may ‘billow’ around the tooth direct trauma. The parotid gland is the most vulnerable
during swallowing, and damage may ensue unless particular because of its large size and superficial location behind the
care is taken and equipment incorporating a soft-tissue angle of the jaw. Such injuries can be repaired by wound
guard or clutch is used. The soft palate may also be lacerated debridement, cleansing, and closure of the skin. Salivary
by extraction forceps during oral extraction of a caudal max- cutaneous fistulae are rare after this sort of injury.
illary (especially a caudal supernumerary) cheek tooth. Injuries to the parotid duct at more rostral sites are more
Full-thickness injuries to the soft palate inevitably result common and usually associated with direct trauma to the
in the development of an oronasal fistula because of con- ventral border of the mandible, which the duct crosses
tamination with food and saliva. Whilst some of these beneath before entering the oral cavity. In some cases, there
defects heal by second intention, surgical repair should be may be little evidence of an injury to the duct, and there may
attempted as soon as possible after the injury has been iden- be no need for specific treatment as such wounds may readily
tified. Access for surgical repair is very limited, especially in heal spontaneously. However, in a proportion of cases, there
smaller horses and ponies. A general anesthetic should be is direct continuity between a ruptured salivary duct and a
administered and an oral speculum used to permit access to skin wound that may result in the development of a salivary
the mouth. Good lighting (e.g., a head light) should be facial fistula (Fig. 9.15). Such injuries often have the dra-
provided, and the area should be endoscopically examined matic consequence of creating a profuse discharge of saliva
to assess the extent of the injury. Long-handled retractors during eating and mastication. Although saliva tends to have
should be used to depress the base of the tongue and retract an inhibitory effect on healing, most of these wounds even-
the cheeks in order to evaluate the injury and assist in its tually close within 1–2 weeks, without need for specific
subsequent repair. Long-handled needle holders, forceps treatment. It is the authors’ practice to manage all parotid
and scissors are also of great help when attempting repair of duct fistulae conservatively in the certain knowledge that in
such an injury. Separating the oropharyngeal mucosa from the vast majority of cases the fistula heals uneventfully.
its overlying musculature will facilitate soft palate closure in In those unusual cases in which the fistula does not close,
two layers, enhancing the likelihood of achieving first inten- surgical repair may be effective. The duct should be dissected
tion healing. The musculature and nasopharyngeal mucosa from the edge of the fistula and closed with simple inter-
are closed as one, and the oropharyngeal mucosa as the rupted sutures of 2-metric polyglactin 910. Insertion of a
other. Simple-continuous sutures using polydioxanone for catheter into the parotid duct may facilitate accurate sutur-
each layer are preferred. ing. Injury to the parotid duct may occur inadvertently
Even though such defects may be closed effectively, and during facial or dental surgery. However, an understanding
initially appear to be healing well, dehiscence is common of the local anatomy should preclude such an occurrence.
some days or weeks later. This is because of the high mobil- Transection of the parotid duct may be performed electively
ity of the palate for very prolonged periods during mastica- when carrying out a buccotomy technique for removal of
tion and deglutition, and the presence of food and saliva mandibular or maxillary cheek teeth. In such cases, an end-
within the oral cavity and oropharynx. It is not unusual for to-end anastomosis can be carried out using simple inter-
second and even third attempts at repair of full-thickness rupted sutures of 2 metric polyglactin 910. A parotid duct
palatal defects to fail. However, small fistulae may heal fistula may follow surgical removal of sialoliths, which are
spontaneously. As described above, feeding such cases by occasionally encountered in older horses. Secondary closure
nasogastric intubation for some days postoperatively is of such wounds may be effective or, alternatively, they may
important to reduce the risk of dehiscence of the suture line. be left to heal by second intention.
Similarly, this method of feeding helps in the conservative Injuries to the mandibular or sublingual salivary glands or
management of such a fistula and should be combined with ducts are very rare. The authors have encountered one horse
muzzling of the patient, in an attempt to reduce contamina- with a ranula associated with the sublingual salivary duct
tion of the airway by food and bedding material. that was managed successfully by oral marsupialization.

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 9 Dental disease and pathology

Fig. 9.17  Rostral mandibular fracture impacted with food.

Fig. 9.16  Radiographic projection to highlight the temporomandibular joint.

Temporomandibular articulation
Despite its superficial location, traumatic injuries to the tem-
poromandibular joint are rare. On occasion, an open wound
is encountered with direct communication to the joint; these
cases are typically presented for treatment some time after
initial injury, usually due to non-healing of the wound.
Thorough assessment of the injury using skyline radio-
graphic projections3 (Fig. 9.16; or preferably by computed
tomography if available) and ultrasonography is essential
when planning treatment. Debridement of the wound and
lavage of the joint are performed under general anesthesia Fig. 9.18  Traumatic avulsion of 402 and 403.
and aided by arthroscopy, followed by post-surgical wound
management and antibiotic therapy. This usually results in
sign of discomfort; indeed most fractures are already heavily
successful resolution of the articular sepsis; however, some
contaminated with food material when first examined (Fig.
masticatory dysfunction may be a long-term sequel. Man-
9.17). The injury typically comprises partial avulsion of one
dibular condylectomy and meniscectomy with a successful
or more incisor teeth with a variable amount of associated
outcome have also been described and are an option for
bone. Fractures typically range from simple loss or loosening
cases with severe or longstanding injury.4 Further details of
of a single (usually corner) incisor tooth and its labial alveo-
temporomandibular disease are presented in Chapter 23.
lar bone plate, to more extensive or complex fractures involv-
ing a single fragment accommodating several incisor teeth
Management of mandibular or several fragments. The fractured portion of the mandible
and maxillary fractures is usually displaced ventrally, with a gingival or mucosal
wound on the floor of the mouth communicating with the
open fracture (Fig. 9.18). Bilateral fractures are less common
Rostral mandibular fractures (Fig. 9.19).
Fractures of the rostral mandible are the most common type Near-complete avulsion of a single tooth with only gingi-
of jaw fracture sustained by horses.5,6 Such injuries typically val or minimal bone attachment may be dealt with by
arise from play behavior with or biting of stable furniture removal of the avulsed tooth by sharp dissection of the
such as bucket handles, rack chains, window bars, and remaining gingiva, but most other types of injury warrant an
mangers and are most common in young horses. Although attempt at reduction. Unless obviously devitalized, teeth
they are invariably contaminated and often dramatic in should be left in situ, as removal can take place at a later
appearance, appropriate management usually results in date, if necessary. As these fractures often occur in young
good functional and cosmetic repair.7 Aside from some pro- (1–2-year-old) horses, the avulsed teeth are usually decidu-
trusion of the lower lip and scant hemorrhage, there is often ous incisors and thus the loss of any severely avulsed teeth
little outward sign of injury. Oral pain tends not to be a is of minimal, long-term consequence. In contrast, the frac-
feature, and affected horses are often found eating with little ture often involves the dental sacs of developing permanent

122
 Head and dental trauma

Fig. 9.19  Rostral mandibular fracture with two fragments.

incisor teeth, and every effort should be made to retain these,

given that their loss or disruption causes eventual malerup- Fig. 9.20  Using a Steinmann pin to create a hole in the mandibular bone.
tion of the permanent dentition.
Radiography may be unnecessary for the assessment of
some simple rostral mandibular fractures because the choice
of repair technique is determined by the clinical presenta-
tion of the fracture rather than by its radiological appear-
ance. Radiography is much more important for horses with
bilateral or comminuted rostral mandibular fractures which
usually require a more complicated repair. Surgical reduc-
tion may be performed in the standing sedated patient,
aided by bilateral regional analgesia of the mandibular
nerves within the mental foramina, or under general anesthe-
sia. Following lavage and gentle curettage of the fracture,
satisfactory reduction is usually possible with relative ease.
The objective of fracture repair is to re-establish anatomical
alignment (to optimize cosmetic and functional outcome)
and to stabilize the fracture fragments. Whilst some rostral Fig. 9.21  Using a drill guide to protect soft tissues.
mandibular fractures heal without surgical intervention,
healing in such cases is often delayed and almost invariably
results in long-term disfigurement of the incisor arcade.
Fracture reduction in the young horse can usually be
achieved through placement of single or multiple intra-oral
tension wires attaching the avulsed portion to the caudal
interdental space of the contralateral aspect of the mandible.
Wires can be inserted via appropriate holes in the mandible
drilled with a 2.7- or 3.2-mm Steinmann pin held in a hand
chuck (Fig. 9.20) or by using an air drill (Fig. 9.21). Can-
nulation of the holes with a 14-gauge needle facilitates
placement of the wire between teeth. A 14-gauge needle may
be pushed through the softer mandibular bones of young
foals without prior drilling of holes. At the completion of
the procedure, the wire should pass through the fracture
fragment, across the floor of the mouth, through the contral-
ateral mandibular diastema then around the labial aspect of
the rostral mandible (Fig. 9.22). The exact positioning of the Fig. 9.22  Simple rostral mandibular fracture stabilized.
anchoring holes will vary depending on fracture configura-
tion and individual anatomical features. Wires are pressed necessary to protect the adjacent soft tissues from the sharp
digitally into the floor of the mouth to remove as much ends of the knot. A small amount of silicon polymer dental
‘slack’ as possible and to ensure they impinge as little as impression material, or acrylic bone cement can be affixed
possible on the tongue. The ends are then brought together to the wire knot; alternatively, the tips of the wires can
on the labial aspect of the mandible at a site distant to the be sheathed with plastisol covers, which prevent labial
fracture. Once the wire has been tightened and cut, it is abrasion.

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 9 Dental disease and pathology

Fig. 9.23  Removing wire from a jaw fracture repair.

Suturing large mucosal lacerations may prevent continued

gross contamination of the fracture site but is not necessary
in most cases. Postoperative lavage (with a saline solution
Fig. 9.24  An oblique interdental fracture.
or even tap water b.i.d or t.i.d) is recommended to prevent
food accumulation in any large oral defects for the few days
it takes for satisfactory granulation of the wound to occur.
However, despite the contaminated nature of many of these Treatment of traumatic, unilateral, hemimandibular frac-
fractures, the incidence of significant postoperative infec- tures is usually unnecessary as the unaffected hemimandible
tions is very low. It is not usually necessary to make any acts as a splint to ensure relative stability of the fragments
significant dietary alterations following repair for a simple and therefore good fracture healing. Clearly, complete bilat-
rostral mandibular fracture. However, hay should be pulled eral fractures result in major instability of the rostral portion
apart and fed loose from the ground or chopped so the horse of the mandible. Such fractures are usually transverse or
does not have to prehend with the repaired teeth. Typically short oblique in configuration, and have minimal commi-
horses show little sign of having sustained an injury and nution (Fig. 9.24). Fractures of the maxillary interdental
bitted ridden work can resume unless signs of pain are space are by comparison much less common but may
observed. If a bit is to be used it should always be inserted involve comminution and some degree of nasal obstruction.
very carefully. Wires should ideally remain in place for 6–8 In addition to premaxillary fractures, there may be concur-
weeks. Removal of the wire is usually simple in the standing rent fracture of the nasal septum, nasal process, facial bones
sedated animal (Fig. 9.23). The visible oral portion of the or hard palate. A full radiographic series, including dorsov-
wire is first cut with wire cutters, then the knot on the labial entral, lateral and oblique views, is indicated to delineate the
aspect of the jaw is grasped and pulled firmly, drawing the fracture(s), and to identify involvement of adjacent teeth
entire implant from the jaw. and osseous fragments. Computed tomography, if available,
With good surgical reduction, complications are rare. The provides comprehensive characterization of the fracture
major long term adverse consequence of a fracture of the configuration.
rostral mandible is malalignment of the incisor arcades. Dis- Repair of fractures of the interdental space is performed
ruption or loss of permanent incisor tooth germs can result under general anesthesia. Intravenous anesthesia or nasotra-
in a failure of some teeth to erupt, or to erupt in inappropri- cheal intubation increases working space for the surgeon in
ate positions. Occasionally, a permanent incisor tooth is the oral cavity, permitting the surgeon access both sides of
noted erupting in the floor of the mouth, beside the original the mandible. If surgical repair of a maxillary fracture is to
fracture line, although this sequel is usually of cosmetic be attempted, a standard orotracheal intubation is usually
importance only. Other sequelae include scarring of the performed.
gingiva and incisor diastema formation. Methods of fixation of fractures of the interdental space
include tension-band wiring, oral acrylic splints, U-bars,
external fixators, and bone plating. Minimally displaced,
Fractures of the interdental space (diastema) unilateral fractures often have sufficient interdigitation at the
Fractures through the interdental space may be unilateral or fracture site to limit movement and pain and usually respond
bilateral. Unilateral fractures usually arise from direct well to conservative therapy, which is the authors` preferred
trauma, but pathological fractures secondary to longstand- option in most cases. However, non-displaced fractures of
ing osteomyelitis/apical dental infection are not unknown. the interdental space may be repaired using tension-band
Bilateral mandibular fractures are common in foals, and wiring. The tension surface of the mandible lies along the
unilateral fractures more typically occur in older horses. dorsal border (oral surface) allowing tension-band wiring to

124
 Head and dental trauma

molded to fit the oral surface of the mandible or premaxilla,

extending from the incisors to the 06, taking care to avoid
the frenulum of the tongue. A thickness of 6–8 mm is suf-
ficient for most splints; the acrylic may be thickened at sites
of wire incorporation to reduce fatigue and thus breakage of
the splint. The splint is removed after curing and rough edges
are smoothed with files. Multiple, 1.2-mm-diameter wire
loops are placed through holes drilled into both sides of the
mandible or premaxillae between the incisors and in the
interdental space, rostral and caudal to the fracture line.
The splint is drilled to match the holes in the mandible or
maxillae and the wires are twisted together and bent down
into the gingiva. Wire loops may also be placed around the
06s (second premolar teeth) to provide caudal anchorage.
Holes for these wires are placed as described above for
tension-band wiring. Alternatively, the methylmethacrylate
splint can be formed over preplaced tension band wires
between the incisors and premolars. This technique allows
the fracture to be reduced completely before application of
the splint.
Intra-oral acrylic splints require minimal surgical invasion
of the mandible, avoid the risk of damage to dental buds or
apices and provide fixation on the tension side of the frac-
ture. Acrylic splinting can be used successfully in foals with
Fig. 9.25  Premaxillary fracture repaired with cerlage wire. inadequate incisor eruption for placement of wires. In foals,
a wire loop can be passed around the mandible in the
diastema as an additional anchorage point for the splint.
be successful when minimal displacement is present. Mini- Care should be taken to pass the wire close to the bone to
mally displaced fractures through the maxillary interdental avoid compression and necrosis of the soft tissues, although
space are rare and almost always bilateral. They have been any gingival damage resolves rapidly after wire removal. The
successfully managed using a conservative approach, but oral cavity should be flushed daily and the splint removed
such fractures also can be stabilized with tension band wires 6–8 weeks after surgery, in the standing, sedated patient.
(Fig. 9.25) or an external fixation device. Although intra-oral placement of U-bars with fixation
Repair of bilateral interdental space mandibular fractures around the teeth using wire has been described7 to treat
involves placing the anesthetized horse in dorsal recum- bilateral fractures of the interdental space, there are simpler
bency; the oral cavity, left and right external cheek surfaces methods of repairing such unstable fractures. There have
are then prepared for surgery. Holes are drilled between been reports of using intra-oral orthopedic plates screwed to
mandibular incisors as described previously. To repair rostral the teeth which seem to have been effective. Both techniques
mandibular fractures, stab incisions are made bilaterally have the obvious drawback of involving a relatively large
through the gingiva immediately caudal to the 06 (2nd intra-oral device.
premolar teeth). For more caudally situated mandibular A simpler approach involves the use of long AO cortical
fractures, horizontal stab incisions are made externally in the screws drilled into either the mandible or premaxilla to fix
cheeks at a site between the 07s and 08s (second and third lateral acrylic bars (Fig. 9.26). This simple technique has
mandibular premolar teeth). Hemorrhage is minimized by proven valuable to repair unstable fractures of the interden-
using blunt dissection to separate underlying soft tissues. tal space (R. J. Payne, unpublished data). A 3.2-mm drill is
The buccal mucosa is incised, and a 3.2-mm drill bit is posi- used to create holes through stab incisions in the gingiva or
tioned between the 07 and 08 teeth just ventral to the gin- cheeks (as described above) at several appropriate sites
gival margin. Soft tissues are protected during drilling by use rostral and caudal to the fracture on both sides of the head.
of a drill guide. Wire is threaded through the holes between Pre-drilled flexible tubing is threaded onto the long cortical
the premolar teeth and directed rostrally to be interwoven screws before their incomplete implantation in the jaw. The
through openings previously made between the incisors. screws are left protruding clear of the jaw to accommodate
Differing patterns for wire placement may be used incorpo- the tubing, which is then filled with acrylic material. This
rating one or two wires. The wire spanning the interdental material rapidly cures to create a very stable fixation of the
space is twisted together to achieve compression at the frac- fracture on either side of the jaw. This method avoids the
ture site. The stab incisions through the cheeks are left to presence of implants within the oral cavity and is as effective
heal by second intention or closed with a single suture. The as proprietary external fixation devices or the use of trans-
wires are removed 6–8 weeks after fixation. mandibular Steinmann pins, which have also been used to
Intra-oral acrylic splints can also provide stable fixation of stabilize such fractures by attaching them to laterally applied
interdental space fractures and are technically easy to use.7 acrylic bars (Fig. 9.27).
Following induction of general anesthesia and preparation The implants occasionally break but can usually be
of the oral cavity and cheeks, the fracture is reduced. replaced without requiring a second general anesthetic. The
Polymethylmethacrylate or cold-curing acrylic is mixed and device is usually removed in the sedated patient at

125
 9 Dental disease and pathology

Fig. 9.28  Fracture of horizontal ramus involving a tooth.

than the focal thickening seen with dental apical infection.

Close examination of the oral cavity may also reveal some
mucosal bruising in the region of the fracture line and on
occasion there is concurrent (usually transverse) fracture of
Fig. 9.26  External fixation for a bilateral mandibular fracture. an adjacent cheek tooth.
While fractures of the mandibular body (horizontal
ramus) are seen occasionally in our hospital, those of the
vertical ramus are very uncommon, in contrast to other
authors’ findings.8 The extent of the fracture and the possible
involvement of teeth, temporomandibular joints, or even
the hyoid apparatus should be assessed using multiple
radiographic projections or computed tomography, if avail-
able. Such imaging is important to assess possible comminu-
tion, and allow a more informed decision regarding the
choice of a surgical versus a more conservative approach to
treatment of the injury. Reported fractures of the vertical
ramus include transverse and oblique configurations, but
perhaps the most commonly encountered involve the angle
of the mandible. Caudal mandibular fractures can be treated
using a conservative approach, or by compression plating or
external fixation.
Most fractures of the caudal region of the body or ramus
of the mandible, but especially those resulting in minimal
instability, malocclusion, and pain, are candidates for con-
servative management. The overlying, deep and tightly
attached pterygoid and masseter muscles confer significant
stability to these fractures, acting much in the manner of
a splint. Anti-inflammatory medication increases patient
Fig. 9.27  Maxillary fracture treated with acrylic U bar. comfort, and feeding mashes of complete pelleted feeds pro-
vides nutrition in an easily consumed form. Antimicrobial
therapy is indicated when the fracture is open to the oral
approximately 6–8 weeks postoperatively. The screw holes cavity, and oral lavage may be of benefit in such cases. Some
usually heal faster than those created by transmandibular horses are inappetant immediately following such injuries
Steinmann pins. and ensuring adequate hydration is imperative in these cases.
However, in those animals without major intra-oral frag-
mentation, it is often surprising how little discomfort they
Fractures of the caudal mandible exhibit compared to human patients with similar injuries.
Fractures involving the horizontal ramus in the region of the Radiological evaluation of the fracture should be per-
molar teeth are typically unilateral with minimal displace- formed periodically. Possible indications for internal fixa-
ment or comminution (Fig. 9.28). They typically arise from tion of the fracture are lack of healing or osteomyelitis at the
external trauma, such as a kick injury or fall, but iatrogenic fracture site; however, the best guide to progress is the clini-
fractures arising from dental repulsion procedures are also cal status of the patient. Most fractures of the horizontal
encountered. Aside from painful mastication, clinical signs ramus involve the alveoli of the adjacent cheek teeth, and
may be non-specific. Thickening of the horizontal ramus the resulting inflammatory response and possible conta­
may be noted, both externally and upon intra-oral examina- mination of the site through external or oral wounds may
tion; this may be subtle and tends to be generalized rather cause pulpitis and loss of vitality of one or more teeth.

126
 Head and dental trauma

Radiological assessment may demonstrate clear evidence of A similar approach may be adopted for fractures of the
such dental infection; however, it is important to defer any vertical ramus. Although most are treated conservatively,
possible dental extraction procedures until such time as the surgical repair may be considered if a fracture is grossly
mandibular fracture has stabilized. Exodontia is rarely a sur- unstable, or if there is marked malocclusion preventing pre-
gical imperative and being traumatic in nature demands a hension or mastication, pain with unwillingness to eat, or if
stable mandible if further injury to the patient is to be the fracture is bilateral. Internal or external fixation can be
avoided. used to stabilize such fractures. However, with the exception
Fracture of the caudal angle of the mandible with deglov- of those causing major dysfunction of the temporomandibu-
ing of the overlying soft tissues has been described.8 The lar joint, the splinting effect of the heavy muscles of mastica-
injury results from placement of the head between stationary tion is usually effective in preventing major fragment
objects and then pulling back; similar injuries can occur fol- displacement until fracture healing. Although bone plating
lowing other forms of direct trauma, and may also cause provides a very stable construct, extensive surgical dissection
facial nerve damage. Communication of such fractures with is required at a site containing many large blood vessels,
the oral cavity or adjacent alveoli is uncommon. Surgical parotid tissue and the facial nerve. Fractures open to the oral
removal of small fracture fragments can be performed with cavity can be expected to become infected, necessitating
minimal functional or cosmetic disturbance. However, it is removal of plates after fracture healing. External fixators can
usually better practice to let these remain in situ in the hope also be used in the treatment of caudal fractures of the man-
that they may be incorporated into the fracture healing dibular body.
process, which is usually the case. It is only occasionally The prognosis for healing of caudal mandibular fractures
necessary to carry out sequestrectomy several weeks post- is guarded to good. Complications are usually associated
injury. Although most heal without complication, internal with communication with the oral cavity and involvement
fixation may be indicated for larger fragments, where a of the teeth. When surgical repair is undertaken, aggressive
ventrolateral approach to the mandible is used. It is critical debridement of the fracture line with thorough lavage, and
that the facial artery, facial vein, parotid salivary duct and closure of oral mucous membranes (if possible) are the
mental nerve are identified and preserved during surgical best means of preventing osteomyelitis and sequestration.
dissection. Elevation of the masseter muscle from the man- Implant-associated infection necessitates removal of plates
dible is necessary and accomplished by transection of the or pins, debridement of soft tissues, lavage, and antibiotic
attachments of the muscle at the ventral border of the man- medication. Resolution of infection after implant removal
dible and reflecting the muscle dorsally. The orthopedic often proceeds without further complication. Failure of frac-
plate used depends entirely on fracture configuration and ture healing is a significant complication. This will depend
size of the patient. The plate should be placed on the vent- on the degree of stability and, most importantly, on the
rolateral aspect of the mandible, if possible. The plate is presence of infection. Use of a more stable means of fixation
contoured and attached to the bone; a minimum of three and addressing any infection ensure the best prognosis for
screws on either side of the fracture is recommended. Dental complete healing. Adjunctive therapy, including autogenous
apices should be avoided when applying screws more ros- cancellous bone grafting and antimicrobial impregnated
trally in young horses. beads, may be indicated.

References
1. Szpaderska AM, Zuckerman JD, DiPietro 4. Nagy AD, Simhofer H. Mandibular 7. Henninger RW, Beard WL, Schneider RK,
LA. Differential injury responses in oral condylectomy and meniscectomy for the et al. Fractures of the rostral portion of the
mucosal and cutaneous wounds. J Dent treatment of septic temporomandibular mandible and maxilla in horses: 89 cases
Res 2003; 82(8): 621–626 joint arthritis in a horse. Vet Surg 2006; (1979–1997). Journal of the American
2. Schrementi ME, Ferreira, AM, Zender C, 35(7): 663–668 Veterinary Medical Association 1999; 214:
DiPietro LA. Site-specific production of 5. Sullins KE, Turner AS. Management of 1648–1652
TGF-β in oral mucosal and cutaneous fractures of the equine mandible and 8. Knox PM, Crabill MR, Honnas CM.
wounds. Wound Repair Regen 2008; premaxilla (incisive bone). Compendium Mandibular and maxillary fracture
16(1): 80–86 Continuing Education for the Practicing osteosynthesis. In: Baker GJ, Easley J, eds.
3. Ramzan PH, Marr CM, Meehan J, Veterinarian 1982; 4(11): 480–489 Equine dentistry. Elsevier, Philadelphia,
Thompson A. Novel oblique radiographic 6. DeBowes RM. Fractures of the mandible 2005
projection of the temporomandibular and maxilla. In: Nixon AJ, ed. Equine
articulation of horses. Vet Rec 2008; fracture repair. WB Saunders, Philadelphia,
162(22): 714–716 1996, pp 323–332

127
 Section 3:  Dental disease and pathology

C H A P T ER  10 
Equine dental pathology
Padraic M. Dixon MVB, PhD, MRCVS, Nicole du Toit BVSc, MSc, PhD, MRCVS,  
Ian T. Dacre PhD, MRCVS
Division of Veterinary Clinical Sciences, University of Edinburgh, Easter Bush Veterinary Centre, Roslin, Midlothian, EH25 9RG, UK

Introduction disorders, such as deep periodontal pocketing following

dental displacement, that were defined as ‘secondary’ apical
Equine dental disorders are of major importance in the UK, infections.11–13 Brigham and Duncanson’s study of 50 abat-
with a survey showing that 10 % of equine practice time is toir skulls found most dental disorders to involve CT, includ-
spent on dental-related work.1 Likewise, a US survey ranked ing recording that 20 % of skulls had CT diastema; 26 % had
dental disorders as the third most common equine medical focal CT overgrowths; 56 % had sharp enamel overgrowths;
problem encountered by large animal practitioners.2 Despite 20 % had missing teeth; 8 % had ‘wavemouth’ and 12 % had
its importance, equine dentistry is a neglected discipline, as CT caries.14 More recently, a high prevalence of dental dis-
exemplified by a survey of 150 adult horses without any orders, and in particular CT diastemata, was demonstrated
history of dental disease which showed 24 % of them to have in aged donkeys in a post-mortem survey,7 and many of
dental abnormalities.3 Numerous post-mortem studies have these serious dental disorders manifested between 15 and
also indicated up to 80 % prevalence of undiagnosed, clini- 20 years of age.15 Horses can suffer a wide range of dental
cally significant dental disorders in equids.4–7 Interestingly, disorders of development and eruption that are covered in
dental disorders, such as cheek teeth (CT) displacements, Chapter 8, and this review primarily deals with acquired
wear abnormalities, and diastemata, have even been noted dental disorders.
in skulls examined from wild equids (Cape Mountain
zebras) that died of causes unrelated to dental disease,8 and Abnormalities of wear
some prehistoric horse skulls in museums also have evi-
dence of similar dental disorders (P.M. Dixon, unpublished Normal tooth wear (attrition) begins when opposing teeth
observations), highlighting that these abnormalities are not come into occlusion and their occlusal surfaces grind off
necessarily diseases of domestication. each other.16 Any asymmetry in the position of the jaws (as
Most earlier studies of equine dental pathology concen- occurs with craniofacial abnormalities) or of individual
trated on gross findings, with many of them examining teeth (e.g., with developmental displacements of teeth)
skulls with unknown dental histories collected from abat- results in uneven dental wear. The periodontal membranes
toirs. In one such abattoir study of 365 skulls, Honma et al adjacent to overgrown teeth are often diseased, including
found that all skulls identified as 12 years of age or older due to abnormal rostrocaudal drifting of overgrown teeth
had dental caries.4 An abattoir study of 218 skulls by Baker9 causing diastemata. Additionally, the pain and possibly
recorded a prevalence of 60 % periodontal disease and 79 % mechanical obstruction caused by dental overgrowths can
infundibular caries in horses aged over 15 years. In a study restrict masticatory movements that in turn restrict intra-oral
of 355 abattoir skulls, Wafa found 13 % of skulls to have saliva and food movements. Overgrowths can also cause soft
abnormalities of development or eruption; 17 % with wear tissue trauma, which can lead to clinical signs such as bitting
abnormalities; 35 % with periodontal disease; 29 % with abnormalities in ridden horses and less commonly to
caries and 6.5 % with dental pulp exposure.6 He concluded quidding.
this latter disorder was ‘of greatest clinical significance’ and
that all of the periapical infections identified could be attrib-
uted to exposure of the dental pulp.
Cheek teeth enamel overgrowths
Dixon et al detailed the prevalence of dental disorders in The presence of anisognathia in equids and the fact that their
a referred population of 400 dental cases, most being of a maxillary CT are wider than their mandibular CT contributes
severe nature as would be typical of referred cases,10–13 to the development of enamel overgrowths on the buccal
including 162 cases which were referred because of what was aspect of their maxillary CT and lingual aspect of their man-
termed ‘primary’ (i.e., of unknown etiology) CT apical dibular CT17 (Fig. 10.1).
abscessation.10 Pulpar exposure was clinically identified in a These sharp points may lead to soft tissue ulceration of the
small number of these 162 cases of CT apical abscessation, buccal mucosa (rarely to tongue ulceration) and in severe
in contrast to Wafa’s findings.6 Many additional CT apical cases may cause clinical signs, such as bitting problems and
infections were found to have arisen from concurrent dental even quidding.17 Recently, the masticatory movements of the

129
 10 Dental disease and pathology

Fig. 10.1  Intra-oral view of buccal ulceration (arrow) caused by prominent

vertical ridges on caudal maxillary CT. These CT appear to have minimal
occlusal angulation and it is the more lateral prominence of their vertical
ridges (cingulae) that is traumatizing the cheeks.

mandible have been examined using a 3-dimensional kin-

ematic model with differences shown in the amplitude of
movement between individual horses.18 The equine chewing
cycle has three phases: opening stroke, closing stroke and
power stroke, as discussed in detail in Chapter 6. The vertical
‘crushing’ stroke predominates when high levels of concen-
trates are fed19 that, along with the reduced amount of time
spent masticating concentrate foodstuffs, promotes the
development of CT enamel overgrowths and increased CT
occlusal angles. In contrast, horses fed predominantly rough- Fig. 10.2  This right maxillary CT row has markedly increased (circa 45°)
age have a greater degree of lateral excursion during mastica- occlusal angulation, i.e., shear mouth.
tion.20 Roughage also requires more chewing movements
(3000–3500 per kg consumed) compared with concentrates
(800–1200 per kg). The number of chewing movements, per (usually 11–14), on the maxillary and mandibular CT, that
unit of roughage and concentrate, has been shown to be interdigitate with the opposing teeth, and their evolution
higher in ponies than in larger breeds,19,21 possibly due to has been described in Chapter 1. These ridges increase the
the smaller size of their teeth. occlusal surface area for grinding coarse fibers and are the
It is generally believed that equids fed predominantly result of enamel infoldings causing different occlusal wear
roughage do not develop cheek teeth enamel overgrowths; patterns. These ridges can be more prominent in young
for example, earlier studies cited by Becker (1962)22 found horses, with much individual variation in their height. The
no enamel overgrowths in fossilized equine skulls, and presence of multiple tall ridges should not be regarded as an
Becker found minimal or no enamel overgrowths in wild abnormality, despite the dogma of some equine dental
zebras, wild asses, and Przewalski’s horses.22 However, a groups. Such physiological transverse ridges need to be dif-
recent study on working equids that never had any dental ferentiated from true overgrowth (exaggerated or accentu-
treatment showed significant cheek teeth enamel over- ated) transverse ridges which can, for example, develop
growths to be present in them despite being fed a predomi- opposite a wide diastema or occasionally can develop on
nantly roughage based diet.23 Furthermore, a population of individual ridges amongst even-sized ridges, possibly due to
Exmoor ponies that are only fed roughage continue to reduced enamel content on the opposing tooth.
develop sharp enamel overgrowths that are recognised when
they are re-presented annually for routine dental treatments
(P.M. Dixon, N du Toit, personal observations). Some
Shear mouth
domesticated breeds may be genetically predisposed to If the above generalized CT overgrowths are not managed
developing sharp enamel points. For example, it is possible by routine dental floating, they may increase to such an
that variations in the width of the normal vertical ridges on extent that they interfere with the normal side-to-side mas-
the buccal (lateral) aspect of maxillary cheek teeth (cingulae) ticatory action (and the small degree of mandibular rostro-
may be a factor in the development of enamel overgrowths, caudal movement). This further perpetuates the overgrowths
with horses with wider ridges most likely to develop large and may lead to a condition termed shear mouth.13,25 In
enamel overgrowths on the buccal aspect of these ridges that contrast to former beliefs that CT occlusal angles of >15 %
cause clinical signs. Enamel overgrowths predominantly could be termed shear mouth, it is now accepted that affected
cause clinically significant disease in ridden horses, espe- teeth have in fact much steeper angles (>45°) of their occlu-
cially when associated with certain practices, such as the use sal surfaces (Fig. 10.2).26 Horses affected with shear mouth
of tight nosebands.23,24 have reduced effectiveness at grinding food, especially dried
The occlusal surfaces of equine teeth have linearly shaped forage such as hay, and eventually exhibit quidding, due to
groups of cusps (elevations), termed transverse ridges soft tissue injury and to the inevitable periodontal disease

130
 Equine dental pathology

106

107

Fig. 10.3  Post-mortem image of a neglected, aged equine mouth that

Fig. 10.4  These two major maxillary CT overgrowths have been caused by
has multiple dental abnormalities, including wave mouth in the centre of
loss of the opposite 407, with marked caudal drifting of the 406 into the
the CT rows, smooth mouth of the rostral mandibular CT (406, 407 are worn
extraction space. This has caused a rostral overgrowth to develop on the
to their component roots) and step mouth of 111 due to loss of 411.
partly unopposed 106, and a tall, narrow, triangular overgrowth to develop
Diastemata and associated periodontal disease are present between some
on the 107.
teeth (arrows).

that accompanies this disorder. Numerous studies have

shown the prevalence of shear mouth to be low (0.6–
12 %),3,6,7,13 and this was particularly so in a large study of
30 000 (younger) cavalry horses where a prevalence of only
0.03 % was found.22 Two recent donkey studies did not find
an increasing prevalence of shear mouth with increasing
age,7,15 and so it can be concluded that generalized shear
mouth is an uncommon disorder of geriatric equids.

Wave mouth
Wave mouth is the presence of an undulating occlusal surface
of the CT arcade in a rostrocaudal direction (Fig. 10.3).
This disorder has been hypothesized to occur in some CT Fig. 10.5  These caudal maxillary CT (109–111) have minimal enamel
secondary to marked periodontal disease, which disrupts the (focal white areas) remaining and thus have a smooth occlusal surface.
normal eruption process.13 Differential rate of CT eruption Additionally, the more rostral CT in the image (109) is worn down to its
between different CT in a row has also been proposed as a component roots (arrows).
cause of wave mouth (that may even increase with time),22,27
as has the presence of large focal overgrowths28 (e.g., due to missing tooth (variably) drift together, a triangular-shaped
absent or defective opposing teeth) and diastemata,15,29 but overgrowth can develop (Fig. 10.4).31 These overgrowths can
it is most likely that the etiology of wave mouth is multifac- mechanically interfere with normal mastication, leading to
torial. Severe wave mouth can cause restricted mastication, wave mouth or shear mouth. They may also cause oral pain
and concurrent dental (e.g., shear mouth or diastemata) and that may be manifested as oral pain with quidding, halitosis,
periodontal disorders are inevitably present. The prevalence and weight loss.28
of wave mouth has been shown to be relatively low (2–19 %) The maxillary CT of older horses with worn infundibula,
in most equine surveys,3,6,7 and (in contrast to shear mouth) or maxillary CT with developmentally short infundibula or
wave mouth was significantly associated with age in two infundibular caries, have reduced enamel content that allows
donkey studies.29,30 the opposite mandibular CT to focally overgrow. Similarly,
older horses or horses with reduced peripheral enamel
infolding of their mandibular CT develop overgrowths of the
Step mouth
opposite maxillary CT. A clinical survey of donkeys showed
Classically, the loss of a cheek tooth is alleged to cause a step mouth to be significantly associated with the presence
rectangular shaped overgrowth due to ‘super-eruption’ of the of missing, overgrown and worn CT, and CT diastemata.30
unopposed opposite CT, leading to a condition termed step The prevalence of step mouth varied from 3.7 to 12 % in
mouth (Fig. 10.3). Dixon et al13 found that 40 % of cases different equid studies3,6,7,13 and is significantly associated
of step mouth were caused by CT maleruptions, such as dif- with increasing age in donkeys.29,30
ferent rates of eruption of opposing CT, with the earlier
erupted CT becoming and remaining overgrown (‘domi-
nant’).17,22 As noted above, less severe cases of CT malerup-
Smooth mouth
tion may lead to wave mouth and there is often an overlap In older equids, the loss or reduction of enamel ridges is a
between these two disorders. Overgrown teeth may be rec- normal physiological end-stage phenomenon of dental attri-
tangular in shape, especially in the early stages following loss tion32 (Fig. 10.5). This leads to the development of a smooth
of an opposite tooth, but as the teeth on either side of the occlusal surface containing predominantly cementum and

131
 10 Dental disease and pathology

dentin, with minimal protruding enamel that is termed

smooth mouth. Such dentin and cementum are no longer
protected from increased wear by harder enamel, and such
teeth are ineffective at grinding, becoming more rapidly
worn.33 Older equid teeth commonly develop hypercemen-
tosis of the apical area, which will increase once the roots
become exposed, which is a protective mechanism to prolong
the dental lifespan of geriatric equids.32,33 As expected,
smooth mouth is significantly associated with increasing age
in donkeys.29,30 The prevalence of smooth mouth has been
shown to be quite low (up to 5 %) in some general surveys,
with an increased prevalence (20–35 %) in equids over 20
years of age.6,7,15 Occasionally smooth mouth can develop in Fig. 10.6  This post-mortem image of a caudal right hemimandible has two
younger equids where, as noted above, there is insufficient valve diastemata (narrow occlusally and wider at gingival level) with deep
enamel infolding of peripheral enamel, absence of maxillary periodontal food pocketing between the two CT on the right.
CT infundibula28 or the presence of enamel dysplasia (see
Chapter 8).

Diastemata
All 6 CT in each row should act as a single functional unit
and should be tightly opposed to each other at the occlusal
surface due to the rostrocaudal angulation of the rostral and
caudal CT. Cheek teeth diastema, which is defined as a
Fig. 10.7  These mandibular CT (306–307) have an open diastema between
detectable interdental (interproximal) space between adja- them, but due to the shape of the diastema, it contains no food pocketing.
cent teeth, was diagnosed as the primary dental disorder in Consequently, the underlying gingiva, although recessed, has a smooth
4 % of 400 horses referred for dental disorders by Dixon appearance and is of normal color.
et al12 and in 3.6 % of horses in an abattoir survey by Wafa.6
The caudal mandibular CT were more commonly involved,
particularly the interdental (interproximal) spaces between
09s–10s and 10s–11s.12,34–36 As noted in Chapter 8, diastem-
ata can be termed primary (developmental), which develop
due to inadequate rostrocaudal CT angulation or due to
embryonic buds developing too far apart.34,35,37 In contrast,
if the supporting bones are not large enough to support the
developing dental buds, overcrowding of erupted teeth
results in displacement of these CT with subsequent second-
ary developmental diastemata developing.35
Equine CT taper towards their apices, and the angulated
equine CT (6s, 10s and 11s) lose their angulation with age.
Therefore, with continued dental eruption, senile diastemata
commonly develop between the CT in aged horses.36
Diastemata can also develop secondary to loss of CT or
adjacent to acquired CT displacements, more commonly
seen as lingual (medial) displacement of the mandibular 10s Fig. 10.8  These two mandibular CT have a valve diastema between them
and 11s.34,35 Interestingly, diastemata have also been identi- that has led to marked periodontal recession at, and adjacent to, the
diastema. These two CT also have loss of much of their peripheral
fied in a survey of free-ranging Cape Mountain Zebras (Equus
cementum likely due to prior peripheral dental caries, with marked staining
zebra zebra).8 of all exposed calcified tissues. (Courtesy of Alistair Cox and Sionagh Smith.)
Diastemata have also been classified as closed/valve
diastemata (narrower occlusally; Fig. 10.6) or open (same
width at occlusal and gingival margin) diastemata With marked food entrapment, the periodontal disease
(Fig. 10.7).38 Sharp overgrowths or exaggerated transverse progresses to cause lysis and remodeling of alveolar bone
ridges on opposite CT may widen diastemata and compress and even osteomyelitis of the mandible or maxillae17 or
food into them;12,28 however, the most clinically significant oromaxillary fistula formation. The most common clinical
valve diastemata have a narrow (1–3 mm) space between sign seen with CT diastemata is quidding and so periodontal
the teeth occlusally (Figs 10.6, 10.8–10.10), with no detect- disease is regarded as one of the most painful dental disor-
able overgrowth on the opposite tooth. The presence of ders of horses.12,28,34 Open mouth radiography (Fig. 10.10)
diastemata usually leads to compression of food into the is of great value in assessing the cause, severity and prognosis
abnormal space between the two adjacent teeth, with result- with CT diastemata.39 In younger horses with this disorder,
ant periodontal food pocketing (especially into valve further eruption of the CT and compression of the CT rows
diastemata) and periodontal disease,6,36 as previously illus- may even result in resolution of the diastemata, provided
trated in Chapter 8. there is sufficient CT angulation.
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 Equine dental pathology

410 411

Fig. 10.11  Decalcified longitudinal section of an equine mandible showing

the normal subgingival structures between the two adjacent cheek teeth,
including the very vascular alveolar bone (AB), with its irregular margins on
both sides attached to the periodontal ligaments (PDL). The peripheral
cementum (PC) has a smooth margin with the periodontal ligament, but a
scalloped margin with the adjacent enamel (ES – enamel site – as enamel is
fully removed during decalcification). (Original magnification ×100.)
(Courtesy of Alistair Cox and Sionagh Smith.)
Fig. 10.9  A longitudinal section from an undecalcified hemimandible
showing two adjacent CT (410, 411) that have a valve diastema between
them. There is recession of the gingiva overlying the mandibular bone horses,41,46 and periodontal disease secondary to diastemata
beneath the diastema, with pocket formation (arrow). (Courtesy of Alistair
has also been described in zebras.8
Cox and Sionagh Smith.)
More recent studies of horses have also recognized perio-
dontitis as a significant disorder.6,9,12,13,47 Baker (1970) and
Wafa (1988) found that 60 % of horses over 15 and 20 years
of age, respectively, suffered from periodontal disease.6,9
However, most often this periodontal disease was secondary
to other disorders such as displaced teeth or CT diastema.
More recent clinical studies have also shown virtually all
equine periodontal disease to be associated with abnormal
411
408 409 410 interdental spaces, such as between CT diastemata.12,13 Peri-
odontal disease in donkeys is also significantly associated
with diastemata, overgrown teeth, displaced teeth, and
increasing age.30 Both Baker and Wafa also recognized a mild
transient periodontitis associated with CT eruption, with a
prevalence of 40 and 52 % respectively, in immature skulls.6,9
Little pathological research has been performed on equine
Fig. 10.10  Open mouth radiograph of a right hemimandible showing a
periodontal disease, and it is likely that these constantly
valve diastema between 408–409 (that has been mechanically widened)
and an open diastema between 409 and 410. There is adequate angulation remodeling tissues (in a hypsodont species) differ from
of the caudal CT in this horse, but the CT have developed too far apart in those in brachydont species. A histological image of
this hemimandible. normal equine periodontal and adjacent tissues is shown in
Figure 10.11.
Periodontitis in brachydont species is initiated by the
adherence of organic dental plaque and bacteria to teeth.42
Periodontal disease Later, the plaque may become calcified to form dental cal-
culus that consists of 70–90 % minerals. A similar finding in
Periodontal disease (periodontitis, paradontal disease, alve- equine teeth is illustrated in Figure 10.12. The main compo-
olar disease and alveolar periostitis) describes inflammation nent of equine dental calculus is calcite, which has a chalky
of the supporting structures of the tooth, i.e., the gingiva, appearance. In horses, dental calculus most commonly
periodontal ligaments, cementum, and alveolar bone.6,40,41 occurs on the lower canine teeth and less commonly on the
In addition to its enormous importance in human dentistry, buccal aspects of the rostral maxillary CT (excluding the wolf
periodontitis has been recorded as an important disease in tooth),16 and the associated, usually low-grade, periodontal
dogs and cats,42 sheep43,44 and cattle.45 Coyler described peri- disease usually resolves following removal of the calculus.
odontitis as a most significant equine dental disease (‘the In general, dental calculus is not a significant problem of
scourge of the horse’) with a prevalence of 33 % recorded in equine CT that do not have intercurrent dental disorders.6,9,13
an abattoir survey of 484 horses.40 However, examination of This low prevalence of calculus on equine CT may be due to
photographs of Colyer’s specimens40 shows that the perio- the prolonged time horses spend masticating, as the pro-
dontitis was predominantly secondary to other disorders, longed intra-oral movement of fibrous food and saliva
such as diastemata and displaced teeth.12 Other early studies during mastication may deter the formation of plaque,42
have also reported the presence of periodontal disease in although equine teeth are covered with an organic pellicle.
133
 10 Dental disease and pathology

Fig. 10.12  Decalcified histological section of a CT diastema showing Fig. 10.14  Decalcified histological section of subgingival connective tissue
organic plaque deposition (arrow) on the peripheral cementum on both in the interproximal space of a CT diastema showing moderate infiltration
sides of the diastema. (Original magnification ×100). (Courtesy of Alistair   with mononuclear inflammatory cells. (Original magnification ×200.)
Cox and Sionagh Smith.) (Courtesy of Alistair Cox and Sionagh Smith.)

pc n

Fig. 10.15  Localized periodontitis where a neutrophilic infiltration (n: inset

lower right) is present within the gingiva (g), and the peripheral cementum
(pc) has already receded through carious attack (H and E).

Fig. 10.13  Decalcified histological image of the base of a valve CT necrosis and infection. Eventually the tooth becomes loose
diastema showing erosion and hyperplasia of the gingiva in the
and may even spontaneously be shed due to loss of support-
interproximal space. (Original magnification ×100.) (Courtesy of Alistair Cox
and Sionagh Smith.) ing structures.40 More localized extension of the periodontal
disease can lead to infection of the pulp, apical infection,
and ultimately death of the tooth.42,46 A periodontal disease
In brachydont teeth, periodontal disease starts with loss grading system (0–4) used in small animals that is based on
of the normal tight gingival attachment between adjacent the percentage of dental attachment loss42 could be used in
teeth. This gingiva then becomes inflamed due to mecha­ equids (Table 10.1).
nical irritation, e.g., to impacted food particles and from
chemical irritation from bacteria, food, and plaque. As the Disorders of pulp
gingival destruction continues, the gingival defect becomes
further impacted with food, and the process perpetuates
itself with the periodontitis extending deeper into the peri-
Pulpitis
odontal ligament and also to the buccal and lingual margins Pulpitis or inflammation of the pulp in human teeth occurs
of teeth, forming large periodontal food pockets16 most commonly secondary to dental caries that has pene-
(Figs 10.13–10.15). This inflammation and infection may trated the enamel and dentin,48 and is usually associated
even extend to the alveolar bone, and even supporting with pain (often a dull, throbbing pain synchronous with
bones, causing alveolar bone remodeling and even bone the heartbeat as blood pressure increases in the inflamed but

134
 Equine dental pathology

Table 10.1  Equine periodontal disease grading system

Stage 0 Normal
Stage 1 Gingivitis
Stage 2 Early periodontal disease (up to 25 % attachment loss) ps
Stage 3 Moderate (25–50 % attachment loss) 1D 2rD 2rD 1D
Stage 4 Severe (greater than 50 % attachment loss)

p
confined pulp, in contrast to the sharp sudden pain of dentin
exposure). Other potential causes of pulpitis in all species
include bacterial penetration via pulp exposure secondary to
attrition, abrasion, or trauma; chemical irritation (e.g., from A
irritant molecules directly applied to pulp or by their diffu-
sion through adjacent dentin after insertion of restorative
material): thermal damage i.e., heat produced from motor-
ized dental equipment; or iatrogenic pulpar exposure.
Because of the intimate relationship between dentin and
pulp, together they have been termed the dentinopulp
complex, which emphasizes the fact that an insult to dentin 2iD
can also insult pulp. 2rD
1D
The inflammatory response by pulp includes the develop-
ment of edema and the influx of lymphocytes, plasma cells, 1D
and macrophages. Due to pulp being completely encased in ps
its rigid dentinal chamber, the inflammatory response
increases the pressure in the pulp chamber/horn that can
cause a collapse of the venous microcirculation. This can
result in areas of pulpar hypoxia and anoxia that may lead
to localized or generalized pulp necrosis and death. However,
equine CT, especially when young, have large apical foramina B
and a large blood supply to their pulp and so can often
survive a degree of pulpar edema and inflammation that Fig. 10.16  (A) A single pulp stone (ps) has formed in the middle of this
would cause pulpar death in brachydont teeth. If the pulp partially autolyzed dental pulp. As it remains entirely within the pulp it is
survives, it allows tertiary dentin formation to seal off the termed a ‘free’ pulp stone (denticle). Regular secondary (2rD) and primary
area of insulted (e.g., exposed) pulp, and this hopefully (1D) dentin are present surrounding the pulp (H and E). (B) This pulp stone
results in complete resolution of the pulpitis.49 (ps) has become surrounded by regular (2rD) and irregular (2iD) dentin.  
The sigmoid curvature of dentinal tubules (as they head from the pulp to
the amelodentinal junction) is partially visible in the primary dentin (1D)  
Pulp stones (H and E).

Pulp stones, more correctly termed false pulp stones because

they are composed of concentric layers of calcified tissue Occlusal pulpar exposure
without any internal tubular structure, have been observed in Odontoblasts that line the pulp cavity produce secondary
equine teeth, both within viable pulp (free stones) and in dentin that gradually obliterates the pulp cavity circumfer-
areas replaced with secondary dentin (Fig. 10.16). A study entially and subocclusally over the life of the tooth.50 In
that examined just four transverse histological sections per particular, subocclusal secondary deposition prevents pulp
equine CT found false pulp stones present in 5/51 normal horns from becoming exposed on the occlusal surface in
maxillary and 1/49 normal mandibular CT,49 but it is hypsodont teeth with prolonged eruption.49,51 Whilst much
obvious that they have a much higher prevalence in healthy of this secondary deposition occurs in a time-dependent
equine CT. Their presence in brachydont teeth is often stated manner, its deposition is increased by occlusal stimulation,
to be evidence of pulpar irritation or inflammation that such as by mastication, and in hypsodont teeth (that have
could arise from focal areas of anachoretic pulpitis, or from exposed odontoblast processes on the occlusal surface), this
other noxious stimuli including chemical, bacterial, vibra- stimulation is likely to be of more importance in dentinal
tional (mechanical) or thermal stimuli.50 The formation of deposition, than is the case in brachydont teeth. It was previ-
pulp stones creates a corresponding decrease in the func- ously believed that an imbalance between CT occlusal wear
tional size of the pulp chamber that may compromise pulpar and secondary dentin deposition sub-occlusally could result
microcirculation and in turn may affect the rate of dentin in exposure of the pulp horns on the occlusal surface, result-
production. However, their frequent occurrence in grossly ing in food becoming impacted within the exposed pulp
normal equine CT as indicated above shows that many horns, descending infection and ultimately apical infection
equine CT contain (false) pulp stones that do not compro- of the CT.6,37,52 However, recent studies53–56 have indicated
mise their pulp vitality.49 that occlusal pulpar exposure does not occur in healthy

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 10 Dental disease and pathology

Fig. 10.17  This mandibular CT, which was extracted because of apical
infection, has pulpar exposure of the two lateral pulp horns, and a probe
has been inserted through the defective secondary dentin into one pulp
horn.

Fig. 10.18  This maxillary CT has occlusal pulpar exposure of all 5 pulp
horns (food is protruding from all) with coalescence of the 3rd and 5th
horns (arrow).

Fig. 10.19  This aged CT (extracted at post-mortem examination) has multiple occlusal pulpar exposure with all pulp horns filled with food material.
Extensive periapical cemental deposition (arrows) has sealed off all the pulp horns (and the common pulp chamber) from the apex and consequently,  
no apical infection is present.

equine CT, but is associated with prior pulpar damage that

caused cessation or reduced deposition of sub-occlusal sec-
ondary dentin that with continued occlusal wear and tooth
eruption, leads to occlusal pulpar exposure (Fig. 10.17).
Cheek pulpar exposure can be recognized clinically10
(Fig. 10.17) and at post-mortem examination6 (Figs 10.18–
10.20). More recently, computed axial tomography has been
shown to be an effective imaging modality to identify occlusal
pulpar exposure and/or apical infections of cheek teeth at post
mortem and in clinical cases,7,57 as shown in the computer-
ized tomography images of these disorders in Chapter 13.
Dacre et al54,55 found occlusal pulpar exposure in 34 % of 41
Fig. 10.20  These aged maxillary 106 and 107 have occlusal exposure
apically infected mandibular CT (of multiple pulps in 22 % of multiple pulps. There was no evidence of apical infection in either,
of these 41 teeth) and in 23 % in 57 apically infected maxillary indicating that the occlusally exposed areas of the pulps were sealed off
CT (multiple pulps in 16 % of these 57 teeth). van den Enden from their more apical aspects by tertiary dentin.
et al56 found occlusal pulpar exposure in 32 % of 79 cheek
teeth with apical infections (multiple pulpar exposure in 27 % exposed on the occlusal surface that may provide a potential
and a single pulpar exposure in 5 % of teeth). These latter route of infection of the pulp from the occlusal surface.58
authors also found that 42 % of 31 CT with idiopathic frac- Decalcified histological sections of occlusally exposed pulp
tures had occlusal pulpar exposure (26 % of multiple pulps; demonstrated the absence of occlusal secondary dentin, as
16 % single pulp exposure).56 Ultrastructural examinations of well as the presence of necrotic pulp and, in some cases, plant
equine teeth have shown that dentinal tubules are often material, within the pulp horns54,55,59 (Fig. 10.21).
136
 Equine dental pathology

infections are relatively common, and were the most common

reason for dental referral in one study.10 Apical infection of
CT is a particularly important disease of horses because of
2rD the length of equine teeth, and consequently the apical infec-
tions usually extend to involve the supporting structures,
2iD including the periodontal ligament, alveolar and, depending
on the site of affected tooth, supporting bones and paranasal
sinuses.10,37,40 The clinical signs caused by CT apical infec-
C
tions depend on the tooth involved, and the duration and
the extent of the infection. A study by Dixon et al of 400
referred horses with dental disease included 41% presented
for primary (of unknown etiology) apical infections, includ-
ing 92 maxillary CT and 70 mandibular CT.10 When the
rostral 2–3 maxillary CT are infected, maxillary swellings and
Fig. 10.21  A decalcified transverse histological section of a CT following sinus tracts occur, with nasal discharge less common (due to
pulpar exposure, when food and bacteria invaded, destroying any the apical abscess draining medially into the nasal cavity).
remaining pulp before progressing to attack secondary irregular dentin (2iD) Sinusitis is almost inevitable if the caudal three maxillary CT
at the carious pulp margin (C). Secondary regular dentin (2rD) is often are infected. Mandibular swellings and sinus tracts com-
attacked subsequently (H and E).
monly occur with mandibular CT infections.10
Apical infections occur most commonly in younger horses,
and Dixon et al showed that the median age for horses with
Occlusal pulpar exposure less commonly occurs in equid apical infections of maxillary and mandibular CT was 7 and
teeth (mainly in older horses) that have no evidence of apical 5 years, respectively.10 A further study showed the dental age
infection,55,59 and thus the presence of pulpar expo­sure does (time since eruption of tooth) of 22 mandibular and 28
not necessarily indicate that pulpar or tooth death is present maxillary CT with apical infections to be 3.5 years in both
(Fig. 10.19). Histological examination of some equid CT groups.54,55
with pulpar exposure has shown a layer of tertiary dentin As noted earlier, recent studies have shown that occlusal
protecting the pulp and sealing it off from an area of insulted pulpar exposure of CT is almost certainly a sequel to pulpar
pulp at the pulp horn tip that allowed (limited) pulpar expo- damage, most usually caused by apical infection, being
sure.55,59 van den Enden et al found occlusal pitting of sec- present in 32 % of 79 cheek teeth with apical infections56
ondary dentin overlying pulp horns in apically infected and in 34 % and 23 % of 41 and 57 apically infected man-
cheek teeth; however, in 10 % of teeth with apical infections, dibular and maxillary CT, respectively.54,55 Cheek teeth with
this pitting did not extend through the full thickness of the apical infection have greatly decreased thickness of second-
secondary dentin to involve the pulp horns.56 However, the ary dentin over all aspects of their pulp canals indicating that
presence of multiple pulp horn exposure, pulpar exposure chronic pulpar dysfunction or pulpar death was present in
with marked dentinal caries around the area of pulpar expo- many of these CT,53 and that the reduced dentinal thickness
sure, or of pulps that on probing are found to be deeply was a non-specific finding associated with apical infections
(>2 cm) exposed, indicates the likelihood that the entire of multiple etiologies (Figs 10.22 & 10.23). A commonly
endodontic system has been severely damaged or is dead. recognized cause of equine CT apical infection was anach-
These occlusal findings are likely to be accompanied by clini- oretic infection, i.e., blood or lymphatic-borne bacterial
cal signs and/or diagnostic imaging changes indicative of infection.10,54–56,60 A diagnosis of anachoresis was reached
apical infection and dental death. following detailed examination of CT with apical infections
In cases of acute pulpal exposure (e.g., gross or fissure that found no other physical route of infection to the apex
dental fractures, iatrogenic exposure during dental treat- (Fig. 10.24). Anachoresis was the most common cause of
ment), the application of calcium hydroxide as a ‘pulp-cap’ maxillary CT (51% of 57 apical infections) and mandibular
results in the rapid formation of a necrotic zone adjacent to CT (59 % of 41 apical infections) apical infections in one
the calcium hydroxide that has a pH of 11 and so has bac- study.54,55 Vertical impactions and hyperemia of the apex due
tericidal actions. A basophilic zone consisting of calcium to large eruption cysts (‘3- and 4-year-old bumps’) may pre-
proteinates forms below this necrotic zone. An adjacent dispose to anachoretic infections,37 and this theory is sup-
fibrous layer and odontoblast cell layer forms within 2 ported by the higher prevalence of CT apical infections in
weeks, followed by a layer of early tertiary dentin 2 weeks younger horses. Furthermore, there are anastomoses between
later.48 The exact mechanism by which calcium hydroxide the periodontal vasculature and the maxillary sinus blood
induces this reparative dentin is unknown. The clinical vessels,61 possibly allowing bacteria from the upper respira-
aspects of this treatment are discussed in Chapter 22. tory tract to be a possible source of CT apical infection, and
the converse, as previously noted, with apical infections
causing sinus empyema.
Apical infections Apical infections can also occur secondary to developmen-
tal disorders (polyodontia, dental dysplasia, hypoplasia,
Apical infection is a more accurate term to use in equids than diastemata, and displacements), usually by an extension of
‘tooth root infection’ as such infections commonly occur in deep descending periodontal disease (because these teeth do
young horses prior to any root development, in addition to not have tight interproximal spaces); wear disorders with
also occurring in older CT with well developed roots. Incisor associated periodontal disease; or fractures (idiopathic gross
or canine apical infections are rare in equids, but CT apical or fissure fractures, as well as traumatic fractures).
137
 10 Dental disease and pathology

Pulpar Blood or lymphatic-

exposure borne bacteria

Periodontal
spread
Gingiva
Fracture

Periodontal Periodontal
ligament ligament
Pulp Cementum
Pulp Cementum
Enamel Enamel

Dentin Dentin

Periodontal spread

Pulpar exposure
Infundibular
Fracture caries

Blood or lymphatic-borne bacteria Fig. 10.23  Proposed routes of apical infection in equine maxillary cheek
teeth. (Reproduced from Dacre et al55 with permission from The Veterinary
Fig. 10.22  Proposed routes of apical infection in equine mandibular cheek Journal.)
teeth. (Reproduced from Dacre et al,54 with permission from The Veterinary
Journal.)

A study of 41 apically infected mandibular CT found

dental fractures to be the second most common cause (20 %)
of infection, and included 2 CT with sagittal fractures and 6
with hairline (fissure) fractures communicating between the
infected pulp and periphery of the tooth54 (Fig. 10.25). The
fissure fractures often had dark (bacterial or food pigments)
staining on cut sections of affected teeth, but these fissures
were usually not very obvious on the surface of the tooth
and were never diagnosed clinically. Increased awareness of
their significance and more careful examinations of suspect
teeth using a dental mirror or intra-oral endoscope should
allow their detection.62,63 Not all idiopathic fractures (e.g.,
lateral slab fractures through the lateral pulp horns) result Fig. 10.24  Apex of a mandibular cheek tooth (orally) extracted because of
apical infection, showing a chronic proliferative reaction of the periapical
in apical infections, as some such pulps can manage to seal tissues (arrow) and slight irregularity on the exposed cementum, but with
off the exposed pulp by laying down a layer of tertiary dentin little evidence of the destructive changes that occur in some apically
to prevent infection spreading down the pulp horn,59 as infected teeth. As no physical route of infection from the oral cavity to the
described later. Fissure fractures, were also found to cause apex was present in this tooth, anachoresis was the likely cause of the apical
apical infections in 9 % of infected maxillary CT.55 infection (×2).
Extension of infundibular caries is a maxillary CT specific
disorder that can also cause apical infections. Infundibular
cemental hypoplasia with subsequent food impaction in the onto the apex.10,37 Dacre et al found some degree of infundib-
cemental defect predisposes to the development of infundib- ular cemental caries present in most apically infected maxil-
ular cemental caries that may cause apical infections, either lary CT examined (Fig. 10.26); however, only 16 % of
by weakening the tooth structure resulting in midline sagittal maxillary CT had gross pathological or histological evidence
fractures or by extension of the caries through the infundibu- of spread of infundibular caries to involve the pulp or, in
lar enamel into dentin and pulp, or occasionally directly one case, directly to the apex.55

138
 Equine dental pathology

Periodontal spread is an important route of apical infec- Certain types of dental dysplasia (covered in detail in
tions in both maxillary CT (12 %) and mandibular CT Chapter 8) are characterized by the presence of dysplastic
(10 %).54,55 A periodontal route of apical infection was rec- enamel and hence of abnormalities of dentin and cemen-
ognized in the above studies when periodontal disease was tum, and such defects were found to predispose to apical
found in conjunction with peripheral cemental changes infections in 2 % and 5 % respectively, of mandibular and
(including dark staining of the residual cementum or maxillary CT.54,55 Dental dysplasia usually resulted in apical
exposed enamel) and the loss of continuous vertical areas of infections via descending periodontal disease, because the
the periodontal ligament from the apex to the gingival abnormally shaped teeth did not fit snugly into the alveoli.55
margin.54,55 Periodontal disease was deemed to be secondary Occlusal and peripheral caries were believed to cause
to apical infections in some CT, including the inevitable apical infections in just 2 % of mandibular and maxillary
local areas of periodontitis around the infected apical area, CT.54,55 As commonly occurs in brachydont teeth, it is
or locally at the gingival margin due to food impaction unre- believed that penetration of bacteria from deep caries
lated to the apical infection.54 More chronic cases of second- down dentinal tubules as demonstrated histologically55,56
ary periodontal disease that had continuous periodontal may result in pulpar and thus apical infection of the tooth
tracts from the apex to the gingival margin were believed to (Figs 10.27 & 10.28).
be caused by secondary changes, due to drainage of exudate A local response in infected pulp horns is to lay down
from the apical infection to the gingival margin. Some of tertiary dentin to seal off the more apically situated pulp
these teeth had areas of cemental hyperplasia on their apices from the exposed or insulted area (Fig. 10.29). However,
and reserve crowns, in contrast to the usual loss of cemen- with death of pulp, such a response is not possible
tum in teeth with descending periodontal infection.54 (Fig. 10.30).

Dental caries
Caries is characterized by destruction of the calcified dental
4 3
tissue with bacteria as the primary initiator of a chain of
5
events. Bacterial fermentation of carbohydrate releases acids
that decalcify the inorganic dental components (mainly
calcium hydroxyapatite) at pH 4–5.516 (Fig. 10.31). In
A 5 brachydont teeth (which have a complete enamel covering),
3 B 1
dentin is demineralized very rapidly once the caries has
penetrated fully through the enamel and the amelodentinal
junction is reached, and the discolored, carious dentin
results in the classic black appearance of caries.64
Fig. 10.25  The reverse (apical) face of the occlusal section of an infected The most common type of dental caries identified
309, dental age 5 years. All five pulp chambers are occluded with secondary
dentin; however, pulp chamber 5 is darkly stained around a central fissure
in equine teeth is maxillary CT infundibular cemental
(B). A hairline fracture (A) extends through the cementum and enamel at caries.10,11,14,65,66 Colyer66 observed a prevalence of 13 % of
the caudal aspect of the tooth, to join up with the fissure present in the infundibular caries, and Honma et al4 reported a prevalence
secondary dentin around pulp chamber 5. An enlargement of this area is of 100 % in (maxillary) CT of horses over 12 years of age
shown in the insert on right, with arrows identifying the hairline fracture. (Figs 10.32 & 10.33). The maxillary CT of older horses are
This infection was acute as evidenced by the presence of normal thickness predisposed to developing caries due to presence of devel-
of dentin and of pulp remnants in all pulp horns more apically. It is possible
opmental cemental hypoplasia of the infundibula, often at
that if this tooth was not extracted it would have developed a sagittal
‘idiopathic’ fracture through the 4th and 5th pulp chambers. Note that a deeper levels, including towards the apical aspect of the
newer pulp identification system is now in use – see Chapter 5. infundibulumn, that only becomes occlusally exposed with

A B C

Fig. 10.26  Occlusal (A), mid-tooth (B) and apical (C) sections from an infected 107 CT that has occlusal pulpar exposure of all 5 pulp chambers, which are
filled with food down to the apex. The rostral infundibulum (r) has cemental caries, especially more apically. The caudal infundibulum (c) has central
cemental hypoplasia with localized cemental caries. Infundibular caries was not found to penetrate the infundibular enamel at any level in either
infundibulum, indicating that infundibular infection did not cause the apical infection in this tooth. Infection was ultimately attributed to anachoresis.  
(Reproduced from Dacre et al,55 with permission of The Veterinary Journal.)

139
 10 Dental disease and pathology

1D
3D

V
3D

p
Fig. 10.27  Higher power image of decalcified transverse sub-occlusal
section of dentin from an apically infected maxillary CT showing  
bacteria (arrows) present in obliquely-sectioned, primary dentin tubules
(H&E × 400). (Reproduced from Dacre et al,55 with permission of
The Veterinary Journal.)
Fig. 10.29  Tertiary dentin (3D) has been laid down within the pulp of this
equine cheek tooth in response to focal noxious stimuli. As seen more
clearly in the insert (top right), there is no continuation of dentinal tubules
into this tertiary dentin (as occurs between primary and secondary dentin).
The pulp (p) has been exposed latterly through dental attrition resulting  
in the pulp horn filling with vegetable material (V), and destruction of any
pulp that remained (decalcified transverse H and E section).

Fig. 10.28  Pioneer organisms (bacteria) are present within the central
dentinal tubule in this transmission electron micrograph. Such
microorganisms may invade down dentinal tubules and infect the pulp if
the host defense mechanisms are inadequate.
Fig. 10.30  Scanning electron microscopy image of carious dentin lining a
pulp chamber that contains necrotic pulp. Many areas have localized loss of
integrity of intertubular dentin (arrows). (Reproduced from Dacre et al55 with
age.67 A recent study of 786 maxillary cheek teeth, from 33 permission of The Veterinary Journal.)
horses (median age 10 years), that were sectioned longitu-
dinally found that only 11 % of infundibula were completely
filled with grossly normal cementum, and areas of cemental accounting for 47 % (29/62) of these carious teeth.68 This
hypoplasia and cemental discoloration, respectively, were prevalence of 8 % infundibular caries is much lower than
observed in 22 % and 72 % of infundibula.68 reported by other authors,10,11,14,65,66 possibly due to classifi-
Cemental hypoplasia of the infundibula can develop sec- cation of infundibular cemental hypoplasia as infundibular
ondary to premature destruction of the dental sac, such as caries in some of these earlier studies.
by premature removal or loss of overlying deciduous CT.33 The decalcified histological appearance of infundibular
However, recent examinations of CT of 1–3 years dental age caries in donkey CT showed loss of normal cementum with
demonstrated the presence of a viable blood supply to the the presence of necrotic material and vegetable matter in
apex of infundibula, which was confirmed histologically68 affected infundibula59 (Fig. 10.33). Undecalcified histology
(see Chapter 5). This blood supply allows continued demonstrated an extension of the carious process from the
infundibular cemental deposition to occur (at least in the cementum to the infundibular enamel, resulting in a ragged
apical aspect of the infundibulum) for a few years following appearance of the amelocemental junction instead of its
maxillary CT eruption. In that study, widespread infundibu- normal smoothly scalloped appearance, indicating the pres-
lar cemental caries was found in 8 % (62/786) of infun­ ence of enamel demineralization.59 Scanning electron micro-
dibula, with the Triadan 09 positions disproportionally scopy also demonstrated extension of caries along the

140
 Equine dental pathology

Enamel
Saliva Plaque
(Cementum)

Sucrose Bacteria
F–
Critical
Buffers ACID
–
pH5.5
F C
Ca2+ Ca10(PO4)6(OH)2
PO43–
NEUTRAL
Ca2+ Ca2+ Ca10(PO4)6(OH)2
PO43– PO43–
F– Ca10(PO4)6F2
Fig. 10.34  High-power SEM image of the distal aspect of a longitudinal
Fig. 10.31  Diagrammatic representation of principal biochemical aspects section of a 209 infundibulum showing carious changes (arrow) to the
of factors influencing caries under acidic (pH < 5.5) conditions (favoring periphery of the cementum (C) with loss of the normal amelocemental
caries) following degradation on carbohydrates (e.g., sucrose) and at a junction. (Reproduced from du Toit et al,59 with permission of The Veterinary
neutral pH, e.g., following buffering by saliva. Journal.)

Table 10.2  A grading system for equine dental caries

0 degree No macroscopic visible caries (can include infundibular

hypoplasia)
1st degree Caries only affecting the cementum
–  from small pitting superficial spots (class 1)
–  extensive destruction and loss of cementum (class 2)
2nd degree Caries affecting cementum and adjacent enamel
3rd degree Caries affecting cementum, enamel and dentin
4th degree Caries now affects the integrity of the tooth, i.e.,
108 109 110
development of an apical abscess or secondary tooth
Fig. 10.32  Infundibular caries is present in both rostral and caudal fracture
infundibula of maxillary CT 109 and 110. The infundibula have not coalesced
at this stage, but both the infundibular enamel and dentin between the two
infundibula are carious.

amelocemental junction resulting in destruction of cemen-

tum and enamel in the apical aspect of the infundibulum59
(Fig. 10.34). Interestingly, studies have shown that caries in
human dentin and enamel start with demineralization (due
to low pH) of these tissues prior to bacterial infection,
whereas in caries of cement, demineralization and bacterial
infection occur simultaneously.69 The above-noted equid
cemental SEM studies59 would also support these findings.
Infundibular caries has been classified by Honma4 accord-
ing to the degree of its spread into different dental tissues.
A modified classification of infundibular caries has been
proposed by Dacre,37 which is also applicable for grading
peripheral caries in equine teeth (Table 10.2).
Caries of the peripheral aspect of the equine teeth (Figs
10.35 & 10.36), although apparently common, has been
poorly described70,71 and as it most obviously involves the
peripheral cementum it is sometimes termed peripheral
cemental caries, which does not describe the full extent of
this disorder. Peripheral dental caries may affect infolded
Fig. 10.33  Decalcified histological image of vegetable matter (arrows) lying peripheral cementum including cementum that lies on the
in defective cementum within an equid cheek tooth infundibulum. occlusal surface, and therefore can predispose to an increased

141
 10 Dental disease and pathology

311 310 309

Fig. 10.37  Caudal maxillary cheek teeth from a horse with severe
3 cm generalized peripheral caries and secondary fractures and periodontal
disease associated with feeding an almost total processed maize diet.

Fig. 10.35  Widespread peripheral cemental caries of mandibular CT

309–311. Note how the caries has removed much of the supporting lingual
cementum from the clinical crown of 311, leaving its discolored enamel.

Fig. 10.38  These incisors (from a horse on the same diet as the horse in
Fig. 10.37) have multiple fractures due to generalized dental caries that was
associated with feeding very high levels of a processed maize diet.

Fig. 10.36  Caries of peripheral cementum in a decalcified section from a

mandibular CT. This shows the characteristic pitting nature of these lesions volume of buffering saliva may predispose to prolonged
(H and E).
periods of low pH in the oral cavity and demineralization
of calcified dental tissue. Peripheral caries is also concur-
rently found with other dental abnormalities, where res­
rate of occlusal wear and fracture of unsupported (brittle) tricted food and saliva movement may predispose to its
enamel. By causing destruction of the normal peripheral development. Extensive generalized caries has also been
cementum-periodontal attachments, peripheral caries can recorded in horses fed diets with a low pH, where excessive
also initiate local periodontal disease. As noted earlier, acids were added to silage/haylage and also in diets consist-
infundibular cemental caries may extend through the enamel ing largely of simple carbohydrates, i.e., processed maize
to dentin and pulp, resulting in apical infection.54,55,72 foodstuffs (Figs 10.37 & 10.38).
Infundibular caries can also extend concentrically along the It is also likely that some individual horses are predisposed
inner (medial) aspect of the infundibular enamel – even to peripheral dental caries. There is minimal published
causing coalescence of both infundibula that may be sur- knowledge on the normal bacteriology of the equine mouth
rounded by tertiary dentin that seals off the pulp horns from and even less on the bacteria that incite dental caries forma-
the infection. Nevertheless, these processes can mechanically tion, and this is an area that needs urgent investigation.72,73
weaken the tooth and result in midline sagittal fractures of
affected maxillary CT.67 Dental fractures
High levels of severe peripheral dental caries involving
all classes of teeth (incisors, canines, and CT) have been
found in groups of equids under certain management prac-
Traumatic dental fractures
tices, such as feeding high concentrate, low roughage diets, Although the teeth of horses are largely composed of equine
where the reduced time spent masticating and decreased type-2 enamel that is relatively fracture resistant, traumatic

142
 Equine dental pathology

dental fractures, particularly of the incisors, are relatively L

common in horses, due to external trauma such as kicks,
crib-biting, biting hard objects, and collisions with solid
objects, e.g., gates, fences and walls.74 Dixon et al11 found
that 8 of 11 referred cases with incisor fracture were caused
by trauma. Equine CT are composed of high levels of hard
R C
but brittle equine type-1 enamel, with higher proportions of
type-1 enamel in equine maxillary than mandibular CT.75
Nevertheless, traumatic equine fractures of CT are less
common than incisor fractures due to their anatomical pro-
tection (especially of maxillary and caudal mandibular CT).
Only 8 % of horses referred because of CT disorders
had traumatic fractures, with the majority (71 %) being
mandibular CT fractures, with kick injuries and iatrogenic B
fractures (use of dental shears) being the most common
Fig. 10.39  Common patterns of idiopathic mandibular cheek teeth
causes of fracture. Traumatic CT fractures are usually accom- fractures. R, rostral; C, caudal; B, buccal; L, lingual. The most common
panied by mandibular or maxillary bone fractures, which are fracture pattern (red lines) runs through the two pulp chambers on the
covered in Chapter 9. Some fractured teeth can be preserved buccal aspect of the tooth. (Reproduced from Dacre et al76 with permission
by endodontic therapy, as covered in Chapter 22. of The Equine Journal.)

Idiopathic cheek teeth fractures

B
The majority of equine CT fractures have no known history
of trauma and have been classified as idiopathic CT frac-
tures.76 These fractures can be subtle and are sometimes not
detected on oral examination. Nevertheless, with training
they can commonly be found, with one practice-based
survey indicating a median prevalence of 0.4 % of idiopathic
fractures in a mixed population of horses.77 The clinical signs R C
most commonly seen with dental fractures are quidding,
followed by bitting and behavioral problems, and halito-
sis.76,78 Some horses, especially those with smaller slab frac-
tures, can be asymptomatic, and the fractures are only noted
during routine dental examinations.77 A pathological study
of 35 CT with idiopathic fractures found that maxillary CT
(in particular the maxillary 09s) were more commonly
involved than mandibular CT, and a similar distribution was P
found in both general practice and referral clinic surveys,77,78 Fig. 10.40  Common patterns of idiopathic maxillary cheek teeth fractures.
and in a pathological survey,76 but the reason for this pattern R, rostral; C, caudal; B, buccal; P, palatal. The two most common fracture
is unknown. The most common fracture patterns in idio- patterns run through the two pulp chambers on the buccal aspect of the
pathic CT fractures are lateral slab fractures through the two tooth (red lines) and through the infundibula (green lines). A variety of other
lateral (buccal) pulp cavities,76–78 possibly because the min- fracture patterns can also occur through the other pulp horns (purple lines).
(Dacre et al76 with permission from The Equine Journal.)
eralized dental tissues are thinner at the sites of the pulp
horns and, therefore, the CT are weakest at this point76
(Figs 10.39 & 10.40).
A common fracture pattern in maxillary CT is a midline that survive following an idiopathic fracture have long-term
sagittal fracture through both infundibula in the CT with radiographic changes to their apical regions, and addition-
infundibular caries that, as noted, is believed to be predis- ally have scintigraphic changes to this region (at least for
posed by infundibular cemental hypoplasia.76 some months following the development of fractures), indi-
Histological quantitative measurements of dentin showed cating a widespread, but subclinical endodontic response to
reduced thickness of dentin in 25 % of CT with idiopathic these CT fractures.
fractures, indicating prior pathological changes to pulp. A proportion of fractured CT develop pulpar infection
Consequently, the resultant thinner dentin mechanically that extends to affect the apex clinically, with the resultant
predisposes to fracture development in these particular CT.76 clinical signs depending on which tooth is involved (Figs
Dental pulps are inevitably involved in all (maxillary and 10.41 & Fig 10.42). Such clinical signs are common with
mandibular) idiopathic fractures, including the smaller max- maxillary CT midline sagittal fractures and mandibular CT
illary CT ‘slab’ fractures.76–78 However, many lateral slab frac- fractures, and such CT require dental extraction. In other CT,
tures, in particular, have been shown to clinically resolve mobility of one or more fragments causes periodontal
without development of clinical apical infections,13 indicat- stretching and pain during quidding until smaller dental
ing that the resultant pulpitis remains low grade or that the fragments are spontaneously shed or until they are extracted.
underlying pulp has been sealed off from the fracture site by Other fractured CT develop food impaction into the fracture
the deposition of tertiary dentin.79 Many such fractured CT site causing lateral or, less commonly, medial displacement

143
 10 Dental disease and pathology

of the more mobile, smaller fracture segment that causes soft

tissue (usually buccal) ulceration and resultant quidding.
Removal of the displaced fracture segment is indicated. Pre-
vention of dental fractures secondary to infundibular caries
3 has been attempted (especially in horses with pre-existing
5 CT fractures) by removal of carious infundibular cementum
and filling the infundibular defect with endodontic restora-
tive materials, but objective research on this treatment needs
to be performed to determine its value.

Equine odontoclastic tooth resorption

Fig. 10.41  Advanced caries of pulp horn 3 (3) which extends into pulp
and hypercementosis (EOTRH)
horn 5 (5) in this fractured mandibular CT. This fractured tooth was
extracted orally and crush marks from the extraction forceps are seen on the Recently, an uncommon disorder of incisor and canine teeth
buccal face of its clinical crown. Note the hyperplastic peripheral cementum of aged horses, causing periodontitis, with resorptive or pro-
on the reserve crown that has been laid down in response to the apical liferative changes of the calcified dental tissue has been
abcess present. described by Klugh,80 Baratt,81 Caldwell,82 and Kreutzer
et al.83 A pathological study of this disorder by Staszyk
et al84 resulted in the disease being termed equine odonto-
clastic tooth resorption and hypercementosis (EOTRH). No
plausible etiopathogenesis for this apparent immune-
mediated syndrome has been described. The study by Staszyk
et al84 found the disorder to primarily affect the intra-
alveolar aspect of the teeth and showed the presence of
odontoclastic cells in affected teeth by using tartar resistant
acid phosphatase staining. These odontoclastic cells cause
resorptive lesions extending into cementum, enamel, dentin,
and even into pulp, causing marked loss of normal architec-
ture in some teeth. In several areas, the resorbed areas and
unaffected dental surfaces had irregular cementum deposi-
tion by cells of the periodontal ligament that led to hyper-
cementosis in some areas (Figs 10.43 & 10.44).84 The pulp
chambers of some affected teeth had irregular cementum
deposition over tertiary dentin lining the chambers. This
disorder shares many features with similar dental syndromes
described in people85,86 and cats,87,88 but in many affected
horses, a massive proliferative hypercementosis of all inci-
Fig. 10.42  A scanning electron micrograph of primary carious dentin
sors is the main feature,89 in contrast with the more destruc-
present on a mandibular CT following a dental fracture. Note the
fenestrated appearance of the carious dentinal tubules. tive syndrome observed in human and feline teeth.

Fig. 10.43  (A) The incisors of this horse have extensive cemental deposition subgingivally, and some have sinus tracts (arrow) caused by EOTRH.
(Courtesy of Hojgard Hestehospital.) (B) Radiograph of incisors of a 17-year-old pony that had marked gingival swelling without any sinus tracts, which  
shows very extensive hypercementosis of the reserve crowns of all incisors, with minimal destructive changes apparent. (Courtesy of M. Parr.)

144
 Equine dental pathology

A B

C D

Fig. 10.44  (A) Toluidine blue-stained decalcified transverse section of the mid-tooth region of 103 of horse 5. Irregular cementum (irC) fills a deep resorptive
lesion that extends into normal cementum (nC) and dentin (D). The border of the irregular cementum (irC) is marked by a reversal line (open arrowheads).
Wavy incremental lines (black arrow heads) indicate irregular but phasic growth. This irregular cementum contains a large vascular channel (vc).  
(B) Subsequent serial section of above tooth stained with Picrosirius red showing concentric deposition of intrinsic collagen fibers around the vascular
channel (vc). There is parallel arrangement of the extrinsic collagen fiber bundles (white arrow heads) within the normal cementum (nC). (C) Toluidine
blue-stained decalcified transverse section of the mid-tooth region of 101 of horse 4. Irregular cementum (irC) deposited in a resorptive lesion. (Inset) The
white arrow indicates an ongoing resorption process at the dentinal surface. igt: inflamed granulation tissue. (D) TRAP stained decalcified transverse
mid-tooth section of a 101 of horse 4, showing TRAP-positive, multinucleated odontoclasts (Oc) lying in a Howship’s lacuna at the dentinal surface (D).
Mononucleates, precursors of odontoclasts (arrows) are located at a short distance behind the resorption surface. (Reproduced from Staszyk et al84 with
permission of The Veterinary Journal.)

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 Section 3:  Dental disease and pathology

C H A P T ER  11 
Oral and dental tumors
Derek C. Knottenbelt† OBE, BVM&S, DVM&S, Dipl ECEIM, MRCVS,
Donald F. Kelly* MA, BVSc, PhD, MRCVS, FRCpath, Dipl ECVP
†
Division of Equine Studies, Department of Veterinary Clinical Studies, University of Liverpool, Leahurst, Merseyside CH64 7TE, UK
*Department of Veterinary Pathology, University of Liverpool, Leahurst, Merseyside CH64 7TE, UK

Introduction An added complication is that some non-neoplastic oral

conditions, such as epulis, gingival hyperplasia, granulation
Any tissue can develop neoplastic changes, and the struc- tissue, and hamartoma can give the clinical suspicion of
tures of the mouth, including the soft tissues, the bone, and neoplasia. Indeed, some masses have histological features
the teeth, are no exception. In general, however, this is an that support a diagnosis of neoplasia but are not, in fact,
area of equine clinical oncology that has been largely ignored cancerous.8–10 For example, fibrous metaplasia of the nasal
in spite of its importance to eating and its usually high vis- region and hard palate have been described,11,12 and benign
ibility. Moreover, most published reports of specific onco- neoplastic growths are seen occasionally in association with
logic conditions involve single or few cases, or are broad abnormal germinal tissue of tooth apices13 (Fig.11.1). These
reviews based on these.1–4 include:
In common with other neoplastic disease, primary oral • Papilloma
and dental tumors are usually classified according to their • Epulis
tissue of origin as (Fig. 11.1): • Polyp
1. Dental (odontogenic) tumors • Aneurysmal bone cyst
2. Bone (osteogenic) tumors • Fibrous dysplasia/metaplasia.
3. Soft-tissue tumors There are also some cystic dentigerous disorders that may
and according to their clinical behavior and pathologic fea- easily be mistaken for neoplasia.
tures as: Histological confirmation of the exact nature of oral tumors
may prove difficult for a number of reasons. Both soft tissue
1. Benign or malignant and osetogenic and odontogenic tumors may be complicated
2. Invasive or localized and defined by concurrent, long-standing infection or granulation tissue
3. Proliferative or ulcerative. proliferation that may mask the true nature of the underlying
As with almost all equine cancerous conditions, there is no lesion. Secondly, some of the hard tissue oral tumors are
meaningful information on any tumor staging of any of the extremely difficult to biopsy and then to process for his-
orodental tumors of horses. The tissue of origin, the location topathologic examination. The rather variable classification
of the tumor, the extent of secondary tissue involvement, of oral lesions also makes initial assessment of tumors diffi-
and the clinical and pathologic tumor behavior all inevitably cult. Some tumors fall into the undifferentiated or unclassifi-
have a profound effect on the feasibility and choice of treat- able myxoma/spindle-cell tumor group,14 which have
ment, as well as the prognosis for the horse. ill-defined histological characteristics and variable clinical
When orodental neoplasms occur, they are often clinically features. The variation in classification of equine tumors
important and can in many cases be life-threatening.5 Whilst makes the specific diagnosis of many clinically obviously
some such tumors are recognized rapidly, the majority are neoplastic diseases difficult and is further affected by the vari-
not; often the secondary changes, such as weight loss or dif- able interpretation of different pathologists. It has to be rec-
ficulty with eating (dysmasesis) are the main reason for pres- ognized, however, that oral and dental tumors are relatively
entation. Even the most astute owners may not notice oral uncommon. This means that individual pathologists are
lesions in their early stages, and so, many tumors are in an unlikely to have an extensive database of experience of neo-
advanced state when first presented. This makes the general plasms at this anatomical site. It also means that careful con-
diagnosis of neoplasia relatively straightforward, but rather sideration and appropriate sample collection are essential.
disappointing in most circumstances, since treatment Although there have been some advances in the manage-
options are then extremely limited.6 Additionally, since the ment of many neoplastic conditions in the horse, the low
gross appearance of many neoplastic masses in their early incidence of oral tumors makes it difficult to define the best
and advanced states can be similar, the definitive diagnosis approach to any particular tumor, and there is a lack of
inevitably depends on histological examination.7 comparative evidence-based efficacy studies for the various

149
 11 Dental disease and pathology

ORODENTAL
MASSES

True Neoplasia Non-Neoplastic Masses

Soft Tissue Osteogenic Odontogenic

Neoplasia Neoplasia Neoplasia

1 Osteoma 1 Ameloblastoma 1 Epulis

Primary Oral Neoplasms
2 Osteosarcoma 2 Ameloblastic odontoma 2 Papilloma
1 Squamous cell carcinoma 3 Complex odontoma 3 Polyp
2 Sarcoid 4 Compound odontoma 4 Aneurysmal bone cyst
3 Fibroma/fibrosarcoma 5 Cementoma 5 Fibrous dysplasia
4 Melanoma 6 Foreign body granuloma
5 Ossifying fibroma 7 Dental cysts and
6 Myxoma complex abnormalities
7 Hemangiosarcoma
8 Salivary adenocarcinoma

Secondary Neoplasms
1 Lymphosarcoma/lymphoma
2 Hemangiosarcoma

Fig. 11.1  Classification of orodental masses in the horse. The most common lesions are shown in bold font.

therapeutic options. Treatment options may also be affected than the underlying condition. Also, neoplastic tissue is
by the delayed detection of tumors. Many have a benign more susceptible to infection and trauma, and so the clinical
character, but their size may make them impossible to treat appearance may be more severe than the tumor alone war-
by currently available means. Clinicians frequently have to rants. These factors have a considerable bearing on the
make compromises from the ideal treatment options. The ability to diagnose the oral lesions simply from clinical sup-
early diagnosis of an untreatable condition may not always position and experience.
be in the horse’s best interests, since euthanasia may be There are few pathognomonic signs for any particular type
performed before it is strictly necessary on welfare grounds, of tumor apart from the distinctive visual appearance of
thus depriving the horse of some additional quality life and some conditions. The general presenting signs encountered,
the owner of enjoyment. Often insurance and financial con- which are often subtle in the early stages, include:
siderations take priority over the welfare issues.
1. Gross appearance of an abnormal mass of tissue, or
Considering that most cases are presented late in the
secondary anatomic alterations due to proliferation or
course of disease, determining the prognosis for a particular
destruction of tissue within the oral cavity or adjacent
case is frequently the primary objective of the clinician,
structures, such as the cheeks, nasal cavity, and
rather than providing any realistic treatment. Owners are
paranasal sinuses
generally more concerned with the prognosis than with the
2. Oral bleeding (manifest as hemosalivation or melena)
disease itself, but some expect treatment to be successful in
3. Dysprehension / dysmasesis (dysmastication) /
every case. As most of these conditions are rare (or very rare),
dysphagia
a realistic and objective prognosis, with or without treat-
4. Weight loss
ment, may be difficult to provide. The course of most oro-
5. Recurrent fever and depression
dental tumors is unpredictable, and so the prognosis
6. Halitosis.
frequently becomes very subjective. Further, it is unfair to
expect a pathologist to provide an accurate prognosis when For example, oral carcinoma can result in loss of buccal
there are few recorded cases of individual tumor type, and sensation, and so the horse may suffer from significant self-
extrapolation from other species is usually not justified. trauma to the soft tissues of the mouth. A destructive oral
However, more frequent reporting has improved the under- carcinoma involving the palate may produce an oronasal
standing of most equine neoplastic disease from both clini- fistula that might be recognized first by the presence of a
cal and pathological perspectives. nasal discharge, with or without overt food material. A
Some oral neoplasms are very destructive, and so there space-occupying mass in the mouth may simply present with
may be extensive secondary changes that are more obvious anatomic distortion and some functional deficits.

150
 Oral and dental tumors

Investigation of a suspected oral mass should always begin 3. Magnetic resonance imaging (MRI) is an ideal modality
with a detailed clinical history. A physical examination for imaging soft tissues, and whilst the facilities for this
should be performed to establish both the clinical nature and are currently limited, they are increasing. MRI imaging
extent of the neoplasm, to identify the structures involved, suffers from the need for immobility and takes a
and to try to assess whether these changes are primary or considerable time to perform; therefore, general
secondary. A relatively small lesion in the mouth or adjacent anesthesia is almost compulsory. Again, a three-
structures may be secondary to a much more extensive lesion dimensional image can be generated, and this greatly
elsewhere. A good example of this is lymphosarcoma – the helps in dealing with soft tissue tumors and other
oral or pharyngeal lesions may be clinically insignificant, yet masses within sites that preclude full inspection. The
there can be extensive internal organ involvement. full extent of the tumor and its anatomic relationships
Biopsy of any suspected neoplastic lesion is the mainstay can be revealed (Fig. 11.2).
of investigation. While biopsy of a suspect mass is frequently 4. Gamma scintigraphy:
performed, it should be preceded by investigations that help (a)  Gamma scintigraphy can currently be used in a
to establish the extent and possible nature of the condition. non-specific way to identify small and large foci
For example, it may be very important to know if bone or of tissue inflammation; the detection of a focus
other structures are involved, and this may influence both in either soft tissue or bone phase scans
the site of biopsy and the method required to obtain diag- presently has low specificity as it simply
nostic material. In many cases, it is useful to consult with identifies areas of tissue remodeling and
a pathologist before performing a biopsy to ensure that inflammation. Nevertheless, the images derived
the best diagnostic specimens are obtained and also so that can be dramatic.
the pathologist can orientate the specimens correctly in the (b) With increasing interest in monoclonal
context of precise anatomic location. technology using radiolabeled antibodies, it is
The prognosis varies markedly with the specific character- entirely reasonable to expect that this method
istics of the tumor. In some cases, these may not be the same may in future be added to the investigative list.
as the classical description in other species. For example 5. Ultrasonography:
histopathology may suggest high malignancy, but the tumor (a) Ultrasonography is becoming increasingly
may show no clinical evidence of this behavior. The converse valuable as more sophisticated equipment is
situation can also arise. developed. The details obtained of soft-tissue
masses can be remarkable.
(b) Clearly, there are limitations in the head region
Diagnostic procedures for suspected relating mainly to the superficial bones, but soft
neoplastic disease tissue structures, such as the tongue, cheeks, and
orbit, can be usefully examined.
1. Radiography is the standard imaging method in the
practice situation (see Ch. 13). These two-dimensional
images do, however, create some interpretative
difficulties. Where radiography is the only available
imaging modality, carefully positioned images can be a
major diagnostic help and a satisfactory diagnosis can
be achieved or at least assisted in many cases. Unless
experienced, it is useful to have a reference book
available on normal radiographic variation because
interpreting radiographs of the equine head can be
difficult. Oblique projections can be helpful and
fluoroscopy can be a significant aid in both diagnosis
and treatment of head tumors. Contrast angiography
can be a useful aid to surgical and possibly medical
therapy, especially in aggressive tumors with large
blood supplies.
2. Computed tomography (CT) is becoming increasingly
available in veterinary practice and can now be
performed on the standing sedated horse. It provides
a three-dimensional radiograph and is particularly
valuable for those conditions that are difficult or
impossible to palpate or inspect (such as tumors
within the paranasal sinuses or those associated
with the teeth). CT images also help to establish
the presence or absence of any secondary changes in
the bone and other structures. This gives a greatly
improved appreciation of the extent and nature of the Fig. 11.2  This oro-nasal palatine carcinoma was subjected to MRI scanning,
challenges and complications likely to be faced by the and the 3-dimensional images significantly assisted the assessment of the
surgeons in particular (see Ch. 13). options available to the clinician. (Courtesy A.J. van den Belt.)

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 11 Dental disease and pathology

(c) In some cases the nature of the tumor/mass can conditions usually result in hemoptyalism
be identified, e.g., soft-tissue masses can easily (presence of blood in saliva) which, even in
be differentiated from those involving bone, microscopic amounts, can be detected simply
and some tumors, such as melanoma, have using a urine dipstick. It is, however, obviously a
strongly suggestive, ultrasonographic very non-specific test.
characteristics. (b) Non-specific changes, including
(d) The blood supply to the mass can sometimes hyperfibrinogenemia, hypoalbuminemia, and
be identified, and this may provide useful occasional evidence of the paraneoplastic
therapeutic information. syndrome (including hypercalcemia and
6. Direct examination and endoscopy: organ failure), can be variable hematological
(a) Oral examination whilst using a head-mounted, markers.
bright light source is helpful in many cases, (c) No specific circulating tumor markers
but the most caudal teeth and the oropharynx have been identified for horses yet, but it is
may be obscured, especially if there are likely that these will be found in time.
significant tissue distortions, either directly or Whether it is helpful, however, to have a
secondarily due to the tumor. Sedation is very early marker for a serious tumor type
invariably very helpful. A useful range of gags, is a debatable point since localization and
mirrors, endoscopes, and specula are now then treatment of the tumor may be major
available, and there can be little excuse for problems.
an inadequate visual inspection of the mouth 8. Biopsy is inevitably the most reliable method of
(see Ch. 12). establishing a definitive diagnosis. Accessibility is not
(b) Oral endoscopy with a flexible endoscope is a usually a major obstacle with orodental tumors, but
risky procedure in the conscious standing horse – specialist approaches including trephination of sinuses
even when the horse is sedated. There may be and ultrasound or fluoroscopic guidance may be
logical reasons to perform this under general helpful. Biopsy of a suspected neoplastic mass can be
anesthesia (both to protect the equipment and achieved in several ways, including:
to ensure a thorough examination), but the use (a) Excisional biopsy. The whole gross lesion is
of rigid intra-oral endoscopes has been well removed and examined. There are risks in this
described in the standing horse. Suspect lesions process but also benefits: in the event that total
can be biopsied via the endoscopic channel excision is achieved, the prognosis is excellent.
using suitable forceps. However, transendoscopic However, failure to remove all the tumor or
biopsy specimens have limited value since they contamination of the wound site with tumor
are so small, and they are very liable to cells during surgery can be potentially serious.
artefactual distortion during collection, such For example, the equine sarcoid may be
that a reliable diagnosis may be frustrated. removed safely in a few cases but total excision
Often it is only possible to obtain a biopsy from is seldom achieved, and seeding of the wound
the most superficial parts of the tumor, and the with tumor cells during the surgery can result
specimen may contain granulation tissue, in numerous new satellite lesions at the
necrotic tissue, and areas of superficial infection original site.
and inflammation. (b) Wedge or sectional biopsy. A small portion
(c) Nasal endoscopy can be very helpful in of the tumor is removed solely to establish the
identifying tumors that involve both the oral diagnosis. A rational approach can then be
cavity and the nasal cavity or paranasal sinuses. made to treatment selection. It is important to
Percutaneous sinusoscopy is a useful and simple try to select viable and representative tumor
procedure that can be performed via a small tissue and to avoid areas that are ulcerated or
trephine in the wall of the affected sinus. necrotic, since such tissues are less likely to
Retrograde endoscopy via a tracheostomy can yield diagnostically useful information. Biopsy
also be helpful in a few cases and is a relatively of non-typical regions can be helpful if the
easy and safe procedure that is usually well tumor is complicated by infection and
tolerated by the horse. granulation tissue and so, in some circumstances,
7. Hematology and biochemistry: obtaining several biopsies can be helpful. In this
(a) Hematological findings are seldom specific in event, it may be possible to photograph the
neoplastic diseases but anemia (deriving from lesion and identify the sites of biopsy as an aid
chronic inflammation, paraneoplastic syndromes, to the pathologists.
or persistent bleeding) and alterations in (c) Hollow needle (Trucut) biopsy. This method
leukograms may confirm that there are is used to obtain a core biopsy through the
significant secondary effects. Localized tumors lesion with minimal damage to the overlying
usually present no significant specific skin or mucosa. A specific location can be
hematological changes. Anemia is a common selected clinically or by ultrasonography,
feature of the paraneoplastic syndrome in horses, radiography, or computed tomography. This
but most primary oral tumors have little or no method has significant advantages in creating
effect on the major body systems. Ulcerative oral minimal trauma, but the samples are often

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 Oral and dental tumors

A
B

Fig. 11.3  (A) Fine needle aspiration requires no specialized equipment. It is best performed with a fine needle 23-g and a small 2-ml syringe. A fine needle is
inserted into the margin of the lesion, and suction is applied via a 2-ml syringe 3–4 times. (B) The collected tissue should be jetted on to a clean slide, and air
dried rapidly. The slide is identified with a pencil and sent directly to a cytologist. Alcohol fixation may be required.

small and artefactually damaged, and it is of the needle is directed at a clean, grease-free, glass micro-
difficult to be sure that representative specimens scope slide and the cells ‘jetted’ onto it by repeated ejection
are obtained. Again, ultrasonographic or of air from the syringe. Several samples can be taken, and
fluoroscopic guidance can be helpful. Of course, some can be spread onto the slide, and others simply left in
there are significant physical difficulties in situ. Thick preparations should be smeared immediately
sampling bone and tooth and, as noted, before being rapidly air-dried and fixed according to the
processing the specimens is frequently requirements of the pathologist. An important practical con-
problematic. sideration for cytology is to ensure that smears are not
(d) Fine needle aspiration. This is almost exposed to formalin fumes since the latter spoil cellular
atraumatic to the tumor, and so there are preparations for subsequent staining with Romanowsky
reduced risks of significant tumor interference. cytological stains. It is best to identify the slides by writing
A soft or fluid-filled mass can usually be on the frosted area with a pencil before the smears are made;
aspirated with an 18-gauge needle (or finer). markings made with a pencil will remain during alcohol
However, the technique of fine needle aspiration fixing, and the pathologist will know which is the correct
of solid tumors is often performed badly, and side of the slide to look at, even if there are only a few cells!
the specimens are often handled badly – Interpretive cytology is best performed by a skilled
collection of aspirated cells must be performed cytopathologist because low numbers of tumor cells may not
with care. Poor specimen handling means be easily recognized among normal cells.
that the method has a poor reputation that Specimens that are obtained via endoscopic biopsy instru-
is not entirely justified. Tumors vary in the ments have limited value since they are so small, and because
ease with which they are aspirated, and so they are liable to artefactual distortion during collection; a
cytology may not always support a firm reliable diagnosis may not be obtained. Often it is only pos-
diagnosis. sible to obtain a biopsy from the most superficial parts of
the tumor and the interpretation may be confused by the
The best fine needle aspiration technique involves the use of presence of granulation tissue, necrosis, superficial infection,
a small-gauge needle (21-g or less) and a small syringe (2-ml and inflammation around the tumor.
ideally; Fig.11.3). Larger needles may seem an attractive Useful information can sometimes also be derived from
option but usually they will harvest blood and gross tissue impression smears made from ulcerated tumors. The same
from the vicinity of the tumor and this is not helpful diag- principles apply here – it is far better to have several slides
nostically – a few good cells, properly collected are far more with a few cells than one with a thick cellular accumulation.
useful than a few cells submerged in a large amount of Impression smears can be improved by gently blotting the
necrotic tissue and blood. The needle should be inserted into ulcerated surface of the tumor with clean paper towel, to
the margins of the lesion – not the center, as many tumors remove extraneous cells and excess fluid, and if possible, by
have a necrotic center, and so, at that site, tumor cells may gentle squeezing of the tumor itself.
be degenerate, or non-specific inflammatory cells may be Notwithstanding the specific tests that can be applied in
abundant. The best technique involves only 3–5 suction the investigation of oral and dental tumors, most of the
efforts with a maximum vacuum volume of 2 ml. Greater commoner tumors are fairly distinctive, and a tentative diag-
vaccuum is not achieved with a bigger syringe! Furthermore, nosis can usually be made by intuitive supposition. Prob-
prolonged or marked vacuum pressures may damage cells lems may, however, arise with rarer tumors and those with
significantly! The needle is then withdrawn, and the point prominent secondary inflammation and necrosis.

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 11 Dental disease and pathology

General principles of differential diagnosis An additional and severely limiting aspect is, of course,
whether the tumor has already metastasized. Where this has
Oral tumors are conveniently divided into: occurred, palliative treatment can still be carried out to
improve the short-term quality of life, but the prognosis is
1. Primary tumors (of dental, soft tissue, or bone origin) by then very poor. Even when some tumors have spread
2. Secondary tumors (of non-orodental tissues) beyond the oral cavity, the horse might not warrant immedi-
3. Tumors of adjacent structures and associated organs ate destruction since, in some circumstances, the metastases
invading into the oral cavity or its associated may have few effects and may be slow-growing. It is clear
structures. that some procedures, such as hemimandibulectomy, and
Secondary tumors with primary lesions elsewhere and removal of part of the tongue can be well tolerated by many
tumors invading the mouth from adjacent structures such as horses. All treatment modalities have inherent limitations,
the skin, the paranasal sinuses, and the nasal cavity must be and these simply have been accepted as part of the overall
considered when investigating an oral mass since identifying case management.
the origin might be diagnostically helpful and may have
therapeutic implications. For example, a destructive nasal
adenocarcinoma might invade the hard palate, creating an Surgery
oronasal fistula and loosening some of the teeth. It would
then be pointless to attempt to deal with the oral aspect of The limitations of all treatment modalities, and particularly
the tumor alone (even if there was some method to do this). surgery, are well recognized. Limitations relate to accessibil-
The lack of reported series of individual oral tumors and ity and the associated problems of defining the margins of
tumor-like masses testifies to the fact that most of these a tumor to ensure its total removal. Often the margins
conditions are uncommon16–19 and that no significant cannot be defined, and the constraints of the oral cavity
attempt has been made to classify them and to quantify their mean that there is less scope for removal of extra tissue to
prevalence through multicenter studies. The specific difficul- achieve a safer margin, and so recurrence almost inevitably
ties that are presented by the tumors and their profound occurs. When surgery of any type is performed, all of the
effects (whether benign or malignant) mean, however, that tissues removed should be submitted for histological exami-
veterinarians are expected to make prognostic decisions that nation, and the risk of failure to achieve an adequate margin
are inevitably based on limited experience rather than sound, should not deter the surgeon from submitting the tissues. If
evidence-based principles. Recommendations for treatment the pathological report states that safe margins have not
of rare conditions cannot be made with any certainty, and been achieved, the owner should be informed immediately
pathologists are often expected to provide information that and decisions made on the next sensible stage of the treat-
simply does not exist. The reported satisfactory or unsatisfac- ment. Combinations of treatments using different surgical
tory treatment of a single case does not entitle pathologists techniques, or surgery plus other modalities, such as immu-
or clinicians to refer to ‘common’ treatment or ‘usual’ tumor notherapy, radiation, or chemotherapy, improve the chances
behavior. of a good outcome.

General principles of management for Sharp surgery

neoplastic disease Sharp surgical excision of a tumor is clearly the fastest and
most convenient method of treatment in most cases. Local-
Ideally, of course, any diagnosis of a neoplastic disease ized, benign or early localized, malignant tumors may be
would be followed by a timely and specific curative therapy. amenable to surgical excision. For example a squamous cell
However, the nature of the condition, the almost inevitably carcinoma of the tip of the tongue, a gingival fibrosarcoma,
high cost of treatment and the owner’s attitude have a sig- or a buccal sarcoid may be treated effectively by surgical
nificant bearing on the choice of treatment. Often, treatment excision.
is not attempted because of one or more of these factors.
Progress is being made in the management of tumors in
many veterinary species but the improvements in equine
oncology have been disappointingly slow. This may reflect
Laser surgery
the fact that, on most occasions, a diagnosis is made very The increased availability and relatively low price of
late in the course of the condition, and so at initial presenta- diode lasers now makes this a realistic option in most prac-
tion the prognosis is sufficiently poor to warrant euthanasia. tice circumstances. It is still a surgical method and suffers
Also, anti-cancer medications are expensive and particularly from the same limitations as sharp surgery (Fig. 11.4). The
so for large horses. There is a general opinion that horses do advantages of laser surgery are its accuracy, the relatively
not tolerate systemic chemotherapy well. The secondary bloodless surgical field, and the fact that some extra ‘die-
(unwanted or side-) effects of most systemic anti-cancer back’ occurs when tissues are cut with a laser; the latter is
therapy mean that few owners and veterinarians are willing also something of a disadvantage in that healing is slower,
to subject a horse to their side-effects. Surgical options are and sutured wounds may break down. Laser surgery also
necessarily limited by facilities, access to the tumor, and the minimizes the risks of tumor seeding into the operative site.
possibility of unacceptable functional problems after the This is particularly important in the treatment of sarcoid
surgery. tumors.

154
 Oral and dental tumors

A B

Fig. 11.4  (A) This oral fibroma had caused external cheek swelling and hemoptyalism. (B) Following laser surgical excision in the standing sedated horse,
the tumor did not reoccur.

Diathermy limits the opportunities for its use, and where tumors are
presented late, the scope for effective treatment remains
This is very similar in use to diode laser surgery. Again, the limited. Electrochemotherapy using electrical energy to
margins remain relatively bloodless (at least until the surgery increase the permeability of tumor cells to cisplatin (and
has been completed), and tumor seeding of the site is possibly) 5-fluorouracil has recently been described for the
limited. treatment of buccal21 sarcoid and there are anecdotal reports
of the benefits in squamous cell carcinoma and melanoma
treatment also. The advantages of this system include the fact
Cryosurgery that the current can be restricted to the tumor location, but
this method requires repeated general anesthesia. The bio-
Small, focal, and superficial tumors can be treated by cryo­ degradable sponge or bead systems appear to be very logical
necrosis. Systems using liquid nitrogen are the only ones and these may become the preferred practical approach in
that are effective in horses; however, the crude application many circumstances. However, there are no comparative
of liquid nitrogen to a tumor mass to induce an uncon- evidence-based studies on these methods to date.
trolled freeze is unacceptable. The advantage of cryosurgery
is that it is possible to destroy a wider area of tissue and
allow a natural demarcation to develop over the following Immunotherapy
weeks. Cryosurgery is not suitable on its own for larger Whilst various forms of immunotherapy, ranging from
aggressive tumors since it is almost impossible to define the ‘autogenous vaccines’ (for melanoma) to intralesional BCG
margin of the ‘freeze’ without complicated use of thermo- protein injections (for sarcoid, in particular), have been sug-
couples, and in any case, the oral cavity appears to be much gested to treat equine neoplasms, assessment of their value
more difficult to freeze effectively than normal skin. is limited by the lack of comparative clinical studies. Sarcoid
seems to be the most prevalent tumor type that is subjected
to this therapy, and there are some reports of its positive
Chemotherapy effects in certain types of sarcoid.

The options for chemotherapy in horses are limited to

topical and intralesional medication. Usually, the materials
Radiation therapy
are specific antimitotic or cytotoxic drugs, such as cisplatin Radiation therapy is the gold standard therapy for most
(in stable emulsion, wax, or biodegradable bead forms), cutaneous and deep-seated malignant tumors in the horse.
5-fluorouracil (in solution, bead, or sponge forms), bleomy- Radiation is used to eradicate the tumor cells, preferably
cin, or mitomycin C in injectable solution. Although these without affecting the architecture and cellular elements
are attractive options because they are logistically simpler of the adjacent normal tissues. Both gamma and beta
and invariably cheaper than other methods, there is little radiation are used therapeutically through plesiotherapy,
information regarding their use in equine oral neoplasms in brachytherapy, and teletherapy. Radiation brachytherapy
particular. Broadly, they have applications in the manage- causes no material systemic toxicity and in contrast to surgi-
ment of sarcoid, melanoma, and squamous cell carcinoma,20 cal methods of treatment, has no anatomical constraints.
but more information is being published about their use and However, it is seldom available for equine therapy for cost
applications for other tumor types. As might be expected, and logistical reasons. The likelihood of a successful outcome
the position and size of the specific tumor being treated with radiation therapy is inversely proportional to the size

155
 11 Dental disease and pathology

of the tumor; this is a common constraint given the late lymphoma and squamous cell carcinoma of the face and
presentation of most cases of equine oral tumors. The prog- head have been treated successfully in this way.
nosis also depends on the tumor type, and its particular
growth characteristics and susceptibility to radiation; slowly
expanding tumors tend to respond more slowly and less Other ‘treatments’
favorably than rapidly dividing ones. For example, squa-
mous cell carcinoma is probably more susceptible to gamma Cancer always warrants a proper investigation and sensible
radiation than the fibroblastic sarcoid, and melanomas tend treatment that has a prospect of helping, and where treat-
to respond poorly to all types of radiation. However, the ment is impossible an honest and direct opinion should be
same tumor type may respond differently in two different given to the owner. In spite of the availability of a variety of
anatomic sites and in different horses, and so variations in appropriate treatment options there are still many occasions
‘effective’ doses are almost infinite. when useless or even dangerous treatments are inflicted
Disappointingly, there are few facilities that offer any sort upon horses. Whilst homeopathy, for example, cannot pos-
of radiation therapy for horses. This reflects a totally unac- sibly do any good, its main danger lies in the failure to
ceptable lack of interest in cancer medicine in a species that provide effective and timely treatment and in causing unnec-
makes an enormous contribution to mankind! However, essary delays before proper therapy is instigated. This also
radiation can be used, and there are cases where interstitial means that the prognosis is far worse when proper treatment
brachytherapy or teletherapy has made a significant differ- is finally requested and when that fails, the poor outcome is
ence for oral tumors in particular. usually taken as indication of the inadequacy of the conven-
tional methods! Since homeopathy has a positive explana-
tion for any of the possible outcomes ranging from success
Brachytherapy to failure it must be viewed with a considerable degree of
Interstitial brachytherapy has considerable advantages in skepticism by any scientific mind. In spite of the consider-
that high doses of radiation can be delivered precisely, safely, able cost and the lack of any evidence of any efficacy what-
and conveniently over a short time without significant risks soever, these methods continue to be peddled by people
to the other parts of the body. Radioactive sources are who exploit the ignorant, the vulnerable, the gullible, and
implanted into tissues directly and are left in situ until a the disillusioned!
precalculated overall dose of radiation is delivered. The dose
necessarily varies for the various types of tumor, but little is
established about the best options for oral masses. Thera- Tumors of dental-tissue origin  
peutic radiation ionizes the DNA in cells within the thera- (odontogenic tumors)
peutic range of the sources but is not discriminatory for
tumor cells alone. This means that susceptible normal cells
Tumors in this category are rare, although it has been sug-
are usually destroyed as well. The most susceptible normal
gested that they are more common in horses than in other
cells in the skin are melanocytes, and so pigmentary changes
species.17 Odontogenic tumors are classified according to the
are common. Iridium-192, gold-198, and iodine-125 are the
inductive effect of one dental tissue on the others.18,23 These
most common isotopes used in this way. The procedures are
tumors can be benign or non- metastasizing malignant, with
all highly specialized, requiring careful dosimetry and spe-
the latter often locally invasive and aggressive in their clini-
cialist facilities both for insertion and hospitalization. The
cal behavior. As a general rule, dental tumors are best treated
results obtained in 12 cases of oral neoplasia22 suggest that
by wide surgical removal (to ensure complete ablation of
this is a potentially very satisfactory method of treatment.
tumor and abnormal tissue) at an early stage in their devel-
However, there are obvious difficulties relating to the avail-
opment when such surgery has a chance of success. In most
ability and costs of such treatment. Since one of the major
cases, however, the masses are not recognized sufficiently
constraints on the outcome is the size of the tumor, the costs
early, and so local recurrences are common in spite of
and the dose required can be reduced significantly by prior
attempts at wide surgical excision.19 Most oral bone and
surgical debulking of large tumors.
dental tumors are benign but can cause serious secondary
effects, such as nasal obstruction and dental and facial
deformity, resulting in dysmasesis and weight loss. There are
Teletherapy some similar clinical conditions that resemble neoplasia that
Teletherapy uses a generated beam of radiation (high energy are in fact simply abnormal tooth formation (Fig. 11.5). An
beta or gamma rays) focused into the tumor mass. The main important diagnostic aspect in these cases is that the condi-
advantages are that no operator risks are incurred, the dose tion is present from the time of formation of the tooth.
can be focused accurately, and several sub-lethal rays can be However, on presentation they may be very difficult to tell
focused into a deep tumor without causing significant apart. Since the advent of equine dental medicine as a spe-
damage to the surrounding tissues. Where the beams meet, cialty, early recognition of abnormalities and deformities as
a radiation ‘hot-spot’ is produced that receives a lethal radia- well as neoplastic dental disorders, has become much more
tion dose. The problem is that this method, whilst being the frequent.
true gold standard, is not available to horses at this time. Odontogenic tumors are of variable histological appear-
General anesthesia would be required to allow treatment of ance and are categorized currently on their morphologic
most equine oral tumors, and no quantified dosimetry has basis23 (Table 11.1). Their features are summarized in
been calculated for any equine tumor. A few cases of sarcoid, Table 11.2.

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 Oral and dental tumors

Table 11.1  Equine dental tumors derived from odontogenic

epithelium (E) or mesenchyme (M)

Histologic designation Synonyms

Ameloblastoma (E) Keratinizing ameloblastoma
adamantinoma
Cementoma (M)
Fig. 11.5  This tumor-like mass developed in the incisive gingiva of a
Complex odontoma (E)/(M)
12-year-old gelding. Biopsy was inconclusive, and only after full surgical
removal was a diagnosis of an inflammatory reaction possible. Even then Cementifying fibroma (M)
there remained some doubt, but as the condition did not recur, the matter
was not pursued. Ameloblastic fibroma (E)/(M) Ameloblastic fibro-odontoma

Table 11.2  Summary of features of odontogenic tumors based on published characteristics20,36

Tumor type Age group (yrs) Clinical behavior Best treatment option Prognosis
Ameloblastoma Wide range Benign/locally invasive Surgical excision/ Fair–good; eating
hemimandibulectomy ± radiation difficulties may be severe
Ameloblastic   <3 Benign/locally invasive Surgical excision/ Fair–good; eating
odontoma hemimandibulectomy ± radiation difficulties may be severe
Cementoma Onset uncertain Benign Surgical removal Good
Compound odontoma <5 Benign malformation Surgical removal Fair (if removal feasible)
Complex odontoma
Cysts/hamartoma Various Benign Surgical removal Fair (if removal feasible)

Ameloblastoma should also be considered (although the latter tend to be

destructive rather than proliferative). Osteosarcoma is singu-
Definition larly rare in the horse. Infections of tooth apices and adja-
These tumors are derived from odontogenic epithelium. cent bone can be similar, but are associated with extensive
True ameloblastoma produce no inductive changes in the necrosis and typical radiographic features often complicated
connective tissue and so lack dentin and enamel. by maxillary reactive bone proliferation with obvious facial
swelling. Jaw fractures and other dental abnormalities,
including malerupting and supernumerary cheek teeth,
Occurrence should also be considered.
These are most commonly found in the mandibular region
(including medulla) of older horses24–29 but can involve Diagnostic confirmation
the maxilla. Several cases have also been reported in Biopsy and radiographic findings are typical but can be
young foals.30,31 similar to other tumor masses. Ameloblastomas usually have
a rubbery consistency and have a roughly spherical or mul-
Clinical features tilocular shape with a cystic radiographic appearance (Fig.
11.6B). Odontomas are radiolucent or partially mineralized,
They may be overtly tooth-like, or contain little or no
with foci of calcified tissue mixed throughout. Even when
obvious dental tissue. They often develop a central, cystic
there is extensive ulceration, there should be little confusion
region and cause bony/solid swellings and abnormalities in
between ameloblastomas and carcinomas or sarcomas,
the associated dental arcade (Fig. 11.6). Occasionally, they
which tend to be much more destructive than tumors of
can present with a discharging sinus on the side of the face.
dental origin.
Late presentation shows an advanced and aggressively
destructive epithelial tumor with extensive bone loss Pathology
(Fig. 11.7).
Ameloblastoma is characterized grossly by swelling of
the affected jaw and osteolytic changes within the jaw
Differential diagnosis (Fig. 11.6C). They can be solid or cystic and are usually
Ossifying fibroma and other tumors of the jaw, such as discrete. The major characteristic histological feature is the
invasive squamous cell carcinoma and myxomatous tumors, presence of odontogenic epithelium (Fig. 11.6D). If there is

157
 11 Dental disease and pathology

A B

D
C

Fig. 11.6  (A) Facial swelling caused by an ameloblastoma. The tissue contained no obvious dental tissue remnants. This differentiates it from an
ameloblastic odontoma. (B) Radiographic appearance of an ameloblastoma in a 2-year-old Thoroughbred colt showing the characteristic multiloculated
nature with radiodense fragments throughout the mass. Reproduced with the permission of Dr Bruce Bladon. (C) An ameloblastoma excised from a
2-year-old Thoroughbred colt showing the relationship to the tooth and the expansive mass at and around its root. (D) Histologic section of an
ameloblastoma showing clusters of orderly ameloblasts separated by connective tissue and spicules of hard dental material.

A Fig. 11.7  (A) Massive ameloblastoma is present in the rostral mandible. (B) Boiled out post-mortem
specimen showing gross destruction of the rostral mandible caused by an ameloblastoma.

158
 Oral and dental tumors

marked epithelial keratin formation, the lesion is termed

keratinizing ameloblastoma. The lesion may be well circum-
scribed, or there may be local infiltration by odontogenic
epithelium.

Treatment
Surgical removal can be curative if treatment is initiated early
and wide excision can be performed. Horses seem to cope
well with rostral hemimandibulectomy and especially so if
the mandibular symphysis remains intact. Rostral man-
dibulectomy can also be successful, but special measures are
required to ensure adequate nutritional intake. Radiation
therapy is probably the best option and has been used
successfully.31
However, suitable teletherapy facilities are not generally
available, as noted, and so other options are usually sought.
Topical chemotherapy is singularly unsuccessful.

Prognosis
The expansile nature of these tumors and their late recogni-
tion (particularly in foals and young horses) make the
outlook poor. Many horses are euthanased soon after they
are diagnosed with the tumor, although the rate of growth
may be slow and some useful quality of life may be possible
even if surgery is not feasible. Fig. 11.8  Cementoma of the crown of an incisor tooth in a 3-year-old
Hanoverian mare.

Cementoma
Definition presence of mosaic-like, basophilic cement lines, with
Cementoma is a rare, benign or reactive tumor derived anchoring of Sharpey’s fibers into the cement matrix. With
from mesenchymal tissue and so does not contain epithelial reactive cementoma, there is additional inflammation and
components. It typically occurs in the apical region of fibrosis. Cementifying fibroma is a rare lesion that is analo-
the developing tooth. There are few published reports of gous to ossifying fibroma, but the tumor matrix includes the
this tumor, but one such lesion affected an incisor tooth complex basophilic lines of typical cementum.
(DCK, unpublished). It is possible that some of the features
of this condition could be found in abnormal or super­ Treatment
numerary cheek teeth where extensive distortion of the
Removal of the tooth in its entirety is feasible but may be
dental structures by reactive cement deposition is encoun-
hindered by the large, cylindrical aggregation of hard
tered. However, it is often impossible to confirm the diag-
tissue at the tooth apex. In some circumstances, it might
nosis of cementoma or to differentiate them from dental
even be better to accept the condition since it is generally
abnormalities.
very benign, and its slow onset may enable the horse to
adapt well to it.
Clinical features
The location of these tumors (at the apex of the tooth) Prognosis
makes their early recognition and diagnosis unlikely, and The lesion is benign and removal is curative. Some horses
they are only recognized when there is overt jaw swelling remain unaffected for many years with the condition being
(Fig. 11.8). Radiographically, they have a distinctive, very identified incidentally or at post-mortem examination.
radiodense appearance, and the tissue contains sheets of However, where clinically significant secondary changes
cementum-like material. Secondary alveolar changes involv- occur, the prognosis depends on the possibility of removal
ing either infection or reactive bone proliferation may, of the affected tooth.
however, make them harder to recognize. Alterations in the
crown are unusual but make the condition more recogniz-
able clinically. Complex/compound odontoma
Definition
Pathology A complex (compound) odontoma is an irregular, tumor-
This lesion presents as a mass in the jaw or as a mass like mass of dental tissues in a well-differentiated form.
that involves the nasal cavity or maxillary sinus. It may Complex odontoma contains all the elements of a normal
be secondary to traumatic tooth fracture, dental impaction, tooth, but the structure is chaotic. A compound odontoma
or periodontitis. It is characterized histologically by the is similar, except that the tissue is organized into
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 11 Dental disease and pathology

C C
E
D
D
E E
D

Fig. 11.10  Undecalcified thick section of a complex odontoma in a

Fig. 11.9  The gross distortion of the maxilla due to a compound
2-year-old Morgan colt. Well-differentiated but disorganized components  
odontoma.
of tooth formation are shown. D, dentin; C, cementum; E, enamel.
(Reproduced with the kind permission of Dr R.R. Dubielzig and Iowa  
State Press.)

recognizable, tooth-like structures (denticles), although they

may be grossly distorted. There is some justification for con-
sidering some compound odontomas to be hamartomas of Compound odontoma presents as a similar lesion but
dental tissue, rather than true tumors. radiographically shows several abnormal tooth-like struc-
tures (denticles) within the mass. Histological features are
reminiscent of normal tooth development. In older lesions,
Occurrence epithelial tissue may be sparse.
Both young and older horses may be affected, with a greater
prevalence in younger animals. Treatment
Surgical removal may be feasible and curative. Surgical
Clinical features removal and cryosurgery combined can be used, but some
Many cases are identified incidentally. Firm, painless swell- masses require more than one treatment.
ings over the apical regions of the maxillary cheek teeth or
the premaxilla are characteristic.33 Swelling may not be Prognosis
obvious if the more caudal maxillary cheek teeth are involved
as the expansion is contained in the maxillary sinuses (Fig. Full surgical removal should resolve the problem, but
11.9). Secondary sinusitis seems to be a rare complication. repeated surgery may be needed. There are insufficient
reports to establish a definitive prognosis but, the few
published cases suggest that the outlook is reasonable or
Differential diagnosis even good.
Dental infection with new bone formation and lysis. Sinus
cysts may be associated with these in some cases. Incidental tumor-like dental masses
This group includes temporal teratoma – a rare curiosity in
Diagnostic confirmation the horse, in which dental tissue (which may be instantly
The radiographic appearance is characteristic – multiple, recognizable as such) is located at sites away from the jaws
small lobulated masses within a well-defined cyst-like struc- (Fig. 11.11). The most common site is in the temporal
ture at the apex of a maxillary tooth are typical. Radiographic region where a sinus tract discharges viscous, milky material
interpretation of the lesion becomes difficult when second- from a discrete opening on the leading edge of the pinna.
ary changes occur in the adjacent teeth and sinuses. The cystic structure may be situated some way from the ear
itself but sometimes there is an obvious dental structure
Pathology located against or attached to the temporal bone of the cal-
varium. Sometimes the structure has no obvious dental
Complex odontoma presents as a radiodense calcified lesion tissue and comprises a smooth, cystic lining lying below the
within the jaw of young horses. Grossly, they are very hard ear. Radiographs are used to establish the presence or absence
and difficult to prepare for histological examination. Cut and the location of any dental tissue.
surfaces reveal variegated cementum, dentin, and mineral-
ized enamel (Fig. 11.10).34 The gross features are confirmed
histologically, and there can be variable amounts of odon- Pathology
togenic epithelium. In the horse, there is plentiful These rare lesions are lined by stratified squamous epithe-
cementum. lium and often contain abnormal dental structures.35–38 The

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 Oral and dental tumors

They are all very rare tumors, but there have been several
reports involving the jaws and the mandible in particular,
which indicates that this may be a predilection site.40 The
histological characteristics of bone-derived tumors have
been described,41 and the classification of this group of
tumors is based upon these features.

Osteoma
Osteomas, which are extremely rare lesions, are slow-grow-
ing, solitary, well-differentiated masses of bone enclosing
A marrow and fat, and many pathologists regard them as a
developmental anomaly or hamartoma, rather than neo-
plasms. They are reported to occur in all ages of horse, with
most being located in the head region, including the man-
dible, maxillae, and paranasal sinuses. The osteoma may
reach a large size and have a distinctive, discrete, radiodense
outline. They are benign, but their growth may compro­
mise adjacent tissues, causing disfigurement, obstruction of
the nasal passages or interference with mastication and
swallowing.
Macroscopically, they consist of dense bone. The histologi-
cal features are of orderly cancellous bone; the intertrabecu-
lar fibrous connective tissue may include adipocytes and
hemopoietic cells.
Surgical removal may be feasible, but most are a signifi-
cant surgical challenge, and the prognosis is very guarded.

Osteosarcoma
Definition
B Osteosarcoma is a malignant mesenchymal tumor of bone
affecting horses of any age, in which the neoplastic cells
Fig. 11.11  (A) A discharging sinus had been present on the anterior produce modified or distinctive osteoid or bone matrix in a
margin of the pinna (where probe is inserted) for 2 years. The tract leads to haphazard arrangement.
an obvious solid non-painful mass just rostral to the base of the ear. This is
the typical clinical appearance of a dentigerous cyst. (B) Oblique radiograph
of the temporal region of the same horse as in (A). An obvious tooth-like Occurrence
structure with an associated ‘alveolus’ is present and is typical of many cases
of dentigerous cysts. In the absence of obvious tooth-like structure, contrast Osteosarcoma is an extremely rare tumor in the horse at any
radiography will identify a distinct or occasionally a poorly defined cystic site. However, over 80 % of reported osteosarcomas involve
structure at this or a neighboring site. the head, and the majority are reported in the mandible.42,43
There is a report of an osteosarcoma in the mandible of a
6-month-old Quarterhorse colt, which suggests that age is
surgical treatment of temporal teratoma can carry a good probably not a significant factor,44 although, typically,
prognosis, particularly where the lesion is simply a cystic younger horses appear to be more prone to oral or dental
structure, although every part of the cystic lining must be neoplasia in general than older ones. Trauma is implicated
removed to avoid recurrence. However, where aberrant as a risk factor for later osteosarcoma in other species such
tooth material is enclosed within a false alveolus protruding as the cat, but there is no convincing evidence for this in
into the calvarium (see Fig.11.11B), surgery becomes much horses.
more of a challenge. Such cases must be fully assessed by CT
scan, if possible, or at least by radiography (possibly with
Clinical features
contrast material introduced via the sinus tract). In some
cases, the cyst and the tooth-like structures are not obviously The condition is usually presented as a painful, hot, progres-
connected. Some cases can justifiably be left alone since the sive swelling of the mandible with a characteristic ‘sun-burst’
discharging tract is usually a cosmetic and managemental radiographic appearance of bone lysis and irregular deposi-
nuisance, rather than being clinically significant. tion of trabecular reactive new bone44 (Fig. 11.12). Patho-
logical fractures can occur in affected bones.
Tumors of bone (osteogenic tumors)
Differential diagnosis
Osteosarcoma, osteoblastoma, chondrosarcoma, and fibro- Infection resulting in osteitis or osteomyelitis (particularly
sarcoma have been described as arising in bone in horses. with Actinobacillus spp.) can be very destructive, and appear

161
 11 Dental disease and pathology

Fig. 11.12  (A) & (B) This 5-year-old Irish Draught mare was presented with a 4-week history of a mandibular swelling, gingival bleeding, weight loss and
dysmasesis. The mandibular incisors were palpably loose and the mandible was warm to the touch and mildly painful on palpation. (C) & (D) Lateral and
occlusive radiographs gave the suspicion of a neoplastic lesion. (E) A bone biopsy was taken from several sites, and the horse was diagnosed with
osteosarcoma.

similar clinically and radiographically to osteosarcoma. friable pink to white material containing variable amounts
Various cystic structures, such as ameloblastoma, ossifying of cancellous bone (Fig. 11.12E). It is easy to miss tumor
fibroma, and fibrous dysplasia can be clinically similar but tissue in small bone biopsies, and florid, non-neoplastic
usually have characteristic radiographic differences. reactive bone or fracture callus can easily be mistaken
histologically for neoplasia. Multiple biopsies should,
Diagnostic confirmation therefore, be collected from sites identified by radiography
or CT or MR imaging methods, but this is not an easy
Their radiographic appearance is highly suggestive, but procedure.
biopsy provides the only definitive diagnosis. There is a
characteristic combination of cortical bone destruction and
periosteal new bone formation giving the area a ‘sunburst’ Pathology
radiographic appearance. Several histological types of osteosarcoma are recognized in
Bone biopsies of osteosarcoma are sometimes easy to other species where its incidence is higher, but this tumor is
obtain, since the bone is usually softer than normal and so rare in horses that it is probably unwise to extrapolate
the medullary cavity is filled with diagnostically significant from these findings. The tumor tissue is, however, usually

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 Oral and dental tumors

Table 11.3  Summary of the clinical features of some equine oral soft-tissue tumors

Age group most

Tumor type often involved Clinical behavior Treatment options Prognosis
Squamous cell   5–14 y Benign but can be very Radiation; cisplatin Guarded
carcinoma destructive
Sarcoid All Locally invasive. Only malignant Radiation; cisplatin; surgery Very guarded
forms can be very aggressive (nodular type only)
Melanoma >7 (gray horses) Low Benign neglect; cisplatin Fair
Cimetidine per os A few are malignant
Oral papilloma <2–3 y Benign Leave alone;   Good but some persist
surgical excision
Epulis >10 y Benign Dental hygiene/descaling Good
Salivary adenocarcinoma >10 y Malignant Radiation possible Hopeless
Equine juvenile ossifying 2 mo–2 y Benign Surgical excision Fair–good
fibroma
Myxoma/myxosarcoma n/k Variable n/k Poor–hopeless

n/k = not known/insufficient reports to make a judgment.

not densely cellular with formation of fibrillar stroma, bone soft tissue tumors than for calcified tumors. Many individual
or osteoid tissue. The cells have a high mitotic index and an veterinarians have preferred treatments for most of the
atypical irregular morphology. common soft tissue tumors, and some report good results
Since this tumor is so rare in the horse, the expected his- while others are less successful with the same methods.
tological appearance is a speculative one based on experi- The clinical features of the main equine oral, soft-tissue
ence of the lesion in other species. Osteosarcomas are tumors are summarized in Table 11.3.
characterized by painful bony swellings with variable degrees
of bone lysis, tumor bone formation and reactive periosteal
bone proliferation. The histological features are of neo­ Squamous cell carcinoma
plastic osteoblasts with variable numbers of osteoclasts. The
extent of formation of tumor osteoid and/or bone is varia-
Definition
ble. The tumor bone may, therefore, be hard or soft and A squamous cell carcinoma is a malignant neoplasm of
hemorrhagic. stratified squamous epithelium that appears to have a pre-
dilection for mucosal junctions.
Treatment
Radiation offers the only hope of success, but the tumors are Occurrence
likely to be locally malignant, and so treatment is usually Squamous cell carcinoma (SCC) is probably the commonest
not contemplated. Euthanasia is the only realistic option. oral neoplasm. Although mucocutaneous junctions are com-
monly affected with SCC outside the mouth, where there is
Prognosis an apparent correlation with non-pigmented skin and pos-
There are insufficient data for a reliable prognosis. Although sibly with high levels of ultraviolet light, many of the most
metastasis is seldom reported in osteosarcoma at any site in severe and aggressive SSC tumors occur within the mouth.46
the horse, it is impossible to predict anything about these The role of ultraviolet light in the pathogenesis of facial and
very rare tumors. Some may progress relatively slowly and lip carcinoma is uncertain, but the Clydesdale breed and
are, therefore, at least tolerable for limited periods. However, horses with non-pigmented skin of the face and lips are
the highly aggressive nature and rapid course in most cases more often affected than other breeds and colors. Putative
justify a hopeless prognosis. carcinogens include chronic irritation, such as epulis, foreign
body reactions, chronic wounds, and possibly dietary factors.
Older horses are more likely to be affected.
Tumors of soft-tissue origin There is often a suggestion that the primary tumor devel-
ops in the paranasal sinuses or nasal cavity and the destruc-
Soft tissue tumors of the mouth are far more common than tive tissue involves the hard palate, but it may be difficult
those affecting the teeth and facial bones. A wide variety of to identify whether the primary lesion is in the sinus or
tumors have been reported, but only a few occur with any the hard palate.47 SCC possibly arises in chronically
regularity. There is generally more information concerning irritated hyperplastic alveolar epithelium in cases of chronic
the diagnosis, management, and prognosis for these equine periodontitis.

163
 11 Dental disease and pathology

Clinical features Metastases to local lymph nodes can occur, although the
general sentiment is that they do not do so commonly.49 In
SSC tumors are characteristically slow growing but occasion-
theory, they may disseminate to the lungs and elsewhere.
ally have a more rapid course. They can be proliferative at
However, this behavior is rare in oral forms of SCC.50
least initially, but usually become very destructive, ulcerative
Oral SCC may involve the lips (Fig.11.13A), hard palate51
and infiltrate widely into local tissues of the mouth includ-
(Figs 11.13B,C), tongue51,52 (Figs 11.13D,E) or oral mucosa
ing the lips, buccal mucosa, hard palate and tongue.48 Early
(Fig. 11.13F). It is also quite common for oral SCC to invade
lesions may simply resemble a non-healing wound but more
the nasal cavity and the paranasal sinuses (often to the point
advanced, destructive carcinoma lesions have a characteristic
of gross distortion or obstruction to airflow).53 Some SCCs
foul odour.

A
B

Fig. 11.13  (A) A destructive carcinoma on the lip of a 23-year-old pony gelding. Note the extensive tissue destruction and the loss of the maxillary teeth.
Treatment with intralesional cisplatin and topical 5-fluorouracil was not effective. (B) Facial distortion due to nasopalatine squamous cell carcinoma in a
12-year-old pony gelding. (C) A histologic section of the endonasal carcinoma shown in (B). Solid cords of squamous carcinoma are surrounded by fibrous
stroma and trabeculae of non-neoplastic reactive bone (arrows). (D) Squamous cell carcinoma of the pharynx, which was identified some 3 months after a
lesion had been detected in the hard palate. It is possible that this developed independently or that it was an extension of the earlier lesion. (E) Carcinoma of
the free portion of the tongue. The local lymph node was enlarged (see J); slide courtesy of Dr R.R. Pascoe.

164
 Oral and dental tumors

F G

H I

Fig. 11.13 continued  (F) This highly destructive oral carcinoma developed in a 4-year-old Warmblood. It involved the maxillary bone and resulted in dental
problems also. (Courtesy of Chris Louf.) (G) This horse was presented with weight loss and dysphagia. The highly destructive oral and invasive carcinoma was
not visible endoscopically from the pharynx and was only seen with difficulty during an oral examination. (H) Photomicrograph of cords of solid squamous
cell carcinoma with deep invasion of the tongue. (I) Metastasis of squamous cell carcinoma to regional lymph node showing cords of tumor cells (arrows)
beneath cortical lymphoid tissue.

involve the base of the tongue (Fig. 11.13E) and pharynx present projecting from the gum or hard palate as a grayish,
(Fig. 11.13G) and can physically affect their function. Where ulcerated and bleeding mass. Where the tumor surrounds
the nasal cavity and paranasal sinuses are involved, there a tooth, this may become dislodged, and in almost
may be altered airflow (or even complete obstruction of the all cases there is a fetid odor from the mouth. Involvement
ipsilateral nostril). Horses with pharyngeal and lingual SCCs of the lips and gums is usually clinically obvious; early
may present with dysphagia of progressive, insidious onset. tumors are often identified incidentally during routine
In all cases, weight loss and poor general health are common. dental procedures.
More extensive spread may involve the orbit and the
cranial cavity with secondary involvement, respectively, of
the eye or even rostral brain when the cribriform plate is Differential diagnosis
eroded by tumor. It is also quite common for nasal SCC to The differential diagnosis includes other proliferative and
invade the hard palate, forming an oronasal fistula. In all invasive soft tissue lesions of the lips, including equine
cases, there may be extensive soft-tissue disruption and con- sarcoid, hemangiosarcoma, basal cell carcinoma, and myxo-
sequent loosening/shedding of the teeth. matous tumors. Non-healing oral wounds may be confused
The location of SCC means that tumors are frequently with early cases, and carcinomatous changes may be a cause
detected late when a large invasive mass may already be of non-healing.

165
 11 Dental disease and pathology

Diagnostic confirmation
Biopsy is characteristic (Figs 11.13H,I). The pathologist
should try to classify the degree of differentiation of the
cells; highly differentiated carcinomas are far less dangerous
than the undifferentiated ones. Biopsy sites should be
carefully chosen to reflect the main carcinoma, with inclu-
sion of a marginal zone as well. Punch or wedge biopsy sites
should not be scrubbed or even washed before collection,
and the biopsy site should not be sutured afterwards
since wound dehiscence is almost certain. Fine needle
aspirates and impression smears can be used but may be
misleading, since they often consist mainly of stroma and
inflammatory cells.
Radiographic examinations can be used to identify masses
in the sinuses and the extent of bone destruction produced
by invading carcinoma. Fig. 11.14  A small hemorrhagic and destructive lesion was noted on the
tongue of this 22-year-old gelding. Biopsy confirmed it to be squamous cell
carcinoma, and surgical excision was performed with a safe margin of
Pathology excision.
Histologically, the tumor has distinctive characteristics with
irregular cords of downward-invading neoplastic kerati­
nocytes. (Figs 11.13H,I). A SCC characteristically has large
amounts of non-neoplastic fibrous stroma in which inflam- Recently, cisplatin, 5-fluorouracil, and mitomycin C have
matory cells are plentiful. The abundant stroma results in a been used in various intralesional or topical formulations
lesion that is characteristically tough or scirrhous when pal- for treatment of cutaneous and other equine carcinomas.
pated or excised. The accumulation of variable amounts of Some SCCs respond well to intralesional cisplatin,* either
keratin produces ‘keratin pearls’ in well differentiated tumors in water-soluble form with frequently repeated injections,
that can be used to define the likely malignancy of the lesion. as an emulsion of the solution, containing at least 1 mg/ml
Poorly differentiated carcinoma shows a more anaplastic cell with an equal volume of sesame or almond oil,55 or
structure, higher rates of division (high mitotic index), and in biodegradable bead or pellet forms. The use of the
much less keratin and, therefore, can closely resemble aggres- above drugs in treating oral SCC has apparently not
sive myxosarcoma. SCC is one of the better defined equine been reported, but use of all these materials carries operator
oral neoplasms. safety risks. And as such, their use should probably be
restricted to specialist oncology centers. There is no justifica-
Treatment tion in taking human health risks through their use by
untrained personnel.
While surgical excision of oral SCC lesions has been reported The response of equine SCCs to immunomodulation
to be successful,54 this treatment can be very difficult and in using mycobacterial protein materials, such as Bacillus
some sites is clearly impossible. There is a very high rate of Calmette-Guérin (BCG), is disappointing in horses when
recurrence following such surgery. Small discrete tumors compared to treatment of squamous cell carcinoma in other
may, however, be amenable to surgical removal if detected species, such as cattle (DCK, unpublished observations).
early (Fig. 11.14), and extensive excision involving hemi- Treatment of labial SCC with 5 % fluorouracil cream applied
mandibulectomy, such as has been described for other topically has been shown to resolve some cases and improve
tumors of the jaw, may also possibly remove the tumor but others.57 It is, however, a very useful adjunct to other forms
may leave unacceptable cosmetic or functional deficits. of treatment and may be particularly applicable to small,
Squamous cell carcinoma appears to be relatively sensitive ulcerated, buccal or lip lesions.
to gamma radiation, and this therapy offers the best prog-
nosis, with a reasonably high success rate (DCK, unpub-
lished observations). Teletherapy is logical and can be finely Prognosis
controlled, but repeated fractionated doses need to be used, The tumors are always locally invasive but usually slow to
and the horse, therefore, needs repeated general anesthesia. metastasize, so while the clinical prognosis is inevitably
The number of centers where this can be performed is very poor, many cases can survive long periods even with quite
small, and the procedure is necessarily very expensive. The extensive oral involvement. Oral SCC is a low-grade invasive
much simpler 192-iridium interstitial brachytherapy using tumor that tends not to metastasize beyond the local lymph
linear platinum-sheathed sources has been used to good node. However, it is probably unwise to assume that this
effect (DCK, unpublished observations). There are serious will be the case in all affected patients. Secondary complica-
logistic and human health risks involved with the procedure, tions such as facial or oral distortion and destruction, dys-
however, and limitations on the size and location of phagia, loosening of teeth, and nasal obstruction inevitably
the tumors that can be treated. Placement of the radiation suggest a poorer prognosis.
source within the highly mobile tissues of the mouth carries
serious dangers if the horse were to dislodge the wires and
swallow them. *cis-diamminedichloroplatinum, or cis-DDP, cis-platinum.

166
 Oral and dental tumors

Sarcoid Pathology
The equine sarcoid is the commonest cutaneous fibroblastic The clinical term ‘sarcoid’ encompasses a histological spec-
tumor of horses. It commonly involves the cheeks and trum of fibroblastic tumors that may be accompanied by a
lips.58,59 The term sarcoid is used clinically to describe a variable epithelial component. The fibromatous variant is
spectrum of cutaneous tumors that variously involve con- grossly well circumscribed, solitary or multiple, with a tough,
nective tissue and epithelium with a range of clinical behav- pale, fibrous cut surface. Adjacent epidermis is often attenu-
ior.60 There are usually two distinct forms that affect the ated and may be intact or ulcerated. Most of the lesion
mouth itself (as opposed to the skin of the lips and cheeks). consists of randomly arranged, well-differentiated fibro­
The nodular form remains subcutaneous, and is most often blasts with plentiful collagen. The malignant variant has
located at the angle (commissure) of the mouth or the ill-defined margins; adjacent epithelium may be ulcerated or
cheeks and may extend into the mouth (Fig.11.15A). The intact. Histological features are of randomly arranged, acti-
verrucose form often involves the perioral skin. In the peri­ vated fibroblasts that form interlacing bundles and whorls.
oral skin and the tissues of the cheeks, in particular, it often Individual tumor cells have degrees of anisokaryosis, and
has a highly invasive behavior, then being classified as mitoses may be plentiful. At the histological level, it may be
malignant sarcoid;60 it can also ulcerate into the mouth. difficult to discern the limits of the tumor, especially in small
tissue samples. The verrucose sarcoid has histological fea-
tures similar to those in the malignant form and is usually
Clinical features associated with marked pseudoepitheliomatous epidermal
Intracutaneous or subcutaneous nodules on the cheek or hyperplasia (Fig. 11.15E).
within the lips having an ulcerated surface are the common-
est oral manifestation of sarcoid (Figs 11.15B,C). The Treatment
nodules frequently ulcerate either on the cutaneous surface
The options are limited. In some cases, the lesions can justifi-
or into the mouth. The verrucose form is also a common
ably be left alone in view of the risks of exacerbation by
type in the perioral skin but does not often involve the oral
incomplete excision. However, inadvertent trauma can also
mucosa; however, where the lesions are mixed, a deeper
result in severe deterioration, and so early treatment may be
component can be expected and should be sought carefully.
strongly recommended in most cases.
Combinations of nodules within the skin and cutaneous
Treatment of buccal forms of the disease is notoriously
involvement of verrucose sarcoid are also common. Nodules
difficult, with radiation, cryosurgery, hyperthermia, laser
may extend through the cheek musculature into the oral
excision, and intralesional cisplatin carrying some chance of
mucosa. The fibroblastic forms also occur in the perioral
success. Referral to a specialist center is probably justified
tissues and appear as a fleshy, ulcerated mass of friable and
simply on the grounds that failure of a treatment may result
easily traumatized tissue that is very similar to granulation
in significant exacerbation of the lesion.
tissue; this form often develops following trauma or failed/
The best treatment is undoubtedly with radiation either as
partial treatment attempts. The malignant form usually com-
brachytherapy using interstitial linear or pelleted radioiso-
prises various combinations of the sarcoid types but is highly
topes with a gamma emission capability. Radiation has a
invasive and nodules may be linked by cords of sarcoid
cure rate of over 95 %, and the cosmetic results of this
tissue (Fig. 11.15D).
method are impressive. The most frequent isotopes used
Primary sarcoid has not been reported on the tongue,
include iridium-192 and gold-198. The former is presented
gingiva or palate.
in linear sources, sheathed with platinum that renders the
isotope effectively a total gamma emitter. Gold-198 is used
Differential diagnosis as pellets and has a very short half-life (48 hours) and so
The equine sarcoid can resemble some forms of viral papil- this is logistically easier to handle (the sources do not need
loma, and the nodular forms may be also mistaken clinically to be removed) but clearly this method carries much higher
for melanoma and mastocytoma. In addition, the fibroblas- operator risks than the lower emissions over a longer period
tic and nodular forms may resemble oral fibroma, inflam- characteristic of iridium. Linear iridium sources are left in
matory nodules (e.g., foreign body and parasitic granuloma) situ for the calculated period to deliver the required radia-
and granulation tissue arising from any cause. tion dose and are then removed (Fig.11.15F). During the
treatment time, the horse must be confined within an
approved radiation unit. Complications involving wire dis-
Diagnosis placement and injury or colic during the treatment period
Usually an intuitive tentative clinical diagnosis can be made. can add considerably to the logistic problems. Teletherapy
Horses with a single sarcoid lesion located in the mouth is an ideal method of treatment, but there currently are very
without any other lesion are very unusual. Horses that have few facilities for this treatment.
the characteristic features and show lesions at other sites can Other treatments all carry a worse prognosis, with surgery
usually be assumed to have sarcoid lesions. being the most difficult. Intralesional cisplatin using stable
Biopsy is not usually recommended because there are emulsions with sesame oil has recently gained some reputa-
recognized dangers with biopsy of sarcoids.62 However, tion,63 but the method carries very serious carcinogenic risks
the histological features are characteristic and provided for operators and handlers alike. Biodegradable beads con-
that a suitable contingency plan for treatment is ready taining cisplatin (Matrix II, Royer Inc, USA) or sponges with
prior to the results of biopsy, then it can be a logical 5-fluorouracil have been used to generally good effect but
diagnostic step. correct placement is critical, and retention of beads or

167
 11 Dental disease and pathology

Fig. 11.15  (A) This locally invasive sarcoid also involved the buccal surface of the cheek. (B) A localized ulcerated nodular sarcoid. (C) A mixed sarcoid with
verrucose and ulcerated nodular components. (D) A locally invasive malignant sarcoid in the cheek with extensive deep involvement of the muscles and oral
mucosa. (E) Histologic section of verrucose sarcoid showing a bulging exophytic lesion with pseudoepitheliomatous hyperplasia of the epidermis and diffuse
subepithelial fibroblastic proliferation. (F) Linear iridium-192 interstitial brachytherapy was successfully used to treat an invasive sarcoid in the cheek.

168
 Oral and dental tumors

sponges is sometimes a problem. Cisplatin use should be have a correspondingly aggressive histopathological appear-
restricted to specialist institutes where facilities for fecal and ance. Generally it is accepted that small, early lesions
urine disposal ensure that risks to people are minimized. The are benign, but that, with time, most become more
risks with the bead systems are markedly reduced. malignant (whether or not they invade locally or metastasize
Topical cytotoxic chemicals, such as 5-fluorouracil, imi­ to remote sites).
quimod (Aldara, Graceway Pharmaceuticals, LLC Bristol,
UK), and Xxterra (20% zinc chloride and Sanguinaria Clinical features
canadensis root extract paste) have also been used with
variable results. They all require repeated applications, and Oral melanomas are usually benign and expand slowly but
penetration of lesions is difficult, so failures are common. even histologically benign variants can reach considerable
Scarring is a major hazard particularly if the cheeks are size. Surprisingly, tumors on the lips (Fig.11.16A) and gin-
involved and functional difficulties can arise. givae are often only noticed when they are large. They usually
Intralesional immune ‘stimulants’, such as mycobacterial do not cause systemic effects (unrelated melanomas may,
cell wall extracts or BCG, can be effective in some nodular however, develop simultaneously in other organs). Extensive
or fibroblastic forms, but the prognosis is far worse than the lesions can develop in the parotid and pharyngeal lymph
corresponding results from treatment of periocular sarcoids nodes and may extend into the parotid salivary gland either
of the same type.63 Treatment is tumor-volume related, and directly or by contiguous spread (Fig.11.16B).
so large lesions require more BCG material and, of course, Melanomas affecting the masseter muscle and those that
each individual lesion requires its own injections. Repeated ulcerate into the mouth usually affect mastication, even
injections are invariably required, and each one carries the causing weight loss and dymasesis. In spite of the large size
risks of causing anaphylaxis. The possibility of anaphylactic of some of these lesions, the clinical effects are usually
reactions can be reduced (but probably not eliminated) by minimal and relate simply to their space-occupying nature
premedication with flunixin meglumine and dexametha- (Fig. 11.17).
sone intravenously some 15–30 minutes before the proce-
dure is carried out. Ensuring that true intralesional injection
has occurred can also reduce these risks.

Prognosis
The prognosis for any sarcoid treatment is very guarded.
Recurrences are common, and new lesions can also develop
in many sites. While the malignant form is less common
than the other variants, it carries a very poor prognosis. The
cheek area seems prone to the malignant form. The progno-
sis for oral or facial sarcoids is also related to the loss of
effective work use as a result of interference with tack. Lesions
and scarring as a direct result of treatments at the angle of
the mouth or in the cheeks can adversely affect the use of
bits and harness. Repeated trauma from harness results in
continued exacerbation, and so the tumor and the horse
become increasingly difficult to manage.

A
Melanoma
These are tumors of melanocytes occurring in the skin and
in other organs (including the mouth and cheeks). The
nomenclature of melanocytic masses in the horse is con-
fused and contradictory. There is a spectrum of benign and
malignant tumors involving melanocytic cells that are pre-
dominantly encountered in gray horses – indeed most gray
horses over 5–8 years old have melanomas at some site.
Rarely, horses of other colors are also affected. The lips are
a relatively common site, but tumors in the cheeks (masseter
muscles), gingivae, and tongue may occur.
There is a strong tendency for melanoma to develop in the
parotid salivary glands and associated lymph nodes. Tumor
development in these sites is usually obvious on clinical
inspection. It is not easy to characterize the degree of malig- B
nancy in melanomas without resort to biopsy, and even
histology may not always provide a firm prognosis. The large Fig. 11.16  (A) A large melanoma in the lip of an aged gray horse.
majority of melanomas are benign, but some have an aggres- The lesions expanded slowly but the horse remained symptom-free for
sive appearance and aggressive growth rate; these usually years in spite of superficial ulceration. (B) Salivary gland melanoma.

169
 11 Dental disease and pathology

A B

Fig. 11.17  (A) This 9-year-old gelding was presented with weight loss and dysmasesis. The mass in the right masseter muscle, and a similar mass in
the left masseter muscle were palpably obvious. (B) Cisplatin biodegradable beads (Matrix II Royer Inc USA) were implanted into the lesion with moderate
improvement over 6 months. A second implantation was performed with only a modest further improvement. Insert: biodegradable cisplatin impregnated
beads.

Differential diagnosis cytoplasmic pigmentation. The diagnosis of such less

well-differentiated melanoma may be clarified by the use
Equine sarcoid and mast cell tumors should be considered
of immunostaining against cell markers, such as Melan A
in the differential diagnosis of lesions that develop in haired
and S100.65
skin adjacent to the lips. Parasitic and foreign body granu-
lomas and oral penetration-induced abscesses or granuloma
have a similar clinical appearance. Treatment
Many melanomas are left alone without any significant
Diagnostic confirmation problem apart from the cosmetic aspects. For lip melano-
mas, surgical excision is sometimes feasible, especially in
The diagnosis of melanoma is easy to establish from clinical
early cases, and is then usually effective, provided that a
features and, if necessary, by use of a fine-needle aspiration
surgical margin can be achieved. Regrowth at the site can be
or hollow-needle biopsy.
a problem because during surgery minute tumors may be
seen in the locality, and it is almost inevitable that some of
Pathology these will be left to develop later. Often, however, by the
Melanomas are bulging, well-circumscribed, gray-black time functional defects are present, surgical treatment
masses that compress adjacent soft tissues, sometimes pro- options are very limited. This is complicated by the long-
ducing ulceration of the compromised surfaces. Cut surfaces term ‘conventional wisdom’ that melanomas should be left
of the tumor are usually glistening, firm, and uniformly alone and that there is a risk of metastasic dissemination if
black. Occasional lesions may be less homogeneous, less surgery is performed. The reality is that pathologic descrip-
pigmented, or even amelanotic. tions confirm that very small lesions are very benign and so
Most equine melanomas are characterized histologically are a reasonable surgical option. In contrast, advanced
by the presence of myriad round-to-oval cells with plentiful, lesions often have a malignant histological appearance, and
densely pigmented cytoplasm. Two distinct types of cells so, at this stage, the risks are far higher. There is some justi-
constitute the tumor: fication, therefore, in the concept that small lesions in acces-
sible sites should be removed as soon as feasible so that at
1. Melanin-producing cells (melanocytes) least these particular ones will not become a significant clini-
2. Macrophages that contain phagocytosed melanin cal problem and will not become malignant!
(melanophages). Prolonged daily oral administration of cimetidine at doses
Pigmented tumor cells may extend into adjacent soft tissues of 7.5–15.0 mg/kg bodyweight has been suggested as being
but this is not a reliable histological criterion of malignant effective, but the results are not convincing in many cases.66,67
behavior. Most tumor sections have to be bleached so that Treatment of single or few oral tumors on their own prob-
the underlying cytological features can be assessed. Nuclei ably does not warrant this approach.
are usually solitary with a large nucleolus and coarse nuclear The use of repeated intralesional cisplatin either in stable
chromatin. Mitoses are usually sparse. emulsion with sesame oil and water, or more sensibly in
There are occasional melanomas with clinical features biodegradable beads (Matrix II, Royer Inc, USA), may bring
of malignancy (invasion and metastatic spread); these some improvements in some lesions (Figs. 11.17A,B), but
have corresponding histological features of anisocytosis complete cures are most unlikely. Radiation therapy is not
and anisokaryosis, with plentiful mitoses and variable usually effective against melanoma.

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 Oral and dental tumors

Fig. 11.18  (A) Oral papilloma lesions in an aged horse. (Slide courtesy of Dr Marianne Sloet.) (B) This young horse developed severe papillomatosis of the
perioral skin and at the same time showed marked periodontal disease. It was severely immunocompromised by an extensive, multicentric lymphosarcoma.

Prognosis verrucous form in the mouth, differentiation should be

simple. ‘Skin tags’ also occasionally develop in the mouth.
The prognosis necessarily depends on the location, the par-
ticular pathological characteristics and the extent of second-
ary effects. The prognosis is usually relatively favorable as Diagnosis
the majority have no metastatic tendency, but occasionally The diagnosis is usually simply based on epidemiology and
tumors are locally invasive, and others are very aggressive clinical appearance. Biopsy is characteristic, and most lesions
with extensive metastatic spread and serious secondary resolve with age, although they may be very persistent in
effects. As might be expected, older lesions tend to be more older horses.
malignant, at least in histological character and possibly
clinical behavior. Pathology
Papillomas are characteristic exophytic verrucose lesions
Oral papilloma that may be superficially ulcerated and inflamed. Histologi-
Viral papilloma is a relatively common occurrence on the cal examination reveals filiform fronds of hyperplastic epi-
skin of the mouth and lips and, in some cases, they can thelium on fibrovascular cores that often contain plentiful
extend into the oral cavity. Host-specific equine papilloma lymphocytes and plasma cells. Intranuclear inclusions may
viruses are the causative virus and usually affect horses in be plentiful or sparse.
their first year or two of life. Less commonly, they affect older
horses and particularly those that have an immunocompro- Treatment
mising disorder, such as pituitary pars intermedia dysfunc- Most papillomas resolve spontaneously over some months,
tion (PPID/ equine Cushing’s disease). but individual lesions may persist, often for many years.
Therapeutic measures used have included autogenous vac-
Clinical features cines prepared from surgically excised lesions and various
topical chemicals, including podophyllin and formalin gels.
Typically, papillomata appear as single or multiple, discrete Many of these treatments are impractical on intra-oral
or coalescing, verrucose, gray-pink papules around the lesions and, in those circumstances, troublesome papillo-
mouth and, occasionally, on the mucosa of the mouth mata can be removed surgically or with cryonecrosis.
(Fig.11.18A). They seldom ulcerate unless they are trauma-
tized. A few cases have lesions restricted to the oral mucosa,
and it is not known if these reflect a different manifestation
Prognosis
of the same infection. In a few cases, there may be a severe The prognosis is excellent. The majority resolve spontane-
oral infection, and in these cases it is likely that some immu- ously, and those that do not have no apparent harmful effect
nocompromising state exists (Fig.11.18B). on the horse.

Differential diagnosis Epulis

Viral papilloma can be mistaken for some forms of the The term epulis is a clinical description of a smooth gingival
equine sarcoid, but as the latter seldom occur in the nodule and can encompass different types of lesion, such as

171
 11 Dental disease and pathology

A B

Fig. 11.19  (A) Benign, gingival hyperplasia epulis in an aged horse. The lesions were noted incidentally and were symptom-free. (B) Small epulis-like gingival
proliferations are present around the base of the upper and lower canine teeth (arrows). After removal of the calculus these inflammatory lesions
disappeared.

hyperplasia, granuloma, or even neoplasia. These tumor- Treatment

like masses develop from the fibrous tissue of the gingiva
Removal of the causative factors usually results in complete
and are often, but not always, associated with the accu­
resolution. Many cases resolve spontaneously after any
mulation of dental calculus caused by chronic local irritation
dental calculus or damaged dental or adjacent soft-tissue
due to persistent periodontal infection. In horses, they are
structures are removed. Recurrence of both calculus and
much less common than in some other species, such as the
epulis should encourage a careful assessment of the whole
dog and cat, and seldom reach significant proportions
horse in case there is any systemic disease present.
(Fig.11.19A).

Clinical features Prognosis

Usually epulis appears as a benign expansion of the gingival The prognosis is excellent. There are no reports that they are
epithelium resulting in thickening and prominence of the precursors to more malignant tumors, such as squamous cell
gingiva particularly evident at the gingival margin where it carcinoma, but one case developed a locally aggressive car-
may be focally raised (Fig.11.19B). A few cases develop cinoma some years after a benign epulis was removed from
ulcerated proliferating masses at the site that can be much the base of a canine tooth (DCK, unpublished observation).
more like a true neoplasm, and these may closely resemble It is probably unwise to draw any causative inference from
oral fibroma. this single case.

Differential diagnosis
Oral fibroma
Viral papilloma, sarcoid, and the proliferative forms of
squamous cell carcinoma are the main differential diag- Definition
noses; all are easily identified histologically after surgical This is a well defined exophytic fibroma that occurs with
removal. some regularity in the horse. The clinical similarity of
this tumor with sarcoid and epulis can be diagnostically
Diagnosis confusing. Possible causes include persistent local inflam-
mation due to periodontal infection or calculus build-up,
The condition is distinctive clinically, but refinement of
or foreign body reactions (similar to epulis). However,
the clinical diagnosis depends on histological examination
many of these lesions occur in otherwise normal mouths.
of resected epulides or a biopsy. Biopsy may, however, be
Most are slow-growing and symptomless; almost all early
misleading if granulation tissue is present, and in any case
cases are detected incidentally during routine dental
they may still be very similar histologically. The main dif-
examinations. The benign forms may progress to invasive
ferential diagnoses are, however, usually easily identified
fibrosarcoma.
histologically.

Pathology Occurrence
There is poor histological characterization of the epulides, There are few reported cases of oral fibrous tumors in horses
probably because they are easily recognized and are seldom in spite of their relatively common occurrence. Older or
treated: few are examined histologically. mature horses appear to be more often affected. The buccal

172
 Oral and dental tumors

gingivae of the maxillary cheek teeth are the commonest site, Clinical features
but they occasionally occur on the lingual margin and in the
The majority of these tumors occur unilaterally in the rostral
mandibular arcades.
mandible. They rarely develop in the maxilla and in very rare
cases can be bilateral. They often reach considerable size
Clinical features and, initially, are covered by a domed, smooth/normal oral
A localized, fleshy, ulcerated and hemorrhagic mass is easily mucosa. Gross distortion of the lip and the associated teeth
visualized lying usually alongside the maxillary cheek teeth is likely. Later some ulceration is common (Figs 11.20A,B).
(Fig. 11.4A,B). There may be some external distortion of the There is some variation in the clinical presentation, with
cheek outline with larger growths. Dysmasesis or hemoptyal- some lesions being flatter and fleshier in appearance; they
ism may be noticed by an astute owner. can then resemble other soft tissue tumors. The expanding
lesion also causes loosening of the teeth and consequent
difficulty with prehension.
Diagnostic confirmation The tumor can predispose the mandible to pathological
Biopsy is essential to differentiate it from squamous cell fracture. Although the lesions may frequently be clinically
carcinoma, sarcoid, and epulis, in particular. obvious, they may only be identified late in their course,
probably because there is little indication to examine the
Pathology mouth of many young horses.

There are two forms of the oral fibroma. The first is a result
of irritationally induced changes and is not a genuine neo- Diagnostic confirmation
plasm (see epulis above), and the second is a genuine Radiographically the dense tissue is obvious with only some
(usually benign) neoplastic change in the fibroblasts. Patho- lesions showing the calcification more commonly encoun-
logically, the latter are usually firm nodules that develop as tered in other species (Fig. 11.20C). More ulcerated and
aggregated protuberant tumors within a firm indurated secondarily infected lesions may resemble other soft-tissue
plaque. They often ulcerate. Histologically they are very cel- tumors.
lular with well differentiated fibroblasts arranged radially
within a sparse extracellular matrix. Mitotoses are usually
Pathology
evident but are not as common as in the more aggressive
forms of fibrosarcoma. There may be deep extension into the Ossifying fibromas may develop as alterations in the growth
subcutaneous fat. They are histologically distinctive and characteristics of the periodontal membrane or the develop-
cannot really be confused with sarcoid. ing teeth. The masses are reported to arise from a sessile base
on the surface of the bone and expand to replace and dis-
place normal structures with dense fibrous or fibro-osseous
Treatment tissue. The lesion has a dense, tough, well-circumscribed
Treatment options are limited to surgical excision. Laser sur- appearance; it may be extensively mineralized and difficult
gical excision or diathermy are effective and produce a rela- to cut. There is a characteristically abrupt histological transi-
tively bloodless surgical field. It is important to clean/descale tion from fibroblastic stroma to osteoblasts, which form
adjacent teeth of calculus at the same time in case the calcu- spicules of osteoid. The dense gritty nature of the mass some-
lus acts as a focus for growth of a new mass. times makes biopsy difficult.

Prognosis Treatment
These tumors are commonly considered to be very benign Surgical excision is curative provided that sufficient attention
in behavior; most are slow-growing, and their treatment is paid to identifying the true extent of the abnormal tissue.
carries a good prognosis. There is no recorded suggestion Extensive surgical debulking followed by cobalt-60 telether-
that they are a precursor to squamous cell carcinoma, but in apy radiation and treatment using cobalt-60 teletherapy
theory at least, fibrosarcoma could develop. alone in a standing sedated horse have also been used suc-
cessfully.69 Hemimandibulectomy or hemimaxillectomy is
Ossifying fibroma also an effective option, particularly if the mandibular sym-
physis can be retained (Fig. 11.20D). Limited disabilities
Definition and acceptable cosmetic effects can be expected following
An ossifying fibroma is a poorly defined proliferative, fibro- treatment of more localized lesions. Cases subjected to this
osseous, tumor-like, solitary lesion, that typically develops surgery should recover well and will usually cope well and
in the rostral mandible, of younger horses in particular. lead active normal lives.69 However, if extensive excision is
required, it may leave unacceptable cosmetic and functional
deficits.
Occurrence
Most cases are reported in horses less than 1 year of age.
They may, however, not be observed until the horse is
Prognosis
handled at a later age, by which time there may be significant Regrowth of the tumor is common because of the difficulty
ulceration of the buccal mucosa and distortion of the under- of identifying the margins of the abnormal tissue. All
lying tissues.68 resected tissue should, therefore, be submitted for

173
 11 Dental disease and pathology

A B

C
D

Fig. 11.20  (A, B) This ossifying fibroma was presented in a 3-year-old mare. (C) Radiographically the mass was found to involve the incisor teeth with loss of
203 and it had an obvious radiolucent center. A hemimandibulectomy (D) was performed with a good outcome.

histological examination, with particular attention paid to creates obvious distortion of the maxilla, with secondary
examination of the surgical margins, which need to be iden- nasal and sinus obstruction. Loosening of teeth and infec-
tified by the surgeon for the pathologist. tion of alveolar bone may later result, but in the early stages
there is usually little bone destruction (Figs. 11.22).
Myxomatous tumors of the jaw and gingivae
Definition Diagnostic confirmation
Biopsy is essential. Radiographically, there is an aggressive
These are very rare tumors derived from embryonal connec-
lytic appearance of these lesions, with a diffuse mixture of
tive tissue. The tumors are identified by their characteristic
bone and soft tissues, often in a partially loculated form. The
histological appearance.
cardinal radiographic signs of the more malignant forms,
however, are the combined destruction of normal bone and
Occurrence bizarre irregular new bone formation in random arrange-
In the few reported cases, older or mature horses appear to ment. The radiographic appearance can be very similar to
be more often affected. The incisor and molar dental arches osteosarcoma (see above) and squamous cell carcinoma.
of the maxilla are the most common sites.
Pathology
Clinical features This group of tumors includes a spectrum that extends from
These tumors are characteristically destructive (Fig. 11.21). benign myxoma to malignant myxosarcoma. The tumors
The combined destruction and proliferation of tumor tissue have a soft gelatinous gross appearance, and may be highly

174
 Oral and dental tumors

infiltrative with a tendency to metastasize. Cut surfaces of metastatic spread of the malignant forms of these tumors,
the tumor may be lobulated and slimy. Histologically, the but this may reflect the short clinical duration, which inevi-
lesion contains characteristic stellate cells with abundant, tably results in euthanasia before secondary tumors could
amorphous extracellular matrix. These tumors can also develop elsewhere.
resemble severely ulcerated juvenile ossifying fibroma, but
the latter are usually slow growing and expansive rather than Prognosis
destructive. Additionally, ossifying fibroma has a character-
istically different anatomic site, usually involving the rostral These tumors are very unpredictable in behavior; some are
mandible. slow growing and remain relatively benign; others are highly
aggressive and so carry a hopeless prognosis.
Treatment
Treatment options are very limited – the margins of the
Oral hemangiosarcoma
tumor and their usual anatomical site make surgical excision This is a malignant neoplasm of endothelial cells that can
virtually impossible. There are no definitive reports of arise in any part of the body. They are reported to metasta-
size early, and so tumors in any locality may be primary or
secondary. There are few reports of this tumor in the
mouth.70,71 Aged horses are more likely to develop them, and
there may be concurrent tumors at other sites, such as around
the eye (DCK, unpublished observation).

Clinical features
A red or purple ulcerated mass in the oral mucosa (on the
sides of the tongue or the gingiva is typical). The mass is
likely to be slow-growing and, being subject to repeated
trauma, there may be oral hemorrhage. The lesions may be
identified incidentally during a clinical examination, but
where periocular lesions occur, the clinician should carefully
examine all the visible mucous membranes, including the
mouth, for other evidence of the tumor.

Differential diagnosis
Foreign-body reactions and ulceration arising from the
attachments of Gastrophilus sp. may be similar.

Diagnosis
Biopsy is the only definitive way of establishing the
diagnosis.

Pathology
Fig. 11.21  Myxomatous tumor of the premaxilla in a 14-year-old hunter
gelding. Note the extensive destruction that is very similar to squamous cell Histological features are of a solid, soft-tissue sarcoma with
carcinoma. The diagnosis can be confirmed relatively easily by biopsy. marked anisocytosis, anisokaryosis, and myriad mitoses.

Fig. 11.22  (A) This malignant myxosarcoma was

identified incidentally during routine dental
treatment. (B) Radiographs showed only limited
alveolar and maxillary bone involvement.

A
B

175
 11 Dental disease and pathology

There is variable formation of large or small vascular chan- Treatment

nels lined with neoplastic endothelial cells. In histologically
Surgical excision is theoretically possible if diagnosis is made
equivocal cases, immunohistochemical staining for Factor
sufficiently early, but this is unlikely in most cases.
VIII-related antigen helps in identifying neoplastic endothe-
lium. Tissue margins of resected lesions should be assessed
carefully to ensure that excision is complete, although the Prognosis
latter may be difficult for tumors of the gingiva. The high malignancy of most salivary gland carcinomas
makes the prognosis very poor.
Treatment
Surgical excision may be effective but there are considerable Disorders of the jaws and teeth  
technical difficulties and risks of incomplete excision. Where resembling neoplasms
other tumors are also present elsewhere, local palliative
treatment is all that can be advised. Mandibular aneurysmal bone cyst
Although localized (usually very small) bone cysts are rela-
Prognosis
tively common in long bones and in particular in their epi-
The presence of more than one lesion may not necessarily physeal regions, mandibular cysts are very rare in horses. In
indicate that the tumor has spread metastatically, but man, they probably arise from circulatory disturbances
hemangiosarcoma is a malignant tumor of horses, and so within the bone structure74 or traumatic alteration of the
this possibility must be considered. blood supply to a small area of bone.75 While such structures
might be expected in young horses, they may also occur in
Salivary adenocarcinoma older horses, possibly as a result of trauma.10 There is no
evidence to suggest that these lesions are truly neoplastic,
Salivary gland neoplasia is uncommon in horses. For but diagnosis based on radiographic examination alone is
example, in one study of 687 necropsies and 635 biopsies probably unwise. While there are no reports of concurrent
only three salivary tumors were described; two were carcino- neoplasia in the horse, complexes of tumors and cysts are
mas and one was a cystadenoma.4 Another review of 1148 reported in other species.
equine tumors included only two salivary adenocarcino-
mas.72 Six of 14 documented equine salivary gland tumors
Clinical features
were adenocarcinomas; where recorded, the sites of involve-
ment were the parotid salivary gland (three cases) and the These bone cysts present as sterile, firm, expanding swellings
submandibular salivary gland (one case). The age range was usually on the horizontal ramus of the mandible (Fig. 11.23
7–18 years.73 Recognition is important because they are A,B). The mandible becomes thickened from progressive
reported to be highly malignant, and up to 33 % may develop destruction of cortical bone accompanied by reactive perio-
pulmonary metastases. steal new bone formation. Some pain associated with mas-
tication may develop, and teeth may be shed as their alveoli
are destroyed. The region may be warmer than the normal
Clinical features contralateral mandibular ramus. The rate of expansion may
Recognition of salivary tumors is difficult, but, clinically, the be sufficient to cause disruption and bleeding into the sur-
affected gland becomes enlarged. Palpation is uncomforta- rounding tissues and may easily suggest the presence of a
ble but not painful. Only one gland is involved, and so the neoplastic lesion. As the destruction becomes more aggres-
enlargement is asymmetrical, which differentiates it from the sive, the mandible may suffer a pathological fracture.
more usual very benign and transient parotid salivary gland In advanced cases, the extent of bone destruction can be
swelling commonly seen in grazing horses. considerable (Fig. 11.23C), and pathologic fractures are now
likely. Although parotid duct obstruction can occur, this is
Differential diagnosis an insignificant clinical event.
Benign swelling of parotid salivary glands occurs frequently
in grazing horses. This idiopathic condition is invariably Differential diagnosis
transient and self-resolving. Obstruction of the salivary ducts Ossifying fibroma and destructive ameloblastoma are the
by sialoliths (usually in the parotid gland) occurs within the main differentials. Paranasal sinus cysts have a similar radio-
gland substance or in the more rostral part of the duct. This graphic appearance but occur in a very different location.
results in a solid obstructive lesion with generalized glandu-
lar swelling. This remains hot and painful for some days
Diagnosis
before it subsides naturally as atrophy of the gland follows.
The radiographic appearance reveals a complex, loculated,
cyst-like structure containing bone fragments and soft tissue,
Diagnosis usually with a fine rim of thin bone around the periphery
Diagnosis is reliant upon biopsy, but so few cases have (Fig. 11.23B). The structure closely resembles a complex
been described that a characteristic histological appearance paranasal sinus cyst, which may also arise congenitally or
is not established. Post-mortem histological features are develop at later ages. Aspiration of the affected mandible
described.15 reveals small volumes of yellow or red-orange fluid.

176
 Oral and dental tumors

Fig. 11.23  (A) This 19-year-old pony mare

developed a non-painful thickening of the
horizontal ramus of the mandible. Gross
distension of the proximal portion of the
parotid duct and outward displacement of the
masseter muscle were obvious. After some 12
months, she became painful and ate slowly.  
(B) Radiographs showed a multilocular cyst-like
condition, and aspiration produced around
250 ml of a clear yellowish fluid with low cell
count. (C) Gross destruction of a mandible C
caused by an aneurismal bone cyst.

Pathology
Histologically the cystic lesion contains bone fragments,
granular debris, siderophages, multinucleated giant cells,
and fibrovascular tissue with areas of organizing and free
blood. Histological examination of curetted fragments of
cyst contents may often correlate poorly with the radio-
graphic appearance.

Treatment
The only effective treatment is deep and aggressive curettage
of all abnormal tissue. The defect may be filled with cancel-
lous bone grafts collected from a remote site. Repair may be
slow, and the site may be cosmetically compromised, but
some cases can be cured effectively. However, in most cases,
treatment is not justified, and palliative care should be pro-
vided until euthanasia can be justified.

Prognosis
The prognosis is poor unless the lesions are detected early
and treated with aggressive surgical ablation and suitable
reconstructive measures. However, the chances of early diag-
nosis are low, and so the prognosis for these lesions is
usually bleak. Complications including tooth loss and path- Fig. 11.24  A radiograph of fibrous dysplasia of the rostral portion of the
ological bone fractures reduce the prognosis considerably. mandible of a young horse.

177
 11 Dental disease and pathology

A D

E
B

Fig. 11.25  (A) Multiple discreet dermal nodules in a pony with histiocytic lymphosarcoma.
(B) Cutaneous histiocytic lymphosarcoma with involvement of the gingival tissues. The
ill-defined swellings of the gingiva were due to aggregations of abnormal lymphocytes. These
lesions might easily be overlooked but are a regular finding in these cases. (C) Pharyngeal
lymphosarcoma lesions that can sometimes be identified endoscopically. These lesions were
symptom-free but larger ones can cause dysphagia. (D) Photomicrograph of the tongue from
an aged horse with oral lymphosarcoma showing epithelium and diffuse subepithelial
C accumulation of neoplastic lymphoid cells. (E) Lymphosarcoma of the tongue showing
neoplastic cells around and between muscle fibers.

Non-aneurysmal cystic lesions of bone horses as a smooth contoured bone deformity arising from
loss of bone structure with extensive formation of fibro-
Non-aneurysmal cystic lesions of the jaws also present as osseous matrix (Fig.11.24). The lesion is probably not a true
bony swellings that may affect mastication. Radiographically neoplasm, and its major effects in the jaw/face region are
the cysts differ from the multiloculated destructive aneurys- due to the expansive space-occupying nature of the slowly
mal cysts in being rounded with a smooth bony lining and expanding mass. The changes are easily recognized histologi-
radiolucent center. The generic term, odontogenic cyst, is cally but may be confused with neoplastic lesions both
appropriate for these non-inflammatory cysts lined by epi- radiographically and clinically. Suspicious masses should be
thelium.23 Radicular cysts occur adjacent to tooth roots. They subjected to the full range of diagnostic tests, including
are reactive lesions associated with oral inflammatory radiography, gamma scintigraphy, biopsy and, where
disease. Histologically they are lined by stratified squamous feasible, computed tomography.
epithelium with associated inflammatory cells.
Pathology
Fibrous dysplasia Grossly normal bone is replaced by dense gritty tissue and
Fibrous dysplasia of the bones of the skull has been reported may be surrounded by reactive bone. Histological features
in man,76 and a clinically similar condition is recognized in include fibrous dysplasia and the presence of ‘naked’

178
 Oral and dental tumors

very rare event, even in highly malignant tumors and in any

case, the oral signs may be trivial compared to the other
systemic involvements. The mouth may be secondarily
diseased through systemic effects from functional tumors
such as the pituitary adenoma-related Cushing’s disease and
renal tumors.

Lymphosarcoma
Multicentric (generalized) and cutaneous histiocytic lym-
phosarcoma may have oral manifestations (Fig. 11.25).
Usually the clinical appearance is of ill-defined nodular
lesions of variable size embedded within and below the
mucosal surface, which probably reflects the involvement of
the normally-diffuse lymphoid tissue of the nasopharynx.
The gingival mucosa is often affected. A similar nodular
appearance is often present in the pharynx and in the sub-
lingual tonsillar tissue where larger swellings may cause dif-
ficulty on swallowing. The lesions may ulcerate or become
infected. Simultaneous submandibular lymphadenopathy,
and other secondary effects, such as anemia, lethargy, and
weight loss may signify serious systemic involvement.

Pituitary pars intermedia dysfunction

Fig. 11.26  Pituitary adenoma/Cushing’s disease. Oral ulceration showing a
(PPIDD / equine Cushing’s disease)
singular lack of healing is a common sign (food is present on some teeth). Hyperplasia of the pituitary pars intermedia is responsible
Other dental and oral lesions may be present also. for secondary oral disease, such as extensive non-healing
oral ulcers (Fig. 11.26), and dental and periodontal infec-
tions. The condition is regarded by some as a neoplasm of
the pars intermedia, and is very common in older horses
spicules of woven bone in a dense fibrous stroma. The bone (usually > 14–17 years). Extensive dental and alveolar
appositional surfaces lack recognizable osteoblasts. disease (including periodontal disease and periapical sepsis)
commonly develops. This, with advancing, age-related short-
ening of the residual crown of older horses, predisposes the
Treatment affected animals to secondary sinusitis, and there may be
Surgical removal may be undertaken but many such lesions tertiary consequences from this, including early shedding of
remain static and do not affect the horse. teeth, oronasal and oromaxillary fistulae, oral ulceration and
anemia.
Other tumors that may affect  
the mouth and jaws Other distant tumors
Paraneoplastic changes, such as hypercalcemia and oral
Oral tumors arising by metastatic spread from remote organs ulceration, can develop as a result of neoplastic disease in
and by invasion of the oral cavity from neighboring areas, other tissues (usually myeloproliferative neoplasia).77 It is
such as the nasal cavity and paranasal sinuses can occur in important to remember that the mouth may be one of the
horses. Tumors remote from the mouth and oral structures early sites where clinical evidence of neoplastic disease, such
may have a serious influence on the mouth through meta- as anemia, icterus, and azotemia, may be manifested. The
static spread (such as in hemangiosarcoma and lymphosar- lesions seen in the mouth may not be readily attributable to
coma). Secondary involvement of the mouth is, however, a neoplastic disease either at a local or remote site.

References
1. Jackson C. The incidence and pathology 2. Hagdoost IS, Zakarian B. Neoplasms of 4. Sundberg JP, Burnstein T, Page EH, et al.
of tumors of domestic animals in South Equidae in Iran. Equine Vet J 1985; 17: Neoplasms of equidae. J Am Vet Med
Africa: a study of the Onderstepoort 237–239 Assoc 1997; 170: 150–152
collection of neoplasms with special 3. Pirie RS, Tremaine WH. Neoplasia of the 5. Smith P. Large animal internal medicine.
reference to their histopathology. mouth and surrounding structures. In: Mosby, Philadelphia, 1996, p. 696
Onderstepoort Journal of Veterinary Robinson NE, ed. Current therapy in 6. Baker GJ. Oral examination and
Science and Animal Industries 1936; 6: equine medicine. WB Saunders, diagnosis: Management of Oral Diseases.
1–460 Philadelphia, 1997, pp 153–155 In: Harvey CE, ed. Veterinary dentistry,

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WB Saunders, Philadelphia, 1999, 24. Wahl P. Adamantinoma polycysticum 42. Thorp F, Graham R. A large osteosarcoma
pp 217–220 ossificans am Unterkiefer eines Pferdes. of the mandible. J Am Vet Med Assoc
7. Richardson DW, Evans LH, Tulleners EP. Deutsche Tierartztliche Wochenschrift 1934; 84: 118–119
Rostral mandibulectomy in five horses. 1936; 46: 113–117 43. Jacobson SA. Parosteal osteoma
J Am Vet MedAssoc 1991; 199: 1179– 25. Peter CP, Myers VS, Ramsey FK. juxtacortical osteogenic sarcoma in
1182 Ameloblastomic odontoma in a pony. animals. American Journal of Pathology
8. Purdy CM. Mandibular aneurysmal bone American Journal of Veterinary Research 1969; 58: 85a
cyst in a horse. Equine Practice 1985; 7: 1968; 29: 1495 44. Livesey MA. Wilkie IW. Focal and
22–24 26. Vaughan JT, Bartels JE. Equine multifocal osteosarcoma in two foals.
9. Verstraete FJM, Ligthelm AJ. Excessive mandibular adamantinoma. J Am Equine Vet J 1986; 18: 410–412
granulation tissue of periodontal origin Vet Med Assoc 1968; 153: 45. Gorlin RJ, Meskin LH, Brodey RS.
in a horse. Equine Vet J 1988; 20: 454–457 Odontogenic tumors in man and
380–382 27. Hanselka DW, Roberts RE, Thompson animals; pathological classification and
10. Lamb CR and Schelling SH. Congenital RB. Adamantinoma of the equine clinical behavior – a review. Annals of
aneurysmal bone cyst in the mandible of mandible. Veterinary Medicine for the the New York Academy of Science 1963;
a foal. Equine Vet J 1989; 21: 130–132 Small Animal Clinician 1974; 69: 108: 722–771
11. Gibbs C. The equine skull; its 157–160 46. Strafuss AC. Squamous cell carcinoma in
radiographic investigation. Journal of the 28. Jones SL, Brumbaugh GW. horses. J Am Vet Med Assoc 1976; 168:
American Veterinary Radiology Society Ameloblastoma in mandible of horse. 61–62
1974; 15: 70–78 What is your diagnosis? J Am Vet Med 47. Howie F, Munroe G, Thompson H,
12. Wyn-Jones G. Interpreting radiographs 6: Assoc 1991; 199: 630–631 Murphy D. Palatine squamous cell
Radiology of the equine head part 2. 29. Summers PM, Wells KE, Adkins KF. carcinoma involving the maxillary sinus
Equine Vet J 1985; 17: 417–425 Ossifying ameloblastoma in a horse. in two horses. Equine Veterinary
13. McIlwraith CW. Equine digestive system. Australian Veterinary Journal 1979; 55: Education 1992; 4: 3–7
In: Jennings PB, ed. The practice of large 498–500 48. Schuh JCL. Squamous cell carcinoma
animal surgery, WB Saunders, 30. Lingard DR, Crawford TB. Congenital of the oral, pharyngeal and nasal mucosa
Philadelphia, 1984, p. 579 ameloblastoma in a foal. American in the horse. Vet Pathol 1986; 23:
14. Moulton JE. Tumors in domestic animals, Journal of Veterinary Research 1970; 31: 205–210
3rd edn. University of California Press, 801 49. Johnson PJ. Dermatologic tumors
Berkeley, 1990, pp 167–168 31. Roberts MC, Groenendyk S, Kelly WR. excluding sarcoids. Veterinary Clinics of
15. Head KW. Tumors of the alimentary tract. Ameloblastomic odontoma in a foal. North America Equine Practice 1998; 14:
In: Moulton JE, ed. Tumors in domestic Equine Vet J 1978; 10: 91–93 625–658
animals, 3rd edn. University of California 32. French DA, Fretz PB, Davis GD. 50. Barker IK, van Dreumel AA, Palmer N. In:
Press, Berkeley, 1990, Mandibular adamantinoma in a horse; KVF Jubb, PC Kennedy, N Palmer, eds.
pp 347–374 radical surgical treatment. Veterinary Pathology of domestic animals, 4th edn,
16. Baker JR, Leyland A. Histological survey Surgery 1984; 13: 165–171 Volume 2, Academic Press, New York,
of tumors of the horse, with particular 33. Dillehay DL, Schoeb TR. Complex 1993, p. 27
reference to those of the skin. Vet Rec odontoma in a horse. Vet Pathol 1986; 51. Knottenbelt DC, Pascoe RR. Diseases and
1975; 96: 419–422 23: 341–342 disorders of the horse. Wolfe, London,
17. Cotchin E. A general survey of tumors 34. Dubielzig RR, Beck KA, Levine S, Wilson 1994, p. 303
of the horse. Equine Vet J 1977; 9: JW. Complex odontoma in a stallion. 52. Henson WR. Carcinoma of the tongue in
16–21 Vet Pathol 1986; 23: 633–635 a horse. J Am Vet Med Assoc 1936; 94:
18. Gorlin RJ, Meskin LH, Brodey R. 35. Mason BJE. Temporal teratomata in the 124
Odontogenic tumors in man and horse. Vet Rec 1974; 95: 226–228 53. Leyland A, Baker JR. Lesions of the nasal
animals; Pathological classification and 36. Fessler JF. Heterotopic polyodontia in cavity and paranasal sinuses of the horse
clinical behavior – a review. Annals of horses: nine cases 1969–1986. J Am Vet causing dyspnoea. British Veterinary
the New York Academy of Science 1963; Med Assoc 1988; 192: 535–538 Journal 1975; 131: 339–346
108: 722–771 37. Lindshaw WA, Bech KA. Temporal 54. Orsini JA, Nunamaker DM, Jones CJ,
19. Turrel JM. Oncology. In: Kobluk CN, teratoma in a horse. Compendium of Acland HM. Excision of oral squamous
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diseases and clinical management. WB Veterinarians 1986; 8: 168–171 Surgery 1991; 20: 264–266
Saunders, Philadelphia, 1995, 38. Kramer IRH, Pindborg JJ, Shear M. 55. Theon AP. Cisplatin treatment for
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20. Theon AP. Intralesional and topical 2nd edn. Springer-Verlag, Berlin, 1993, Current therapy in equine medicine, 4th
chemotherapy and immunotherapy. pp 151–156 edn. WB Saunders, Philadelphia, 1997,
Veterinary Clinics of North America 39. Pindborg JJ, Kramer IRH, Torlini H. pp 372–377
Equine Practice 1998; 14: 659–671 Histologic typing of odontogenic tumors, 56. Paterson S. Treatment of superficial
21. Rols MP, Tamzali Y, Teissie J. jaw cysts and allied lesions. World Health ulcerative squamous cell carcinoma in
Electrochemotherapy of horses: a Organisation, Geneva, Switzerland, 1971, three horses with topical 5-fluorouracil.
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2002; 55: 101–105 40. Livesey MA Wilkie IW. Focal and 57. Pulley LT, Stannard AA. Tumors of the
22. Theon AP. Radiation therapy in the horse. multifocal osteosarcoma in two foals. skin and soft tissues. In: Moulton JE, ed.
In: Veterinary clinics of North America Equine Vet J 1986; 18: 407–410 Tumors in domestic animals, 3rd edn.
equine practice 1998, 41. Slayter MV, Boosinger TR, Pool RR, et al. University of California Press, Berkeley,
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23. Dubielzig RR. Tumors of the alimentary joint tumours of domestic animals, 2nd 58. Knottenbelt DC, Edwards SER, Daniel EA.
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domestic animals, 4th edn. Iowa State of Pathology, Washington DC, 1994, equine sarcoid. Practice 1995; 17:
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59. Knottenbelt DC. A suggested clinical 65. Goetz TE, Ogilvie GK, Keegan KG, 72. Stackhouse LL, Moore JJ, Hylton WE.
classification for the equine sarcoid. Johnson PJ. Cimetidine for the treatment Salivary gland adenocarcinoma in a
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60. Pascoe RR, Knottenbelt DC. Neoplastic 66. Goetz TE, Long MT. Treatment of 73. Head KW. Salivary gland disease in
conditions. In: Manual of equine melanoma in horses. Compendium of domestic animals. In: de Burgh P,
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61. Brostrom H. Equine sarcoids: a clinical, 67. Morse CC, Saik JE, Richardson DW. Wolfe, Philadelphia, 1995, pp 367–389
epidemiological and immunological Equine juvenile mandibular ossifying 74. Biesecker JL, Marcove RC, Huvos AG,
study. PhD Thesis, University of Uppsala, fibroma. Vet Pathol 1988; 25: 415–421 Mike V. Aneurysmal bone cysts; a
Sweden, 1995, pp 9–70 68. Robbins SC, Arighi M, Ottewell G. The clinicopathological study of 66 cases.
62. Theon AP. Cisplatin treatment for use of megavoltage radiation to treat Cancer 1970; 26: 616–625
cutaneous tumors. In: Robinson NE, ed. juvenile mandibular ossifying fibroma in 75. Dabezies EJ, D’Ambrosia RD, Chuinard
Current therapy in equine medicine, 4th a horse. Canadian Veterinary Journal RG, Ferguson AB. Aneurysmal bone cyst
edn. WB Saunders, Philadelphia, 1997, 1996; 37: 683–684 after fracture. Journal of Bone and Joint
pp 372–377 69. Kawcak CE, Stashak TS, Norrdin RW. Surgery 1982; 64: 617–621
63. Knottenbelt DC, Kelly DF. The diagnosis Treatment of ossifying fibroma in a horse 76. Jacobson SA. The comparative pathology
and treatment of periorbital sarcoid in by hemimaxillectomy. Equine Practice of the tumors of bone. Charles C
the horse: 445 cases from 1974 to 1999. 1996; 18: 22–25 Thomas, Springfield, Illinois, 1971
Veterinary Ophthalmology 2000; 32: 70. Fry FL, Knight HD, Brown S. 77. Williams MA, Dowling PM, Angarano
169–191 Hemangiosarcoma in a horse. J Am Vet DW, et al. Paraneoplastic bullous
64. Kelly DF. Diagnostic problems in Med Assoc 1983; 182: 287–289 stomatitis in a horse. J Am Vet Med Assoc
nasopharyngeal amelanotic melanomas. 71. Sweigard KD, Hattell AL. Oral 1995; 207: 331–334
Equine Veterinary Education 2003; 15: hemangiosarcoma in a horse. Equine
25–26 Practice 1993; 15: 10–13

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 Section 4:  Diagnosis

C H A P T ER  12 
Dental and oral examination
Jack Easley† DVM, MS, Dipl ABVP (Equine), W. Henry Tremaine*
BVet Med, MPhil, Cert ES Dipl ECVS, MRCVS
†
Equine Veterinary Practice, LLC, Shelbyville KY 40066, USA
*Senior Lecturer in Equine Surgery, University of Bristol, Langford, Bristol BS40 5DU, UK

Introduction Equipment
Oral and dental diseases are common occurrences in horses, The technique for restraint and size of equipment needed
as evidenced by the results of studies carried out on abattoir varies for different ages and sizes of equine patients. Very
specimens.1–5 Signs of dental disease are often not apparent large (1000 kg or more) draft breeds need restraint with
to the owner until the disease is well advanced.6 Casual more heavily constructed equipment than the typical
dental examination as part of a complete physical examina­ (500 kg) riding horse. On the other extreme, the pony
tion is not sufficient to detect most equine oral or dental (100 kg) and miniature breeds require smaller equipment.
problems, as demonstrated by the reported high incidence Oral examination and dentistry on small horses may also be
and the comparatively low clinical diagnosis of dental aided by walking the horse up on an elevated platform to
disease.7 Clinical signs of dental disease are often not specific have the oral cavity at a more comfortable height for the
and may be reflected as systemic disorders, such as weight operator’s visualization and work plane. Equipment should
loss, diarrhea, colic, endocarditis, and septicemia, both in include a large noseband halter, a metal-framed dental halter
the horse and other species.8–14 In order to diagnose diseases or head stand, mouth speculum, light source, oral irrigator,
afflicting the buccal cavity, the same degree of systematic dental probes and picks, lingual and buccal retractors, and
rigor must be applied as would be the case during a lameness an intra-oral mirror or endoscope.16,17 Further details of this
investigation. equipment are given in Chapter 16.
A complete dental examination includes detailed obser­
vation and palpation of both hard (teeth and supporting
Dental signalment
bones) and soft oral tissues (lips, cheeks, tongue, palate,
gingiva, oral mucosa, salivary glands, and ducts and
Data on the horse’s owner and trainer/manager/agent/groom
muscles of mastication) for evidence of pathological
should include their names, addresses, and means of contact.
changes.
This is especially important for the person granting permis­
The basis of modern clinical therapy is achieving an
sion to work on the horse and the person responsible for
accurate diagnosis with information obtained by a clinical
payment of services rendered. The horse’s insurance status
examination and ancillary tests. Although performing a
and type of policy (mortality, loss of use, major medical,
comprehensive history and physical examination on
and surgical) should be recorded. Informed consent should
every patient having routine dental work would be a valu­
be recorded before embarking upon any corrective proce­
able service to clients, this is not practical in most cases.
dures. Recording the stable name and address and the horse’s
However, one must identify any possible medical problems
location on the premises (barn number, paddock, stall
that may impact the safe delivery of dental care. The minimal
number, etc.) can be helpful if re-examinations are needed.
dental examination must be thorough enough to detect
The horse should be identified on the record by name and
abnormalities in their early stages of development. Treat­
described by breed, color, sex, age, type of work, and any
ment can then be initiated before irreversible damage occurs.
special identifying markings, scars, brands, or tattoos.
The extent of the examination should be based on the infor­
mation obtained in the history and the findings from the
initial examination. Variations and/or abnormalities detected Dental history
at the time of the examination must consistently be docu­
mented. A standard dental record form can be an invaluable The dental history should focus on oral-, dental- and
aid in helping develop good examination habits (Fig. 12.1). gastrointestinal-related areas. Special consideration must
Computerized dental records allow information to be more be given to other body systems related to masticatory func­
available for retrieval (Fig. 12.2).15 tion or issues that may affect the safety of the horse or

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 12 Diagnosis

DENTAL EXAMINATION RECORD

Date Owner Farm name/phone Work phone

Address City State Zip Home phone

Horse reg. name Stable name Color Breed Sex Yr. foaled

Hair coat: Ex Vg G P Condition score: Feces: Fine Med. Coarse

D.age Lateral jaw excursion: N AB Palpation: + -

History: Soft tissue

#1 #2

11 11
10 10
9 9
8 7 8
7 5 5 6 11
11 6 10
10 9 #1 #2 4 9
#4 8
4
8
7 6 7
6
5 5
3 2 1 1 2 3
4 4

32 1 1 2 3

#4 #3

Comments
M3
M2 M3

M2
M1
M1
P4
P4
P3
P3
P2
P2
P1

Re-Exam Date ________________

Right C Left Right Left

upper upper lower lower
C

I3 Canines I3
I2 Reduction needed? Yes No I2
I1 I1

Fig. 12.1  An equine dental record form.

veterinarian. A history of cardiac abnormalities, respiratory show or race schedule may have an impact on when work
disease, renal problems, hepatic disease, or neurological is performed and whether drugs used to sedate or treat the
signs could affect the way the animal is restrained for exami­ horse could be considered prohibited substances. The owner
nation and treatment. The animal’s breeding history and should be questioned about the horse’s fitness and type of
pregnancy status could have an effect on dental care schedul­ exercise, temperament, stable vices, eating and drinking
ing, although it has been shown that it is safe to sedate mares habits, fecal consistency, and physical abnormalities. Spe­
at any time during gestation.18,19 Additionally, the horse’s cific questions asked could begin with these examples: has

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 Dental and oral examination

Fig. 12.2  Computerized equine dental record

incorporating digital images.

the horse gained or lost weight over the past year? Have the process while the horse eats several different types of food.
horse’s temperament or stable habits changed? Does the This can be time consuming, but it is often unwise to accept
horse train well, and what type of bridle and bit does he the owner’s report of ‘normal eating.’8 Horses with sharp
wear? Have any changes been noticed in the horse’s head enamel points may pack forage in the buccal space, pushing
carriage or demeanor when bitted? Does the horse make any the cheeks away from the upper teeth before eating grain.
noises or wear a tongue-tie when exercised? Details of the Information about water sources and drinking habits should
horse’s eating habits and vices should be taken, and changes be ascertained, and one should question if excessive saliva­
in eating or drinking patterns described. tion, oral malodor, or nasal or lacrimal discharge has been
Clinical detection of dental disease may at times be diffi­ noticed.
cult because of the subtlety of signs. These may include The diagnosis of dental-related head shaking or bit
reluctance to start eating, slow or intermittent eating, drib­ resentment may be relatively easy in cases with obvious
bling of food from the mouth (quidding), and head shaking dental disease, but is often very difficult where there is no
or head tilting when eating. Sometimes, these signs are only overt evidence. Head shaking is often attributed by lay
detectable by careful direct observation of the mastication persons to the presence of wolf teeth, their position, and/or

187
 12 Diagnosis

Table 12.1  Description of the numerical body condition

score system21

1  Poor: emaciated. Prominent spinous processes, ribs, tailhead, and

hooks and pins. Noticeable bone structure on withers, shoulders, and
neck. No fatty tissues can be palpated.
2  Very thin: emaciated. Slight fat covering over base of spinous
processes. Transverse processes of lumbar vertebrae feel rounded.
Prominent spinous processes, ribs, tailhead, and hooks and pins.
Withers, shoulders and neck structures faintly discernible.
3  Thin: fat built up about halfway on spinous processes, transverse
processes cannot be felt. Slight fat cover over ribs. Spinous processes
and ribs easily discernible. Tailhead prominent, but individual
vertebrae cannot be visually identified. Hook bones appear rounded,
but easily discernible. Pin bones not distinguishable. Withers,
shoulders and neck accentuated.
4  Moderately thin: negative crease along back. Faint outline of ribs
discernible. Tailhead prominence depends on conformation; fat can
be felt around it. Hook bones not discernible. Withers, shoulders, and
neck not obviously thin.
5  Moderate: back is level. Ribs cannot be visually distinguished but can
be easily felt. Fat around tailhead beginning to feel spongy. Withers
Fig. 12.3  Human hand infected with Staphylococcus aureus. Dental appear rounded over spinous processes. Shoulders and neck blend
practitioners should wear gloves to protect against skin abrasions from smoothly into body.
sharp tooth points. 6  Moderate to fleshy: may have slight crease down back. Fat over ribs
feels spongy. Fat around tailhead feels soft. Fat beginning to be
deposited along the sides of the withers, behind the shoulders, and
along the sides of the neck.
7  Fleshy: may have crease down back. Individual ribs can be felt, but
size. Likewise, horses with facial pain around the mental noticeable filling between ribs with fat. Fat around tailhead is soft. Fat
or infraorbital nerves may present with signs of head deposits along withers, behind shoulders, and along the neck.
shaking.8 8  Fat: crease down back. Difficult to palpate ribs. Fat around tailhead
The horse’s vaccination and deworming status should be very soft. Area along withers filled with fat. Area behind shoulder filled
determined. This is a good time to discuss these important in flush. Noticeable thickening of neck. Fat deposited along inner
preventative health topics, as further discussed in Chapter 4. buttocks.
Tetanus toxoid should be given to unvaccinated horses if 9  Extremely fat: obvious crease down back. Patchy fat appearing over
ribs. Bulging fat around tailhead, along withers, behind shoulders and
corrective dental procedures, such as wolf tooth extraction,
along neck. Fat along inner buttocks may rub together. Flank filled  
are performed or if oral abrasions occur during dental
in flush.
procedures. The owner should be questioned about the ani­
mal’s history of infectious disease, as well as the presence of
infectious or contagious disease on the farm. This informa­
tion may affect the degree of sanitation used between
patients on the premises and the degree of disinfection or
sterilization of equipment and personal items required performed must allow for safe restraint and should be
before visiting the next stables. Epidemiological studies have free of obstacles that could injure the horse, an attendant,
shown 10 % of the horse population in some regions carry or the veterinarian. An area with a high ceiling shaded
methicillin-resistant Staphylococcus aureus (MRSA). So, it is from bright sunlight with solid walls and a soft, non-slip
advised for operators working in the equine oral cavity to floor is ideal. Access to warm water and electricity are
wear gloves (Fig.12.3).20 beneficial.
If the equine patient is being examined for a particular The horse should be observed, and his temperament
dental complaint, a complete history of the problem should assessed. Hair coat and body condition should be evaluated
be ascertained and documented. It has been shown that by observation and palpation. Body condition scores
horses presented with a dental complaint are 5.8 times as range from 1–9, with 1 describing an extremely emaciated
likely to have one or more selected dental abnormalities.7 animal and 9 describing obesity (Table 12.1). The optimal
However, a complaint of a specific dental problem should condition score is between 5 and 6.21 Objective data, such
not deter the veterinarian from obtaining a complete dental as photographs and weight measured with a scale or tape
history and performing a thorough dental and physical can be recorded. These data can be a valuable tool in man­
examination. agement of dental health and patient nutrition. The animal’s
posture and stance should be observed, and abnormalities
such as swellings, injuries, and hoof problems should be
Patient observation brought to the attention of the owner/groom and noted in
the record.
Observation of the animal in its normal surroundings can The stable floor should be surveyed for grain dropped
provide information about stable management, eating from the horse’s mouth or partially chewed boluses of
habits, and vices. The area where the dental examination is quidded hay (Fig. 12.4). Feces should be examined for

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 Dental and oral examination

Fig. 12.6  Firm enlargement rostral and dorsal to facial crest. This horse
suffered from an apical infection of 207 confirmed on radiographs.

typical of the Arabian breed, may have a more curved arcade

with marked dorsal angulation of the lower 10s and 11s
(exaggerated Curvature of Spee). Breeds that typically have
long straight heads (Thoroughbred and some Warmblood
Fig. 12.4  Horse dropping grain due to poor mastication secondary to breeds) are predisposed to malocclusion of the cheek teeth,
periodontal disease.
leading to rostral and caudal cheek tooth overgrowth (‘hook’)
formation. Miniature horses and ponies are more prone to
dental overcrowding and subsequent misplaced or
malerupted dentition.

Extraoral physical examination

During the basic physical examination (temperature, pulse,
respiratory rate, auscultation of heart, lungs, and abdomen)
the clinician can assess the horse’s temperament. The
examination should be performed using techniques of
good horsemanship that gain the confidence of the horse
and owner.
The head should be evaluated for symmetry, balance, and
gross abnormalities that may give clues to dental problems.
Standing at the horse’s side, head shape and conformation
should be assessed, and bumps or protuberances noted.
Young horses between the ages of 2.5 and 4 years will have
symmetrical, non-painful bony enlargements beneath the
Fig. 12.5  Manure from horse with poor mastication due to periodontal mandible and/or over the maxillary region as a result of
disease. normal eruption cyst development beneath the developing
permanent teeth. If these enlargements are hot, swollen,
asymmetrical, or associated with a draining tract, apical
infection should be suspected (Fig. 12.6).
volume and consistency, as this can reflect how well the The eyes should be clear and free from lacrimal discharge.
horse is masticating its feed (Fig. 12.5).22 Manure should be Standing directly in front of the horse, the ears, eyes, facial
semi-moist, and fecal balls should be formed. Feces with crests, and nasal bones should be symmetrical. The tempo­
long forage stems or whole grain indicate poor mastication. ralis and masseter muscles and temporomandibular joints
Long stems in poorly masticated feed can predispose the should be observed and palpated. The mouth should be
horse to esophageal choke, intestinal impaction colic, or opened slightly, and the frontal and maxillary sinuses per­
diarrhea. cussed. The parotid salivary glands and intermandibular
The horse’s body and head type should be assessed and lymph nodes should be palpated, as should the ventral
recorded. Head conformation can be reflected in the confor­ aspect of both sides of the mandible, for the presence of
mation of the dental arcades. Horses with short dished faces, enlargements. The blood vessels and parotid salivary duct at

189
 12 Diagnosis

the rostral edge of the masseter muscle should be palpated. The labial mucosa should be salmon-pink and glisten
It has become popular to evaluate acupuncture points in the with saliva. Ulcers or erosions should be documented, and
temporal region to aid in the diagnosis of dental or myofa­ their cause determined, keeping in mind the possibility of
cial problems.23 The hands should be placed under the nose viral lesions, such as vesicular stomatitis, which is a report­
band of a loose halter and pressure exerted on the cheeks at able zoonotic disease in some countries. If dental abnor­
the level of the upper cheek teeth. Palpation from the level malities are suspected from the history or examination,
of the medial canthus of the eye, progressing rostrally over consider observing the horse eating before the mouth is
the masseter muscle to the level of the nasal notch, allows washed for the oral examination and before sedation is
detection of abnormal wear patterns on the lateral aspect of administered.
the upper cheek teeth. If the horse resists this maneuver by When evaluating the horse’s eating patterns, a distinction
tossing its head, it is most likely the result of pain from sharp must be made between the horse having trouble with pre­
enamel points pressing against the buccal mucosa. If such hension and mastication and the horse that is dysphagic
sharp points are present, they should be floated prior to (unable to swallow). Prehension requires neuromuscular
using a full-mouth speculum. Otherwise, as the mouth is coordination and an intact jaw and incisor arcade. Mastica­
opened with the speculum in place, the cheeks are pushed tion is usually altered by dental disease or abnormalities in
tightly against the sharp enamel points, and the horse will the jaws, muscles, or temporomandibular joints. Tongue
object to opening its mouth and resist examination. lesions or basal ganglion problems can also adversely affect
The nasal passages are observed and the false nostrils pal­ prehension and mastication. Swallowing is a more complex
pated, with any asymmetry of air flow, odor, or discharge process, and neurological, muscular, or mechanical abnor­
from the nostrils noted. Sepsis of the cheek teeth commonly malities in the pharynx or esophagus should be considered
results in either nasal or paranasal sinus sepsis or respiratory in addition to dental disease. Rabies is a fatal zoonotic
obstruction. disease that, in its early stages in the horse, mimics other
The lips should be observed and palpated for bit injuries, types of prehension and swallowing disorders. Equine
noticing especially any scars or ulcers in the commissures, practitioners and any assistants working in horses’ mouths
and any focal lesions that may indicate previous suppurative should be vaccinated for rabies and have antibody titers
tracts from incisor apices. The lips of grey horses are a checked periodically in areas where rabies is endemic.24
common site for melanomas. The upper lip should be rolled While standing in front of the horse, the lips are parted
up and the underside examined for a tattoo (Table 12.2). and the incisor teeth evaluated for number, shape, and sym­
metry. When viewed from the front, the occlusal line of the
upper and lower incisors should be horizontal or parallel to
the ground and the presence of diagonal incisor malocclu­
sion is recorded (Fig. 12.7 A,B).25 When viewed from the
Table 12.2  A note on lip tattoos
side, the incisor occlusal surfaces should be parallel to the
Most horses that race in the USA are permanently identified with a angle of the facial crest, which is usually about 10–15° rela­
freeze brand on the neck or a tattoo on the upper lip. Each breed tive to the lower molar table surface. The incisors should be
registry has a different alphanumeric system for identifying horses by checked for anatomical characteristics used in assessing the
their upper lip tattoo. horse’s dental age, and the estimated age is then compared
with the horse’s real age, with a discrepancy between these
The Jockey Club of North America uses an alphanumeric system that
consists of a letter of the alphabet followed by numbers. The letter two values possibly indicating abnormal incisor develop­
corresponds to the year the horse was foaled, with 1997 starting a new ment or wear. It is important to acknowledge the variation
26-letter series. Therefore, 1996 would be Z and 1998 would be B. Horses between horses in their incisor appearance and real age26–29
imported into the USA are identified with an asterisk (*) at the beginning (see Ch. 7). The incisors should be observed while the jaw
instead of a letter. is moved. Rostrocaudal movement of the mandible can be
The American Quarter Horse Associationer (AQHA) uses a more random
evaluated by observing the relationship between the upper
alphanumeric system of five numbers in older horses and since 1983, and lower incisor when the chin is raised and lowered. A
four numbers followed by a letter. However, in 2009 the last books with normal foal has 3–4 mm (adult horse 6–8 mm) of rostral-
the numbers followed by Z were sent out to lip tattooers. The new caudal jaw excursion when the head is raised and extended
books will have a series of 5 numbers. In the past, AQHA has advised as much as possible and then flexed back into a vertical posi­
owners that a series of 5 numbers indicates a paint tattoo number. That tion.30,31 Horses with severe wear abnormalities, such as tall
will no longer be accurate in 2009 or later. cheek teeth, focal overgrowths, or a step-mouth may have
The American Paint Horse Association uses a numbering system that limited rostral-caudal range of mandibular motion.
consists of five digits. The first digit corresponds to the last digit of the Lateral jaw excursion is best evaluated by standing to one
horse’s year of birth. These first digits would be repeated every 10 years. side of the horse and holding the head stationary with one
hand on the bridge of the horse’s nose. The other hand is
Since 1982, the United States Trotting Horse Association has used a
used to grasp the mandible and, while pressing the mouth
system starting with A followed by three or four numbers (A in 1982 to
Z in 2002). Horses born prior to 1982 were tattooed with three digits
shut, move it from side to side. As the jaw is moved from
followed by a letter. Starting in 1996, 98% of trotters are freeze branded one side to the other, the range of lateral movement present
only. before contact is made by the cheek teeth (and thus separat­
ing the incisors) is recorded. The more rostral cheek teeth
Arabian and Appaloosa horses that race in the USA require lip tattoos for
contact first, and the more caudal cheek teeth later contact
identification. Their six-digit registration number is tattooed on their
upper lip.
as the jaw moves more laterally. Horses that have had their
rostral cheek teeth reduced in height have to move the lower

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 Dental and oral examination

Fig. 12.7  (A) 14-year-old American Quarterhorse

with a facial curvature. This horse was injured as a
yearling, and 208 did not erupt, leaving only 5
cheek teeth in the left upper arcade. (B) Incisors of
the same horse, with diagonal incisor malocclusion
(200/400 DIM).

A B

jaw further before their incisors separate. Excursion to molar Male horses between 4 and 6 years old may have canine
contact (EMC) is the distance the mandible travels laterally teeth in various stages of eruption. The upper canines usually
to cheek teeth contact. The average light breed horse has an erupt 2–8 months after the lowers. Eruption cysts or tenting
EMC of 12.3 mm (SD = 3.1 mm), while miniature horses of the mucosa with ulceration over these teeth can cause oral
and ponies have an EMC of 5–6 mm, and draft breeds an pain and bitting problems. Long sharp canine teeth can be
EMC of 15–16 mm.32,33 a danger to the examiner, and care should be exercised to
The second measurement noted in this procedure is the avoid injury when manually examining the mouth. About
total lateral distance the mandible travels. By observing the 25 % of mares have one – four rudimentary canine teeth.38
incisors and listening to and feeling the molar arcades grind Dental calculus around the canines leading to gingivitis is
on one another, one can gain information about the occlusal common in older horses.
slope of the cheek teeth and the symmetry of the occlusal The upper and lower interdental spaces should be observed
contact between the upper and lower cheek teeth.34–36 The and palpated. By firmly running a thumb over the mucosa,
average light horse can move the center of the mandibular one can feel for protuberances above or below the gingiva
incisors laterally 45 mm ± 5 mm while chewing.37 Normal and observe the horse’s response to pressure. The lower bars
lateral excursion produces a relatively even, subtle to moder­ should be checked for bony irregularities, mucosal ulcers, or
ate vibration and sound. Deviations from this can be an thickenings or the presence of wolf teeth.39 Remodeling of
indication of abnormal dental contact due to cheek teeth the mandibular cortex rostral to the 2nd premolar can be
overgrowths. It must be kept in mind that this maneuver palpated through the gingival mucosa and can indicate pre­
does not replicate the chewing motion of the horse as out­ vious bit trauma, and may be associated with bit-sensitivity.
lined in Chapter 6. If the horse resists this part of the dental The upper diastema is then palpated for bony abnormalities
examination, sedation may be indicated to help the horse and the presence of wolf teeth. Unerupted wolf teeth, referred
relax and allow a more thorough physical examination. With to as ‘blind wolf teeth,’ can cause oral discomfort and train­
sedation, a complete dental examination can be carried out ing problems in bitted horses. The distance from the com­
more safely and thoroughly, although the benefits of this missures of the lips to the rostral edge of the first cheek teeth
may require explaining to some owners who may have an should be noted as this varies among horses. This distance
innate apprehension of the perceived side-effects of sedation affects the ease with which one works on the rostral teeth
(see Chapter 15). and may affect the most comfortable position of the bit in
a working horse.
Oral examination The tongue should be checked for function, and any ana­
tomical abnormalities noted. Tongues are frequently injured
The mouth is the window into the body. For too long, many from harsh bits or neglected tongue ties and from sharp
equine veterinarians have assumed erroneously that the gas­ teeth. The so-called ‘lampas’, or thickening of the palatal
trointestinal tract starts with the esophagus. The oral mucous mucosa just behind the upper incisors, is common, and a
membrane is a thin sheet of tissue that permits the veterinar­ normal feature in young horses that are erupting permanent
ian to view changes in vessels and connective tissue beneath dentition. The hand can be introduced into the interdental
the oral mucosa. There are relatively few sensory nerve space and a thumb pressed on the hard palate to make the
endings in the gingiva, which makes it a safe area to depress horse open its mouth. Great care should be exercised when­
for observing vascularity and capillary refill time (CRT). ever a finger is placed in the mouth, to avoid serious injury.

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 12 Diagnosis

Fig. 12.9  View of the oral cavity with a mouth speculum, basket-type
retractor, and attached light in place.
Fig. 12.8  Horse sedated with head resting on a dental stand. The mouth is
open with the speculum in place. The operator is seated in a comfortable
position, allowing complete digital and visual examination of the oral cavity.

The easiest and safest way to thoroughly evaluate the oral

cavity is by using a full-mouth speculum and a bright light
source. Prior to placement of the speculum, it is advisable
to rinse excess food from the mouth with a syringe, hose, or
other device. To place the McPherson-type speculum in the
mouth single-handed, the examiner stands to the left side of
the horse. With the left hand holding the mouthpiece and
the right hand holding the poll strap, the mouthpiece is
introduced between the incisors in the same manner as a bit.
The left thumb and forefinger are used to open the mouth
and guide the mouthpiece into place between the incisors
while the right hand applies steady tension to the halter
strap from behind the horse’s poll. When the speculum is
properly positioned, the left hand tightens the halter’s buckle
to adjust the strap length until the speculum strap is snug.
The bite plates are adjusted to square them with the incisors. Fig. 12.10  Sharp enamel points on the 210 causing a deep buccal
A final check is made to ensure that the teeth and incisor ulceration. This photo was taken using a rigid endoscope with a 45° optic.
plates are free of tongue, lips, and examiner’s digits when
opening the speculum. It is important to loosen the nose­
band and chin strap to allow a stable yet comfortable fit on
the horse. The jaws of the speculum are opened one notch 12.9). The oral soft tissues should be observed with special
at a time alternating each side until the jaws are adequately attention paid to the palate, tongue, and buccal mucosa (Fig.
opened. If the mouth cannot be opened with the speculum 12.10). The teeth should be evaluated for conformation,
in place, the temporomandibular joints and bony structures position, number, and abnormalities. Enamel points on the
of the jaw should be carefully evaluated before excessive buccal and lingual enamel folds or cingula usually do not
force is placed on the jaw. At this point, the oral cavity is protrude beyond the level of occlusal surface of the cheek
ready for visualization and palpation. Use of a head support teeth. The acute angle between the vertical edge of the tooth
stand or metal frame dental halter is recommended to and the occlusal surface can cause sharp enamel points to
elevate the head of a sedated horse to a comfortable height look and feel quite prominent. A dental pick with a long
for good visualization and palpation (Fig. 12.8). shaft can be used to probe the four corners of the cheek teeth
To examine the oral cavity, good illumination is critical. A to detect and clean out periodontal pockets (Fig. 12.11A, B).
battery-operated light that attaches to the upper incisor plate A calibrated pick can be used to measure gingival pocket
of the speculum or a powerful headlight provides good illu­ depth, which will range from 0.5–12 mm for normal teeth.
mination while allowing both hands to be free for intra-oral It has been shown that gingival pocket depth measurements
procedures. A blade retractor fitted with an illuminator aids at the corners of the teeth significantly increases with perio­
in the evaluation of the buccal recesses. A basket retractor dontal disease.40,41 Defects have been found over the pulp
keeps the tongue and buccal mucosa pulled away from the horns on the occlusal surfaces of a large number of periapi­
teeth for good visual access to the last few cheek teeth (Fig. cally infected teeth and can be detected by carefully probing

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 Dental and oral examination

Fig. 12.11  (A) An equine oral mirror used to visualize an ulcerated area in the palatal tissue above a small diastema between 108 and 109. (B) A periodontal
probe used to clean the pocket between 109 and 109. Gastrophilus (bot fly) larvae were removed from the shallow ulcerated area.

Fig. 12.12  A fine dental pick is used to explore the #1 pulp horn of 106.
This pulp horn contained plant fibers in the area that should be covered Fig. 12.13  The caudal aspect of the left lower dental arcade is ramped. The
with firm secondary dentin. This is a common finding in teeth with apical crown height above the gum helps determine whether this is a true caudal
infections and pulpitis. dental elongation (hook) or simply the last molar erupting in the curve of
the jaw (Curvature of Spee).

the secondary dentin of the occlusal surfaces of suspect teeth An oral examination is not complete without evaluating
(Fig. 12.12).3,42,43 the mouth with the aid of an equine dental mirror or
The oral cavity should be palpated, feeling the buccal, ridged endoscope. A dental mirror designed for use in the
occlusal and lingual surfaces of all four arcades. The gingival horse’s mouth needs to have a diameter of at least 5 cm set
margins of the cheek teeth should be uniform with no feed at 30–45° and should be set on a rigid shaft long enough
packed between them. The crown height should be the same to reach the back of the horse’s mouth. Warming the mirror
on the rostral and caudal aspect of each tooth, but should in hot water or applying an anti-fogging spray helps keep it
be taller on the buccal aspect of the upper and the lingual clear. The rigid shaft allows the mirror to retract the tongue
aspect of the lower cheek teeth. Any deviation or asymmetry and buccal tissue as it is moved into the more caudal parts
in the cheek teeth occlusal surface height or angle should be of the mouth. Oral endoscopy has been found to be superior
noted (Fig. 12.13). Each cheek tooth crown should be to all other examination methods in identifying all types
grasped between the thumb and forefinger and checked for of dental disease, except for occlusal wear abnormalities
stability, noting any movement or pain reaction. The occlu­ (Fig. 12.14).44–47
sal surfaces of the cheek teeth should be palpated, noting
any defects or asymmetry in the occlusal crown surface,
bearing in mind that a defect in one cheek teeth row is
Oral endoscopy
usually reflected in a wear abnormality or defect in the oppo­ Dental endoscopy facilitates the exploration, visualization,
site row. magnification, and recording of lesions of the oral cavity and

193
 12 Diagnosis

Fig. 12.15  Double crown fracture of 210. Buccal and lingual slab fracture
fragments have been lost, and the surrounding gingiva healed. This photo
was taken using a rigid endoscope with a 90° optic.

Fig. 12.14  Proper positioning for performing an oral endoscopic

examination. The monitor should be positioned at the level of the horse’s
shoulder to allow good orientation.

has a great role to play in education as well as the demon­

stration and documentation of lesions within the oral cavity.
Dental endoscopy enhances the diagnostic value of the oral Fig. 12.16  Endoscopic occlusal view of an apically infected 409. A flexible
examination and has become a routine part of dental and probe has penetrated the degenerate secondary dentin overlying the #1
oral disease investigations. pulp horn. This photo was taken using a rigid endoscope with a 90° optic.
Dental endoscopy can be performed with either a flexible
fiberoptic or videoendoscope but is much easier using a
rigid telescope, such as an instrument designed for human surface in turn, and noting any defects in the occlusal surface
laparoscopy, which is less vulnerable to traumatic damage that may be of pathological significance (Fig. 12.15). Any
by the teeth. potential defects in the surface, particularly of the secondary
A 40–50-cm telescope with a 30–90° viewing angle is dentin corresponding to the pulp horns or areas of infundib­
ideal. The durability is improved if the telescope is protected ular cemental hypoplasia, are re-examined while inserting a
in a stainless steel sheath. An additional outer plastic sheath fine occlusal probe or pick into the defect (Fig. 12.16). The
is a useful addition to dampen any vibrations when the endoscope is then rotated and repositioned to examine the
telescope contacts the rostral teeth during examinations. The palatal mucosa and interdental spaces, noting any fibrous
telescope is coupled to a chip camera and monitor to enable food entrapment and diastema.
viewing and, if necessary, recording of the images. More The endoscope is finally rotated to the buccal aspect of
recently, a specifically designed oral endoscope, angled at 106, and advanced caudally to identify diastema, displaced
90° to the shaft with chip camera and image capture, has teeth and in particular, mucosal ulcers. The gag may need to
become commercially available. be loosened slightly to enable sufficient cheek tooth retrac­
Horses should be sedated for dental endoscopic examina­ tion to thoroughly explore the buccal mucosa. Deep perio­
tions. The ideal depth of sedation results in the horse resting dontal pockets are thoroughly cleaned using a pick and
its chin on a stand or suspended halter with a low probabil­ water jet and then re-examined for the presence of inflamed
ity of upward jerking of the head. Tongue movement can or granulating tissue (Fig. 12.17). The findings for each
impair a thorough endoscopic examination. Additional arcade are annotated into the dental chart, and the second
muscle relaxation can be achieved using 5–10 mg of arcade commencing with 206 is examined. The mandibular
diazepam, IV. arcades are examined in a similar fashion. When examining
The endoscopic examination is always preceded by a thor­ the mandibular arcades, the lingual aspect of the arcade may
ough visual and digital examination of the oral cavity. Start be visualized more successfully if the tongue is retracted.
with examining the occlusal surfaces and buccal and lingual Oral endoscopy has been invaluable in the identification
aspects of all teeth beginning with cheek tooth 106 and then of open pulp horns, infundibular caries, periodontal disease,
advancing the endoscope caudally, inspecting each occlusal and oral soft tissue lesions, which are almost impossible to

194
 Dental and oral examination

confirm whether or not the discharge is coming from the

nasomaxillary opening. Malerupted teeth have been seen to
obstruct the nasal passages, which can make passing an
endoscope difficult if not impossible on the affected side.
Sinoscopy has been valuable in diagnosing and treating
some sinus disorders without the need for exploratory flap
sinusotomy, as described in Chapter 14.49,50,51

Dental records and treatment planning

The horse’s signalment, use, and management should be
recorded. Pertinent history should be noted, with special
emphasis on digestive system or performance problems. The
horse’s general body condition should be recorded, and a
numbered body score assigned. The results of the mastica­
tory system examination should be recorded, and problems
listed in order of significance. A plan for treatment of each
Fig. 12.17  Endoscopic view of a 310–311 diastema 3 months after
periodontal treatment. Feed is no longer packing in the periodontal pocket, problem should be outlined based upon the results of
and the mucosa is healed. This photo was taken using a rigid endoscope history, clinical findings, and oral examination before pro­
with a 90° optic. ceeding with any dental work. This problem-orientated
approach is important because the owner and/or trainer
should be informed of any abnormalities, given a plan for
identify on the most thorough visual examination. The pres­ treatment, and an estimate of the cost before any corrective
ence of small fissures in the secondary dentine may indicate procedure is performed. An owner consent statement is
a communicating tract between the oral and pulp cavities, often included in record forms and can minimize problems
or previous pulpal insult that has resulted in failure of sec­ should a legal claim be filed against the veterinarian or a bill
ondary dentin production in the coronal pulp horn. A fine come in dispute for collection. Recording images, videos,
pick can be inserted into the fissure in an attempt to deter­ and radiographs digitally allows these images to be incorpo­
mine its depth. Infundibular cemental hypoplasia is com­ rated in the computerized dental record.15,52
monly observed by dental endoscopy. The size and shape of
the infundibula depends on the age of the horse. In young
horses, the presence of wider infundibula that resemble Oral and dental charting
incisor cups, is normal. In older horses, infundibular cemen­ Charting is the process of recording the state of health or
tal hypoplasia most commonly affects the 109 and 209, and disease of the teeth and the oral cavity.53 To properly chart
increases the likelihood of food impaction and decay (Fig. the mouth, the dental formula and anatomical locations in
12.17). After removal of the entrapped food, the extent of the mouth must be standardized to make documentation
inflammation associated with periodontitis and the depth of consistent. Use of standard abbreviations for dental terms to
periodontal pockets, can be assessed. The angled view and describe anatomical boundaries, abnormalities, diagnostics
magnification provided by endoscopy often reveal small and therapeutic procedures make communication possible
buccal or lingual ulcerations. between equine practitioners and other colleagues in both
the veterinary and human dental professions.16,54
Ancillary diagnostic tests The American Veterinary Dental College Nomenclature
and Classification Committee has endorsed the use of the
If the initial dental examination findings reveal signs of Triadan tooth numbering system55,56 (see Ch. 5).
dental disease, other diagnostic techniques can be employed To fully understand equine tooth development and
to make a more definitive diagnosis. Where plant awns or anatomy and to properly document abnormalities for dental
bot fly larva are detected, soft tissue lesions inside the oral record keeping, certain oral topographical terms have been
cavity should be assessed grossly, and surface scrapings taken defined. For a unique identification of each surface of a
for microscopic evaluation. Larger oral masses can be biop­ tooth, the following descriptions are used:
sied for histopathology. Molecular methods of tissue testing • Apical: toward the apex (or root once developed)
permit definitive identification when standard culture and • Occlusal: masticatory surface
phenotypical criteria are inconclusive (see Ch. 11). Skull • Vestibular: toward the vestibule of the cheeks or lips
radiographs, both plain and contrast film studies, and intra- • B buccal: toward the cheeks
oral radiographs give added information about dental, • Labial: toward the lips
osseous, and sinus structures48 (see Ch. 13). Other imaging • L lingual: toward the tongue in the upper or lower
modalities, such as ultrasonography, computerized tomog­ arcade
raphy, nuclear scintigraphy, or fluoroscopy may reveal a • P palatal: toward the palate in the upper arcade
more accurate picture of some dental abnormalities. • IPM or D: proximal or interproximal: between teeth,
Disease of the upper last four cheek teeth may be associ­ mesial or distal
ated with sinus disease, commonly presenting with unilat­ • Mesial: anterior or rostral (interproximal surface nearest
eral nasal discharge. Endoscopy of the nasal passages can to mandibular symphysis)

195
 12 Diagnosis

• Distal: posterior or caudal (interproximal surface • BS: bit seat (rounding the rostral margins of 2nd
farthest from mandibular symphysis). premolars).
Computerized dental charting and record keeping are used • I/OD: incisor odontoplasty: incisor crown reduction.
in human and veterinary dentistry. Standardized abbrevia­ • TI: ‘tooth impacted’, ‘blind’ (not completely erupted
tions and record forms are essential to make this transition and completely or partially covered by bone or soft
into equine practice. Some common dental abnormalities tissue).
and a standardized grading system are presented to help • RRT: retained root tip.
chart dental findings in a uniform manner. The system pre­ • RTR: retained tooth root.
sented here has been proposed by the American Academy of Other shorthand systems have been used to grade or stage
Veterinary Dentistry and the American College of Veterinary dental lesions.
Dentistry but other systems and abbreviations are in use.
• TO: tooth overgrowth: for incisors determined after
Periodontal Disease Index adapted
cheek teeth reduction to achieve arcade balance.
for equine anatomy57
• MAL2: Class II malocclusion, overbite, brachygnathism,
parrot mouth. 0 Normal
• MAL3: Class III malocclusion, underbite, prognathism, 1 Local gingivitis with hyperemia and edema: no
monkey mouth.   attachment loss (probing depth, less than 5 mm)
• CV: ventral curvature of the incisor arcade, ‘smile’. 2 Early periodontal disease (less than 25% attachment
• CD: dorsal curvature of the incisor arcade, ‘frown’.   loss)
• DGL or DIM: diagonal incisor arcade. Given a number 3 Moderate periodontal disease (less than 50%
with respect to which lower incisor arcade is the   attachment loss or bone loss)
longest. (i.e., DGL/4, 400 arcade longer or the two 4 Advanced periodontal disease (more than 50%
longer arcades 200/400DIM). (See Fig. 12.7.)   attachment loss or bone loss)
• PTS: sharp enamel points (these can affect individual
teeth, entire rows of teeth, or all four arcades
uniformly). These enamel elongations have been Tooth Mobility Index57
classified as mild (1–3 mm tall), moderate (3–5 mm 0 Normal with no crown mobility
tall), severe (>5 mm).47 1 First distinguishable sign of movement up to 0.5 mm
• HK: crown hook, elongation longer than wide. 2 Movement of the crown up to 3 mm
• BK: beak, small enamel point on the ends of the 3 Movement greater than 3 mm in any direction.
arcade.
• RMP: ramp, elongation wider than long.
• STP: step. Grading of infundibular caries3
• WV: – wave. Grade 0 – No visible caries
• ETR: excessive transverse ridge. Grade 1 – Caries of the infundibular cementum
• CUPD – cup in central portion of crown. Grade 2 – Caries of infundibular cementum and
• TC: tall crown. surrounding enamel
• BI (L, A, or U): buccal injury (laceration, abrasion, Grade 3 – Caries of infundibular cementum, enamel, and
ulcer). dentin
• LI (L, A, or U): lingual injury (laceration, abrasion, Grade 4 – Splitting of the tooth as a result of caries
ulcer). Grade 5 – Loss of tooth due to caries.
• PD: periodontal disease, stage 1–4.
This system is used on the sample dental charts provided. A
• PP: periodontal pocket, a depth in mm can be assigned.
dental chart can be used to record the examination, assess­
• FX: fracture.
ment, and pathology. A second diagram can be used to
• CAL: calculus.
denote the specific treatment and post-treatment result or a
• RD: retained deciduous cap.
single diagram can be used as a combined report form.
• CA: caries.
• INF/CA-infundibular caries, grade 1–5.
• SN: supernumerary.
• O: missing tooth. Summary
• WC: worn crown.
• ROT: rotated. The basis for a complete equine dental examination is the
• X: extraction, simple. development of a routine treatment plan that is used on each
• 506X, 606X, etc. (cap extraction or retained deciduous patient. By utilizing proper restraint techniques and equip­
tooth removal). ment, a thorough examination can be performed with
• 105X (wolf tooth extraction). minimal stress to the horse and risk of injury to the veteri­
• XSS: surgical extraction. narian. Finally, a complete written record of the dental
• OD: odontoplasty (reduction of excessive crown from examination, findings, treatment plan, and follow-up rec­
occlusal surface). ommendations is essential for the long-term management
• FTL: float (reduction of lingual and buccal enamel of equine oral health. For a visual demonstration of the oral
points). examinations, view the accompanying DVD.

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 Dental and oral examination

Acknowledgments
Author wishes to thank veterinarians Oliver Liyou, Ed Early,
Robert Baratt, and Shelby Life editor, James Mulcahy, for
their photo contributions to this chapter.

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endocarditis of dental origin in a horse. 204 diagonal incisor malocclusion World Equine Dental Congress
Equine Vet Educ 2008; 245–250 corrections in the horse. J Vet Dent 2007; Proceedings 1997, pp 92–95
12. Tamzil Y. Chronic weight loss syndrome 24: 145–149 41. Dixon PM, Tremaine WH, Pickles K, et al.
in the horse: a 60 case retrospective 26. Walmsley JP. Dental aging in horses Equine dental disease part 2: a long term
study. Equine Vet Edu 2006; 372–378 between five and seven years of age. study of 400 cases: disorders of
13. Pavlica Z, Petelin M, Juntes P, et al. Equine Vet Edu 1993; 5 development and eruption and variations
Periodontal disease burden and 27. Richardson JD, Lane JF, Waldron KR. Is in position of cheek teeth. Equine Vet J
pathological changes in organs of dogs. dentition an accurate indication of age in 1999; 31: 519–528
J Vet Dent 2008; 25: 97–105 the horse? Vet Record 1994; 135(2): 42. van den Enden MSD, Dixon PM.
14. duToit N, Burden FA, Dixon PM. Clinical 31–34 Prevalence of small occlusal pulpar
dental examinations of 357 donkeys in 28. Richardson JD, Cripps PJ, Lane JG. An exposure in 110 equine cheek teeth with
the UK: part 2, Epidemological studies evaluation of the accuracy of ageing apical infections and idiopathic fractures.
on the potential relationships between horses by their dentition. Vet Record Vet J 2008; 178: 364–371
different dental disorders, and between 1995; 137(5): 117–121 43. duToit N, Burden FA, Kempson, SA, et al.
dental diseases and systemic disorders. 29. Muylle S, Simoens P, Lauwers H. Aging Pathological investigation of caries and
Equine Vet J 2009; 41(4): 395–400 horses by an examination of their incisor occlusal pulp exposure in donkey cheek

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teeth using computerized axial 48. Barakzai SZ, Dixon PM. A study of Lippincott-Raven, Philadelphia, New
tomography with histology and open-mouthed oblique radiographic York, 1997, p. 96
ultrastructural examinations. Vet J projections for evaluating lesions of the 54. Pence P. The dental examination. In:
2008; 178: 387–395 erupted (clinical) crown. Equine Vet Edu Pence P, ed. Equine dentistry: a practical
44. Tremaine H. Equine endoscopy in the 2003; 5(3): 183–188 guide. Lippincott, Williams and Wilkins,
horse. Cl Tech in Eq Pract 2005; 4: 49. Freeman DE. Sinus disease. Vet Clinics N Philadelphia 2002, pp 53–78
181–187 Am Eq Practice 2003; 19: 209–243 55. Floyd MR. The modified Triadan system:
45. Goff C. A study to determine the 50. Ruggles AJ, Ross MW, Freeman DE. nomenclature for veterinary dentistry.
advantages of oral endoscopy for the Endoscopic examination of normal J Vet Dent 1991; 4: 18
detection of dental pathology in the paranasal sinuses in horses. Vet Surg 56. Foster DL. Nomenclature for equine
standing horse. Am Assoc Eq Pract 1991; 20: 418–423 dental anatomy based on the modified
Proceedings 2006; 52: 266–268 51. Ruggles AJ, Ross MW, Freeman DE. Triadan system. Proceedings, Annual
46. Easley J. How to perform and interpret Endoscopic examination and treatment Meeting of the International Association
an endoscopic examination of the equine of paranasal sinuses in 16 horses. Vet of Equine Dental Technicians, Detroit,
oral cavity. Am Assoc Eq Pract Surg 1993; 22: 508–514 1993, p. 35
Proceedings 2008; 54: 383–385 52. Galloway S. Equine oral photography. 57. Klugh DO. Periodontal disease. In:
47. Simhofer H, Griss R, Zenter K. The use of Notes from Am Assoc Eq Pract Dental Current Therapy in Equine Medicine 6.
oral endoscopy for detection of cheek Wet Lab 2008, Lexington, KY Robinson EN, ed. Sprayberry KA.
teeth abnormalities in 300 horses. Vet J 53. Wiggs RB, Lobprise HB. Veterinary Saunders, St Louis 2009, pp 328–
2008; 178: 396–404 dentistry principles and practice. 334

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 Section 4:  Diagnosis

C H A P T ER  13 
Dental imaging
Safia Z. Barakzai BVSc, MSc, DESTS, Dipl ECVS, MRCVS
Royal (Dick) School of Veterinary Studies, University of Edinburgh, Easter Bush Veterinary Centre, Roslin, Midlothian EH25 9RG, UK

Introduction Radiography
Imaging is an extremely important diagnostic tool for Radiographic techniques
evaluation of equine dentition, particularly for those parts
of the teeth and associated structures that cannot be evalu­ Familiarity with correct radiographic techniques is probably
ated during oral or endoscopic examinations. Radio­graphy the single most important factor in obtaining diagnostic
is still the most widely used and accessible diagnostic tech­ quality radiographs of the equine skull and cheek teeth.
nique for veterinarians in general practice and the adoption The radiographic techniques described in this chapter are
of computed and direct digital radiography in many equine applicable to all equine practice situations, because portable
practices has undoubtedly resulted in improved image radiography machines are adequate for obtaining all radio­
quality as compared with traditional film techniques. Radio­ graphic projections of the equine teeth. Exposure require­
graphy produces a two-dimensional image of a three- ments are not high for equine dental radiography, especially
dimensional structure, and therefore, superimposition of if cassettes with rare-earth intensifying screens are used.
the anatomically complex structures of the equine skull can Excellent quality radiographs can be obtained in the stand­
present challenges to radiographic interpretation in some ing, heavily sedated horse, and consequently there is no
cases. In recent years, the use of three-dimensional imaging requirement for general anesthesia.
techniques, particularly computed tomography (CT), has
become increasingly widespread. These techniques have Equipment
led to significant improvement in our ability to accurately
diagnose disorders of the equine dental structures and X-ray machines
the anatomical regions that are closely associated with Both portable and gantry-mounted machines can be used to
them, by their ability to produce high resolution images obtain X-rays of the equine skull. It is extremely useful if the
in multiple planes, and three-dimensional reconstructions X-ray machine can be moved through a range of angles in
of areas of interest, as seen later in this chapter. Magnetic three dimensions in order to allow the user to more readily
resonance imaging (MRI) is most useful for investigation obtain accurately positioned, oblique radiographs in stand­
of soft tissue structures of the equine skull, and, in particular, ing horses; however, movement in two dimensions is ade­
the central nervous system; however, limitations in its quate. It is also advantageous (but not essential) if the light
ability to image structures containing mineralized material beam diaphragm can be rotated to allow collimation of the
and gas mean that the technique is not ideal for dental primary beam in any direction, because the horse’s skull
imaging. is usually not aligned in a truly horizontal or vertical
Scintigraphy reflects active physiological processes rather position.
than the structural features portrayed by radiography, ultra­
sonography, CT, or MRI. The ability of scintigraphy, using
99m
Technetium (99mTc) bound to phosphates, to detect bone
Radiation safety
remodeling before changes become radiographically appar­ Radiation safety should be strictly adhered to when taking
ent (because increased bone turnover usually precedes struc­ equine head radiographs, because personnel holding the
tural change) is one of the key advantages of this technique horse and the cassette are potentially close to the primary
in the equine patient. The main application of scintigraphy beam. The primary beam should be collimated to include
in the equine upper respiratory tract is the investigation of only the areas of interest, and the hands of personnel should
potential periapical infection of the cheek teeth where it can be kept as far as possible from it. All assisting personnel
often help differentiate between dental sinusitis and other should wear lead aprons, lead gloves, and radiation exposure
causes of sinusitis. badges (dosemeters), and should maintain a distance of at

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 13 Diagnosis

least 1 m and preferably 2 m from the primary beam. If staff Table 13.1  Suggested exposures for various radiographic
are required to hold horses or cassettes for radiography on projections of the equine skull. Exposures have to be altered for
a regular basis, consideration should be given to providing different X-ray machines, different film-screen combinations, and
them with extremity dosemeters and thyroid guards. Heavy varying size of patient
sedation of the horse reduces head movement and thereby
reduces the need for repeat exposures due to movement Region Projection (s) kV mAs
artefacts.
Incisors/canines Intra-oral Pony 50 5

Patient preparation TB 52 6

Most horses require sedation in order to obtain diagnostic Incisors/canines Lateral Pony 55 6.3
radiographs of the skull due to the requirement to have both TB 60 6.3
the cassette and X-ray tube in close proximity to their head.
Sinus Lateral, Pony 60 6.3
Heavy sedation (such as with xylazine, detomidine, or romi­
Lateral oblique
fidine plus butorphanol) reduces head movement and facili­ TB 63 6.3
tates the radiographic examination. Resting the nose of the Maxillary cheek Lateral, Pony 63 6.3
horse on a stool or headstand may also help to minimize teeth apices Lateral oblique
swaying movements caused by heavy sedation. A fabric TB 66 8
(rope or webbing) head collar without metal components Mandibular   Lateral, Pony 66 6.3
should be used during radiography of the equine skull. cheek teeth Lateral oblique
However, even a rope headcollar can create artefacts on a TB 66 8
apices
radiograph, and if possible, it should be moved out of the
Skull Dorsoventral Pony 70 8
area of interest.
Occasionally, dental radiographs must be performed with TB 73 8
the horse anesthetized, most commonly for intra-operative Cheek teeth Open-mouthed Pony 60 6.3
radiographs during cheek tooth repulsion or removal of occlusal aspects oblique
radio-opaque tissues (e.g., cementomas, dystrophic miner­ TB 63 6.3
alization, tooth root fragments, odontogenic tumors) from
TB = Thoroughbred-type horse.
the sinuses or nasal cavity.

radiography. Other than slight modifications in exposure

Imaging systems values, the technique of acquiring radiographic views and
Most equine veterinary practices now use cassettes with rare- the ancillary equipment required are the same regardless of
earth (‘fast’) intensifying screens. These require a lower expo­ which radiographic system is used.
sure but produce images with less detail than ‘slow’ screens,
which contain calcium tungstate. In equine skull radiogra­ Exposures
phy, the risk of movement blur is high; therefore, a fast
film-screen combination is preferred. In general, the film The choice of exposure factors depends on the output of the
type must match the screen being used. The use of large X-ray machine and speed of the imaging system in use.1
(35 × 43 cm) cassettes is very helpful when evaluating a Table 13.1 gives examples of exposures suitable for obtain­
complex structure such as the equine head. This allows the ing dental and sinus radiographs.
entire cheek teeth row plus all adjacent structures of clinical
significance to be included in the radiograph. Hence, the Accessory equipment
position of any observed abnormality can be assessed in
relation to obvious anatomical landmarks. Specific equip­ Grids
ment for intra-oral radiography of the cheek teeth is dis­ The use of grids is discouraged for standing radiography as
cussed in that section. they are not required for obtaining high quality radiographs,
Computed radiography systems are rapidly superseding because the amount of scattered radiation is usually minimal,
conventional film-based imaging systems in equine practice. and their use increases the risk of radiation exposure to
In indirect computed radiography systems, cassettes contain personnel. Additionally, for oblique views, it may be diffi­
phosphor screens (but no film) and are available in the same cult to accurately align and center the X-ray beam with the
range of sizes as conventional cassettes. The latent image grid, which may result in image artefacts.
produced by X-rays is held within the screen until scanned
by a laser. The images are similar in quality to the best film Cassette holders
images, but have the advantage that they can be manipulated The use of cassette holders is essential in order to minimize
to adjust factors, such as brightness, contrast, and magnifica­ exposure of personnel to the primary beam, and holding
tion, which can markedly improve their diagnostic useful­ cassettes by hand should be considered unacceptable. A flex­
ness. The vast majority of radiographic images in this chapter ible and readily adjustable system is required to allow radio­
were produced on such a computed radiography system. graphy of different sized horses and varying resting head
Alternatively, direct digital radiography systems produce positions. This is most easily achieved using a long-handled
images immediately without a processing stage, and the cassette holder, which can be constructed from wood or
image quality is superior to that of indirect computed aluminum, with a handle up to 2 m long and which can be

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Box 13.1  Practical tips for dental/skull radiography

• Using a large cassette and collimating the primary beam to

include a large area, e.g., the entire maxillary cheek teeth row and
sinuses if a maxillary dental disorder is suspected, can make
interpretation of skull radiographs easier as abnormalities can be
related to easily identifiable anatomical structures
• Resting the nose of a deeply sedated horse on a stool or
headstand may help to reduce swaying movements of the head
• Attaching the cassette directly to the head using bungee type
elastic cords is an alternative way to prevent movement blur and
removes the need for a second person to hold the cassette holder
• Using a lower exposure to view the paranasal sinus contents,
incisors or wolf teeth, as compared with the relatively radio-
opaque cheek teeth
• Using a small radio-opaque marker taped on an area of facial
swelling or a blunt probe passed into a draining tract can provide
invaluable information regarding the significance of radiological
Fig. 13.1  Use of a long-handled cassette holder to increase the distance findings (see ‘Contrast studies’)
between personnel and the primary beam. Note the horse is wearing a rope
headcollar. • Radiograph the contralateral (unaffected) cheek teeth row if you
have difficulty deciding if a suspected abnormality is pathological
or physiological (see ‘Normal radiographic anatomy’)
adjusted to different heights and varying angulations (Fig.
13.1). Alternatively, vertical suspension systems linked to
the X-ray tube are also suitable for lateral or latero-oblique
radiographic views, as is simply suspending the cassette in a
image the cheek teeth. The cassette should be placed between
fabric bag (e.g., pillowcase) hanging from a mobile (e.g.,
the incisors, as far caudally as possible, and held in position
drip) stand. Long adjustable ties at each side of the bag allow
using long-handled hoof trimmer testers or a similar instru­
varying heights and angles of the cassette to be obtained.1
ment, with the cassette held at a distance from the assistant.1
The X-ray beam is directed at 60–80° from the dorsal plane
Radiographic projections (which runs parallel to the hard palate), depending on the
conformation of the incisors, using a rostrodorsal–caudo­
Introduction ventral oblique to image the maxillary incisors/canines and
a rostroventral–caudodorsal oblique to image the mandibu­
Indications for equine dental radiography are numerous but lar incisors/canines. The beam should be centered on the
most commonly include clinical signs associated with peri­ Triadan 01s (central incisors), and collimation should
apical dental disease, including disorders of the paranasal include the rostral and lateral aspects of the lips. If necessary,
sinuses or nasal cavities (unilateral nasal discharge, facial or the X–ray beam can also be angulated slightly from left to
mandibular swellings, quidding, discharging sinus tracts), right to try and highlight the apices of incisors at the edges
head trauma, developmental abnormalities, or periodontal of the incisor arcade without superimposition of adjacent
disease. Various radiographic projections and techniques teeth (Figs 13.3 & 13.4).
have been reported,1–7 but the ‘standard’ set of radiographs
required to investigate a clinical case depends on the indi­
vidual case presentation, clinician preference, and hospital Lateral projections
protocols. In the author’s (SB) hospital, lateral, lateral These radiographs are occasionally indicated, although the
oblique and dorsoventral radiographs are considered stand­ superimposition of incisors of the right and left sides usually
ard for investigation of a horse with suspected maxillary makes individual incisors impossible to distinguish. They
cheek tooth periapical infection and concurrent sinusitis. For can be useful for identification and orientation of dysplastic
suspected mandibular cheek tooth periapical infection, a or retained incisors or for assessment of fractures of the
lateral oblique view, plus the same view with a radio-opaque premaxilla or rostral mandible. Adding a slight (5–10°) ros­
marker placed on the clinical area of interest (swelling or trocaudal angulation to a lateral radiograph centered on the
draining tract), usually suffices. In some cases, additional canines can provide separation of left and right sides and
views, such as open-mouthed, intra-oral, or lesion- allow examination of individual reserve crowns and apices
orientated obliques are useful. Practical tips for dental/skull of these teeth.
radiography are given in Box 13.1.
Canines and wolf teeth
Incisors and canines
Lateral oblique projections
Intra-oral radiographs (Fig 13.2) All or part of the canines may be visible on intra-oral
The smallest cassette available should be used, and the films (see previous section), but in many horses the reserve
patient must be sedated to prevent damage to the cassette. crown and roots of the canines, as well as the wolf teeth
A low exposure is required compared with that needed to (Triadan 05s, 1st premolars), are best imaged using a lateral

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 13 Diagnosis

Fig. 13.2  Cassette and X-ray beam positioning for intra-oral projections of the incisors and canine teeth.

Fig. 13.3  Intra-oral view of the lower incisors of a horse with abnormally Fig. 13.4  Intra-oral view of the same horse as in Fig. 13.3. The radiograph is
small and fractured 01s and 02s. This radiograph was taken with the X-ray taken at a slight angle (25°) to the frontal plane from left to right. Note that
beam perpendicular to the frontal plane. Note there is superimposition of on the right side of the radiograph, the apices of 302 and 303 are no longer
the apices of the 02s, 03s and canines. superimposed.

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 Dental imaging

projection of the rostral skull with a small amount (15–20°)

of either rostrocaudal or dorsoventral angulation of the
X-ray beam. The angulation prevents superimposition of the
contralateral tooth.

Cheek teeth
Lateral projection (Figs 13.5–13.7)
The lateral view is useful to visualize fluid lines and abnor­
malities of the maxillary or frontal bones or within the para­
nasal sinuses because the anatomy of the sinuses is not
distorted by obliquity of the X-ray beam. The major disad­
vantage of the lateral view is that lesions cannot be localized
to the left or right sides because both sides are superim­
posed. For this same reason, individual cheek teeth apices
cannot be evaluated using this view.
The horse should be positioned with the lesion side adja­
cent to the cassette. The cassette should be held in the cas­
sette holder in a vertical plane, parallel with the dorsal
contour of the head, and as close to the head as possible.
The primary beam should be horizontal and perpendicular
to the long axis of the head. The primary beam should be
collimated to reduce scatter, and rotating the light beam
diaphragm unit to align it with the orientation of the horse’s
skull helps to keep the collimation tight.
For maxillary cheek teeth, the beam should be centered
just dorsal to the rostral aspect of the facial crest if the cheek
teeth and/or paranasal sinuses are being examined. The
entire facial area should be included to ensure that the entire
maxillary cheek teeth row and all the paranasal sinuses are
Fig. 13.5  Direction of the X-ray beam (arrow) and cassette position for
included in the radiograph. Hence, topographic markers for lateral projections of the skull.
collimation include: the caudal aspect of the diastema (‘bars
of mouth’) rostrally, the eye caudally, and the dorsal aspect
of the skull (Fig. 13.6).

Fig. 13.6  Centering point (red cross) just dorsal to the rostral aspect of the facial crest and collimation (red outline) for lateral and lateral oblique radiographs
of the maxillary cheek teeth and paranasal sinuses.

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 13 Diagnosis

Fig. 13.7  Lateral radiograph of a normal mandibular cheek tooth row.

Note that the soft tissue opacity of the thick masseter and pterygoideus
muscles are superimposed over the caudal 3 cheek teeth.

30

Fig. 13.9  Radiographic positioning to obtain a latero30°dorsal-lateroventral

oblique radiograph of the maxillary cheek teeth apices.

often not apparent in oblique views, being replaced with

indistinct soft tissue opacity. Additionally, it can be more
difficult to localize abnormalities to specific sinuses due to
superimposition of some structures e.g., the dorsal aspect of
Fig. 13.8  Diagram showing direction of the X-ray beam (arrow) and the caudal maxillary sinus and the dorsal-conchal sinus are
cassette position for latero30°dorsal-lateroventral oblique radiograph of   often superimposed.
the maxillary cheek teeth apices. The standing horse should be positioned so that the
lesion side is next to the cassette, which is held in the
cassette holder in a vertical plane, close to the horse’s
Lateral views of the mandibular cheek teeth are less fre­ head. The primary beam should be angled latero30°dorsal-
quently indicated, but the beam should be centered over the lateroventral (i.e., at 30° from the dorsal plane, which runs
area of interest (usually indicated by a discharging tract or parallel to the hard palate) and centered 3–5 cm dorsal to
mandibular swelling), and rostrocaudal collimation should the rostral aspect of the facial crest (Fig. 13.6).
be adjusted to include the entire cheek teeth row, if possible. The primary beam should be collimated to reduce scatter
The thick masseter and pterygoideus muscles overlie the (as for the straight lateral view) and should include the
caudal three mandibular cheek teeth (Fig. 13.7), and hence entire maxillary cheek teeth row and the paranasal sinuses.
higher exposures are required to image the apices of these Inadvertent rostrocaudal angulation of the X-ray beam is a
teeth as compared to the rostral mandibular cheek teeth. common fault and should be avoided if possible. Excessive
rostrocaudal (or dorsoventral) angulation distorts anatomi­
cal structures, particularly the apices of the cheek teeth,
Latero30°dorsal–lateroventral oblique making them difficult to evaluate accurately.
projection (Figs 13.8–13.9) For anesthetized horses, which are usually positioned in
This view separates structures on the left and right sides of lateral recumbency with the affected side uppermost (to
the skull so that they are not superimposed on each other. allow access for surgery), the cassette is placed beneath the
It gives the clearest view of the apices of individual maxillary horse’s head, i.e., next to the unaffected side, rather than next
cheek teeth and can help to localize sinus lesions to the left to the affected side as is the case for standing horses. There­
or right sides if this is not clinically obvious. A higher fore the angle of the X–ray beam must be reversed (compared
exposure should be used to radiograph the radio-opaque to the standing horse) to obtain oblique projections of the
cheek teeth as compared to the relatively radiolucent sinus cheek teeth or sinuses, e.g., for maxillary cheek teeth apices
contents. with the affected side uppermost, a ventrolateral to dorsola­
Disadvantages of the oblique view are that it can be more teral beam direction is required (Fig. 13.10). This projection
difficult to consistently obtain good quality oblique radio­ creates more magnification of the image but should not have
graphs, because the angulation of the standing sedated a deleterious effect on surgical decision-making unless meas­
horse’s head is usually somewhere between vertical and hori­ urements for surgical implants (e.g., dynamic compression
zontal, making it difficult to direct the X-ray beam accu­ plates) are being made. In such cases, placing a metal
rately. As noted, having an X-ray machine that can be moved marker of known size in the region of interest allows for
in three dimensions helps enormously when obtaining these calculation of the degree of magnification and subsequent
views. It should be noted that fluid lines in the sinuses are correction.

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 Dental imaging

of the cheek teeth, making them difficult to evaluate accu­

rately. The minimum dorsoventral angle of X-ray beam
30 40 which clearly separates the left and right cheek teeth apices
should be used. Using a very large oblique angle gives better
separation of the cheek teeth rows and allows visualization
of more reserve crown, but also causes artefactual distortion
of the apices.
The standing horse should be positioned so that the lesion
side is closest to the cassette, which is held in the cassette
holder in a vertical plane. The primary beam should be
angled 35–45° lateroventral-laterodorsal (angled up from
the dorsal plane which runs parallel with the hard palate)
and centered at the area of interest, such as a mandibular
swelling or cutaneous discharging tract – whose presence is
Fig. 13.10  Lateral oblique radiographic projections of the maxillary (red the usual indication for taking this radiographic view. The
arrow) and mandibular (blue arrow) cheek tooth apices in an anesthetized,
laterally recumbent horse undergoing surgery. The affected side is placed
primary beam should be collimated to reduce scatter but
uppermost to allow surgical access to the lesion (orange circles), and the should include the ventral mandibular cortex and the entire
cassette is placed underneath the head. The X-ray beam must be directed cheek teeth row, if possible.
in the opposite direction to conventional views, and more magnification of For anesthetized horses, which are usually positioned in
the image results. lateral recumbency with the affected side uppermost (to
allow access for surgery), the cassette is placed beneath the
horse’s head i.e., next to the unaffected side, and the direc­
tion of the X-ray beam is reversed (Fig. 13.10).

Dorsoventral projection (Figs 13.12–13.13)

This view is quite easy to obtain in the sedated horse and is
particularly useful for visualizing the ventral conchal sinus,
nasal cavities, and nasal septum. Additionally, it can be used
for evaluating maxillary/mandibular fractures; bony distor­
tion of the maxilla associated with periapical infection of the
rostral cheek teeth or intra-sinus masses. Laterally or medi­
ally displaced teeth and fractured maxillary teeth (particu­
larly sagittal fractures) can also be visualized with this
view; however, these abnormalities should be apparent
during a thorough oral examination. The extremely dense
35 _ 45
bone of the hemimandibles makes it almost impossible to
Fig. 13.11  Positioning of cassette and angle of X-ray beam to obtain a evaluate normally positioned mandibular cheek teeth using
latero35–45° ventral–laterodorsal oblique radiograph of the mandibular this projection.
cortex and cheek teeth apices. An increased exposure is required for this projection com­
pared to those used for lateral or lateral-oblique views of the
skull. The X-ray beam is directed perpendicular to the dorsal
plane of the head (which runs parallel to the hard palate)
Latero35–45°ventral–laterodorsal oblique with the cassette held parallel with the ventral mandible and
projections (Fig. 13.11) positioned as caudally as possible (Fig. 13.12). Because the
This view is used to separate the left and right hemiman­ mandibular cheek teeth rows are so close together (anisog­
dibles and mandibular cheek teeth apices in order to view nathia), even a small degree of obliquity obscures one nasal
the affected side without superimposition of the contra­ cavity, ventral conchal sinus, and maxillary cheek teeth row
lateral hemimandible. As previously noted, a higher expo­ and prevents accurate comparison of left and right maxillary
sure is required when imaging the caudal three cheek teeth sinus opacity; therefore, great care must be taken to ensure
because of the overlying thick masseter and pterygoideus that the head is absolutely straight and the beam perpen­
muscles (Fig. 13.7). Additionally, a higher angle is usually dicular to the dorsal plane. The centering point is in the
required for radiography of the caudal cheek teeth apices midline of the dorsal aspect of the head at the level of the
because these are positioned more dorsally within the man­ rostral aspect of the facial crests. Collimation of the primary
dibular bone. For the same reason, the cheek teeth of old beam should include the left and right lateral extents of the
horses with short reserve crowns also need to be radio­ skull, the caudal aspects of the bony orbits and the dia­
graphed using a higher angle. stemata, rostrally (Fig. 13.13).
Similar to the latero30°dorsal–lateroventral oblique view, In the anesthetized horse, ventrodorsal radiographs can be
inadvertent rostrocaudal angulation of the X-ray beam is a obtained with the horse positioned in dorsal recumbency
common fault with this view of the mandible, and should and the head and neck fully extended. Ideally, the endotra­
be avoided, if possible, because excessive rostrocaudal angu­ cheal tube should be removed to prevent its superimposition
lation distorts anatomical structures, particularly the apices on the nasal cavities and conchal sinuses.

205
 13 Diagnosis

Fig. 13.12  Diagram showing cassette

position and angle of the X-ray beam for
obtaining a dorsoventral radiograph of the
skull.

15

Fig. 13.14  Photograph showing sedated patient with a Butler’s gag

separating the incisors to allow an open-mouthed oblique dental
radiograph to be obtained.

alveolar disease and maxillary osteitis.1 A rope is placed

around the interdental space, and the mandible is displaced
to the contralateral side by an assistant pulling on this rope.
Fig. 13.13  Diagram showing area of collimation and centering point A dorsoventral projection is then obtained as described
(cross, at the level of the rostral aspect of the facial crests) for dorsoventral above.
radiographs of the skull.
Open-mouthed oblique projections
(Figs 13.14–13.18)
Dorsoventral projection with offset mandible This radiographic view is used to image the erupted crowns
This radiographic projection is uncommonly indicated, but of the cheek teeth and the occlusal aspect of the alveolus
gives a clearer unilateral view of the medial aspect of one (alveolar crest).6 Disorders of the erupted crown such as
row of maxillary cheek teeth and the nasal cavity/conchal diastemata, clinical crown fractures, and abnormalities of
sinus immediately axial to them. It has been suggested that wear can be imaged.6 The patient must be sedated so that it
this projection is particularly useful for demonstrating subtle accepts a Butler’s gag placed between its incisors (Fig. 13.14).

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 Dental imaging

10 _ 15

15

Fig. 13.17  Open-mouthed oblique view centered on the 05s (wolf teeth)
showing large, rostrally displaced and abnormally angulated upper 05s with
Fig. 13.15  Diagram showing angle of incidence of the X-ray beam to long thin roots. The Butler’s gag is separating the incisors.
obtain open-mouthed oblique views of the maxillary (blue arrow) and
mandibular (red arrow) erupted crowns. The affected side is nearest to  
the cassette.

Fig. 13.18  Latero30°ventral-laterodorsal open-mouthed oblique view of

a horse immediately after 09 dental extraction. The contents of the mid  
and more occlusal aspects of the empty alveolus can be visualized without
superimposition from cheek teeth of the contralateral row.
Fig. 13.16  Latero10°ventral-laterodorsal open-mouthed oblique view of an
aged horse with a supernumerary mandibular cheek tooth (Triadan 12).
Note the large overgrowths present on this supernumerary tooth and the
excessive wear of the corresponding upper 11. often helpful for examining alveoli for possible dental frag­
ments after dental repulsion (Fig. 13.18). Open-mouthed
oblique projections are also useful for imaging the Triadan
Alternatively a short length of hollow PVC tubing or a block 05s (wolf teeth) (Fig. 13.17).
of wood can be used to separate the incisors and thus the
occlusal aspects of the cheek teeth.
The cassette is positioned vertically on the lesion side, Intra-oral oblique projections (Figs 13.19–13.20)
close to horse’s head. For these open-mouth views, the These projections, where a flexible film package or cassette
X-ray beam is directed in the opposite direction to conven­ is placed into the oral cavity, represent a modification of the
tional (closed mouth) oblique views i.e., a dorsolateral– bisecting angle technique used widely in human dental
ventrolateral to image the mandibular erupted crowns or a imaging. They have the advantages that there is no superim­
ventrolateral–dorsolateral to image the maxillary erupted position of structures from the contralateral side of the skull,
crowns. Additionally, the angle of incidence of the X-ray and can also give good detail of the interdental bone and
beam is reduced compared to conventional oblique views: alveolar crest region. However, in the author’s experience,
latero10°dorsal–lateroventral (ventrally) for mandibular these projections can be difficult to obtain in standing
cheek teeth, latero15°ventral–laterodorsal (dorsally) for sedated horses, due to difficulties keeping the film in place
maxillary cheek teeth. The primary beam should be centered within the oral cavity.
on the rostral aspect of the facial crest and collimated to The use of human dental film packs4 or of improvised
include all the erupted crowns in the cheek teeth row cassettes made of vinyl7 or heavy-duty black polythene1 has
(Fig. 13.16). been described for intra-oral projections in horses. Pre-
To image the full length of the cheek teeth reserve crowns, packed human dental film is often only large enough to
open-mouthed oblique projections using approximately the image one or two cheek teeth on each radiograph, and this
same angles as for standard closed-mouth views may be is a major disadvantage, particularly because the affected
used, although to prevent superimposition of the contralat­ tooth is not commonly identified prior to the radiographic
eral maxillary arcade completely, laterodorsal angles slightly examination. Improvised cassettes can be made into a suit­
greater than 30° may be required. These projections are also able shape for the equine oral cavity (circa 10 × 25 cm) by

207
 13 Diagnosis

70 _ 80

50

Fig. 13.19  Diagram showing intra-oral position of the cassette and angles Fig. 13.21  Lateral oblique radiograph of the hemimandible of a horse
of incidence of the X-ray beam to obtain intra-oral cheek teeth radiographs which presented with a swelling on the ventral aspect of its mandible.  
of young horses with long reserve crowns (left) and older horses (right). A radio-opaque marker has been taped to the area of maximal facial
swelling, which corresponds to an area of clubbing (short, rounded
appearance) of the caudal root of the 08 due to loss of the apex of  
that root and surrounding radiolucency.

film is placed in the oral cavity, parallel to the hard palate

(Fig. 13.19). If using a small sized film, it must be placed at
the level of the tooth of interest. For teeth of mature or older
horses, the X-ray beam is directed at an angle of 50°–60° to
the horizontal, but to examine the longer reserve crowns of
young horses, increased incident angles (70°–80°) are
required (Fig. 13.19). The centering point is somewhere
between the level of the facial crest and up to 6 cm dorsal
A to the facial crest, depending on the length of the tooth
being radiographed i.e., in younger horses, a more dorsal
centering point is required compared to aged horses with
short reserve crowns.

Contrast studies
Placement of a radio-opaque marker over an area of
facial swelling and repetition of a radiographic projection
(Fig. 13.21) can be an invaluable aid when assessing the
clinical significance of radiographic changes. If a cutaneous
draining tract is present, as is common in cases of periapical
B infection of the mandibular cheek teeth or upper 06s and
07s, a blunt metallic probe can be placed into the tract, held
Fig. 13.20  (A) Intra-oral radiograph of a maxillary cheek teeth row. in place with tape (Fig. 13.22) and a repeat radiograph taken
Radiograph courtesy of J. Easley. (B) Intra-oral radiograph taken intra- (Fig. 13.23). This very simple form of contrast study often
operatively during a dental extraction procedure. A small bone-opacity provides unequivocal evidence that a tooth is infected.
fragment can be seen in the rostral aspect of the alveolus (arrow). Water soluble iodinated contrast media may also be intro­
(Radiograph courtesy of W.H. Tremaine.) duced into a tract i.e., fistulography. To avoid leakage, injec­
tion should be made through a self-retaining catheter with
an inflatable bulb (e.g., Foley) and discontinued immedi­
cutting down film and card-mounted intensifying screen(s) ately resistance is felt.1
before double wrapping them in closely fitting, light-proof
bags e.g., of heavy-duty black polythene, and sealing the Normal radiographic anatomy
edges with light-proof adhesive tape.1 The disadvantages of
this system include the time taken to prepare the above
materials, poor film/screen contact and the need for wet
Deciduous dentition
processing of films. Deciduous incisors are more radiolucent, have shorter
A self-retaining, full-mouth speculum is used to open the reserve crowns and roots, and have a smaller cross-sectional
mouth of the heavily sedated or anesthetized horse, and the area than their permanent counterparts (Fig. 13.24).

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 Dental imaging

Fig. 13.22  (A & B) A blunt metallic probe placed

into a cutaneous discharging tract and secured
with radiolucent tape can provide strong evidence
as to which tooth is infected in cases of suspected
periapical infection.

A B

Fig. 13.23  Lateral oblique radiographs with a blunt metallic probe in place in cases of periapical infection with discharging cutaneous tracts involving the
mandibular (A) and rostral maxillary (B) cheek teeth.

Fig. 13.24  Intra-oral radiographs of the

mandibular incisors of: (A) a yearling with a
fractured mandible (note the obliquity of the left
incisors compared to the right). The developing
buds of the permanent 301 and 401 can be seen
mesial to the 701 and 801. (B) A 3-year-old horse.
The 301 and 401 (central incisors) are erupted but
the deciduous lower 02s and 03s remain in wear.
Note the canines are superimposed on the
developing permanent 03s.

B
A

209
 13 Diagnosis

Fig. 13.25  Lateral oblique view of a foal’s skull. Note the short spicular
roots of the 3 deciduous cheek teeth in each row. The dental buds of  
the permanent cheek teeth are not apparent yet.

Fig. 13.27  Intra-oral radiograph of the rostral mandible of a teenage horse.

Note the triangular cross section of the occlusal surfaces of the 01s and  
02s (central and middle incisors) as compared to those of a young horse
(Fig. 13.24). There is a vestigial dental remnant lying just caudal to 303.

beam can be used to prevent this superimposition

(Fig. 13.4). The incisor teeth gradually change their angle
throughout life, the occlusal angles changing from almost
vertical in a young horse to an increasing angle of incidence,
and the occlusal surface becomes more triangular in cross
section with advancing age. In recently erupted incisors, the
Fig. 13.26  Lateral oblique radiograph of the maxillary cheek teeth of a
2-year-old horse. The 09 has erupted and is in wear, and the 10 is just
infundibula can be recognized on the obliquely projected
erupting. The dental buds of the permanent 06, 07, and 08 can be seen occlusal surfaces and in those that have been longer in wear,
developing dorsal to their deciduous counterparts, with the deciduous 06 traces of infundibular enamel and cement may be visible as
about to be shed. The dental bud of the 11 (arrow) is developing at the thin, elliptical conical radiodense shadows.1 The pulp cavi­
caudal aspect of the maxilla. ties of the incisors should be evident as curvilinear radiolu­
cent structures in the middle of these teeth.
The canine teeth, and particularly the lower canines, are
positioned in close proximity to the 03s (Fig. 13.24B) and
Deciduous canines (if present) are vestigial, spicule-like
it may be difficult to clearly delineate the roots and reserve
structures that do not erupt above gum level, but which are
crowns of the canines due to superimposition of the roots
occasionally evident radiographically.
and reserve crowns of the 03s (the corner incisors) in some
Linear, radio-opaque enamel folds may be seen within the
horses. Small unerupted canines may be present below the
developing deciduous cheek teeth of the fetus, and soon
gingiva in mares. If present, the 05s (‘wolf teeth’, Fig. 13.18)
after birth foals should have 12 deciduous cheek teeth
are normally situated immediately rostral to the 06s (1st
present in the oral cavity. These teeth have short, spicular
cheek tooth). Up to 4 wolf teeth may be present; however,
roots (Fig. 13.25) and can be distinguished from developing
mandibular 05s are very rare. Wolf teeth may vary markedly
permanent premolars by their greater mineral content and
in the size of their clinical crown, and the roots of these
relative lack of internal structure.1 As the germs of the per­
brachydont teeth can vary from a few mm to >2 cm in
manent cheek teeth develop beneath the deciduous cheek
length. In a survey of radiographs of 134 horses, wolf teeth
teeth (Fig. 13.26), they cause resorption of the apices of their
were present in 30 % of horses, but this may not be a true
overlying deciduous counterparts.8
reflection of their incidence due to the common practice of
‘prophylactic’ or ‘therapeutic’ removal.9
Permanent dentition
Incisors, canines and wolf teeth Cheek teeth
The reserve crowns and apices of the permanent incisors The radiographic appearance of equine cheek teeth, and
converge towards each other on an intra-oral radiographic particularly their apices, varies markedly with age, and
projection, and there may be partial superimposition of the between individual cheek teeth positions. Consequently an
reserve crowns and roots of the Triadan 02s and 03s (middle appreciation of normal radiographic variation is required to
and corner incisors) on a true dorsoventral radiograph enable proper interpretation of dental radiographs. Most
(Fig. 13.27). If the roots and reserve crowns of these teeth apical infections occur in young horses where there can be
are to be examined in detail, a slight angulation of the X-ray marked differences in the radiographic appearance of the

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 Dental imaging

Alveolar bone

Fig. 13.29  Lateral oblique radiograph of the hemimandible of a normal

3-year-old horse. Note the wide, rounded, radiolucent periapical regions of
the 07 and 08 which are termed ‘eruption cysts’. The ventral cortex of the
mandible beneath the 08 is convex and extremely thin and appears
radiolucent.
Enamel

Fig. 13.28  Close up X-ray of a maxillary cheek tooth. The lamina dura
(black arrows) is a linear radio-opacity that lines the alveolus. Note that the
lamina dura denta is not visible along the entire contour of this normal
tooth. The periodontal ligament (white arrows) is represented by a
radiolucent area between the lamina dura and the periphery of the tooth.

Fig. 13.30  Lateral oblique radiograph of the maxillary cheek teeth row of
a 10-year-old horse. Note the pointed appearance of the apical areas  
which represents the development of ‘true’ roots. In this particular horse,
the rostral root of the 08 is positioned rostral to the maxillary sinuses.  
apical areas of normal adjacent teeth, and where immature Arrow = maxillary sinus septum.
apices with eruption cysts can radiographically resemble
apical infections.
Enamel, dentin, and cementum (along with bone) are the The dental buds of the permanent cheek teeth in the young
densest materials in the body, and therefore the cheek teeth horse are large, rounded, radiolucent structures, with a stri­
appear as very radio-opaque structures, within which the ated, vertical radiodense pattern, which is due to partially
radiolucent pulp horns may be seen running longitudinally. calcified enamel folds (Fig. 13.26). As a dental bud develops
Dentin and cementum have a lower proportion of mineral into a cheek tooth, its apical aspect appears as a round,
content than enamel and have a radio-opacity similar to radiolucent area with a very wide periodontal space, which
bone.2 Younger cheek teeth contain little dentin relative to is termed an eruption cyst. The lamina dura is often not
aged cheek teeth, and are, therefore, comparatively radiolu­ visible around the apices of developing teeth. The perma­
cent.2 The reserve crown of the cheek teeth is attached to the nent equine CT erupt between 1 and 4 years of age (see Ch.
alveolar bone by the periodontal ligament, which is evident 5). Between 2 and 4 years of age (Fig. 13.29), the reserve
radiographically as a narrow parallel radiolucent line crown is very long, and many of the cheek teeth still have
between the tooth and the alveolus (Fig. 13.28). This space large eruption cysts. At this age, the ventral border of the
lies adjacent to a radiodense rim of cortical alveolar bone, mandible becomes convex in some breeds (‘3- and 4-year-
radiographically, termed the lamina dura, which lines the old bumps’) to accommodate these large dental structures,
alveolus (Fig. 13-28). Although disruption of this structure and the ventral mandibular cortex beneath the eruption cysts
can occur with dental disease, the irregular contour of equine is very thin or even appears fully eroded. This convex appear­
cheek teeth means that the lamina dura may not be visible ance is lost as the horse ages due to continued eruption of
on some radiographic projections of normal teeth, and (in the reserve crown, maturation of the cheek teeth apices, and
contrast to brachydont radiographs) absence or partial dis­ remodelling of the mandibular cortex.
continuity of the lamina dura is not a reliable indicator of As the horse ages and the cheek teeth erupt, the true roots
apical or periodontal disease.9,10 The area of the periodontal (i.e., enamel-free areas) develop, and the apices change
ligament may widen due to disease processes, but the apices from being rounded to developing a number of pointed
of young equine cheek teeth also have wider radiolucent structures, i.e., true roots (Fig. 13.30). Bearing in mind that
areas adjacent to the lamina dura in the area of the eruption the equine cheek teeth erupt at different ages, it is normal
cysts (Fig. 13.29). for young horses to have adjacent cheek teeth with very

211
 13 Diagnosis

DCS FS

RMS E
CMS

06 07 08
09 10
11

Fig. 13.32  Maxillary arcade of an aged horse (cadaver). The reserve

crowns are very short, and the roots have lost definition due to excessive
cementum deposition around their periphery (‘hypercementosis’). A wave
Fig. 13.31  Anatomy of the paranasal sinuses as viewed in a lateral mouth is also present.
radiograph. RMS, rostral maxillary sinus; CMS, caudal maxillary sinus;  
DCS, dorsal conchal sinus; FS, frontal sinus; E, ethmoturbinates;  
arrows, rostrolateral portion of the maxillary sinus septum. The 06 and  
07 are positioned rostral to the paranasal sinuses.

radiographically variable apical areas (Fig. 13.29). For

example, major differences are present between the apices of
the 08s (3rd cheek teeth) and 09s (4th cheek teeth) in a
4-year-old horse, because the 09 is 3 years older than the 08.
Consequently, caution must be exercised when comparing
the radiographic appearances of adjacent cheek teeth apices
in young horses.
The apices of some equine maxillary cheek teeth are posi­
tioned within the paranasal sinuses, and knowledge of this
anatomic relationship is important in order to detect changes
due to periapical infections (Fig. 13.31). Although there is
some individual variation, generally the apices and reserve Fig. 13.33  Mandible of an aged horse (cadaver). The reserve crowns are
crown of the 06s and 07s and rostral aspect of the 08s (Fig. very short, there is hypercementosis of the roots and multiple (senile)
13.30) lie within the radio-opaque, rostral aspect of the diastemata are present (arrows). The most severe diastemata have
associated loss of bone from the alveolar crest (arrowhead).
maxillary bone, and therefore, a slightly higher exposure is
required to image these optimally. The caudal aspect of the
maxillary 08s and all of the 09s are generally positioned
within the rostral maxillary sinus, and the maxillary 10s and
11s lie within the caudal maxillary sinus (Fig. 13.31). continues to erupt, despite cementum being increasingly
The rostral and caudal maxillary sinuses are usually com­ laid down around the roots (Figs 13.32 & 13.33). This apical
pletely separated by a thin obliquely oriented bony septum hypercementosis has the effect of obscuring some radio­
which on lateral or lateral-oblique radiographs originates graphic detail of the tooth roots, and making them appear
adjacent to the caudal aspect of the upper 09s, and courses thicker (clubbed) and more radiodense. Equine cheek teeth
from rostrolateral to caudomedial. Although the maxillary taper in towards their roots, and as the reserve crown length
sinus septum is not always radiographically distinguishable shortens, the rostrocaudal length of the erupted crown there­
from other intrasinus septae, its most lateral aspect is often fore decreases. Because the cheek teeth are no longer tightly
represented by a linear radiopacity,11 extending dorsocau­ apposed on the occlusal surface, aged horses are predisposed
dally from the caudal aspect of the upper 09s (Fig 13.31). to developing (senile) cheek teeth diastemata (Fig. 13.33)
The position of the maxillary sinus septae may vary between and periodontal infection, due to food pocketing in these
right and left sides. The infra-orbital canals are radiographi­ spaces.
cally apparent on lateral and lateral-oblique radiographs,
lying directly dorsal to the apices of the caudal cheek teeth Radiological interpretation
in young horses.
Due to the different times of eruption, the reserve crowns
of the permanent cheek teeth are not all the same length –
Sensitivity and specificity of radiography
the 09s are consistently shortest, these being the first perma­ When using a diagnostic test in practice, it is useful to know
nent cheek teeth to erupt. The 06s are also shorter and the sensitivity and specificity of that test. The sensitivity of a
squarer shaped than the other cheek teeth. test represents the probability that the diagnostic test will be
As the horse ages, the reserve crown of the cheek teeth positive, given that the disorder is present. Specificity repre­
reduces in length as the tooth wears at its occlusal aspect and sents the probability that the test will be negative, given that

212
 Dental imaging

the disorder is absent. Most studies published to date and

outlined below have used film-based radiographic evalua­
tion. It is likely that with the widespread use of digital and
computed radiography in equine practice, our ability to
radiographically detect dental abnormalities will be signifi­
cantly improved.

Dental disorders
Radiographic changes consistent with periapical infection
are most readily identified in the rostral maxillary equine
cheek teeth whose apices lie rostral to the maxillary sinuses,
and the mandibular cheek teeth, whose apices are contained
within the mandible.9 In the more caudally positioned max­
illary cheek teeth where secondary dental sinusitis is
common, apical infections can be recognized with confi­
Fig. 13.34  Intra-operative lateral radiograph. This foal has suffered a rostral
dence in only 50–57 % of cases using radiography alone.9,12 mandibular fracture with resultant mandibular shortening. The premaxilla
Two more recent studies by Weller et al and Barakzai that has been fitted with a bite plate to allow some contact with the remaining
have investigated the accuracy of radiography for diagnosis lower incisors and so help prevent further ventral deviation of the
of equine dental disorders found radiographic sensitivities premaxilla. (Radiograph courtesy of P.M. Dixon.)
of 52 % and 69 % (respectively) and specificities of 95 % and
70 %.13,14 The differences between the results of these two
studies are likely to be attributable to the different anatomi­
cal distribution of disorders in the two studies, with a con­ however, the radiographic appearance of the teeth associated
siderably higher proportion of cases with dental sinusitis in with these abnormalities has been illustrated in a review of
the latter study as compared to predominantly mandibular congenital dental disorders18 and in Chapter 19.
or rostral maxillary dental lesions in the study performed
by Weller et al (2001).13 A further study, using computed Oligodontia
radiography,10 reported that periapical sclerosis, periapical
lucency, and clubbing of tooth roots are the most reliable The absence of a tooth or teeth due to failure of development
radiographic changes associated with periapical infection, of a tooth bud may result in abnormal occlusion and wear.
but that mild changes in any of these categories are not This condition is common in miniature pony breeds
dependable indicators of infection. This study also reported (Fig. 13.35), and further images of this disorder are pre­
that loss of the lamina dura denta is a very insensitive (high sented in Chapter 8.
number of false positives), but highly specific (low number
of false negatives) indicator of periapical infection. Polydontia
Extra, or supernumerary, teeth may have a normal anatomy
Paranasal sinus disorders or may be misshapen, malformed, and often misplaced (see
The sensitivity (85.2 %) and specificity (79.2 %) of radio­ Ch. 8). Due to their abnormal apical areas, it may be difficult
graphy for detecting abnormalities of the equine sinuses to definitively ascertain if supernumerary teeth are apically
have been shown to be moderate.15 The findings of Barakzai infected or not. Quinn et al19 described a ‘domed soft-tissue
et al’s15 study are similar to the reported sensitivity (73– opacity in the floor of the maxillary sinuses’ dorsal to the
76 %) and specificity (79–80 %) of radiography for detecting apices of supernumerary 12s (Fig. 13.36) to be a relatively
acute sinusitis in human beings.16,17 It should be mentioned, consistent finding in affected horses. Supernumerary teeth
however, that although radiography is a very useful tool for can easily go unrecognized, particularly if the entire cheek
determining if sinusitis is present or not, establishing the tooth row is not included in the radiograph. Supernumerary
cause of sinusitis can be considerably more difficult! cheek teeth are often very long, due to lack of attritional
wear, and diastemata may develop between supernumerary
and adjacent teeth.
Abnormalities of development and eruption
Gross abnormalities of the erupted crown may be evaulated Dysplastic teeth
with a detailed oral examination; however, radiography is Teeth with abnormal structure are relatively common in
often useful in order to assess the structure of and location equidae (Fig. 13.37), and it can be difficult to ascertain
of the reserve crowns and apical areas.1 Many radiographs of whether such teeth are apically infected or not. They may be
these disorders are presented in Chapter 8. associated with abnormalities of eruption and dental impac­
tions, and also with periodontal disease.
Brachygnathia (parrot mouth, Fig. 13.34),
prognathia (sow mouth) and wry nose Abnormalities of eruption
Radiography is not usually required to diagnose these devel­ Disorders of eruption may affect the incisors (Fig. 13.38),
opmental disorders of the premaxilla and/or mandible; canines, wolf teeth, or cheek teeth (Fig. 13.39) and are

213
 13 Diagnosis

Fig. 13.35  Oligodontia. The pony in (A) has anodontia of 308, 408 and 108, C
although the deciduous remnant (‘cap’) of one lower 08 is still present.
Radiograph courtesy of P.M. Dixon. The pony in (B) has only 5 teeth in both
Fig. 13.36  Polydontia. Supernumerary maxillary cheek teeth (Triadan12s)
mandibular rows, with large overgrowths of the upper 10s and 11s and
are the most common supernumerary cheek teeth in horses. The 12 is
secondary diastemata formation between the upper 09s and 10s.
usually markedly overgrown as in (A) but may be unerupted as in (B) if there
is inadequate space (overcrowding). Note the abnormal shape of the apical
area of the 112. (C) An example of overgrown bilateral supernumerary
mandibular 12s.

often predisposed to by dental impactions, and malformed

or malpositioned teeth. Radiography is invaluable in assess­
ing which teeth are involved, which, if any, are deciduous, Apical infection (Fig. 13.41)
which are permanent, and which teeth to extract in order to
treat the disorder. Both clinical and radiographic signs of periapical (apical)
infection are often specific to the tooth involved. For
example, the apices of the maxillary 06s and 07s (and
Temporal teratoma (Fig. 13.40) variably the 08s) and all the mandibular cheek teeth are
The clinical signs of temporal teratoma (anomalous dental contained within thick bone; hence, cases of periapical
tissue in the parietotemporal region of the skull) are often infection of these teeth typically present with facial swelling,
pathognomic for this developmental disorder, but radiogra­ which appears radiographically as bone lucency often
phy can be very useful in order to confirm the diagnosis and surrounded by sclerosis and periosteal new bone formation,
evaluate the nature (whether or not it contains calcified and also cutaneous draining tracts. The maxillary 08s–11s
dental structures), location, and size of the lesion prior to apices are contained within the maxillary sinuses; hence,
surgical excision. horses with periapical infection of these teeth present

214
 Dental imaging

08 09 10
07
Fig. 13.37  (A) Maxillary cheek tooth row of a miniature Shetland pony with
06 11 marked dysplasia of the 109, 110, and 111 and a corresponding wave mouth
on the mandibular row. (B) Markedly enlarged, radiodense, dysplastic 110,
which has displaced the reserve crowns and apices of 111 and 109 caudally
B and rostrally, respectively. (C) Abnormally small 302. The deciduous 702
remnant is retained (arrow).

Fig. 13.38  (A & B) Malformed and malerupting

302 with retained deciduous 702. The malerupting
302 has an abnormal (reversed) rostral curvature in
the lateral view (arrow) (B). 703 is present lateral to
702, but 303 does not appear to have developed.
(Radiographs courtesy of B. Chilvers.)

A B

clinically with nasal discharge and radiographically with

changes associated with both dental infection and secondary
sinusitis.
Radiographic changes consistent with early periapical
infection include widening of the periodontal space and
focal loss or irregularity of the lamina dura. When periapical
infection has been present for many weeks, the affected apex
and adjacent alveolar bone develop lytic changes, especially
in mature teeth where the true roots (non-enamel areas) are
well formed, due to decalcification and/or destruction of
dental and adjacent alveolar tissues. These changes manifest
as periapical radiolucent ‘halos’, and with time, a rounded
or ‘clubbed’ appearance of the tooth roots can develop due
to gross lysis/destruction of the root structures. In more
chronic periapical infection, a zone of radiodense sclerosis
Fig. 13.39  This horse has retained 708 and 808 remnants which are may surround the periapical ‘halo’, due to new bone deposi­
displaced lateral and slightly caudal to the erupted permanent 08s (arrow). tion around the lytic infected dental/alveolar area. More
marked sclerosis develops around the apices of the rostral
maxillary and mandibular cheek teeth than around the

215
 13 Diagnosis

Fig. 13.40  Temporal teratoma. This horse presented with bilateral draining
tracts just ventral to the pinnae that have had blunt metallic probes placed
in them. One dentigerous cyst is seen as a rounded, tooth-like structure
(arrow), positioned rostral to one of the tympanic bullae.

apices of the caudal maxillary cheek teeth, because the apices

of the former teeth are positioned in denser bone than those
of the caudal maxillary cheek teeth, which are situated in
only thin alveolar bone within the maxillary sinuses.
External draining tracts are common with mandibular
cheek teeth periapical infections and sometimes occur with
rostral maxillary cheek teeth infections. These tracts may be
apparent radiographically if there is a zone of bony sclerosis B
around their margins, but otherwise cannot be identified on
plain radiographs. Infections of the caudal maxillary cheek
teeth rarely present with external draining tracts, but affected
horses may rarely have cellulitis of the masseter or pterygoi­
deus muscles. If an external sinus tract is present, a blunt,
malleable metallic probe should be inserted into the tract,
and an appropriate lateral-oblique radiograph taken (Fig.
13.41D). This procedure can provide irrefutable evidence of
dental disease, identify the affected apical area of the tooth,
and provide a landmark for placement and angulation of the
dental punch, if tooth repulsion is to be performed. Longer
standing mandibular cheek teeth infections often have gross
new mandibular bone formation beneath the affected apex,
making the hemimandible thickened on palpation.
Focal, soft-tissue radio-opacities may also be apparent in C
the sinuses if periapical infection of the caudal 3–4 maxillary
Fig. 13.41  Radiographic signs of periapical infection. (A) Radiolucent halos
cheek teeth has occurred. These opacities may be due to a
are evident around both roots of an infected 408, with widening of
rounded, (soft tissue) granuloma or later, an encapsulated periodontal space, sclerosis of the ventral mandibular cortex and periosteal
abscess developing over the infected apex. Fluid lines may new bone deposition. (B) A zone of sclerosis is present around this infected
be apparent in straight lateral views of the sinuses, due to 306. The affected apex is somewhat blunter than those of adjacent teeth;
accumulation of liquid purulent material. In cases of dental however, this can be a normal feature of 06s. An arrow points to a small
sinusitis, as in other sinusitis cases, inflamed and hypertro­ radio-opaque marker placed on the skin at the site of facial swelling.  
phied sinus mucosa may cause increased soft-tissue opacity (C) Infected 108. A periapical radiolucent halo surrounded by marked
sclerosis is evident around the infected apex of this tooth, which lies
within the sinuses.9,12 outwith the rostral maxillary sinus in this horse.

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 Dental imaging

Fig. 13.42  Ameloblastoma of the rostral mandible, which has displaced the
303 laterally and caused erosion of the 302 and 301 incisors. These tumors
can have varying degrees of calcification – this one is well calcified.
(Radiograph courtesy of P.M. Dixon.)

periapical infections, no such repair process occurs and pro­

gressive destruction of the infected apex results in initial
radiolucency and then loss of the apex and adjacent reserve
crown of the affected tooth (‘clubbing’). Dystrophic miner­
alization (‘coral formation’) of the cartilage of the nasal
conchae may also occur with chronic maxillary cheek teeth
periapical infections, particularly those involving the more
rostrally positioned maxillary teeth.9,12

Periodontal disease
Oral examination is superior to radiography for the detec­
tion and investigation of periodontal disease, but open-
mouthed, oblique or intra-oral radiographs may occasionally
be useful for demonstrating the effects of severe periodontal
F disease on the alveolar crest (Fig. 13.33) and adjacent struc­
tures. Occasionally, very severe and deep periodontal disease
Fig. 13.41 continued  (D) Gross destruction of the architecture of this may extend towards the apex of the tooth and may be the
infected 407 dental bud is present, with loss of much of the apical aspect of cause of periapical infection. Radiography may be used to
its crown. Multiple radio-opaque fragments are present in the alveolus,
outline the dimensions of diastemata and the angulation
which may represent dental fragments or cementoma formation. A draining
tract (with probe inserted) and gross mandibular new bone formation are and distance between the cheek teeth. It may also provide
evident. (E) Marked sclerosis is present around an apically infected 210. This additional information on displaced teeth, which usually
horse had concurrent sinusitis. (F) Massive reactive cementoma deposition is have associated periodontal disease.
present around the apex of chronically infected 207. Dystrophic calcification
of the nasal conchae is likely also contributing to the radio-opaque
appearance in the area rostral to the alveolus of 207. Most of the reserve Odontogenic tumors
crown of this tooth was still present; however, it is quite radiolucent, due to Tumors of dental-tissue origin are all rare, but may be more
demineralization caused by chronic infection.
common in horses than in other species20 and are discussed
in detail in Chapter 11. Five types of odontogenic tumors
have been recorded in horses, and their radiological charac­
teristics have been reviewed in detail.21 Ameloblastomas and
In less destructive chronic periapical infections, reactive ameloblastic odontomas can have a similar radiographic
abnormal deposition of (radio-opaque) cementum may appearance.21 They are expansive, soft-tissue opacity masses
occur on the infected tooth apex in an attempt to help containing lytic areas and sometimes areas of irregular
control the infection, often resulting in an increase in granular calcification21 and often displace adjacent teeth
size and blunting of the apex. In more destructive chronic (Fig. 13.42). Complex and compound odontomas are

217
 13 Diagnosis

irregular, tumor-like masses of dental tissues in well differ­

entiated forms (Fig. 13.43). Complex odontomas contain
all the elements of a normal tooth but within a disorganized
structure, hence radiologically they appear as multiple,
small, lobulated radio-opaque masses within a well-defined
cyst-like structure.20,21 In contrast, compound odontomas
contain an orderly pattern of dental tissues which form
recognizable tooth-like structures. Cementomas are very
radio-opaque mineralized structures, often rounded in
appearance and associated with chronically infected tooth
apices (Fig. 13.41F) or their alveoli following extraction of
the infected tooth.

Other tumors and cystic structures

A
affecting dentition
Any tumor or other space-occupying lesion affecting the
mandible, incisive bone, maxilla, or paranasal sinuses may
affect the teeth by displacing them or destroying their archi­
tecture, often through pressure resorption. Osteoma, osteo­
sarcoma, osteoblastoma, chondrosarcoma, and fibrosarcoma
are all tumors of bone that can arise in the regions of the
equine jaws, and in the mandible in particular.22 It can
be very difficult to differentiate between these individual
tumor types radiographically, with proliferation of a bone-
opacity mass being the most common radiologic presenta­
tion. Osteosarcomas may have a characteristic ‘sun-burst’
appearance of bone lysis and irregular, radiant deposition of
reactive new trabecular bone. Other tumors of soft-tissue or
mixed soft-tissue/bone origin, such as ossifying fibroma,
fibrous dysplasia, and squamous cell carcinoma (Fig. 13.44)
can have similar radiographic appearances to bony tumors
as they often replace bone with fibro-osseous tissue. In their
earlier stages, localized swellings caused by malignant
tumors may be clinically similar to those caused by dental
B
periapical infection, and consequently, the radiographic
demonstration of bone destruction in the presence of normal
dental apices may be an important differentiating feature of
jaw tumors.1 Cyst-like lesions of the mandible and paranasal
sinuses of horses are commonly reported, and may displace
the teeth due to their expansile effects.23

Traumatic dental injuries

Horses with skull and in particular, mandibular fractures
often have dental injuries, and radiography, along with
detailed oral examination, is useful in evaluating such cases
(Fig. 13. 45). Fractures of the rostral mandible and premaxil­
lary (incisive) bone occur frequently in young horses (Fig.
13.24A) and radiography may demonstrate whether tempo­
rary, permanent or both types of dentition have been
damaged. Fractures of the cheek teeth also commonly occur
alongside traumatic damage to the mid- and caudal mandi­
ble; however, even if identified acutely, treatment of dental
fractures beyond removal of palpably loose fragments is
usually best left until the supporting bone is healed as some
fractured teeth can survive the acute pulpitis and do not C
become chronically infected.
Fractures of the erupted crown are more likely to be patho­ Fig. 13.43  Radiograph (A) and CT images (B and C) of a compound
logical (idiopathic cheek teeth fractures – see Ch. 10) or odontoma in a 2-year-old TB colt. (Images courtesy of J. Easley.)
iatrogenic than traumatic in etiology, and these fractures are
best imaged using an open-mouthed, oblique radiographic

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 Dental imaging

Fig. 13.44  Squamous cell carcinoma of the mandible with an unusual

degree of linear calcification. Triadan 308 which was loosened by the
invading mass has been extracted.

Fig. 13.46  Open-mouthed oblique radiograph of a horse with a fractured

erupted crown of 108. A fragment is missing rostrally, and a displaced
caudal fragment is still in place.

Fig. 13.47  This horse has a fracture of the interdental space – caused by
damage from the bit when it stood on its reins. (Radiograph courtesy of
P.M. Dixon.)

rather than the structural features portrayed by radiography,

ultrasonography, CT, or MRI. Scintigraphy involves the
B
intravenous administration of a gamma ray-emitting radio­
isotope, which is bound to a tissue-seeking molecule.99mTc
Fig. 13.45  (A) Pre- and (B) 6-week postoperative intra-oral radiographs of a
horse with a complete, comminuted, displaced fracture of the pre-maxilla, is currently the most commonly used radioisotope in the
with loss of one central incisor. equine field, and is a meta-stable radionuclide that emits a
gamma ray of 140 keV, with a physical half-life of 6 hours.
The radio-isotope is cleared at a fast rate from the blood and
projection (Fig. 13.46). Imaging their apices is often also soft tissues, and is incorporated selectively into bone in areas
worthwhile. of resorption or formation.
Bitting injuries commonly involve the physiological Although scintigraphy has been used in equine ortho­
diastema (interdental space; between the incisors and the pedics for many years, only recently have reports of its use
cheek teeth), and radiographs may reveal sequestrum forma­ for the detection of skull disorders in large numbers of
tion on the dorsal mandibular cortex and, rarely, a mandibu­ horses begun to emerge.13–15,24,25 The ability of scintigraphy,
lar fracture (Fig. 13.47; see Chapter 9). using 99mTc bound to phosphates, to detect changes in bone
before changes become radiographically apparent (because
bone remodeling with increased bone mineral turnover
Scintigraphy usually precedes structural change) is one of the key advan­
Scintigraphy is unique among the imaging modalities tages of this technique in the equine patient. Disadvantages
because the images reflect active physiological processes of scintigraphy include the expense of setting up a dedicated

219
 13 Diagnosis

building, gamma camera, and appropriate software pro­ Scintigraphic views and normal anatomy
grams; licensing for the use, storage, and disposal of radioac­
Right and left lateral, dorsal, and ventral views are the most
tive waste; appropriate stabling facilities that comply with
commonly acquired equine skull scintigraphic views, with
radiation protection legislation; time required to isolate the
oblique views being occasionally useful for assisting lesion
patient (in most centers, horses are considered ‘radioactive’
localization.27 The reserve crowns of the cheek teeth appear
for 24–48 hours post injection and cannot be handled),
as ‘cold spots’ of reduced uptake of radiopharmaceutical
thereby delaying further diagnostic procedures or treat­
agent, and are surrounded by zones of increased radiophar­
ment; the requirement for technical expertise when reading
maceutical uptake (IRU) corresponding to the alveolar bone
scintigraphic images; and the risk of radiation exposure to
and interdental (interproximal) bone. The erupted crowns
personnel.
of the teeth are represented by an area of absent radionuclide
As noted, most equine skull scintigraphy is performed
uptake. The normal ethmoturbinates can be identified as a
using the bone marker 99mTc-MDP. A dose of 1–
region of IRU positioned dorsally and caudally to the 6th
1.5 GBq/100 kg bodyweight is administered intravenously,
maxillary cheek tooth and are located within the frontal
usually via a jugular catheter. Typically, only bone-phase
sinuses. The normal temporomandibular joints are also
images are acquired at 2–4 hours post injection, as the
focal areas of markedly IRU, as is the atlanto-occipital joint.
pool or soft tissue phase images do not usually provide
The ventral and caudal cortices of the mandible and the
any additional useful information, and collection of
zygomatic arch can be clearly identified as areas of high
pool or soft tissue phase images considerably increases the
metabolic activity.
radiation exposure of personnel.13,26 The use of 99mTc-
hexa-methylpropyleneamine(HMPAO)-radiolabeled leuko­
cytes has been described for equine dental scintigraphy,13 Periapical infection
but it does not allow for positive identification of apical Scintigraphy is most useful for diagnosis of cheek teeth peri­
infections due to lack of anatomical resolution; additionally, apical infection when used in combination with other diag­
its use incurs considerable additional cost compared to nostic techniques, such as radiography and, of course,
routine scintigraphy. clinical examination.13–15
99m
Heavy sedation is usually required in order to allow close Tc-MDP uptake associated with periapical infection is
positioning of the gamma camera to the patient and is typically focal and intense, with IRU located over the apical
achieved using a combination of an alpha-2 agonist (e.g., region of the affected tooth (Fig. 13.48). Region of interest
xylazine, detomodine, or romifidine) and butorphanol. A (ROI) studies performed on cases of periapical infection
rope headcollar should be used to prevent artefactual ‘cold have shown IRU of 24–259 % greater than the same region
spots’ being recorded from buckles and rings on regular on the contralateral side when using right and left lateral
headcollars. The horse’s head can be rested on a stool or views.14,25 Because ‘strike through’ (lesions with high uptake
similar object in order to minimize movement induced by may emit gamma rays from the contralateral side of the
sedation. Images may be acquired using static studies, which skull) may occur when comparing two lateral views, ROI
allows for their collection at a higher matrix size (256 × 256) taken from left and right sides on a dorsal (or ventral) view
which theoretically gives more detail; however, most horses can show an even greater IRU % (as high as 700 %14) on the
will not remain adequately still during the required 1–2 affected side compared with the control side. If periapical
minute acquisition period, and such movement causes dis­ infection is accompanied by secondary dental sinusitis, the
tortion (‘blurring’) of both anatomical structures and lesions focal intense uptake over the affected apex is surrounded by
on static images. Dynamic studies (e.g., 30 consecutive 2 a diffuse region of moderately increased activity over the
second frames, 128 × 128 matrix) are usually acquired in affected sinus(es) (Fig. 13.48B). After dental extraction, areas
preference to static studies, because these may be ‘motion of IRU can be present for up to 24 months postoperatively
corrected’, which accounts for the inevitable movements of (Fig. 13.49), presumably due to continued remodeling of
the horse’s head during the acquisition period. the dental alveolus.14

A B

Fig. 13.48  Scintigrams of two horses with periapical infection of (A) 108 lateral and dorsoventral views and (B) 209 (this horse has concurrent sinusitis).

220
 Dental imaging

Fig. 13.49  Seven months after oral extraction of 409 the entire dental Fig. 13.50  Scintigram of a horse with primary sinusitis. Note there is a
alveolus still exhibits marked uptake of radionuclide. This horse had no moderate uptake throughout the maxillary sinuses and a focal area of
ongoing complications associated with the extraction. intense IRU within the sinuses, which is situated too far dorsally to be
associated with the cheek teeth.

Differentiation of periapical infection from Acknowledgments

other skull lesions
The radiographers at the Royal (Dick) School of Veterinary
Areas of IRU on scintigrams are not specific to any particular
Science, University of Edinburgh.
disease process; therefore, other disorders that cause remod­
eling or inflammation of osseous structures around the
cheek teeth must be differentiated from cases of periapical
infection.
Periodontal disease can cause areas of mild to moderate IRU COMPUTED TOMOGRAPHY
on scintigraphy of the equine skull.13,14,25 However, because
this disorder is often bilateral and multifocal and more com­ Hubert Simhofer, Alexandra Boehler
monly affects older horses where the cheek teeth are not University for Veterinary Medicine Department IV, Clinical Department for Companion
clearly delineated, it can be difficult to definitively diagnose Animals and Horses, Veterinaerplatz 1, A-1210, Vienna, Austria

this disorder using scintigraphy. Periodontal disease should

be clinically evident from a thorough examination of the
oral cavity, and therefore there is little additional benefit Introduction
from the use of scintigraphy in its diagnosis.
Horses with primary sinusitis may show variable patterns of Over the past decade, computed tomography (CT) has been
IRU within the affected paranasal sinuses, but generally IRU increasingly used in equine examinations and is now avail­
is more diffuse and less marked (6–300 %)14,25 than is seen able in many referral centers and university hospitals across
with periapical infection. It should be possible to identify the globe.28,29 CT is a valuable diagnostic tool30 that provides
the rostral and caudal maxillary and frontal sinuses indi­ detailed cross-sectional images of tissues, providing good
vidually on scintigrams based on anatomical location with bone and soft tissue contrast and eliminating the problem
respect to the cheek teeth and ethmoturbinates. of tissue superimposition. CT examination of the equine
Some cases of equine primary sinusitis exhibit focal area(s) head region is indicated in cases where clinical and radio­
of moderate to marked IRU (26–320 % increase compared graphic examinations are inconclusive; when the exact loca­
with contralateral side;14 Fig. 13.50). This is an important tion and extent of a lesion is needed for detailed therapy
finding, because if these focal areas of IRU that are observed planning, such as for less invasive surgery or radiation or
in cases of primary sinusitis happen to be positioned over local chemotherapy,31 and also to accurately monitor cases
the apex of a cheek tooth, a false diagnosis of periapical following treatment.
infection may be made. Careful, three-dimensional localiza­ CT has proven to be very useful in the diagnosis of frac­
tion of the focal area of IRU may help prevent such false tures, dental disease, infection and neoplasia of the equine
diagnoses in some cases. head. Protocols for the use of CT in evaluating the equine

221
 13 Diagnosis

Fig. 13.51  Three-dimensional reconstruction (A) of the bone surface image of an irregular depressed fracture involving the right frontal, nasal, lacrimal, and
maxillary bones in a 5-year-old Friesian gelding. The location of fracture lines largely coincides with anatomical suture lines. The distribution and extent of
these fractures are well highlighted in the 3D-reformation.
Transverse section CT image (B) at the level of the caudal aspect of the upper 09s (1st molars) of the above horse. Marked subcutaneous soft tissue
swelling is present, as is mild swelling of the mucosa of the right dorsal and caudal maxillary sinuses (arrowheads). Fragmentation of the right frontal and
nasolacrimal bones is present with palisading new bone formations. A well-defined bone fragment, approximately 3 cm in length, which is hyperdense
relative to the adjacent facial bones and separated from them by a 5-mm wide, hypodense rim can be clearly differentiated (arrow). The dorsal facial bones
are bilateral irregularly thickened. These CT findings indicate sequestrum formation with surrounding osteomyelitis in an old fracture. The dental structures
appear normal in these images.

head have been described in detail.28 Despite the fact that radiodensities.35 However, it is essential to also view the
CT is increasingly used for the diagnosis of equine dental images in an appropriate soft tissue window setting for eval­
disease, comparatively little information has been published uation of possible changes in adjacent soft tissues. Objec­
to date on the appearance of equine dental tissues in health tively measuring the density of specific regions of interest
and disease. (ROI) in Hounsfield Units (HU), allows for improved dif­
ferentiation of soft tissues.32,36 Care must be taken not to
perform measurements in areas that have inherent imaging
Technical principles artefacts, such as streaking artefact28 (Fig. 13.52). In order to
improve differentiation of soft tissue masses, post-contrast
CT is a cross-sectional imaging method that uses a rotating imaging following use of iodinated contrast agents can be
X-ray tube and detector system located in a gantry for image acquired after local application of these agents into fistulous
acquisition. When the narrow X-ray beam passes through a tracts or after intravenous injection.28,37
selected plane of the body, it is partially absorbed when it General anesthesia is usually required for equine CT
passes through tissues with different attenuation coefficients examinations, but more recently some clinics have acquired
(density). Each tissue is assigned a value that represents its facilities to allow CT examination of sedated, standing
attenuation coefficient. Computerized reconstruction pro­ horses to be performed.38 CT examination of the anesthe­
grams are used to assign a gray scale value that correlates to tized horse requires a custom-built table to allow precise
the attenuation value of the tissue being imaged.32 Different positioning of the patient32,37 (Fig. 13.53). The horse should
algorithms can be used for image reconstructions.33 Each CT be positioned as symmetrically as possible32 in either lateral
instrument manufacturer offers algorithms specifically or dorsal recumbency, keeping the head (when in lateral
designed for their individual hardware. For equine dental recumbency) or the hard palate (when in dorsal recum­
imaging, a soft tissue algorithm is useful for imaging of the bency) parallel to the table. The number, size and angle of
soft tissue structures, followed by a reconstruction in a bone slices can be planned after evaluating lateral (Fig. 13.54) and
algorithm (high resolution) from the raw data, to allow dorsal scout views. The gantry tilt should be minimized to
detailed evaluation of dental and bony structures. reduce image distortion (especially for image reconstruction
The acquired sectional images can be reformatted in various purposes). Contiguous, single- or multi-slice helical imaging
two-dimensional planes or three-dimensional models protocols have been described,35 the latter reducing scan
(Fig. 13.51). time most. The recommended slice thickness ranges from 4
Evaluation of CT images for the presence or absence of to 10 mm for evaluating the teeth and sinuses, and from 1
dental disease is usually performed using a bone window.34 to 2 mm for evaluating special regions of interest (i.e., exam­
By using this particular setting, the dental tissues (cement, ining for specific changes in individual teeth or the tempo­
enamel and dentin), as well as the lamina dura denta of romandibular joint). Two- and three-dimensional image
the alveolus, can be differentiated according to their varying reconstructions may assist in the diagnosis39 and also

222
 Dental imaging

Area: 0.4 sq. cm

Mean: 8.8 HU
Std Dev: 17.9 HU

Area: 5.2 sq. cm

Mean: 84.9 HU
Std Dev: 15.1 HU

Fig. 13.52  Transverse images at the level of the caudal aspect of the Triadan 10s (2nd molars) of an 8-year-old Hannoverian mare in a soft tissue window
(A) and bone window (B). A well-defined soft tissue mass lies within the left ventral conchal and caudal maxillary sinuses surrounded by a thin calcified wall
and is causing compression of the dorsal conchal sinus. Density measurements within the mass revealed values of about 10 HU, which is indicative of fluid,
whereas measurements of approximately 80 HU were present in the right masseter muscle, which is typical of soft tissue. Bilateral, mild, gaseous inclusions
are present within the infundibula of both the maxillary cheek teeth that are imaged, but no significant abnormal dental findings were detected. These CT
findings are suspicious of a sinus cyst that was later confirmed during surgery. There is gas present in both infundibula that must be differentiated from pulp
disease, which would be much more likely to lead to sinus granuloma formation. Note the streaking artefacts dorsal to the left maxillary tooth within the
lesion in the soft window settings (A) that are masked in the wide bone window settings (B). Artefacts compromise Hounsfield measurements.

Fig. 13.53  This horse under general anesthesia is positioned in dorsal

recumbency on an air filled mattress with its head and legs fixed to the
table. The head is positioned as symmetrically as possible.

improve surgical planning. The authors recommend the use

of three-dimensional image reconstruction specifically in the
evaluation of questionable periodontal or periapical disease.

Normal appearance of equine dental Fig. 13.54  Lateral scout view of a 4-year-old Pinto gelding under general
anesthesia. The head is positioned with the hard palate almost parallel  
and periodontal tissues to the table so that transverse images are parallel to the long axis of
uppermost (mandibular in this position) cheek teeth. The vertical dotted
On transverse CT images of normal teeth (Fig. 13.55A), the white lines resemble every 5th transverse slice.
peripheral layer of cement is hypodense compared to adja­
cent enamel. The hyperdense zone of peripheral enamel

223
 13 Diagnosis

Fig. 13.55  Transverse (A) and sagittal (B) micro CT sections of an

extracted Triadan 09 (1st maxillary molar). c, peripheral cement; e, enamel;
d1, primary dentin; d2, secondary dentin; rI, rostral infundibulum.
d1 Hypodense gas inclusions where there is absence of infundibular
cl c cementum are indicative of infundibular cemental hypoplasia, cI, caudal
2 3 3
infundibulum; 1–5, pulp cavities; cpc, common pulp chamber.
rl cpc
5
1 4

A e rl
d2

cl

e
d1
B d2

extends from the erupted (clinical) crown towards the apical

region. Dentin is less radiodense than enamel and surrounds
the hypodense pulp cavities.35 The pathway of the pulp vas­
culature through the root canal(s) to the common pulp
chamber (only present in recently erupted teeth) and the
5–7 individual pulp canals located in the reserve crown can
clearly be followed over their length on 3-D reconstruction
images of the cheek teeth. A column of dense secondary
dentin lies over each pulp canal at the occlusal surface of
normal teeth.
The rostral and the caudal infundibula are clearly seen
in the maxillary cheek teeth, with each infundibulum sur­
rounded by infolded enamel. In some teeth, a central
infundibular vascular channel can be detected for the full
length of the infundibulum on certain images. Although the
central infundibular vascular channel canal is a hypodense
structure in sagittal orientation, it must not be misinter­
preted as a pulp cavity (Fig. 13.55B). In particular, infun­
dibula may contain gas in cemental defects that must not
be mistaken for an infected pulp. Fig. 13.56  Transverse CT section of a short 110 of a 16-year-old
The periodontal ligament appears as a narrow, linear, soft- Warmblood gelding. The normal lamina dura (dental lamina) is outlined
tissue structure that separates the tooth from the surround­ (arrowheads).
ing alveolar bone. In healthy teeth, a thin layer of cortical
bone, which is radiographically termed the lamina dura
denta or dental lamina, lines the alveolus (Fig. 13.56). tissue mass around the apical area of the affected tooth
Several publications have described the normal CT anatomy (teeth), which is a feature of chronic dental disease (Fig.
of the equine head,28,33,40–43 including normal CT dental 13.58). Infection of the caudal four cheek teeth often leads
anatomy in detail,44,45 and more detailed information about to secondary sinusitis of the maxillary sinuses34 (Fig. 13.59)
normal CT findings can be found in these papers. when thickened respiratory epithelium, inspissated pus,
and/or fluid-lines may be visible in the adjacent sinuses. As
CT examinations are usually performed under general
Pathological CT findings in equine anesthesia in dorsal recumbency, purulent fluid originating
dental disease from an infected cheek tooth may flow from the maxillary
sinuses into the ipsilateral frontal sinus (Fig. 13.59).
Signs of apical infection include: hypodense widening of the Changes of the calcified dental tissues occur in long stand­
apical periodontal tissues (Fig. 13.57), sclerosis, and defor­ ing cases of apical tooth root infections. Deformation or
mation or disintegration of the apical aspect of the lamina fragmentation of tooth roots may be visible34 (Fig. 13.59).
dura denta. Concurrent thickening of the overlying periapi­ In some chronic cases, considerable amounts of cement are
cal soft tissue, sometimes containing gas inclusions, is also deposited irregularly around the apex (as described in the
usually present. Granuloma formation appears as a soft gross pathology of these lesions in Chapter 10). Hypodense

224
 Dental imaging

Fig. 13.57  Transverse CT section at the level of mid 209 of a 6-year-old

Warmblood gelding that had an intermittent, purulent, left-sided nasal
discharge. Moderate thickening is present in the rostral maxillary sinus Fig. 13.59  Transverse CT section at the level of the maxillary 110s of
mucosa and also medial to the infraorbital canal in the ventral conchal sinus an 11-year-old Warmblood. Total opacification and mild expansion of  
(arrowheads). Mild to moderate widening of the periapical periodontal the right caudal maxillary and ventral conchal sinuses are present. There is
space is present, as is irregular thickening of the dental lamina (arrows) and also some mucosal swelling in the ipsilateral dorsal conchal sinus. The apical
of the bony plate lying beneath the infraorbital canal. A palatal slab fracture dental lamina of 110 is widely separated from the apex and is sclerotic
of 209 is present (circle) without any detectable overlying pulpar reaction. (arrowheads), and there is blunting of both visible roots and irregularity of
the dental lamina on the buccal aspect of the affected tooth. A hypodense,
bulbous enlargement is present in the proximal aspect of the 2nd pulp
canal (arrow). A buccal slab fracture of the crown (circle) has caused
changes in at least one (of the two) involved pulp horns.

Fig. 13.58  Transverse CT section at the mid-level of the maxillary 09s of a

5-year-old Quarter Horse. A focal soft tissue swelling (granuloma) surrounds
the palatal root and hypodense 5th pulp cavity (arrow) of the 209. A
fluid-line is present in the ventral conchal sinus (arrowhead) because the
image was acquired in dorsal recumbency.

(black) areas indicating the presence of gas within the

pulp or root canals are indicative of pulpitis (Figs 13.58 &
13.59), but many clinically normal equine maxillary cheek Fig. 13.60  Transverse CT image of a 6-year-old Polo Pony at the mid 209
teeth have gas within areas of cemental defects in infundib­ level. A sagittal midline fracture is present in 209, and the fracture site is
ula, that must not be mistaken as evidence of bacterial packed with heterogeneous food particles. Note the irregularities and
infection. disruption of the apical dental lamina (arrow) and marked widening of the
Whilst sagittal cheek teeth fractures are usually apparent periodontal space. The rostral maxillary and ventral conchal sinuses are filled
with food with gaseous inclusions. Some thickening of the overlying left
on thorough clinical examination, they are difficult to diag­
nasal bone and mucosal swelling of the dorsal concha are also present.
nose radiographically. However, they are readily detected on
CT images (Fig. 13.60) that also allow the configuration and
extent of dental fractures to be fully evaluated. Transverse
fractures of the teeth are relatively uncommon but may occur

225
 13 Diagnosis

Fig. 13.61  Transverse CT section at the level of the upper 09s in an Fig. 13.62  Transverse section at the mid level of the Triadan 10s of an
18-month-old Welsh Cob with facial swelling of suspected traumatic origin. 8-year-old Noriker mare. A buccal slab fracture is present in 210 with
The CT shows facial asymmetry, left-sided soft tissue (subcutaneous) exposure of the 1st pulp canal (these fractures also usually involve the 2nd
swelling and thickening and irregularity of the external surface of the pulp horn) but with no evidence of pulpar, apical, or periodontal changes
maxillary bone dorsal to the facial crest. The left dorsal and ventral conchal, currently apparent in this tooth. Note the rounded apical area of 110,
and the rostral maxillary sinuses are completely filled with fluid and gas adjacent periodontal widening (arrow) and complete filling of the right
inclusions and, in turn, these structures are causing total obstruction of the ventral conchal sinus (arrowhead) with fluid, indicative of apical infection of
left nasal passages and causing deviation of the nasal septum to the right 110 with secondary sinus empyema.
side. An irregular, radiolucent line running transversely across the apical
third of the reserve crown of 209 (arrowheads) and possibly some buccal
axial deviation of this tooth are likely due to a traumatic fracture of this
tooth. The irregular hypercementosis of the buccal peripheral cemental
layer of this tooth and adjacent periodontal reactions are also likely of
traumatic origin.

secondary to trauma (Fig. 13.61). Lingual or buccal slab

idiopathic cheek teeth fractures (Figs 13.62 & 13.63) have
been described recently as the most common types of cheek
teeth fractures in horses. In such fractured teeth, CT can
usually distinguish between single and multiple pulp cavity
involvement.46 In some acute cases of dental fractures involv­
ing pulp cavities, pulpar changes are not detectable on CT
(Fig. 13.62). These fractured teeth may be healing by produc­
tion of tertiary dentin or, alternatively, might later develop
clinical signs of pulpitis and subsequent periapical infection. Fig. 13.63  Transverse CT section at the level of the upper 09s of a
In the latter type of case, magnetic resonance imaging is 4-year-old Thoroughbred mare. The 209 has a buccal slab facture (with loss
useful in the detection of periodontal disease, pulpitis and of fragment) affecting the 1st (or 2nd) pulp horn, which is slightly widened
pulp necrosis.47,48 and hypoattenuated. The common pulp chamber of this tooth also contains
Infundibular cemental hypoplasia and infundibular caries a rounded, hyperdense structure 4 mm in diameter, most likely a pulp stone
(arrow). The roots of this tooth (dental age 3 years) are blunt (rounded) and
have been well described in equine teeth. Wide and air-filled
there is slight widening of the periodontal space apically and bucally. The
irregular cavities can clearly be seen on transverse CT images buccal alveolar bone is heterogeneously thickened, and irregular sclerotic
of some clinically normal sagittally orientated infundibula34 changes are also present in the periapical alveolar bone (arrowheads). The
(Fig. 13.64). Although easily diagnosed using CT, infundibu­ nasal conchae, including the left ventral and dorsal conchal sinuses, are
lar changes are frequently present in horses that are asymp­ irregularly thickened and distorted, and the adjacent ventral conchal and
tomatic and, in these cases, treatment such as dental rostral maxillary sinuses are partially opacified due to the presence of
extraction is not indicated. A diagnosis of severe infundibu­ exudate caused by the dental sinusitis.
lar caries penetrating the infundibular enamel is possible
using CT examination, and such a finding is of great help

226
 Dental imaging

Fig. 13.64  Transverse section CT image at the level of 207 in a 9-year-old

Warmblood gelding. Gas is present in the proximal aspect of the imaged
infundibulum with irregular thinning of the adjacent infundibular enamel
(arrow). Penetration of caries through the infundibular enamel into the Fig. 13.65  Transverse CT section at the level of the 09s in a yearling. The
surrounding dentin may be present in this tooth. occlusal surfaces of these unerupted teeth are still covered by soft tissue
(dental sac). An expansive lesion above 209 has greatly disrupted the
alveolus and adjacent structures. The enamel folds of 109 are irregular at
their apical aspects, and the buccal surface of the peripheral enamel has a
focal thickening (arrow). The inner borders of the periapical swelling have
when deciding whether to extract or preserve a maxillary thick, irregular new bone formation (arrowheads), and the adjacent ventral
cheek tooth. Dorsal plane reformatted images parallel to the conchal and rostral maxillary sinuses are completely filled with a hypodense
occlusal surface show infundibular caries very well. substrate. The outline of the left facial crest is slightly irregular, and overall,
Considerable efforts have been made recently to improve the maxillary bone appears heterogeneous. In summary, these CT images
diagnosis and treatment of periodontal disease. Detailed indicate a chronic proliferative sinusitis and maxillary bone osteitis
secondary to apical infection of the unerupted tooth.
examination of the periodontal space on CT images can
provide considerable information concerning the extent of
periodontal disease. A specific equine periodontal disease
classification system needs to be established in the near long-standing cases, chronic distension of the sinuses with
future. Periodontal changes that are detectible on CT exudate can cause deviation of the nasal septum (Fig. 13.61),
range from mild, focal changes, such as widening of the distortion of the nasal turbinates (conchae), the facial bones,
(hypodense) periodontal space, cemental erosions, irregu­ and even dental apices. Chronic sinusitis may also cause
larities in the lamina dura denta (dental lamina), alveolar thickening, endosteal sclerosis, and an irregular periosteal
sclerosis or disruption, and extensive food and gas pocketing reaction of maxillary34 and mandibular bone, and new bone
with destruction of the supporting maxillary or mandibular formation may be present along the internal (Fig. 13.65) and
bones. The exclusion of periodontal disease is a prerequisite external (Fig. 13.66) supporting bony walls of sinuses.
for endodontic therapy. The presence of facial swelling and draining sinus tracts is
a common reason for referral of equine patients. Dental
disease, dentigerous cysts (heterotopic polyodontia; Fig.
Dental-associated structures 13.67), head trauma, osteomyelitis and, infrequently, neo­
Sinusitis is a common disease in equids and can be a primary plasms of the head region are the most common causes
sinusitis (i.e., caused by bacterial infection), or secondary to of such facial swellings and tracts. In most affected horses,
dental disease, trauma, cystic lesions, mycotic infections or a definite diagnosis can be obtained using clinical and
neoplasia.32,34,49 One of the first changes of sinus disease radiographic examinations. However, CT can be helpful in
detectable on CT imaging is a focal or diffuse swelling of the the examination of more difficult cases. Despite the fact
sinus mucosa, which must be differentiated from edema of that a specific tumor classification is not possible using CT,
the nasal conchae (turbinates) related to head positioning the extent and the grade of destruction of adjacent hard
under general anesthesia.28 A varying degree of intra-sinus and soft tissues can be clearly evaluated, which enables a
fluid accumulation or increased density due to inspissated more accurate treatment plan and prognosis to be given
material and/or mucosal thickening can also be seen. In (Fig. 13.68).
severe cases of sinusitis, the sinuses are entirely fluid-filled, In complicated cases of ongoing dental-related disease, CT
and the sinus mucosa is indistinguishable from the sur­ examination can be very helpful in assessment of treatments
rounding fluid. In these cases evacuation of sinus exudate and, for example, in planning subsequent treatment strate­
prior to CT examination may facilitate the examination. In gies for oro-nasal fistulae (Fig. 13.69) or sequestration of

227
 13 Diagnosis

alveolar bone or dental remnants, bone necrosis, or ongoing

osteomyelitis (Fig. 13.51).
Disorders of the temporomandibular joints and hyoid
bones can clinically mimic dental disease. The associated
bony structures can be assessed accurately in CT. Alterations
due to infectious disease and fractures have already been
described.50–52 Typical features of infectious temporoman­
dibular joint disease are widening of the joint space, bony
defects, and soft tissue swelling (Fig. 13.70), as further
described in Chapter 23.

Fig. 13.66  Transverse CT section at the level of the upper 06s of a

2-year-old Quarterhorse. A normal eruption cyst overlies the 106 with the
remnant of the underlying deciduous tooth (506) lying beneath it. A much
larger, cyst-like swelling lies over the apex of 206 that is distorted and
abnormally angled medially, towards the ventral nasal concha (arrow), with
disruption of the medial aspect of the alveolus. A marked degree of smooth Fig. 13.68  Transverse CT image at the level of the 410 in a 12-year-old,
lamellar new-bone formation (arrowheads) has occurred along the adjacent New Forest Pony stallion, using a soft tissue window. Amorphous,
maxillary bones along with adjacent subcutaneous soft-tissue swelling. hyperdense structures are clearly visible in the grossly enlarged and
These CT findings indicate chronic infection of the erupting 206 with deformed right hemimandible. Such massive bony destruction caused by
penetration of exudate into the nasal cavity. Note the semicircular white line an expansile lesion is a feature of an ameloblastoma, which was diagnosed
in the dorsal nasal passage due to injection of iodated contrast agent into in this case. CT examination was invaluable for the planning of subsequent
the nasolacrimal duct that flowed to this site when the horse was in dorsal radiotherapy. The neoplasm did not enlarge for at least two years following
recumbency under general anesthesia during CT imaging. this therapy.

A
B

Fig. 13.67  Dorsal (A) and transverse (B) CT sections at the level of the temporal bone of a 6-month-old female Noriker foal. A horizontally orientated,
heterotopic cheek tooth (‘dentigerous cyst’) lies within the right calvarium. The cerebral bony lamina is markedly thinned to just 1 mm wide (arrowheads) at
the rostral aspect of this tooth. Gaseous inclusions and bony fragments lie within the soft tissues lateral and ventral to the dentigerous cyst, which was
caused by the previous surgical removal of a second heterotopic tooth.

228
 Dental imaging

A
B
Fig. 13.70  Transverse CT images at the level of
the temporomandibular joints (TMJ). Marked soft
Fig. 13.69  Transverse CT images at the level of the 08s some 6 months following extraction of the
tissue swelling is present in the left temporal
208, as viewed in a soft-tissue (A) and bony window (B). A soft-tissue swelling overlies the left
region. The left TMJ joint space is widened, and
maxillary bone, which has an irregular bulbous expansion and contains irregular, hypersclerotic
the joint has irregular bony surfaces. There are
areas. An oro-nasal fistula (arrowheads) is evident as an irregular lateral expansion of the maxillary
discrete, lytic changes in the subchondral bone of
bone, and a sclerotic appearance of the medial aspect of the ventral concha. An isolated, small,
the mandibular condyle (arrows) and mild
hyperdense bone sequestrum or dental remnant (arrow) is identified more easily in the soft tissue
irregular periosteal new bone formation on the
window (A) as compared to the bony window (B).
dorsolateral aspect of the left hemimandible
(arrowhead). The articular disc can be identified
as a slightly hyperdense structure lying in the
center of the left TMJ.

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 Section 4:  Diagnosis

C H A P T ER  14 
Ancillary diagnostic techniques
Justin D. Perkins† BVetMed, MS, MRCVS, Dipl ECVS, James Schumacher*
DVM, MS, MRCVS, Dipl ACVS
†
Department of Veterinary Clinical Sciences, Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield, Hertfordshire AL9
7TA, UK
*Department of Large Animal Clinical Sciences, College of Veterinary Medicine, University of Tennessee, Knoxville, TN 77901-1071,
USA

Cytological examination and A wide variety of bacteria, including aerobic and anaero-
culture of exudate bic, Gram-positive and Gram-negative bacteria, have been
isolated from exudate obtained from the sinuses of horses
Empyema of the paranasal sinuses is a common complica- affected with primary bacterial sinusitis. Hemolytic Strepto-
tion of periapical infection of those cheek teeth whose apices coccus spp. are the most commonly isolated bacterial
reside within a maxillary sinus and of primary infection of species.4,5 Streptococcus equi var. equi, the cause of strangles,
the upper portion of the respiratory tract. Determining the is rarely isolated,3,6,7 but the presence of this organism may
underlying cause of paranasal sinus empyema is important be masked by the overgrowth of other bacterial species. If a
because the cause of empyema influences treatment of the horse suffering from sinusitis has had signs typical of stran-
affected horse. Although periapical infection of teeth rostral gles, PCR examination of exudate obtained from the para-
to the maxillary sinuses is readily identified during radio- nasal sinus should be considered to rule out infection caused
graphic examination of the skull, periapical infection of by S. equi var. equi.8 The clinical significance of isolating
teeth within the sinuses can be confidently recognized in bacterial species other than hemolytic Streptococcus spp. is
only about half of affected horses.1 largely unknown. Culture of exudate from the paranasal
To help determine whether empyema is caused by dental sinuses of horses affected by primary bacterial sinusitis can
disease or by primary infection, exudate obtained by centesis yield multiple bacterial isolates, especially if the infection is
of the paranasal sinuses can be examined cytologically and long-standing or if the horse has received prolonged admin-
cultured for bacteria. Exudate from within the paranasal istration of one or more antimicrobial drugs,4 and therefore,
sinuses can be obtained by introducing a dog urinary cath- definitively determining the organism responsible for
eter through a small portal created in the frontal bone at a primary infection of the paranasal sinuses on the basis of
site one-third of the distance from the medial canthus of the microbial culture of the exudate is difficult. Waiting for
eye to the dorsal midline, and 0.5 cm caudal to a line con- results of bacteriological examination before proceeding
necting the medial canthi.2 The portal can be created by with other diagnostic tests, such as sinoscopic or radio-
making a stab incision in the skin and either drilling through graphic examination of the sinuses, may not be warranted.
the frontal bone with a small, trocar-tipped, Steinmann pin Odor is seldom helpful in determining the cause of para-
using a Jacob’s chuck or by driving a steel, 14- or 16-gauge, nasal sinus empyema. Although nasal discharge produced
hypodermic needle through the frontal bone with a mallet. because of primary sinusitis is usually not characterized by
The needle should be removed before introducing a catheter necrotic odor,9 primary bacterial sinus empyema can result
into the sinuses. The catheter is passed through the portal in a necrotic odor to the horse’s breath7 if the exudate
and advanced through the underlying frontomaxillary aper- becomes inspissated, because expansion of the inspissated
ture until it contacts the floor of the caudal maxillary sinus exudate causes necrosis of surrounding tissue. Relying on
where exudate, if present, can usually be found, regardless odor to distinguish primary sinusitis from sinusitis occurring
of the site of disease causing empyema. If no exudate can be secondary to other disease, such as dental infection, may
obtained, 10–20 ml of sterile, isotonic saline solution result in inaccurate diagnosis.
should be instilled into the sinus and aspirated (Fig. 14.1). The ventral conchal sinus is frequently the compartment
Identifying a single bacterial species during cytological of the paranasal sinuses in which exudate becomes inspis-
examination of the exudate or culturing a single bacterial sated,4 and a large volume of inspissated exudate within this
species from the exudate indicates that the empyema is prob- compartment usually signifies that the empyema is caused
ably caused by primary bacterial infection.3 If empyema is by primary infection (authors’ observation).
caused by periapical dental infection or an orosinus fistula, Empyema of the paranasal sinuses caused by periapical
multiple types of bacterial colonies are identified, and plant dental disease (i.e., dental sinusitis) is frequently associated
material can sometimes be seen in the exudate. with a necrotic odor because periapical dental infection is

231
 14 Diagnosis

DCB

DA

NS

VCB

Fig. 14.2  Rhinoscopic image of the right caudal middle meatus showing
exudate exiting the ‘drainage angle’ of the right paranasal sinuses.  
DCB, dorsal conchal bone; VCB, ventral conchal bone; DA, drainage angle;
NS, nasal septum.

Fig. 14.1  A sample of exudate is obtained from the sinuses for

bacteriological examination using a dog urinary catheter. the exudate. Exudate that originates within the paranasal
sinuses can usually be observed, during rhinoscopy, dis-
charging into the middle nasal meatus at the drainage angle
usually accompanied by anaerobic infection of alveolar located at the caudal aspect of the nasal cavity (Fig. 14.2).
bone.10 Mycotic infection of the paranasal sinuses should Rhinoscopy is also indicated to determine the cause of
also be considered if paranasal sinusitis is accompanied by obstruction of the nasal cavity. Obstruction, even mild
a malodorous nasal discharge.11 A space-occupying lesion, obstruction, can often be detected by placing the palms of
such as a neoplasm or a progressive ethmoidal hematoma, the hands in front of the nares and comparing the volume
may also produce a malodorous nasal charge from destruc- of air exhaled from each nasal cavity.12 A nasal cavity can
tion of surrounding tissue or stagnation of mucosal become obstructed from a mass originating within the nasal
secretions. cavity, such as a progressive ethmoid hematoma expanding
from the nasal portion of the ethmoid labyrinth, or from
Percussion axial deviation of the conchae caused by an expanding mass
within the paranasal sinuses, such as a neoplasm, an
Percussion of the paranasal sinuses is performed by rapping osteoma, a cyst, inspissated exudate, or a progressive eth-
one’s knuckles against the facial bones overlying the sinuses moidal hematoma whose origin is the sinusal portion of the
and listening for a difference in resonance between right and ethmoidal labyrinth (Fig. 14.3). Partial or complete obstruc-
left sinuses. Percussion may identify loss of resonance within tion of the nasomaxillary aperture may also result in axial
the sinuses, especially if sinuses are completely filled with deviation of the conchae from accumulation of exudate. A
fluid or tissue, but percussion, in general, is unreliable for horse that has developed distortion of the facial bones
detecting disease within the sinuses.12 Resentment of the rostral to the eye should be examined endoscopically to
horse to percussion, however, may signify the presence of determine if the nasal conchae have also been distorted.
inflammation within the sinuses. Percussion is best per- Axial distortion of the nasal conchae indicates that the facial
formed with the horse’s mouth held open with a speculum distortion is caused by an expanding mass or large volume
so that sound produced by percussion is not dampened by of exudate within the paranasal sinuses. Sometimes, subtle
being transferred through the mandible. deviation of the conchae can be appreciated only by endo-
scopically comparing the circumference and morphology of
the two nasal cavities. Distortion of the conchae is not com-
Rhinoscopy monly caused by dental disease.
Lesions encountered during rhinoscopy associated with
Rhinoscopy is performed with a flexible, video- or fiberoptic dental disease include oronasal or oromaxillary fistulas (Fig.
endoscope, with the horse standing. Rhinoscopy is indicated 14.4), apical granulomas, and displaced teeth. An apical
to determine the source of purulent exudate discharging granuloma is visible during rhinoscopy within the rostrola-
from an external naris. The source of purulent exudate at an teral aspect of the nasal cavity and is caused by periapical
external naris could be the ipsilateral nasal cavity or parana- infection of the 2nd, 3rd, or 4th premolars (Triadan 06–08).
sal sinuses, a guttural pouch, the nasopharynx, or the lungs. If accompanied by an oro-nasal fistula, the granuloma is
Finding exudate consistently at only one naris implicates the sometimes covered with exudate and feed. Removal of the
ipsilateral paranasal sinuses or nasal cavity as the source of feed reveals the granuloma (Fig. 14.5).

232
 Ancillary diagnostic techniques

DCB

NS

SCC
NS
NG

VCB

Fig. 14.5  Rhinoscopic image of the right nasal cavity showing a granuloma
VCB associated with an oro-nasal fistula in the ventral meatus. VCB, ventral
conchal bone; NS, nasal septum; NG, nasal granuloma.

Sinoscopy
Fig. 14.3  Rhinoscopic image of the left middle meatus of a horse with a
squamous cell carcinoma growing through the nasomaxillary aperture
The primary role of sinoscopy in the investigation of dental
obscuring the drainage angle and middle meatus. DCB, dorsal conchal
bone; VCB, ventral conchal bone; NS, nasal septum; SCC, squamous cell disease is to rule out other causes of paranasal sinusitis.
carcinoma. Sinoscopy enables the interior of the paranasal sinuses to be
visualized, aiding in the diagnosis of many conditions of the
paranasal sinuses, such as primary sinusitis and the presence
of a mass.
Most of the structures within the paranasal sinuses can be
examined endoscopically, using a flexible, video- or fiberop-
tic endoscope with the horse standing. Although a rigid
arthroscope can also be used, it provides an inferior field of
view because it is unable to navigate around structures such
as the infra-orbital canal, making good visualization of some
structures within the sinuses difficult.
In preparation for sinoscopy, the horse is restrained in a
stock and sedated, usually with detomidine (0.01–0.02 mg/
NS
kg, IV or 0.03–0.04 mg/kg, IM) or xylazine (0.5–1.0 mg/kg,
IV or IM) and butorphanol tartrate (0.02–0.05 mg/kg, IV)
VCB or morphine (0.15 mg/kg, IV; see Ch. 15, Restraint and
anesthesia). After the horse is sedated, its head can be sup-
ported on a stand or small table so that the site for trephina-
tion is at a comfortable level for the surgeon. The sites at
which the endoscopic portals are to be created are prepared
for surgery and desensitized by subcutaneous instillation of
2–3 ml of local anesthetic solution. A portal for insertion of
the endoscope is created through a 2- to 3-cm, longitudinal,
skin and periosteal incision. A portal through the frontal or
FM maxillary bone created with a 3/8-inch (9.5-mm) to 5/8-
inch (1.6-cm) Galt trephine or drill bit accommodates the
insertion tube of most endoscopes and allows for quick
Fig. 14.4  Rhinoscopic image of the right nasal cavity showing retrieval of the endoscope, if necessary (Fig. 14.6). The cuta-
accumulation of food in the ventral meatus. VCB, ventral conchal bone;   neous incision is sutured or stapled after sinoscopy has been
NS, nasal septum; FM, food material. completed. The periosteum is left unsutured.

233
 14 Diagnosis

CMS
IOC

FMA

VCB

DCS

Fig. 14.6  Sinoscopy performed through a conchofrontal approach.

Fig. 14.7  Sinoscopic view of the right conchofrontal sinus. CMS, caudal
maxillary sinus; FMA, frontomaxillary aperture; IOC, infraorbital canal;  
VCB, ventral conchal bulla; DCS, dorsal conchal sinus. The arrow points  
to the entrance of the intra-sinus, nasomaxillary aperture of the caudal
Most of the paranasal sinuses can be examined through a maxillary sinus.
portal through the frontal bone into the conchofrontal sinus
(i.e., the frontal and dorsal conchal sinuses) or through a
portal through the maxillary bone into the caudal maxillary
sinus. A portal into the conchofrontal sinus generally pro-
vides the best visualization of the conchofrontal and caudal
maxillary sinuses. The incision for a portal into the concho­
frontal sinus is centered over the frontomaxillary aperture at
a site one-third of the distance from the medial canthus of CMS
the eye to the dorsal midline, and 0.5 cm caudal to a plane
connecting the medial canthi (Fig. 14.6).2 The incision for a
portal into the caudal maxillary sinus is centered 2 cm
ventral and 2 cm rostral to the medial canthus of the eye.2
To evaluate the rostral maxillary and ventral conchal IOC
sinuses from either the conchofrontal or the caudal maxil- RMS
VCB
lary portal, the bulla of the ventral conchal sinus must be
fenestrated under endoscopic guidance, using an arthro-
scopic rongeur or crocodile forceps passed through the same
portal as the endoscope (Figs 14.7 & 14.8).13 Hemorrhage is
a minor, but not an infrequent complication of fenestrating
the bulla. If hemorrhage obscures visualization, sinoscopy
should be repeated when hemorrhage has ceased or been
evacuated using suction.
The rostral maxillary sinus can also be examined through Fig. 14.8  Sinoscopic view of the right conchofrontal sinus (the same as in
Fig. 14.7) after endoscopic-guided fenestration of the ventral conchal bulla.
a portal created in the maxillary bone directly over the rostral CMS, caudal maxillary sinus; IOC, infraorbital canal; VCB, ventral conchal bulla
or the caudal aspect of the sinus,2,5 although this procedure (fenestrated); RMS, rostral maxillary sinus.
is not without risk of damaging a normal tooth in young
horses (i.e., <5 years old), due to the small size of this sinus
and its anatomic variability among horses. The skin incision
for a rostral portal into the rostral maxillary sinus is oriented poor, and visualization of the rostral maxillary sinus is
longitudinal to the long axis of the head and is created 3 cm reduced in comparison to that obtained through a portal
caudal to the infraorbital foramen and 1 cm ventral to an into the conchofrontal sinus combined with fenestration of
imaginary line joining the infraorbital foramen and the the bulla of the ventral conchal sinus.
medial canthus of the eye.2 The skin incision for a caudal Care should be taken when creating a portal into the
portal into the rostral maxillary sinus is centered at a point rostral maxillary sinus to avoid damaging the reserve crowns
midway between the rostral end of the facial crest and a of the teeth contained within. Damage to the underlying
point on the facial crest at the level of the medial canthus of apices is more likely when creating the rostrally positioned
the eye, 1 cm ventral to an imaginary line drawn between portal into the rostral maxillary sinus than when creating a
the infraorbital foramen and the medial canthus of the eye.2 caudally positioned portal,2,14 and therefore, the rostrally
Access to the ventral conchal sinus through either portal is positioned portal should be used only on horses aged 6 years

234
 Ancillary diagnostic techniques

CMS
P

ET
IOC

CMS

IOC

Fig. 14.9  Sinoscopic view in the left caudal maxillary sinus showing the Fig. 14.10  Sinoscopic view of the left caudal maxillary sinus showing
entrance to the sphenopalatine sinus (arrow). ET, intra-sinus portion of the edema of the mucosa overlying an apical infection of the 5th maxillary
ethmoidal turbinates; CMS, caudal maxillary sinus; IOC, infraorbital canal. cheek tooth (probe). CMS, caudal maxillary sinus; IOC, infraorbital canal.

or older.14 Damage to an apex of a cheek tooth is unlikely include the apex of the 4th cheek tooth (Triadan 09) and a
when using a conchofrontal or caudal maxillary approach. portion of the 3rd and 5th cheek teeth (Triadan 08 and 10),
The respiratory mucosa of the paranasal sinuses should be the long, slit-like conchomaxillary aperture (i.e., the entrance
pink, and its vasculature should be visible. The sinuses to the ventral conchal sinus), and occasionally, the rostro-
should contain little or no fluid. The presence of purulent maxillary portion of the nasomaxillary aperture. Visualiza-
exudate, even a small amount, is abnormal. If visualizing tion of the apices of the 3rd and 4th cheek teeth (Triadan
structures within the paranasal sinuses is difficult because a 08 and 09) through either of the portals in the maxillary
large volume of exudate is present within the sinuses, the bone into the rostral maxillary sinus is comparable to that
sinuses should be lavaged with normal saline solution once achieved through the conchofrontal portal. Because of its
or twice daily for one or two days before sinoscopy is small size, the rostral maxillary sinus is more difficult to
performed. evaluate endoscopically than are the caudal maxillary and
The interior of the conchofrontal and caudal maxillary conchofrontal sinuses. The rostral maxillary sinus of young
sinuses can be visualized directly through the portal in the horses is especially difficult to evaluate because the reserve
frontal bone. Structures that can be identified within the crowns of the 3rd, 4th, and 5th cheek teeth (Triadan 08–10)
conchofrontal sinus include the scroll-like surface of occupy most of the sinus. The size of the maxillary sinuses
the ethmoturbinates, located at the caudomedial aspect of increases, and the apices of the cheek teeth become less
the frontal sinus, and the frontomaxillary aperture located prominent as horses age because of the perpetual extru­
directly below the endoscopic portal (Fig. 14.7). Structures sion and rostral migration of the reserve crowns of the
observed within the caudal maxillary sinus include the max- cheek teeth.
illary septum, which marks the rostral boundary of the Sinoscopic findings specific to dental sinusitis include a
caudal maxillary sinus; the opening of the nasomaxillary swollen and hyperemic apex of an alveolus (Figs 14.10 &
aperture, formed by floor of the dorsal conchal sinus and 14.11), an orosinus fistula (Fig. 14.12), food material within
maxillary septum, at the rostral aspect of the frontomaxillary the sinuses (Fig. 14.13), and an apical granuloma
aperture; the apices of the 5th and 6th cheek teeth (Triadan (Fig. 14.14). Mycotic sinusitis can be primary, or it can occur
10 and 11); the infraorbital canal coursing caudally from the secondary to chronic bacterial sinusitis, such as that caused
caudal aspect of the caudal maxillary sinus to the maxillary by apical infection of a cheek tooth. It can also occur after
septum; and the entrance of the sphenopalatine sinus medial sinonasal fenestration (Fig. 14.15).7,11 Findings during sino­
to the caudal aspect of the infraorbital canal (Fig. 14.9). scopy, such as generalized mucosal thickening and edema,
These same structures can also be observed through the petechial hemorrhages, and inspissated exudate, are fre-
portal into the caudal maxillary sinus created in the maxil- quently non-specific, and although confirming the presence
lary bone ventral to the eye, but visualization of some struc- of sinusitis, do not allow determination of its cause (Fig.
tures in the ventral conchal sinus and the rostral maxillary 14.16). Other diagnostic modalities, such as radiography,1,15
sinus, such as the apices of the 3rd and 4th cheek teeth scintigraphy,16 and computed tomography,17 as discussed in
(Triadan 08 and 09) and the entrance of the sphenopalatine detail in Chapter 13, are often required to confirm a diag-
sinus, is more difficult. nosis of dental sinusitis. Because dental sinusitis is frequently
Structures that can be observed through the portals into chronic, the mucosa is often grossly thickened,18 preventing
the rostral maxillary sinus created in the maxillary bone accurate identification of the affected tooth by sinoscopy.

235
 14 Diagnosis

Fig. 14.11  Sinoscopic view of the rostral maxillary sinus, after fenestration Fig. 14.13  Sinoscopic view of the rostral maxillary sinus after fenestration
of the ventral conchal bulla, showing edema of the mucosa overlying an of the ventral conchal bulla of a horse with an oro-sinus fistula. The rostral
apically infected 4th maxillary cheek tooth (arrow) and exudate (E) maxillary sinus contains small amounts of food (arrow).
associated with the infection.

CMS

P IOC

CT

Fig. 14.12  Sinoscopic view into the rostral maxillary sinus after fenestration Fig. 14.14  Sinoscopic view of the left caudal maxillary sinus showing an
of the ventral conchal bulla. The probe (P) is placed on the apex of the 4th apical granuloma overlying an apical infection of the 5th maxillary cheek
maxillary cheek tooth (CT). The overlying alveolar bone has been eroded.   tooth (arrow). CMS, caudal maxillary sinus; IOC, infraorbital canal.
A chronic oro-sinus fistula (not seen in this view) provided a direct channel
for food to enter the sinuses.

236
 Ancillary diagnostic techniques

IOC

MP

Fig. 14.15  Sinoscopic view of a mycotic plaque (MP) associated with an Fig. 14.16  Sinoscopic view of the right caudal maxillary sinus of a horse
apical dental infection and chronic sinusitis. IOC, infraorbital canal. with chronic sinusitis secondary to apical infection of a maxillary cheek
tooth. The mucosa is edematous and contains petechia. Inspissated exudate
lies on the floor of the sinus.

References
1. Gibbs C, Lane JG. Radiographic 7. Tremaine WH, Dixon PM. A long-term 13. Freeman DE. Sinus Disease. Veterinary
investigation of the facial, nasal and study of 277 cases of equine sinonasal clinics of North America: equine practice
paranasal sinus regions of the horse: II. disease. Part 1: Details of horses, 2003; 19: 209–243
Radiological findings. Equine Vet J 1987; historical, clinical and ancillary 14. Barakzai SZ, Kane-Smyth J, Lowles J,
19: 474–492 diagnostic findings. Equine Vet J 2001; Townsend N. Trephination of the equine
2. Ruggles AJ, Ross MW, Freeman DE. 33: 274–282 rostral maxillary sinus: efficacy and safety
Endoscopic examination of normal 8. Newton JR, Verheyen K, Talbot NC, et al. of two trephine sites. Veterinary Surgery
paranasal sinuses in horses. Veterinary Control of strangles outbreaks by 2008; 37: 278–282
Surgery 1991; 20: 418–423 isolation of guttural pouch carriers 15. Wyn-Jones G. Interpreting radiographs 6:
3. Laverty S, Pascoe JR. Sinusitis. In: identified using PCR and culture of Radiology of the equine head (Part 2).
Robinson NE. Current therapy in equine Streptococcus equi. Equine Vet J 2000; Equine veterinary Journal 1985; 17:
medicine, 4th edn. WB Saunders, 32: 515–526 417–425
Philadelphia, 1997, pp 419–422 9. Mason BJE. Empyema of the equine 16. Weller R, Livesey L, Maierl J, et al.
4. Schumacher J, Honnas C, Smith B. paranasal sinuses. Journal of American Comparison of radiography and
Paranasal sinusitis complicated by Veterinary Medical Association 1975; scintigraphy in the diagnosis of dental
inspissated exudate in the ventral conchal 167: 727–731 disorders in the horse. Equine Vet J 2001:
sinus. Veterinary Surgery 1987; 16: 10. Mackintosh ME, Colles CM. Anaerobic 33: 49–58
373–377 bacteria associated with abscesses in the 17. Henninger W, Frame EM, Willmann M, et
5. Ruggles AJ, Ross MW, Freeman DE. horse and donkey. Equine Vet J 1987; 19: al. CT features of alveolitis and sinusitis
Endoscopic examination and treatment 360–362 in horses. Veterinary Radiology and
of paranasal sinus disease in 16 Horses. 11. McGorum BC, Dixon PM, Lawson GHK. Ultrasound 2003; 44: 269–276
Veterinary Surgery 1993; 22: 508–514 A review of ten cases of mycotic rhinitis. 18. Tremaine WH, Clarke CJ, Dixon PM.
6. Mansmann RA, Wheat JD. The diagnosis Equine Veterinary Education 1992; 4: Histopathological findings in equine
and treatment of equine upper 8–12 sinonasal disorders. Equine Vet J 1999;
respiratory diseases. In: Proceedings of 12. Lane JG. The management of sinus 31: 296–303
the 18th Annual Convention of the disorders of horses – Part 1. Equine
American Association of Equine Veterinary Education 1993; 5: 5–9
Practitioners. Lexington, KY, 1973,
pp 388–487

237
 Section 5:  Treatment

C H A P T ER  15 
Dental restraint and anesthesia
Tom Doherty MVB, MSc, MRCVS, Dipl ACVA, James Schumacher DVM, MS,
MRCVS, Dipl ACVS
Department of Large Animal Clinical Sciences, College of Veterinary Medicine, University of Tennessee, Knoxville,
TN 77901-1071, USA

Sedation support of a stocks partition, or wall to prevent it from

falling. On some occasions, reversing an alpha-2 agonist to
Surgical and diagnostic dental procedures are often per- speed the recovery of the horse from sedation may be
formed with the horse sedated because this eliminates the desirable. This is generally necessary only if a large dose of
risks associated with general anesthesia. In addition, per- detomidine or romifidine was administered. Yohimbine
forming dental procedures with the horse sedated, rather (0.15 mg/kg, IV), even though it is a weak antagonist, is
than anesthetized, incurs less expense and time. Problems usually effective. Alternatively, atipamezole (0.15 mg/kg,
associated with performing surgical and diagnostic dental IV), a more potent antagonist, can be used as a reversal
procedures with the horse sedated include over-sedation, agent. The antagonist should be infused slowly to diminish
which can result in excessive ataxia, insufficient analgesia to the likelihood of the reversal agent causing excitation.
safely complete the procedure, excessive movement compli- If a long procedure is anticipated, sedation can be main-
cating the procedure, and increased risk to personnel. Anal- tained at a more constant level using a CRI of one or more
gesia can be augmented by administering local or regional sedatives after a loading bolus of the sedative has been
anesthesia, but for some procedures, such as extraction of administered. Drugs commonly administered by CRI include
wolf teeth, sedation alone may sometimes be sufficient. detomidine alone (0.02 mg/kg/hour) or in combination
Sedation can be maintained either with bolus injections with either butorphanol (0.012 mg/kg/h) or morphine
of a sedative, alone or in combination with an opioid, or by (0.15 mg/kg/h). To avoid inducing excitement when using
constant rate infusion (CRI) of the sedative, alone or in an opioid in combination with an alpha-2 agonist, a loading
combination with an opioid. A bolus injection of the dose of the alpha-2 agonist (e.g., detomidine [0.008 mg/kg])
sedative is the more common mode of administering should be administered initially before a loading dose of
sedation. Alpha-2 agonists commonly administered as a butorphanol (0.02 mg/kg) or morphine (0.15 mg/kg) is
bolus include detomidine (0.005–0.02 mg/kg, IV), xylazine administered.
(0.3–1.0 mg/kg, IV), medetomidine (0.0035–0.007 mg/kg,
IV), and romifidine (0.03–0.1 mg/kg, IV). The duration of Nerve blocks of the head
sedation achieved by administration of xylazine is short
when compared to the duration of sedation imparted by The portion of the head subjected to a dental procedure can
detomidine, medetomidine, or romifidine. When adminis- be desensitized by using a regional nerve block. Regional
tered intramuscularly, the sedative should be administered nerve blocks of the head include the maxillary, infraorbital,
at least 15 minutes before surgery, and the dose of the drug mandibular, mandibular alveolar, and mental nerve blocks.
should be at least double that of the intravenous dose to A regional nerve block is administered most easily after the
achieve the same effect. To minimize movement, the horse horse has been sedated, and administering the block with
can be re-sedated during surgery with the same or another the horse sedated enhances the safety of the horse and the
sedative (xylazine [0.5 mg/kg, IV]; detomidine [0.01 mg/kg, operator. Application of a nose twitch often facilitates
IV]; medetomidine [0.002 mg/kg, IV]; or romifidine administration of the block.
[0.06 mg/kg, IV]).
Butorphanol (0.02–0.05 mg/kg, IV) is the most common
opioid administered in conjunction with a sedative. Other
Maxillary nerve block
opioids administered include methadone (0.1 mg/kg, IV) Anesthetizing the maxillary nerve at the pterygopalatine
and morphine (0.15 mg/kg, IV). Sedation with an alpha-2 fossa, where the nerve enters the infraorbital canal to become
agonist should precede administration of the opioid to the infraorbital nerve, desensitizes all the ipsilateral dental
avoid opioid-induced excitement. Reducing the initial dose structures of the maxilla and premaxilla, the paranasal
of an alpha-2 agonist and administering subsequent doses sinuses, and nasal cavity. To anesthetize the maxillary nerve
to effect is prudent to avoid over-sedation when using com- at the pterygopalatine fossa, the point of a 20- to 22-gauge,
binations of drugs. A heavily sedated horse may need the 3.5 inch (8.9 cm), spinal needle is inserted just ventral to

241
 15 Treatment

Fig. 15.1  The maxillary nerve can be anesthetized at the pterygopalatine

fossa, by inserting a 20- to 22-gauge, 3.5-inch (8.9 cm), spinal needle just
ventral to the zygomatic process and dorsal to the transverse facial vessels
at the level of the caudal third of the orbit. 15–20 ml of local anesthetic
solution is deposited after the needle strikes bone.

Fig. 15.3  The infraorbital foramen is located by placing a thumb (or middle
finger) in the notch formed by the nasal bone and premaxilla and the
middle finger (or thumb) on the rostral aspect of the facial crest. The
foramen can be palpated with the index finger halfway between 1 and
3 cm caudal to an imaginary line connecting the thumb and middle finger
after elevating the ventral margin of levator labii superioris muscle with the
index finger.

Infraorbital nerve block

The infraorbital nerve block is useful for performing surgery
of the nose or maxillary and premaxillary dental structures.
When the infraorbital nerve is anesthetized rostral to the
infraorbital foramen, where it emerges from the infraorbital
canal, the area desensitized includes the skin of the ipsilat-
Fig. 15.2  The maxillary nerve can be anesthetized at the pterygopalatine eral lip, nostril, and face, up to the level of the infraorbital
fossa by inserting a 6-inch (15.2-cm) needle ventral to the most dorsal foramen. When the infraorbital nerve is anesthetized within
aspect of the zygomatic process and directing the needle rostrally and the infraorbital canal, additional structures desensitized
ventrally, aiming toward the rostral edge of the contralateral facial crest,
until the needle strikes bone.
include the ipsilateral maxillary and premaxillary teeth,
and associated alveoli and gingiva. The effect is the same
as that achieved with a maxillary nerve block, provided
the zygomatic process and dorsal to the transverse facial that the local anesthetic solution completely fills the
vessels at the level of the caudal third of the orbit infraorbital canal.
(Fig. 15.1).1 The tip of the needle is inserted perpendicular To locate the infraorbital foramen, a thumb (or middle
to the longitudinal axis of the head so that it enters the finger) is placed in the notch formed by the nasal bone and
pterygopalatine fossa just caudal to the maxillary tuberosity premaxilla, and the middle finger (or thumb) is placed on
at a depth of approximately 2–2.5 inches (5.0–6.5 cm). The the rostral aspect of the facial crest. The foramen is located
horse may jerk its head if the tip of the needle contacts the with the index finger halfway between and 1 to 3 cm caudal
nerve. An alternative method of anesthetizing the maxillary to an imaginary line connecting the thumb and middle
nerve at the pterygopalatine fossa is to insert the point of a finger (Fig. 15.3). The ridge of the foramen is palpated
6 inch (15.2 cm) needle ventral to the most dorsal aspect of beneath the ventral margin of the levator labii superioris
zygomatic process, directing the needle rostrally and ven- muscle. To anesthetize the infraorbital nerve within the
trally, aiming toward the rostral edge of the contralateral infraorbital canal, a 21- or 22-gauge, 1 1 2 -inch (3.8-cm)
facial crest, until the needle strikes bone (Fig. 15.2). needle is inserted through the skin about 1 2 inch (1.3 cm)
Regardless of the technique used, 15 to 20 ml of rostral to the foramen after elevating the ventral edge of the
local anesthetic solution is instilled after the needle strikes levator labii superioris muscle. The point of the needle is
bone and as the needle is withdrawn slightly. Structures advanced along the surface of the maxilla and inserted about
innervated by the maxillary nerve are desensitized within 1 inch (2.5 cm) into the canal. Four to 8 ml of local anes-
15 minutes. thetic solution is deposited within the canal.

242
 Dental restraint and anesthesia

A B

Fig. 15.4  (A) To anesthetize the mandibular nerve, a 20- to 22-gauge, 6–8-inch (15.2–20.3-cm) spinal needle is inserted at the ventral border of the ramus,
just rostral to the angle of the mandible and aimed dorsally, along the medial aspect of the vertical ramus of the mandible, toward the mandibular foramen.
15–20 ml of local anesthetic solution is deposited. (B) The mandibular foramen is located at a point where an imaginary line that extends along and caudal
to the occlusal surface of the mandibular cheek teeth intersects with another imaginary line that passes from the lateral canthus of the eye perpendicular to
the first line.

Filling the infraorbital canal with a large volume of local

anesthetic solution likely desensitizes all the same structures
that the maxillary nerve block desensitizes because the local
anesthetic solution anesthetizes the infraorbital nerve as far
caudally as the maxillary foramen. The advantage of the
infraorbital nerve block over the maxillary nerve block is that
instilling local anesthetic solution within the infraorbital
canal assures that the infraorbital nerve has been anesthe-
tized. The infraorbital nerve block is tolerated poorly by the
horse, however, because the point of the needle inevitably
contacts the infraorbital nerve directly, so adequate restraint
and great care should be taken during its administration.

Mandibular nerve block

Anesthetizing the mandibular nerve at the mandibular
foramen, where it enters the mandibular canal to become Fig. 15.5  To anesthetize the mandibular nerve, a 3 12 inch (8.9 cm) spinal
needle is inserted along the medial surface of the vertical ramus of the
the mandibular alveolar nerve, desensitizes the ipsilateral
mandible at the angle formed by the intersection of the vertical and
side of the mandible and all its dental structures. The man- horizontal rami and aimed rostrally and dorsally toward the mandibular
dibular foramen is located on the medial aspect of the verti- foramen, the location of which is described in the legend for Fig. 15.4.
cal ramus of the mandible where an imaginary line that
extends along and caudal to the occlusal surface of the man-
dibular cheek teeth intersects with another imaginary line
that passes perpendicular to the first line from the lateral the foramen. A second needle of the same length applied
canthus of the eye. To anesthetize the mandibular nerve, the to the lateral surface of the mandible can be used to judge
point of a 20- to 22-gauge, 6–8-inch (15.2–20.3-cm) spinal the depth of the insertion of the first needle. Structures
needle is inserted at the ventral border of the ramus, just innervated by the mandibular nerve are desensitized within
rostral to the angle of the mandible and aimed dorsally 15–30 minutes.
(Fig. 15.4), or a 3 1 2 -inch (8.9-cm) spinal needle is inserted
at the angle formed by the intersection of the vertical and
horizontal rami of the mandible and aimed rostrally and
Mental nerve block
dorsally (Fig. 15.5). The point of the needle is advanced The mandibular alveolar nerve traverses the mandibular
along the medial surface of the ramus toward the mandibu- canal to emerge at the mental foramen as the mental nerve.
lar foramen, and 15 to 20 ml of local anesthetic solution is Anesthetizing the mental nerve rostral to where it exits the
deposited. mental foramen desensitizes the skin of the ipsilateral lip
Inserting the needle to a point slightly dorsal to the esti- and chin. The mandibular canine, incisor, and cheek teeth
mated location of the foramen helps to ensure that local and associated alveoli and gingiva are innervated by branches
anesthetic solution contacts the mandibular nerve because of the mandibular alveolar nerve, which lie within the man-
the nerve courses ventrally from a dorsal location to enter dibular canal, and so, to desensitize these structures, local

243
 15 Treatment

Fig. 15.7  The site of centesis of the caudal pouch of the dorsal
compartment of the TM joint is located midway between 14 and 12 inch
(0.64–1.3 cm) caudal to an imaginary line connecting the mandibular
Fig. 15.6  The mental foramen can be palpated with an index finger on the condyle and the zygomatic process. The needle is inserted in a rostral and
lateral aspect of the horizontal ramus of the mandible in the interalveolar ventral direction to a depth of about 1 inch (2.5 cm), and 2–3 ml of local
space directly below the commissure of the lips by elevating the tendon of anesthetic solution is infused into the pouch.
the depressor labii inferioris muscle with the index finger. To anesthetize the
mandibular alveolar nerve, a 21- or 22-gauge, 1 12 -inch (3.8-cm) needle is
inserted into the mandibular canal about 12 inch (1.3 cm) rostral to the Analgesia of the temporomandibular joint
mental foramen after elevating the tendon of the depressor labii inferioris
muscle. Analgesia of the temporomandibular (TM) joint is some-
times used for diagnostic purposes, e.g., to determine if a TM
joint is infected or if disease of one or both TM joints could
anesthetic solution must be instilled into the mandibular be the cause of clinical signs of disease displayed by the
canal. Anesthetizing either the mental nerve at the mental horse. The TM joint is the articulation between the base of
foramen or the mandibular alveolar nerve within the man- the zygomatic process of the temporal bone and the man-
dibular canal is termed a mental nerve block. dibular condyle of the mandible.2 A fibrocartilaginous disc
The mental foramen is located on the lateral aspect of the separates the joint into a large, dorsal compartment, with a
horizontal ramus of the mandible in the interalveolar space rostral and caudal pouch, and a smaller ventral compart-
directly below the commissure of the lips (Fig. 15.6). The ment. Whether or not the dorsal and ventral compartments
mental foramen lies beneath the tendon of the depressor communicate is disputed.2,3
labii inferioris muscle, and so to palpate the ridge of the The mandibular condyle is palpated as a smooth protru-
mental foramen, this tendon must be elevated dorsally. To sion approximately midway between the base of the ear and
anesthetize the mandibular alveolar nerve within the rostral the lateral canthus of the eye. Its identity can be confirmed
aspect of the mandibular canal, a 21- or 22-gauge, 1 1 2 -inch by palpating the protrusion while an assistant moves the
(3.8-cm) needle is inserted through the skin about 1 2 inch mandible. The zygomatic process of the temporal bone is
(1.3 cm) rostral to the mental foramen after elevating the identified several centimeters dorsal to the mandibular
tendon of the depressor labii inferioris muscle. Creating a condyle. The site of centesis of the caudal pouch of the dorsal
bend in the shaft of the needle aids its insertion. The needle compartment is located midway between and 1 4 to 1 2 inch
is inserted into the mandibular canal as far as possible, and (0.64 to 1.3 cm) caudal to an imaginary line connecting
5–10 ml of anesthetic solution is deposited. these structures (Fig. 15.7).3 The needle is inserted at this site,
Filling the mandibular canal with a large volume of local with the horse sedated, in a rostral and ventral direction to
anesthetic solution (i.e., >10 ml) likely desensitizes all the a depth of about 1 inch (2.5 cm). Fluid may fill the hub of
same structures that the mandibular nerve block desensitizes the needle when the needle is inserted into the pouch. The
because the local anesthetic solution anesthetizes the man- pouch is infused with 2–3 ml of local anesthetic solution.
dibular alveolar nerve as far caudally as the mandibular Even if the dorsal and ventral compartments do not com-
foramen. The mental nerve block is tolerated poorly by the municate, the local anesthetic solution likely diffuses into the
horse because the point of the needle inevitably contacts the ventral compartment in sufficient concentration to provide
mandibular alveolar nerve directly. analgesia of structures contained within that compartment.

References
1. Fletcher BW. How to perform effective 2. Weller R, Taylor S, Maierl J, et al. 3. Rosenstein DS, Bullock MF, Ocello PJ,
equine dental nerve blocks. In Ultrasonographic anatomy of the equine et al. Arthrocentesis of the
Proceedings, 50th Annual Convention of temporomandibular joint. Equine Vet J temporomandibular joint in adult horses.
American Association of Equine 1999; 31: 529–532 Am J Vet Res 2001; 62: 729–733
Practitioners 2004; 233–236

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 Section 5:  Treatment

C H A P T ER 16 
Equine dental equipment, supplies
and instrumentation
Jack Easley† DVM, MS Diplomate ABVP (Equine), Bayard A. Rucker* DVM
†
Equine Veterinary Practice, LLC, Shelbyville, KY 40066 , USA
*309 Overlook Drive, Lebanon VA 24266 , USA

Introduction Some practitioners have designed fully-contained dental

trailers with all equipment close by, including radiography
Practitioners interested in equine dentistry have much to be and a computer workstation (Fig. 16.4). A well equipped,
excited about. New equipment, equipment enhancements, climate-controlled dental trailer is ideal for having equip­
improved techniques in diagnosing and treating equine ment immediately at hand, but can be expensive. Each new
dental disease, and many avenues for advanced instruction, patient has to be moved in and out of the trailer stocks.
have encouraged more equine veterinary practitioners to Nervous horses may have to be lightly sedated prior to entry
emphasize dental care. The care, safety, and pain control for and alpha-2 agonist reversal agents have to be administered
the patient, as well as the safety and comfort of the care­ to avoid a long post-dental period waiting for a heavily
givers, are ongoing priorities. sedated horse to recover sufficiently to walk safely back to
the stall.1 (See Ch. 15.)
Several types of portable restraint systems that can be
Work location and patient restraint easily towed behind a vehicle are available. Most are hydrau­
lically adjusted and very suitable to perform dental work.
When possible, horses should be handled in a dry, enclosed When working in stocks, equipment should be modified for
area protected from weather. Dentistry can be done outside, safety and ease of use. The front door of the stocks should
but proper patient restraint is essential. Outside work areas not be more than 1 m high to allow the relaxed, sedated
should be free of obstacles, clutter and other animals. horse to drop its head without compressing its trachea on
Shading is important for easier visualization of the oral the door. A butt rope or adjustable rear gate helps keep the
cavity, but if shading is unavailable, position the caregiver horse positioned in the front of the stocks.2 A head stand or
with the sun shining from behind. Stocks provide an suspended dental halter is required for heavily sedated
extra measure of safety whether working indoors or out horses. Having a 10–20-cm overhead extension on the stocks
(Fig. 16.1A&B). Water and electricity should be readily helps keep the suspended dental halter properly positioned
available. Observers should be kept at a safe distance in front of the stocks. An elevated step may be placed in the
while work is performed, then allowed to view the results stocks when working on ponies or miniature horses.3 An
up close. Avoid having owners hold their own horses, if adjustable rolling stool is preferable when using stocks
possible. because it helps maintain proper posture for the caregiver,
Working in a familiar area, such as the horse’s stall, creates keeping one’s back straight while allowing the arms to
less anxiety for the animal. It is preferable for work areas to remain lower than the shoulders. If a rolling mechanics stool
have three solid sides. Avoid low-ceilinged and narrow is not available, knee pads are recommended for working on
spaces in case the horse should rear or go down. Footing the floor in front of the stocks.
should be non-slip when wet, and easy to drain. Buckets and
extraneous items should be out of the way. Horses can be
attended to inside a stall, either backed into a corner or Head stands and dental suspension halters
standing in the stall doorway. When working in a stall,
dental equipment and supplies must be transported from Dental head supports and head stands vary in cost and com­
stall to stall, so a portable workstation is a handy investment plexity, and come in many styles – from a homemade
to hold small instruments, mirrors, and other essential padded PVC pipe or padded crutch to power-adjustable alu­
equipment (Figs 16.2 & 16.3). However, the preferred minum stands (Fig. 16.5) (Box 16.1). All require an assistant
approach is to work from one location, such as in the groom­ to stabilize the head on the support. (Note: avoid using
ing, farrier, or wash area. someone’s shoulder to prop up the head.)
Special mobile dental workstations constructed around Manufactured head stands have several advantages that
stocks or horse trailers have been developed in recent years. include rapid adjustment of height, good stability, and

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 16 Treatment

Fig. 16.2  Portable folding aluminum table used to transport dental

instruments from stall to stall.

Fig. 16.3  An electric golf cart converted to a mobile equine dental station
Fig. 16.1  Portable horses’ stocks or crush. (A) This stocks pulls in-line
(T.A. Banner, DVM, Gainesville, FL, USA).
behind a vehicle. The chest and butt bars, head stand, and sides are
hydraulically adjustable. (B) This stocks pulls on its side and is rotated off its
trailer for setup. The extended overhead bar attached to the suspension
halter keeps the head stable with the mouth speculum in place.
especially in geriatric horses. Suspending the head with two
ropes provides greater stability, but a practitioner working
with few assistants may find a single rope with a quick
often, heavy padding, as well as a washable cover on
release device more manageable. For more restraint and
which the mandible can rest.4 Many stands are designed
handling recommendations, consult Chapters 12, 15, 17,
with attachments for holding equipment and dental
and 18.
instruments.
There are a variety of manufactured, rigid dental halters
available. However, practitioners themselves are quite Oral examination equipment (Box 16.2)
inventive in developing restraint devices and homemade
halters, depending on individual preference and need. Various types of equipment may be used to conduct a thor­
The full-mouth speculum used may determine the type of ough dental examination. The horse’s overall health status
rigid halter used, as the larger specula do not fit inside should be evaluated, and a stethoscope and thermometer
some rigid halters. Some mouth specula have been modified should be available. Continuing the examination process,
to accommodate suspension devices by incorporating a the mouth must be held open to allow a complete visual
metal arch over the nose piece of the speculum for rope and digital examination. A halter with an oversized nose
attachment (Fig. 16.6). Suspending the head with the specu­ band allows the horse to fully open its mouth for inspection
lum nose band is convenient, but if the horse moves rear­ and treatment.
ward, the speculum can be pulled off the head and/or the A bucket is needed to hold floats and disinfectant. Stain­
poll can be over-extended. This can damage incisors, less steel is the usual veterinary choice, but plastic has its

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 Equine dental equipment, supplies and instrumentation

B C

Fig. 16.4  (A) Fully functional equine dental trailer designed to transport equipment and service as a climate controlled workstation with warm water and
electricity. (B) Loading end of a dental trailer complete with adjustable stocks. (C) Interior of dental trailer with horse in stocks. The mouth is open and head
stabilized on a stand. The operator is seated in a comfortable position to perform dental work.

Fig. 16.5  Three types of equine head stands.

Left: adjustable floor stand with a flat removable
padded chin rest. Middle: support with flexible
base and side bars to help keep the chin on the
stand. Right: adjustable floor stand with base at
an angle to chin support and down-turned
corners for added stability.

advantages: for example, using a plastic bucket results guards, restrainers, or liners for float blade protection (Fig.
in less noise when an instrument is dropped into the 16.7). Using a tray or table, rather than dropping small
bucket. Some practitioners place a rubber insert on the instruments into a bucket, prevents breakage and dulling
bottom of the stainless steel bucket to cushion the instru­ sharp edges of expensive and brittle tungsten carbide float
ments. Many instrument companies offer a variety of blades.

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 16 Treatment

Fig. 16.6  McPherson type speculum.This is the most popular and least
expensive type of equine speculum. The stainless steel models are more
durable and easier to clean than the nickel-plated cast iron devices. A metal
nose bar has been added for attachment to a rope to suspend the head
from an overhead support. The ratchet on this type of speculum has limited
adjustments and can be difficult to open. The hinge is close to the incisor
plates (18–20 cm) and does not allow a comfortable fit for large breed
horses (over 800 kg). This speculum comes in a small size for ponies and
miniature horses. Various incisor and gum plates are available, which makes Fig. 16.7  Stainless steel bucket with a rubber lined bottom. PVC tube liners
it quite versatile for use in horses with incisor damage or malocclusions. separate and protect float blades.

Box 16.1  Head support and head stand suggestions

Sanitation
• All types should be well padded
• Flat square supports are more stable in holding the head upright Chlorhexidine gluconate 0.05 % (1–40 dilution of the 2 %
because more of the mandible contacts the support concentration) is the antiseptic of choice for oral rinses and
• The head support should not limit or interfere with mouth access has replaced chlorhexidine acetate because it is less likely to
• The speculum must fit inside a suspended support irritate mucous membranes. Although it is rare, horses may
develop anorexia from chlorhexidine use. Since it may be
• The stand should have a stable base
the taste of chlorhexidine causing the anorexia, a human
• Suspended supports should have quick adjustment and release
product such as Periogard (a Colgate rinse) may prevent this
mechanisms
adverse effect. Periogard and other flavored chlorhexidine
• The stand can be modified to hold floats with multiple
rinses are 0.12 % chlorhexidine. Some practitioners use two
attachments
buckets, both containing diluted chlorhexidine: one bucket
is for instrument immersion and the other is solely for
rinsing the patient’s mouth. Instruments should be cleaned
between horses and sanitized between groups of animals
Box 16.2  Basic dental equipment or farms.
• Stethoscope and thermometer Latex or nitrile gloves should be worn for protection
during all oral examinations and treatments. Nitrile is more
• Head support when heavy sedation is used
resistant to puncture, but when it does fail, there is an
• Examination gloves
obvious hole rather than an unnoticed pinhole. Changing
• Bucket and disinfectant
gloves between each horse is probably not needed in healthy
• Dose syringe or oral irrigator horses grouped together, but it is recommended after
• Full-mouth speculum working on any horse with active periodontitis or suspected
• Arcade speculum infectious respiratory disease. Wearing gloves reduces the
• Bright light source number and severity of cuts and abrasions caused by sharp
• Calipers or clear ruler marked in millimeters for measurement of enamel projections or the handling of rasping instruments.
molar excursion Practitioners should carry a hand brush, medicated soap
or disinfectant, and a towel to clean their hands and finger
• Assorted dental picks and probes to examine gingival attachment,
nails, as well.
periodontal pockets, and infundibula and pulp horns
• Retractors
• Dental mirror Oral irrigation equipment
• Small digital camera
• Form to record findings Large dose syringes are widely used to rinse mouths and are
available with either a pistol grip or in a plunger style. The

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 Equine dental equipment, supplies and instrumentation

Fig. 16.8  Nylon 400 cc, blunt tipped, dosing syringe used to flush the
mouth prior to oral examination. Fig. 16.10  Three diameters of heavy duty plastic tubing. The tube is placed
in the interdental space as a gag when working on incisor teeth.

Fig. 16.9  Oral irrigation unit with two types of nozzles modified to attach Fig. 16.11  One-sided, wedge-shaped mouth gag made from a block of
to any water outlet. This unit was fabricated from mechanic compressed air neoprene. This type of gag is safe for use while working on the incisor teeth.
blower parts.

insertion into the mouth between the incisors, upper and

patient’s mouth should be rinsed prior to the intra-oral por­ lower bars, or cheek teeth arcades. Two types of specula are
tions of the dental examination in order to facilitate proper needed: 1) a gag for incisor procedures and 2) a full-mouth
visualization of the teeth and associated soft tissues. The speculum for cheek teeth examination and equilibration.
rounded blunt end of the nozzle on the large nylon dose The use of gags should be confined to the treatment of the
syringe helps prevent accidental oral injury during flushing incisor teeth. Gags that sit between the bars are easily made
(Fig. 16.8). A 16 oz dose syringe is sufficient for removing from heavy-duty rubber or plastic tubing available at large
food from the mouth, but a powerful spray is needed for home supply stores. Three diameter sizes are needed
rinsing periodontal pockets or an alveolus post extraction. A (3.81 cm, 5.08–5.715 cm, and 7.62 cm) and should be cut
high-pressure rinse can be administered with instruments to the desired length. An elastic cord is to be attached to each
like a power dental flush, which attaches directly to a hose. end of the tube. The tube is slipped into the interdental space
Commercial high-pressure units are available or can be and the cord over the poll. Most horses tolerate this well
made from parts available in the air compressor section of when adequately sedated (Fig. 16.10).
large home supply stores (Fig. 16.9). One-sided metal gags inserted between the cheek teeth,
especially the round Schouppe coil or spool, are not recom­
mended because they may fracture a tooth. Wedge-shaped
Specula gags may be covered with rubber, polyurethane or neoprene,
or may simply consist of metal (Fig. 16.11). Such gags are
Several types of gags and specula can be used to visually and safer than spool or coil gags as they allow several teeth to
manually evaluate the mouth. These instruments work via contact the wedge simultaneously. There are disadvantages

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 16 Treatment

Fig. 16.12  Series 2020 full-mouth speculum with small interchangeable

ratchets for easy opening. A wide range of incisor and gum plates are
available for this speculum. Fig. 16.13  Capps full-mouth speculum with infinite adjustments and
interchangeable incisor plates. This speculum works well on large breed
horses.

with gags – there is limited access to the mouth, the horse

continually chews on them, and they are difficult to keep in
place.
Full-mouth specula are especially helpful in performing
both complete, detailed dental examinations and precise
corrective procedures. All full-mouth specula work on the
same principle: plates inserted on the incisor occlusal sur­
faces hold the mouth open by ratchets, screws, locking pins
or friction clamps. There are three categories of full-mouth
specula: 1) the lightweight, collapsible ratchet speculum
(McPherson, Haussmann, and Series 2000); 2) the screw-
type speculum (Gunther, Stubbs, and Butler); and 3) the
oversized compound-action, hinged-type speculum (Conrad,
McAllen, and Alumispec).
The McPherson or Haussmann types are the most widely
used and most economical specula, and have been in use
for over 100 years.5 Modern specula using ratchets and inter­
changeable incisor plates still employ this basic design.
These specula come in a standard horse size, as well as in a
smaller version for use in ponies and miniature horses. A
McPherson speculum, with three or four teeth in the ratchet,
is difficult to open to the widest setting. This problem has
been overcome by using up to 33 teeth, as in the Series 2000 Fig. 16.14  Gunther screw type speculum. This model (with no cheek
(2020) made by World Wide Equine (Fig. 16.12). Capps plates) works well for taking open-mouth radiographs or working in the
Manufacturing makes a larger speculum similar to the Series mouth of a recumbent, anesthetized horse.
2000, but uses a sliding lock rather than a small-teeth ratchet.
This unit is infinitely adjustable (Fig. 16.13). All McPherson-
type speculum incisor plates can be replaced with palate or
bar plates, allowing use on parrot mouth horses, horses with there is no mechanism next to the cheek (Fig. 16.14). With
no incisors, or horses with incisors too loose or damaged to the Stubbs speculum, a large threaded bolt easily opens the
support the incisor plates. Offset incisor plates are available speculum, and the bolt can be positioned conveniently on
for horses with an underbite or overbite. A 6.35-cm diameter either side of the mouth. This speculum uses heavy wire
plastic pipe (10.16 cm long) can be used to cover the incisor beside the cheeks with the bolt centered on the incisor plates
plates, allowing the speculum to be used as a gag in the by extension arms, and is moved side to side to gain access
interdental space, thus exposing the incisor teeth. to each side of the mouth (Fig. 16.15).
A single-threaded bolt opens the mouth with the Stubbs The McAllen design uses a lever to open the speculum. The
or Gunther screw-type specula. The Stubbs or Gunther lightweight AlumiSpec sold by Veterinary Dental Products is
specula are best suited for open-mouth radiographs or oral based on the McAllen design but uses a heavy nylon tape
surgery when the horse is in lateral recumbency, because and a pinch lock instead of a pin aligning in holes to hold

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 Equine dental equipment, supplies and instrumentation

Fig. 16.17  Stubbs equine dental light. This bright, battery-powered unit
attaches to a headband, dental basket type retractor, and/or a rigid shaft
Fig. 16.15  Stubbs screw mechanism, full mouth speculum with elastic pole dental mirror.
straps. This speculum is easy to open and has infinite adjustments. The
central screw can be rotated from side to side giving good access to all
areas of the mouth.

lights are available; some have been adapted especially for

equine dentistry, but many are intended for a variety of other
activities.
Spelunking and camping head lights are convenient but
limited in intensity and are mounted too far up on the fore­
head to position the light where it is needed. Several magnet­
ized lights attach to the incisor plates of most specula and
allow for continuous illumination of the mouth. Another
nice feature of these lights is that they minimize the effects
of the caregiver’s head movement while keeping the light
positioned on the patient’s oral cavity. Stubbs Equine Inno­
vations offers a multipurpose light that can be used as a head
light and can also be used to illuminate the Stubbs Arcade
Speculum or Stubbs Intraoral Mirror (Fig. 16.17). Hand-
held flashlights or lamps mounted on the floor or ceiling
can be used as well. All of these lights are not bright enough
Fig. 16.16  The AlumiSpec, lightweight, leverage-type, full-mouth speculum if the caregiver is working in bright sunlight or if very bright
has a nylon grip tape locking mechanism for easy opening and infinite illumination is needed. When using a mirror, probes,
adjustments. periodontal instruments, or when extracting cheek teeth, a
halogen light or its equivalent is recommended. All these
lights attach to a head harness, but the light is so bright and
coverage so broad that light position is not as critical.
it open (Fig. 16.16). Because of their large size and weight,
the Conrad, Meister, and McAllen hinged-type specula can
be dangerous in horses that are not adequately sedated and/ Soft tissue retractors
or well restrained. Both the Conrad and the Meister specula
are made from stainless steel and copy the brass McAllen At various points during the dental examination, the practi­
design; however, all are out of production. tioner may find it helpful to have an assistant retract the
All specula can deliver serious injury if the horse swings tongue and/or cheeks of the patient. An abdominal retractor
its head unexpectedly. Everyone in the work area must be or a specially designed equine dental basket or cheek
continuously aware of the horse’s attitude. Owners or any retractor may be used to provide more adequate oral
other person not covered by the caregiver’s liability insur­ visualization.
ance should be a safe distance away.
Mirrors
Illumination
Using a mirror in conjunction with dental picks and/or
Illumination is especially important for a complete oral probes is helpful in allowing the practitioner to identify
examination and performance of corrective procedures with abnormalities in the mouth. Mirror fogging can be a problem
motorized instruments. Head-mounted lights are most when working in the oral cavity, particularly in cold weather.
useful for oral cavity illumination. Numerous types of head Warming the mirror or using alcohol, or an antifog wipe or

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 16 Treatment

Fig. 16.18  A 4 cm, long-ridged shaft dental mirror with a 35° angled head.
This instrument can also be used as a buccal and lingual retractor.

Fig. 16.19  Portable oral endoscopy equipment. This complete system can
spray designed for reading glasses can be helpful in eliminat­ be used to visualize the oral cavity and document findings with still digital
ing this problem. Most mirrors need to be set at a 35°–45° images or video recordings. System contents: 1) rigid (at least 40 cm long)
angle to their handles to allow adequate visualization around laparoscope with a 35–90° wide angle lens; 2) 150 watt halogen light source
the cheek teeth. A long, ridged shaft allows the mirror to be and camera receiver unit; 3) single chip video camera with a focusing
used as a soft tissue retractor (Fig. 16.18). laparoscope adapter, and 200 cm long coaxial cable; 4) fiberoptic cable
200 cm long; 5) still digital image capture device; 6) digital video recorder,
camera; and 7) flat LCD screen for viewing image.
Imaging
Once potential dental abnormalities are identified, imaging blades produce less vibration than grit blades. Their use may
modalities, such as radiographs and ultrasound, may be allow the practitioner to decrease the amount of sedation
used to gain more information about the problem at hand. required. These blades historically have been relatively
A rigid endoscope, digital camera, and/or video recording expensive, but they are so effective and efficient that many
equipment can be used to identify and record lesions practitioners now use them. Most blades originally consisted
and document the performance of various procedures6 of a tungsten carbide rasp blade bonded to a plate of stain­
(Fig. 16.19). This documentation is a useful record of care less steel, variably sized to fit the desired float head. More
and can be used to educate clients and other veterinarians. recently, tungsten blades have been directly bonded with
(See Ch. 12.) adhesive or strong magnets to the float head or shaft, result­
ing in a slimmer float design. Most carbide blades cut in only
Dental floating equipment one direction, so care must be taken to ensure that they are
properly set on the float to cut either on the push or pull,
depending on the desired use. For working on the 11s,
Manual floats blades should be set to cut on the pull, because if the blade
Manual floats continue to be widely used in equine den­ slips off these teeth on the push, the blade will strike the
tistry. The variety of blades, heads, shafts and handles caudal end of the mouth.
currently available to practitioners is extremely useful in Tungsten carbide blades range in classification from
performing prophylactic procedures. The most durable and ultrafine to coarse, with each manufacturer having individ­
aggressive float blades are made from solid tungsten carbide. ual scales of aggressiveness. The finer (less aggressive) blades
For many years, float blades with tungsten carbide chips stay sharp longer and can be resharpened more times than
have been used as abrasives. The process for combining the coarser (more aggressive) blades. Most blade manufac­
tungsten with carbon was discovered in the 1920s. Tungsten turers offer an economical sharpening service to practition­
carbide is very hard, making it a better cutting agent than ers. In general, the fine and medium blades are best for
the previously used steel files. Carbide chips come in several general floating, while the coarse blades are reserved for
sizes, with the small to medium grits being the most versa­ reducing large overgrowths. Though these blades are sharp,
tile. Solid carbide float blades, usually a combination of the teeth of the blades are brittle, so one should handle them
tungsten, carbon, and cobalt, remove tooth material much with care. Since different parts of the blade act as the cutting
more easily than carbide grit. These blades are made from a area when used in different handles, blades can be switched
powder that is compressed into the blade shape, and then to different handles as they become dull in order to get
sharpened. They are smoother because they shave off a layer additional use before they need to be resharpened. It is,
of tooth. Fine to medium blades are better than coarse however, important to recognize when a blade is completely
blades and are more resistant to chipping. Solid carbide spent and needs to be sharpened or replaced.

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 Equine dental equipment, supplies and instrumentation

Fig. 16.20  Three types of manual

interchangeable float blades: (A) medium grit
carbide chip blade; (B) Jupiter speedy cut blade;
(C) solid tungsten carbide blade with a stainless
steel back.

A B C

Manual dental floats are constructed in a variety of con­

figurations. Float heads should be made to cover the sharp
corners of the blade and fit the area of the mouth to be
floated. Float head weight and thickness vary depending on
intended use and operator preference. Float shafts may
be round, three-quarter round or flat. Round shafts slide
through the operator’s fingers more easily than flat shafts.
Flat shafts allow the operator to more accurately assess the
blade’s angulation in relation to the tooth being floated.
Three-quarter round shafts combine the advantages of both
the round and flat shafts. Float handles may be constructed
Fig. 16.21  Solid tungsten carbide interchangeable float blades in several of wood, plastic, metal, rubber or molded acrylic and can be
shapes ranging from fine to coarse cutting surfaces. padded or unpadded. They may be configured in either a
pistol grip or a shaft grip and should be an appropriate size
for the hand of the operator.
Hand floats come in a myriad of shapes and sizes
Solid tungsten carbide is preferred for blades because it (Fig. 16.22). Different shapes and lengths of floats are
reduces by one half, over the carbide grit blades, the average employed to reduce sharp enamel points on the various
equilibration time. Other blade designs are available in addi­ teeth, create bit seats, and reduce more major overgrowths
tion to tungsten carbide, including carbide grit blades, steel (see Ch. 17). A minimal set of floats should consist of: a
file (Dick) blades and Jupiter Speedycut float blades (Fig. short, straight float; a long, straight float; an upper back
16.20). Carbide grit blades come in various sizes of grits or molar (15° angle) float; and a premolar float (15° contra/
coarseness and cut in both directions, i.e., on the push and obtuse angle).
the pull. The Dick blades have been discontinued by most Practitioners may want to consider a variety of specialized
companies because the steel blades are inferior to carbide floats for their dental equipment selection. A long offset
products in durability. The Jupiter blades are made of either float may be used to float the lower dental arcades. A float,
stainless steel or tungsten carbide and are also designed to consisting of a 22.86 to 38.1 cm shaft, offset head and
cut in both directions. short blade box, is used to create and/or ‘polish’ bit seats.
The standard interchangeable float blade has square Some manufacturers offer smaller floats made specifically for
corners and is 7.62 cm long by 2.54 cm wide (Fig. 16.21). miniature horses, and extra-long handles can be purchased
Changes in the size and shape of blades have recently been for use in large/draft horses. Carbide chip or diamond
introduced by several manufacturers. Capps Manufacturing S-floats and steel files are often used to polish bit seats,
uses triangle-shaped solid carbide inserts. The inserts are smooth incisors, and reduce canines. A long, wide S-float,
placed in a triangular holder, and after tightening, form a also called a table float, can be used to reduce sharp areas in
solid cutting surface. The advantage with this type of blade horses with wave mouth or other types of uneven arcades
is that singular inserts have three available cutting surfaces (Fig. 16.23).
and individual inserts are replaceable. Kruuse Veterinary Float selection:
Supply makes a convex shaped blade that makes reducing • Grips should fit, be nonslip, and feel comfortable when
tall teeth easier. handling.

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 16 Treatment

A B

Fig. 16.22  A set of manual equine dental floats with stainless steel, flat shafts, and rounded neoprene handles. Both direct bonded and interchangeable
solid tungsten carbide blades are used with this set.

Fig. 16.23  Table rasps with 40 cm long shafts, curved, carbide chip coated
convex concave blades.

Fig. 16.24  Sedated horse in stocks with head supported in a rigid halter,
suspended from a rope with a quick release friction lock, attached to an
• Having some floats with a pistol grip, rather than an overhead hook. A McPherson type speculum in place with a Powerlite
inline grip, reduces strain on the wrist that occurs when attached to the upper incisor plate, illuminating the mouth. The battery
floats are held in the same position on every float. operated Powerfloat is used to reduce dental elongations. The veterinarian
• Smaller float blades (2.5 cm × 2.5 cm) work best in the wears examination gloves, goggles for eye protection, a dust filtering mask,
and ear plugs.
caudal end of the arcades. Blades glued to the float are
slim and best for 111 and 211 teeth.
• Long, straight floats may have the blade slightly
equine dentistry has generated controversy, but when used
elevated from the handle by the thickness of the blade
or raised from the handle by an offset. correctly, they allow for precise corrective procedures with
minimal soft-tissue trauma. Proper safety precautions for
• Right angle offsets are difficult to use on the upper
both the operator and the horse should be exercised
molar arcades and are generally used for premolar
contouring. (Fig. 16.24). Since more tooth can be removed with less
physical exertion on the part of the operator, excessive crown
• Flat-shafted handles, three-quarter round handles, and
removal and even pulpar exposure has occurred in some
pistol grip handles immediately let the operator know
the blade angle on the teeth. cases. Operators should be especially observant when these
instruments are being used.7–10
• The blade should have blunt corners to prevent soft
Motorized floats come in three basic designs: 1) cable-
tissue injury.
operated, rotating burrs in line with the float shaft (with
or without an articulating head); 2) rotating discs turned
Power instruments 90° to the shaft; and 3) reciprocating floats. They can be
electric, battery, or pneumatic powered. All AC-powered
Motorized equine dental instruments were first used in floats should always be on a stationary Ground Fault
Germany in the 1930s.5 The use of power instruments in Circuit Interrupter or plugged into portable Ground Fault

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 Equine dental equipment, supplies and instrumentation

A B C

Fig. 16.25  Guarded diamond dust equine dental burrs used with a flexible cable motor. (A) Various inline guarded burr heads for reducing dental
overgrowths. (B) Guarded diamond burrs with quick release, medium length shafts. (C) Long shaft, diamond dust, guarded burrs for reducing dental
overgrowths in the caudal aspect of the equine oral cavity.

Interrupter to prevent electrical shock. A variable speed comprises a 2.5 cm tungsten carbide chip disk that rotates
regulator with a handle trigger or foot pedal controller is horizontally at the end of a 45-cm long shaft. This low-profile
helpful to prevent excessive crown reduction and minimize power instrument can be used for numerous corrective pro­
soft tissue damage. cedures, including caudal 11 overgrowths in small ponies.
Rotary cable floats are quite effective in removing sharp The Horsepower hand piece is modified to fit the Dremel or
enamel points and reducing overgrowths. Some motorized Fordon motor with a flexible shaft drive.
equipment still uses Dremel motors. However, the Dremel, Many reciprocating floats are electric or battery-powered
a type of rotary cable grinder, should not be used for equine and are modifications of woodwork power saws, varying in
dental work due to the electric shock hazard of working in stroke length and strokes per minute. Several manufacturers
a moist environment (i.e., the mouth). (Note: Dremel does (Stubbs, Olsen and Silk, and Carbide products) make pneu­
not recommend nor offer warranty for the use of any of their matic reciprocating floats that make short strokes at high
tools in equine dentistry.1) Several manufacturers have speed. Some operators have developed hand problems
various lengths of guards and extensions to facilitate good caused by the vibration of pneumatic floats, and it is sug­
control and minimize soft-tissue damage in all areas of the gested that antivibration gloves be worn when performing
oral cavity. Some instruments have built-in vacuum systems corrective procedures with these floats. Most of these instru­
that reduce the operator’s exposure to dental dust and ments have a thin carbide blade bonded to the shaft, similar
improve visibility. Other units may have irrigation systems to those used on some manual floats (Fig. 16.28). Long-
that reduce dust and decrease the risk of thermal damage to stroke reciprocating floats are also available and are used
the teeth. Some units contain both a light source and an to reduce excess crowns and sharp enamel points. Long-
irrigation system. A built-in clutch makes these units safer stroke reciprocating floats should not be used on the third
for the horse, and decreases the incidence of cable breakage. molars due to risk of iatrogenic mandibular or soft-tissue
Solid tungsten, rotary-powered burrs are available in a trauma. A polymer lubricant used with reciprocating pneu­
variety of cutting teeth and degrees of coarseness. A fine, matic instruments reduces heat produced by friction and
cross-cut burr does not tend to jump off the tooth during airborne dust.
rasping, as is often the case with spiral-cut burrs. Burrs or Factors to consider with motorized equipment:
grinding drums, coated with fine carbide grit or diamond
chips, are available in a variety of shapes (Fig. 16.25). • If used improperly, all motorized floats can overheat
Disk burr instruments have become increasingly popular teeth to the point of pulp damage. Lower speeds in the
as they are less apt than rotary burrs to damage the soft tissues 2000 to 3000 r.p.m. range are preferred because higher
inside the oral cavity. Additionally, it appears to be easier for speed rotation produces heat faster. (Note: use light
an operator to master the use of disk type motorized instru­ pressure on the float, keep it moving.)
ments. These instruments are manufactured with various • Irrigation eliminates thermal damage, but care has to
lengths of shafts and run from fixed electric or battery- be taken to prevent electric shock. Irrigation also
powered drills or flexible shaft motors (Fig. 16.26). Instru­ reduces dust, and suction helps remove both dust and
ment head design and thickness vary between manufacturers. excess water. (Note: irrigation fluid can freeze in colder
The cutting surface of the disk is made from solid tungsten climates.)
carbide, fine carbide grit, or diamond dust. Examples of these • To prevent inhalation of dental dust, a mask should be
instruments include the Eisenhut Swissfloat, the PowerFloat, worn when using the visual method for floating or
and the Horsepower hand piece. The Eisenhut consists of a when incisors are being leveled.
hand-held electric drill motor with a 4-cm, circular, stainless • Cable grinders should have a clutch to prevent soft
steel, carbide or diamond disk that rotates horizontally at tissue damage in case a burr contacts and pulls in
the end of a shaft that comes in three difference lengths up either cheek or tongue. A clutch also prevents cable
to 65 cm (Fig. 16.27). This instrument is useful in reducing breakage if the horse bites down on the burr.
caudal mandibular overgrowths even in large horses due in • Disk tools should have a clutch to prevent motor
large part to the length of its shaft.10 The PowerFloat damage if the horse bites the disk.

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 16 Treatment

Fig. 16.26  (A) Battery operated Powerfloat with

quick release, interchangeable shafts and
grinding heads. (B) Disk carbide grit burr with 45°
beveled head. This burr is used to reduce sharp
enamel points and prominent cingula from the
buccal aspect of the upper cheek teeth and
lingual edges of the lowers. (C) Carbide diastema
burrs that attach to the right angle head of the
Powerfloat. These burrs are used for opening a
space between teeth with valve diastema.

B C

Fig. 16.27  (A) The Swissfloat with right angle disk burr comes with three different length shafts. (B) Close-up of a Swissfloat diamond disk float head.

256
 Equine dental equipment, supplies and instrumentation

extracting tooth and root fragments in aged horses. Some

practitioners have adapted a wire coat hanger as a useful and
inexpensive dental pick or probe. Additionally, an insemina­
tion pipette, curved by being held over a flame just long
enough to make the plastic bendable, is a useful dental
probe and flushing device. Special calibrated human or
small animal periodontal probes can be modified on a long
handle and used to explore and measure periodontal pockets.
Needle probes should be used to access the occlusal surface
for patent pulp horns. Large probes are used to evaluate
gingival attachment and infundibula. High pressure oral irri­
gation units can be used to flush food and debris from
diastemata and periodontal pockets (Fig. 16.31). Human
Fig. 16.28  Stubbs pneumatic powered oscillating floats have a short stroke periodontal systems modified with long handpieces, using
length with variable speeds. This type of instrument comes with quick compressed nitrogen or air to propel water with sodium
release, interchangeable floats and a wide variety of attachments.
bicarbonate, are available for cleaning periodontal pockets.
These units also have high-speed drills for tooth restoration
(Fig. 16.32).

Canine tooth instruments

Instruments have been developed to reduce the crown of
sharp canine teeth as well as to scale and buff older canine
teeth with tartar accumulation. A full set of canine tooth
instruments consists of: 1) a straight-handled, fine-grit, tung­
sten carbide dental rasp; 2) a small dental scaler 3) a wire-
bristle toothbrush or nylon-bristle nail brush; and 3)
Fig. 16.29  Reynolds type upper and lower cap forceps for removal of
retained deciduous premolars. The handle length, shape, and jaw sizes are Oral Cleansing Gel (Addison Biological Laboratory, Fayette,
designed to firmly grip the appropriate tooth for removal. MS). Nippers and cutters should not be used on canine
teeth because these instruments offer minimal to no control
during tooth fracturing. Opening the pulp or dentinal
tubules can lead to pulpitis and tooth death years after the
Safety of the operator, the assistant(s), and the equine reduction. To avoid over-reduction of the canines, small files
patient during motorized instrument use can be optimized or diamond disc grinders (at low speed) should be used only
in several ways. Protective eyewear and an air filter mask for smoothening or to blunt the top of the canine.
reduce the chance of debris and tooth dust getting in the
eyes and/or being inhaled. Ear protection should be consid­
ered if loud electric motors are used close to the operator’s Wolf tooth instruments
head or noisy air compressors are in operation nearby. The length and style of wolf tooth elevators depends on a
practitioner’s preference (Fig. 16.33). To avoid possible root
Special equine dental instruments fracture, one-half or three-quarter circle elevators are pre­
ferred because the palatal, rostral and buccal sides can be
elevated independent of the caudal side. This allows the
Deciduous tooth instruments entire tooth space to move when elevated on the caudal side.
Various forceps, elevators, and dental picks are available to When the elevator is in position, a rubber mallet is used to
remove retained, displaced, or broken deciduous cheek lightly tap the elevator to loosen the tooth on three sides.
tooth remnants (caps) (Fig. 16.29). A set of deciduous tooth Once loosened, the elevator is inserted on the caudal side of
instruments should consist of short-handled molar forceps the tooth for the final elevation. The rubber mallet absorbs
and dental elevators or a modified screwdriver (see Chapters much of the concussion, preventing head motion that can
17 and 20). occur in a sedated horse with an anesthetized tooth. (See
Chs 17 and 20.)
Picks, probes, and periodontal systems
Molar cutters and chippers
Ancillary equipment for a thorough oral examination
includes picks and probes for identifying and measuring The use of percussion instruments to reduce overgrowths has
periodontal pocketing, open pulps, infundibula and frac­ been practiced since the early 1800s. Yet, with the advent of
tures. Scalers and gingival elevators can be used to remove motorized equipment, the use of molar cutters and chippers
calculus from cheek teeth, clean out perio pockets, or elevate has declined. These tools are used to produce a controlled
gingiva prior to extractions (Fig. 16.30). These are in addi­ fracture of a tooth or portion of a tooth. Unfortunately, over
tion to the standard picks used to loosen tooth fragments. the years, there was very little control displayed, and since the
Dental picks are used to clear debris from and to probe general recommendation is to avoid tooth reduction greater
diastemata and crown defects. They are also helpful in than 3–5 mm, molar cutters have just one indication – to

257
 16 Treatment

D
A

C F

Fig. 16.30  (A) Set of long shaft equine dental picks, probes, scales, and periodontal forceps. (B) Calibrated periodontal probes. (C) Dental scalers. (D) Dental
picks. (E) Periodontal forceps. (F) Heavy gauge dental picks.

shorten large tooth overgrowths in geriatric horses Dental extraction equipment

(e.g., a long caudal hook that is too long to apply a
motorized float). Removal of cheek teeth, wolf teeth, canines and incisors
Molar cutters come in three sizes (A, B, and C head cutters) requires special equipment and supplies. Special operating
depending on the space between the jaws, which is 0.635, room support is required in certain circumstances. Equip­
0.952, and 1.27 cm, respectively. Cutters are sized so that ment and techniques for tooth removal are outlined in
when applied to a tooth or part of a tooth, the jaws are Chapter 20.
parallel.
Chisels and mallets, or chisels with sliding captive bolt Periodontic, endodontic, and dental
hammers, have also been used to reduce enamel points, as
well as rostral and caudal hooks. The Equi-Chip guarded
restorative materials
chisel with a sliding hammer is a refinement of earlier Areas of growing interest in equine dentistry include perio­
devices. This instrument is no longer widely used since dontal disease and infundibular decay.6 Specialized equip­
power tools have proven to be more efficient, precise, and ment, instruments, and medication are available to treat
safe in removing these types of overgrowths. equine periodontal disease. Pacific Equine Dental Institute,

258
 Equine dental equipment, supplies and instrumentation

Fig. 16.32  Portable equine dental system with elongated hand pieces.
This system is powered by compressed air. The unit contains an air abrasion
unit as well as a low-speed and high-speed dental drill, water irrigation, and
suction.

Fig. 16.31  (A) A high pressure dental irrigation unit made from a 4 L
garden sprayer with a battery-powered bilge pump that delivers 65 p.s.i.
(B) The right angle nozzle can reach between cheek teeth to clean
periodontal pockets.

Inc. has adapted and modified human and small animal

dental equipment for use in the equine patient. The Equine
Dental System (Pacific Equine Dental Institute, Inc.,
El Dorado Hill, CA) is a self-contained, high-pressure (up to
200 p.s.i.) water-delivery spray unit that can be used to
evacuate deep periodontal pockets. Additionally, this system
contains a Prophy Air Abrasion Unit and a baking soda/ Fig. 16.33  A complete set of wolf tooth instruments including forceps,
chlorhexidine delivery system to clean out periodontal elevator, and Burgess-type extractor.
pockets and areas of infundibular decay. With this system,
the equine practitioner can now provide the same level of
periodontal care that is provided in human dentistry.11,12
As in human dentistry, endodontics, orthodontics, and
crown restorative techniques are now being utilized in Conclusion
equine dentistry. The equipment and materials needed
for such detailed techniques are outlined in Chapters 21 The quality and variety of equine dental instrumentation
and 22. and instruction have improved greatly in just the last 5

259
 16 Treatment

years. New information and techniques emerge regularly, Acknowledgments

and equine practitioners should avail themselves of
these improvements to remain current in the most recent The following veterinarians supplied photographs seen in
developments. Many dental vendors and manufacturers this chapter: Mark Miles, Oliver LiLou, Toots Banner, Tom
can provide the equine practitioner with high quality Johnson, Rudy Steiger, Clay Stubbs, Dennis Rach, Leon
instruments and supplies (see Appendix for supplier Scrutchfield, and Travis Henry. Additional thanks to Henrik
information). Petersen of Kruuse Company, Denmark.

References
1. Allen T, Johnson T, Miller RO. Safety Williams and Wilkins, Philadelphia, Proceedings of 48th Annual Convention
issues and restraint procedures. In: Allen 2002, pp 25–52 of American Association of Equine
T, ed. Manual of equine dentistry. Mosby, 5. Fahrenkrug P. The history and future of Practitioners, 2002, pp 438–441
St Louis, 2003, pp 43–48 equine dental care in: Proceedings North 10. Kempson SA, Davidson ME, Dacre IT.
2. Scrutchfield, WL, Easley, KJ, Morton K. American Veterinary Conference, The effect of three types of rasps on the
Equine dental equipment, supplies Orlando, 2005, pp 151–154 occlusal surface of equine cheek teeth: a
and instrumentation. In: Baker GJ, 6. Easley J. How to perform and interpret scanning electron study. J Veterinary
Easley J, eds. Equine dentistry, 2nd edn. an endoscopic examination of the equine Dent 2003; 19–27
Elsevier, 2005, ch. 15, pp 205– oral cavity. Am Assoc Eq Pract 11. Pence P, Basile T. Dental infection in
292 Proceedings 2008; (54): 383–385 equine dentistry. In: Pence P, ed. Equine
3. Schultze W, Allen T, Mitz C, Johnson T. 7. Greene S. Equine dental advances. Equine dentistry: a practical guide. Lippincott,
Dental tools and equipment. In: Allen T, Practice 2001; 17(2): 319–334 Williams and Wilkins, Philadelphia,
ed. Manual of equine dentistry. Mosby, 8. Dacre KJP, Dacre IT, Dixon PM. 2002, pp 209–229
St Louis, 2003, pp 17–41 Motorized equine dental equipment. 12. Allen T. Other procedures. In: Allen T, ed.
4. Pence P. Dental equipment in equine Eq Vet Edu 2002; 4(5): 337–340 Manual of equine dentistry. Mosby, St
dentistry. In: Pence P, ed. Equine 9. Baker GJ, Allen ML. The use of power Louis, 2003, pp 157–173
dentistry: a practical guide. Lippincott, equipment in equine dentistry. In:

260
 Section 5:  Treatment

C H A P T ER  17 
Corrective dental procedures
Jack Easley DVM, MS, Diplomate ABVP (Equine)
Equine Veterinary Practice, LLC, Shelbyville, KY 40066, USA

Introduction martingale) and allowing free rostrocaudal mobility of the

mandible. Such additional procedures may include round-
Corrective dental procedures in the form of floating or ing off the rostral and buccal edges of the 06s (creating bit
reduction of sharp enamel points and tall tooth crowns seats), the removal of loose deciduous teeth, and the extrac-
have been performed on equine patients for hundreds tion of wolf teeth. Corrective dentistry or dental equilibra-
of years. These procedures performed on a regular basis tion describes the third level of equine dental care and
have traditionally been part of a horse health care program involves procedures devised to reduce dental crown elonga-
with very little scientific evidence to support this practice. tions (odontoplasty) and treat associated pathologies.
Corrective floating procedures are often performed to: 1) Dental overgrowths may involve a portion of a tooth (hooks,
relieve discomfort associated with oral soft tissue injuries abnormal transverse ridges), the entire tooth (step, ramp),
caused by sharp enamel points; 2) reduce dental elonga- several teeth (wave), or the entire arcade (shear mouth).
tions, which place stress on affected teeth and jaws; 3) Dental elongations can place abnormal stress on the affected
improve mastication and digestion of feedstuffs; 4) alleviate tooth. These stress forces can cause the teeth to shift and
stresses on abnormally worn teeth; and 5) prevent discom- ultimately lead to rostral or caudal displacement, linguover-
fort and improve performance in the horse wearing a bit and sion, or buccoversion. The resulting diastema caused from
bridle.1–10 Most dental corrective procedures concentrate on tooth displacement is a leading cause of periodontal disease.
reduction of abnormal dental elongations. The true pathol- This high level of dental care usually requires a more thor-
ogy often involves the tooth opposite or out of occlusion ough examination and at times ancillary diagnostics and
with the elongated dental area. Failure to evaluate and imaging techniques to properly diagnose the problems and
properly address the pathological process may lead to develop a precise plan for correction. Oral and dental
recurrence of the elongations and a temporary or unsatisfac- surgery, periodontics, orthodontics and endodontics, the
tory result for the patient. A careful and complete oral exami- fourth level of equine dentistry, will be covered elsewhere in
nation is critical in the diagnosis of dental pathology and this text.
the planning of dental corrective procedures. A more It is not always possible to assign an equine patient to a
scientific approach to equine dentistry has changed the way level of dental care prior to making clinical contact. A dental
that many cases are managed. The practitioner should history and physical examination along with a complete
strive to do no harm to the horse or its teeth. The utilization oral/dental examination usually establish the level of care
of a complete set of good quality hand floats or power the horse requires. Occasionally, the veterinarian may be
equine dental equipment allows dental corrective proce- involved in what appears to be a routine prophylaxis when
dures to be performed with precision in an efficient manner a tall, decayed, loose, or broken tooth is encountered. This
(see Ch. 16). may move the horse into a higher level of care. Horses
There are four distinct levels of equine dental care. Histori- requiring special diagnostic and therapeutic oral procedures
cally, the first level of dentistry has been labeled dental may require referral to veterinarians with the equipment and
prophylaxis or ‘floating teeth.’ It involves an oral examina- expertise to properly diagnose and treat such problems.
tion and routine dental maintenance procedures, such as Taking a moment to educate trainers and owners about the
reduction of sharp enamel points, and reduction of small value of a thorough dental examination, types of pathology,
crown projections (hooks, beaks, small waves, and trans- and indicated dental corrective procedures is time well spent.
verse ridges). The second level of dentistry is often referred Dental forms or charts should be used to record abnormali-
to as performance dentistry. This includes dental prophylaxis ties, corrective procedures performed, and any planned treat-
and additional procedures developed in the hope of improv- ment. Dental forms also help in itemizing the bill and
ing the horse’s comfort in accommodating the bit or provide an estimate of professional fees before procedures
other equipment (tongue-tie, hackamore, nose band, or are performed (see Ch. 12).

261
 17 Treatment

Fig. 17.1  Performing dentistry by feel. The horse is restrained with its head
and mouth at chest level to the veterinarian. This method allows the
practitioner to remain standing with correct posture for dental work.
Fig. 17.2  Performing visual dentistry. The horse is restrained with its head
elevated, and the veterinarian is working while seated in front of the horse.

Two approaches to performing dental corrective proce-

dures have become standard over the past few years. Both damage to pulp horns from overheating or direct exposure.
involve examination and dental corrections carried out in a It has recently been speculated that horses may suffer dental
standing, sedated equine patient. In rare cases, general pain after corrective procedures.17 A fine-toothed burr or
anesthesia may be required to thoroughly examine and treat dental rasp used with light intermittent cutting strokes causes
dental problems. The less involved type of standing restraint less damage in reduction. An efficient water cooling system
has been described as ‘performing dentistry by feel.’ This and frequently cleaning the burrs may reduce the chance of
type of dentistry is performed with the horse’s head at the thermal injury to the dentin and pulp.18,19
level of the operator’s waist or chest (Fig. 17.1). This requires This chapter is divided into five sections: 1) dental prophy-
minimal sedation and works well for most horses with rela- laxis; 2) performance dentistry; 3) special concerns in treat-
tively normal occlusions that need only minimal routine ment of miniature horses and draft breeds; 4) correction
dental corrective procedures. The horse’s head can be peri- of cheek teeth and incisor overgrowths and associated
odically elevated, and the oral cavity visually evaluated pathology; 5) complications of dental corrective procedures.
during the procedure.11–14 The second method commonly The dental equipment and instruments needed to carry
employed is ‘visual dentistry.15 Working in the horse’s mouth out corrective procedures have been covered previously in
visually requires the patient to be well restrained and more Chapter 16.
heavily sedated (Fig. 17.2). The animal’s head must be ele-
vated and supported at a height that allows visualization of
the mouth while the veterinarian maintains a comfortable Dental prophylaxis
ergonomic body position.16 Visual dentistry allows for a
more thorough dental examination and precise correction of In veterinary medicine the concept of prophylaxis, i.e., the
dental abnormalities. Both methods have their place in prac- ability to use a practice that prevents the development of
tice, but visual dentistry has many advantages over dentistry subsequent serious disease, is the foundation of any health
by feel, especially in horses with dental pathology or severe maintenance program. Dental prophylaxis, the examination
wear abnormalities. Working with dental instruments, of the oral cavity, and the use of corrective procedures to
including power equipment, requires strength, dexterity, and arrest disease processes before clinical signs are seen, have
mastery of technique. The visual method allows better access been reaffirmed as important parts of a patient’s health care
to the mouth and lowers the learning curve on the use of program. Historically, ‘floating’ was a term that originated
equipment. in the masonry and/or carpentry professions to describe lev-
Dental corrective procedures, such as floating teeth, were eling or smoothing out of plaster. In equine veterinary prac-
once considered fairly innocuous. With the development of tice, floating involves the use of files, burrs, or chisels to
better quality and more efficient equipment to instrument remove the enamel points from the buccal aspects of the
the mouth and reduce dental crowns, dental correction can upper and lingual edges of the lower cheek teeth. Reducing
be overdone and have severe detrimental effects on the and smoothing these sharp elongations make these areas
patient. Rasping teeth has been shown to amputate odonto- that contact soft tissue less irritating, thus providing more
blast processes, leave deep grooves in the surface of the comfortable mastication and bitting for the horse.20–25 Float-
dentin, and/or chip the enamel surface and peripheral ing may be the first dental procedure performed and can
cement. Modern motorized dental tools remove greater make the mouth more comfortable when using a full-mouth
amounts of dental tissue, thereby increasing the risk of speculum. Or, it may be preceded by cutting, grinding, or

262
 Corrective dental procedures

Fig. 17.3  Proper positioning of the back molar float with a slim 15° upper
obtuse head. The carbide blade should always be set to cut on the pull Fig. 17.4  A short-shafted float with a 20° downward obtuse head. This area
stroke when using this float in the back of the mouth. of the dental arcade can be more easily floated without the speculum in
place.

extracting teeth to provide a dental arcade that can be prop-

erly rasped. Hand floating by feel with minimal sedation will
be described in detail. However, many practitioners use
power tools in routine floating. Since each type of equip-
ment requires varied techniques, it is recommended that one
works closely with practitioners who have experience with
the specific tools being used. Manufacturer recommenda-
tions on the use of particular power tools should be fol-
lowed very closely.
Equine dental floating should be approached in a sequen-
tial fashion. A full set of floating instruments is needed to
reach the various areas of the mouth. The upper buccal
aspect of the central four cheek teeth is the easiest point of
the arcades to float. The most appropriate tool to reach this
area is a straight head float. The practitioner can introduce
the float to the horse by allowing the animal to view, sniff,
and feel the float’s action on the outside of the cheek before
inserting the instrument into the mouth. The initial strokes
should be light and short, progressing along the length of
the dental arcade. As the horse becomes more receptive to
the tool, the stroke can be lengthened and more pressure
applied to the head of the float. The position of the float
head should be at a 45° angle to the buccal cusps. Hand Fig. 17.5  A straight long-shafted float positioned for removing sharp
enamel points from the lower arcades.
position, which influences float head position, should be
adjusted according to feel and sound. The high-pitched
rough sound of sharp enamel points being rasped softens as
floating continues. The 45° angulation of the float head molars. The final area to be floated on the upper arcade
should not be rigidly maintained, or two sharp angles could involves the second and third upper premolars. The instru-
be left on the buccal aspect of the tooth. The float should be ment of choice to use on these teeth is a short-shafted upper
rotated slightly along the longitudinal plane to round the premolar float with a 20° angled head or a 9-inch offset
buccal tooth edges and reduce prominent singulare. This head float (Fig. 17.4). The float is worked back into the
procedure should be performed on both upper dental mouth along the buccal aspect of premolars 2 and 3. Horses
arcades before proceeding to the next area. with 06 hooks, or performance horses that are bitted, require
The upper caudal molars (110, 111, 210, 211) should be special considerations, and these are addressed later in this
floated next using a long-shafted straight float with an chapter.
upward tilted or obtuse 10–15° head (back molar float; Fig. A 15–17-inch long straight float with a 3-inch head or a
17.3). The instrument is placed in the buccal space and eased carbide chip table rasp can be used to float the lower arcade
to the back of the mouth. With short strokes on the pull, the (Fig. 17.5). This instrument is introduced along the lingual
float head is pressed against the buccal aspect of the last two aspect of the lower molar table with a mouth speculum in

263
 17 Treatment

In drivers, runners, and saddle horses enamel points

are the greatest sources of annoyance. The expert
reinsmen will properly recognize their presence by the
horse’s behavior in harness. Lugging, side reining,
ptyalism, and tenderness about the seat of the bit are
manifestations of pain from the bridle and are
symptoms of these points. The aim in dressing the teeth
of a horse should be to simply blunt the enamel points
along the course of the arcades and to round up the
first superior and inferior molars as smooth as an ivory
ball.26

A recent Swedish study has shown an increased incidence

of oral ulcerations in horses ridden with bit and bridle than
in horses not ridden.2 Floating the teeth to remove sharp
points has been shown in a clinical study to have a positive
effect on the trainer’s perception of the horse’s response to
the bit.27 The effect is enhanced by rounding the premolars
in what has been referred to as ‘bit seating.’ A randomized,
controlled, blinded trial demonstrated that dental floating
increased the rostrocaudal mobility of the mandible when
flexing and extending the head, which may be beneficial to
horses working with a more vertical head carriage.9 Studies
on the position of the bit in the horse’s mouth and surgical
Fig. 17.6  Horse restrained with a metal frame dental halter similar to a correction of bit-induced bar injuries have shed new light on
martingale, to float the lower arcades by feel. bitting problems.28,29 Performance horse dentistry entails:
1) normal dental prophylaxis; 2) slightly rounding the
06s (creating bit seats); 3) care or removal of wolf teeth;
place. Horses have a tendency to raise their heads when the 4) deciduous teeth management; and 5) evaluating canine
lower arcades are floated. A dental halter used as a martin- teeth. Types of bits and contact points on the horse are
gale is helpful in holding the head in proper position reviewed in Chapter 3.
(Fig. 17.6). Tongue retraction should never be used as a When evaluating performance horses, the veterinarian
method of restraint when floating. The hyoid apparatus can must keep in mind that subtle points and hooks or a
be fractured, with serious complications ensuing. A back difficult-to-detect loose or painful tooth may cause great
molar float can then be used to round the caudal edges of personality and performance changes in the elite equine
the last lower molar. Horses with 06 hooks or performance athlete.30 An important consideration when working on the
horses that are bitted require special considerations, and performance horse’s mouth is to remove any sharp or pro-
these are addressed later in this chapter. truding edges from teeth that could make contact with the
With a full mouth speculum in place, the entire upper and tender soft tissues of the mouth. A good test for detection of
lower molar arcades should be digitally and visually sharp points is to position the fingers just in front of the
inspected. Finally, any areas of asymmetry or overlooked masseter muscles on both sides of the cheeks at the level of
sharp points can be addressed. The speculum is removed, the upper molar arcade. Place firm pressure on the cheeks,
and lateral jaw excursion to molar contact (EMC) re- pressing them into the teeth and moving the fingers forward.
evaluated for balance, symmetry, and incisor contact. De­­ Press the commissures of the lips back against the rostral
pending on the horse’s age and use, other corrective edges of premolar 2. If the horse flinches or tosses its head,
procedures may need to be considered (see DVD). the animal is feeling pain from sharp enamel points.31
A regular dental floating usually resolves most problems.
The rostral edges of the upper and lower second premolars
Performance horse dentistry (106, 206, 306, 406) should be carefully rounded to provide
a smooth surface against which the cheeks can rest when
In additional to regular dental prophylaxis, several areas of bit pressure is placed on them. This procedure, termed
the dental arcade are of particular interest to veterinarians ‘creating bit seats’ is performed in an attempt to make
working with performance horses. Since the horse was first the performance horse as comfortable as possible for a
domesticated, reins and bits have been used to send cues reasonable period of time as the bit pulls or pushes soft
from the rider to his mount. Today’s performance horses are tissue against the premolar teeth. These teeth should be
involved in a wide variety of disciplines. In most endeavors, shaped like the end of an index finger. There are differences
the equine athlete wears a bridle and bit for control. Oral of opinion about the need for creating bit seats, the degree
and dental problems often lead to bad habits and vices, such to which the teeth should be beveled, and the smoothness
as resisting the bridle, poll sensitivity, and head shaking. required.21,25,32,33
Over 100 years ago, Merillat, in his thesis on horse dentition, To shape the upper teeth (106, 206), several cuts are made.
summarized the importance of dental care in the perform- The first is the outside (buccal) cut. The instrument of choice
ance horse: for this cut is a 9-inch float with an offset head. When

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 Corrective dental procedures

Fig. 17.8  Wolf teeth come in a wide variety of sizes and shapes.

Fig. 17.7  A short-shaft float with offset head is used to create the ‘bit seat’.
This float can be easily used over the incisor plates of a McPherson-type full
mouth speculum.

floating begins, the handle is held on the ipsilateral side of

the tooth and is subsequently worked across to the opposite
or contralateral side of the face between the open incisors
(Fig. 17.7). This rolls the head of the float from the buccal
aspect of the second premolar to its rostral buccal aspect and
then rostral aspect. This cut is followed by an inside cut to
the same tooth with the same float. The float is positioned
at a 30–45° angle to the lingual surface. Strokes should be
Fig. 17.9  Thirty-month-old horse with wolf teeth positioned close to the
made on the lingual edge of the tooth in order to round the 106 cap and 1 cm rostral to the 206 cap.
rostral aspect. The objectives of the inside and outside cuts
are to produce a narrow edge shaped much like a boat hull
which can be blunted with a crosscut. The float is introduced
from the contralateral side, placed at a 45° angle, to the ‘Wolf tooth’ is the common term used to describe the first
point, and short vibrating strokes are made. Two fingers may premolar.34 The number, position, size, and shape of these
be placed on the outside of the cheeks to serve as guides teeth are quite variable. The appearance of the exposed
(similar to how a person holds a pool cue). To observe float crown is not necessarily a reflection of the size or shape of
placement, the commissure of the lips should be retracted. the root (Fig. 17.8). Forty to ninety per cent of domestic
The last cut made is the fan cut. The float head is placed at horses erupt at least one upper wolf tooth. Lower first premo-
a 30–45° angle to the rostral point of premolar 2, and using lars are uncommon.35 Wolf teeth usually erupt at 6–18
a fanning action, short sequential strokes are made. Strokes months of age but this too may be quite variable. In some
are initially made on the buccal aspect of premolar 2. A half- 2–3-year-old horses, wolf teeth are shed concurrently with
circle is rolled or cut starting buccally and is continued the second deciduous premolar caps. The larger erupting
around the rostral and lingual surfaces of the tooth. This permanent second premolar tooth often causes root resorp-
blends the three prior cuts. The last cut is easier to perform tion of a wolf tooth that is positioned close to the deciduous
using a full mouth speculum. The float is inserted into the second premolar. This probably accounts for the high per-
mouth over the speculum incisor plate. centage (80–90%) of horses under 2 years old with wolf
The final step in performance horse floating requires float- teeth and the lower percentage (15–25%) found in adults,
ing the lower first cheek teeth and shaping the lower bit even in groups of horses having had no previous dental
seats. These lower teeth, like the upper second premolars, work. Wolf teeth are usually positioned just rostral to the
need to be slightly rounded and shaped symmetrically, upper PM2s, but they can be positioned on the buccal side
relative to one another. The bit seats are formed with the of the first cheek teeth or up to 1 cm rostrally to these teeth
same cuts used on the upper arcade. Ideally, the bit should (Fig. 17.9). Double wolf teeth have been seen, as well as
lie on the tongue and not against these teeth. The bit teeth displaced into the interdental space. Unerupted wolf
seats and the rest of the arcade should be evaluated for sym- teeth, referred to as ‘blind wolf teeth,’ can be detected as firm
metry and balance. Sharp buccal points on premolars 3 and nodules under the buccal mucosa rostral to the first cheek
4 should be reduced as they can cause nose band pain. tooth. These are often painful and at times are covered with
Severe tooth damage can occur from over-reduction of the ulcerated mucosa.
crown and lead to pulp horn damage. Finally, lateral jaw The role of wolf teeth in causing oral discomfort has been
excursion should be evaluated. If indicated, the incisor teeth widely debated.36–38 Tradition and client/trainer pressure are
should be addressed appropriately, as is discussed later in the greatest indications for extraction of these vestigial
this chapter. teeth.38 Certainly, most wolf teeth cause no problem to the

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 17 Treatment

Fig. 17.10  Local anesthetic (1–2 ml) administered around the wolf tooth
with a small gauge needle on a short extension set attached to a lure lock
syringe.

horse but cause concern to the trainer for several reasons. It

is difficult, if not impossible, to properly round the rostral
edge of PM2 to accommodate bitting with a wolf tooth in
place. Displaced or sharp crowned wolf teeth can cause
buccal pain and ulceration when bitting pressure is placed
on the cheeks. Some wolf teeth do become loose or diseased
and have been suspected to be a cause of head shaking or
bitting problems.
Some veterinarians advocate floating or grinding the wolf
tooth crown, incorporating it into the bit seat. This has the
potential to loosen the tooth or expose the pulp chamber.
Both conditions could be detrimental in the long term and
predispose the tooth to pulpitis and lead to eventual extrac-
tion. It is, however, customary practice to extract wolf teeth
in young performance horses. In most cases, with proper
restraint and equipment, these single-rooted teeth can easily B
be extracted from the socket in total. Horses should be
sedated and given analgesia or a local anesthetic before these Fig. 17.11  (A) Lower wolf tooth (405) lingual to the crown on 406.
(B) Extracted 405 with a long, slender root.
teeth are removed (Fig. 17.10).37 Blind or unerupted wolf
teeth can be evaluated radiographically if one is uncertain
about their presence or position.
Rarely, a wolf tooth is encountered that is quite large and the same techniques as for the uppers. Extraction techniques
looks as if it has become molarized like the other cheek for removal of wolf teeth are covered in Chapter 20.
teeth.39 These should be evaluated radiographically and, if In the 2.5- to 5-year-old horse, the 24 deciduous incisors
unopposed, they need to be shortened or extracted. These and premolars are replaced by permanent teeth. Horses have
may prove to be supernumerary teeth, in some cases. vertically successional teeth. Therefore, each deciduous tooth
Lower first premolars (305–405) are occasionally detected and its underlying permanent tooth reside in the same alveo-
in the mandibles rostral to the first cheek teeth. These are lar crypt. The development and eruption of the permanent
usually quite small and may only be a small tooth sliver tooth lead to resorption of the roots of the deciduous tooth.
detected soon after the deciduous teeth have been shed. This, combined with attrition of the clinical crown, results
However, they can be large with sharp crowns (Fig. 17.11). in shedding or exfoliation of the deciduous tooth (also
Lower first premolars have caused problems in bitted horses. known as a ‘cap’). Conditions such as permanent tooth dis-
Their presence should always be noted during an oral exami- placement, diastemata formation, and dental impactions are
nation on a performance horse. They can be difficult to see often attributed to disorders of tooth eruption. The equine
on the oral examination because they may be partially teeth in each arcade are in tight apposition and act as a single
covered by a loose fold of buccal mucosa at the lip commis- grinding unit. It is easy to see how maleruption or displace-
sures. Digital palpation just rostral to the first lower cheek ment of a tooth can result in loss of integrity of an arcade.
tooth is the most accurate way to detect these short-crowned This would predispose to both abnormal crown wear and
teeth. Unerupted lower wolf teeth are rare and may only be periodontal desease.40 Some practitioners have expressed
detected radiographically. These teeth can be elevated using concern about the role of early or delayed eruption of

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 Corrective dental procedures

permanent teeth playing a role in the formation of certain

abnormal dental wear patterns noted later in life (i.e., domi-
nant maxillary 10s, lower 08–09 wave, incisor smile, or
frown, etc.).
Incisor caps normally shed from the most mesial teeth
(01s) at about 2.5 years (between 30 and 34 months), from
the 02s at about 3.5 years (40–44 months), and from the
corners (03s) at about 4.5 years (54–60 months of age).
Miniature horses and ponies may not erupt permanent inci-
sors for 6–18 months later than Thoroughbred horses. The
permanent incisors often erupt slightly palatal to the decidu-
ous tooth. Therefore, the incisor cap often retains the more
labial portion of the root and is often displaced slightly
rostral in the socket as it is shed.
Retained deciduous incisor teeth may be a source of dis-
comfort in the 2–5-year-old horse. Head tossing while eating
or rubbing the incisors on the stable wall and/or feed box
can result from retained incisor caps or root slivers. Incisor A
caps are easily removed with small extraction forceps.
Retained root slivers may need to be removed with a root
elevator while the horse is sedated. Retained and displaced
deciduous incisors can appear as a double tooth or a double
arcade of teeth, which should be differentiated from super-
numerary permanent teeth. Uneven eruption of permanent
incisors has been reported as a predisposing factor in incisor
malalignment and uneven wear. Premature extraction,
trauma, or avulsion of a deciduous incisor tooth has resulted
in maleruption, malformation, or failure of eruption.41
The sequence of eruption of permanent equine cheek teeth
has been widely reported in the literature with emergence
times of 2.5 years (813 days) for PM2, 3 years (1095 days)
for PM3, and 4 years (1460 days) for PM4.34 Recent work
has shed new light on premolar eruption times at least in
B
the Thoroughbred horse. In this study, male animals had a
younger age of emergence of 06s by 34 days compared to
Fig. 17.12  (A) Root slivers of this premolar cap (508) can become lodged in
females. Teeth in the lower jaw had a younger age of emer-
the gum if they break off when the tooth is shed. (B) Broken (508) root sliver
gence by 14 days compared to the same teeth in the upper embedded buccal to the permanent tooth.
jaw. The study showed the 06s emerging about 1055 days
of age, 07s at about 1130 days of age and the 08s at about
1350 days of age.42 on the ventral mandibular ramus or maxilla rostral to the
Worn crowns of the deciduous premolar teeth (caps) facial crest, can result from lingual displacement or delay
become loose and subsequently either displaced or shed into eruption of permanent teeth. These facial bony enlargements
the mouth. These wafer-thin portions of deciduous tooth are only cosmetic problems in most cases. However, they
crown can have a variable number of root slivers (Fig. 17.12). can become pathological if eruption is severely inhibited or
The caps can appear much like a table with four legs lying blood-borne bacteria inhabit the inflamed or ischemic
over the top of the permanent tooth. Gingivitis and perio- dental pulp. This can lead to anachoretic pulpitis and facial
dontal disease can result if these root slivers are broken off swelling with a draining tract on the mandible or maxilla.45
and remain in the subgingival space after the cap is shed. Caps should be evaluated by palpation and visual inspec-
The eruption pattern of permanent molarized dentition tion, using a dental mirror or endoscope (Fig. 17.13). In
follows a sequence that predisposes to entrapment (impac- some instances, open mouth radiographs may be required
tion) of deciduous PM3 and PM4. Delayed shedding of to evaluate the retained cap and the status of the underlying
deciduous premolars can predispose to gingivitis and peri- permanent tooth. Occasionally, caps may extend above the
odontal disease. Retained, split, or displaced deciduous occlusal surface of the adjacent teeth but cannot be extracted
premolars can be distracting to the training process of a without using excessive force. These caps should be floated
young horse. Additionally, retained deciduous premolars level with adjacent occlusal surfaces and evaluated 6–8
may cause dismastication, anorexia, and predispose to weeks later.
malocclusion and abnormal crown wear of the permanent Various forceps, elevators, and dental picks are available
teeth.40,43 In some cases they have been recognized as a factor to aid in the diagnosis and treatment of retained deciduous
in dorsal displacement of the soft palate.44 If one cap has teeth. These include Reynolds cap extractor forceps (upper
shed, the cap in the opposite side of the jaw should be evalu- and lower), molar forceps (11 inch), No. 34 gouge dental
ated and, if loose or close to exfoliation, removed. Impacted elevator, and No. 69 dental extraction forceps. To remove
caps, manifested as bony enlargements or eruption bumps the cap of deciduous PM2 and PM3, small extraction forceps

267
 17 Treatment

Erupting canine teeth in 4–6-year-old horses can cause

subgingival pain and bit irritation that has been manifested
by head shaking or other bad habits. This problem was
reported by Percivall over 100 years ago:
I was requested to give my opinion concerning a horse,
then in his fifth year, who had fed so sparingly for the last
fortnight, and so rapidly declined in condition in
consequence, that his owner, a veterinary surgeon, was
under no light apprehensions about his life. He had
himself examined his mouth without having discovered
any defect or disease, though another veterinary surgeon
was of the opinion that the difficulty or inability
manifested in mastication, and the consequent cudding,
arose from the preternatural bluntness of the surfaces of
the molar teeth, which were, in consequence, filed but
without beneficial result. It was after this that I saw the
horse, and I confess that I was, at my first examination,
Fig. 17.13  An intraoral mirror is used to evaluate a 506 cap. The quite as much at a loss to offer any satisfactory
corresponding permanent tooth (106) is seen just erupting through the interpretation as others had been. While meditating,
gum beneath the cap. however, after my inspection, on the apparently
extraordinary nature of the case, it struck me that I had
not seen the tusks. I went back into the stable and
work well. On the PM4 cap, open head molar extraction
discovered two little tumors, red and hard, in the situation
forceps possess a better angle with which to clamp the cap.
of the inferior tusks, which, when pressed, gave the animal
The forceps are clamped firmly on the base of the cap and
insufferable pain. I instantly took out my pocket knife and
pulled lingually across the arcade and the tooth extracted.
made crucial incisions through them both, down to the
Care should be taken not to place the forceps below the level
coming teeth, from which moment the horse recovered his
of the gums as the palatine vessels along the upper arcade
appetite and, by degree, his wonted condition.47
could be disrupted upon clamping, resulting in severe hem-
orrhage. Rolling the cap toward the lingual surface reduces In the mature horse, calculus can build up on canine teeth
breakage of the buccal roots, which can leave slivers of the that have lost the crown enamel. These teeth should be
cap behind. With this method, only the lingual cap roots scaled and brushed to prevent or reduce the degree of gingi-
may break. The residual lingual slivers can be easily removed vitis and periodontal disease (Fig. 17.14).
with a root elevator. If slivers do exist on either the lingual
or buccal sides of the premolars, they can be worked out of
the gum with a dental pick or plucked out with a set of Special concerns in the treatment of miniature
closed head rongeurs. When caps are removed, the underly- horses, ponies, and draft breeds
ing permanent tooth will erupt and should be in wear in
3–4 months. Sharp enamel edges will be present on these Several types of horses deserve special consideration when
teeth in 3–6 months, and the horse should be rechecked and performing dental procedures. In recent years, small ponies
floated at this time. and miniature horses have become popular companion
Canine teeth (104, 204, 304, 404) are usually present in animals and warrant particular attention. Intensive inbreed-
most male horses over 5 years of age. These teeth normally ing to reduce body size and refine the head from a large draft
cause few if any problems. In a study of 400 horses, five type to a light horse type has led to an increased incidence
presented with bitting or head carriage problems related to of dental problems. In genetic studies of other animal species,
canine teeth. In four cases with displaced, supernumerary, it has been shown that teeth diminish in size more slowly
or fractured canines, the teeth were extracted with resolution than the jaws.39 The teeth of a 250 lb miniature horse are
of clinical signs.46 It is suggested that displaced canines that about two-thirds the size of a 1000 lb Quarterhorse.48 Dis-
are causing soft tissue irritation or bit interference may be proportionately large tooth size in relationship to head size
successfully treated by simply rounding to the top of the seen in miniature horses can encourage tooth overcrowding
clinical crown. Care must be taken not to damage the pulp and lead to dental maleruptions and malocclusions. This
which can lead to pulpitis and eventual death of the tooth. predisposes the small horse to a higher incidence of dental
Some mares have small rudimentary canines that generally disease and abnormalities of wear.40,43 For this reason, early
do not cause problems unless they become loose or accu- and frequent oral examinations and interceptive dental cor-
mulate tartar. Long or sharp canines in a stallion or gelding rective procedures are more important in smaller horses.
have been blamed with bit interference, the mechanism of The miniature’s small stature and reduced head size makes
which has not been determined. the oral cavity more difficult to evaluate. Many of these pet
In the past, tall or sharp canine teeth have been cut and horses are poorly trained and require sedation to be
blunted before performing corrective dental procedures, to restrained. Careful calculations of body weight and sedative
reduce the likelihood of injuring one’s hands and/or wrist. medication dosing at a lower mg/kg level are important.
This practice is not in the best interest of the horse and Restraint at a level that allows the examiner/operator to be
should be discouraged. comfortable requires either elevating the horse or lowering

268
 Corrective dental procedures

A B

Fig. 17.14  (A) Severe tartar accumulation (calculus) on 304. (B) Calculus has been removed revealing the tooth crown that is no longer covered with
enamel. The gingival recession is severe. Radiographs revealed loss of crestal bone.

the veterinarian. These horses can be sedated and restrained

at ground level, but this requires the practitioner to work on
his knees. Knee pads offer protection, and a solid bar or skirt
in front of the horse provides a barrier between the operator
and the horse. Elevated stocks or loading dock can bring the
animal’s head to a more comfortable working height.
Special dental instruments may be required to work in the
small oral cavity of miniatures/ponies. Interceptive ortho-
dontics is more often employed in miniature horses because
they experience a higher incidence of dental overcrowding.
It has been found that early removal of deciduous teeth can
result in destruction of permanent tooth buds. This informa-
tion can be used to the horse’s advantage if there is severe
overcrowding and no room for a full set of permanent teeth
in the dental arcade.48 Malformed permanent teeth and
severe early dental decay are other sequelae to premature
deciduous tooth removal, most commonly seen affecting the
upper premolars. Fig. 17.15  Motorized dental burrs with long shafts. This instrument works
well for reaching the caudal recesses of the mouth in large breeds.
Draft and large warmblood breeds present special dental
considerations due to their weight and size. Large horses
weighing over 750 kg usually require less medication for
sedation on a mg/kg basis, than medium-sized animals. A
head support stand or a metal-framed dental halter sus- In large breeds, deciduous tooth shedding may be delayed
pended from a sturdy beam is necessary to support the addi- up to several months compared to the light breeds. This
tional weight of the heavy horse’s head. A sedated draft horse further postpones cap removal. The incidence of certain con-
can become unsteady or stumble, which can be extremely genital craniofacial deformities (wry nose and parrot mouth)
dangerous for the veterinarian or his assistant(s). Sturdy has been over-represented in draft breed horses.49 There
stocks are recommended as a safe area for restraint. The appears to be a disproportionately large number of draft
operator may need a platform on which to stand in order to horses with molar arcade malocclusions leading to hook
maintain an ergonomic working posture. Large horses may formation on the upper 06s and lower 11s. Clydesdale
overpower a regular McPherson type speculum, and the horses have a distinct ‘mustache’ appearance of the upper lip
larger MacAllen or Conrad speculums give the operator and many have large, even molarized, wolf teeth (105, 205).
more security and safety when placing hands and arms into These large wolf teeth often require removal for correction
the caudal recesses of the mouth. The Series 2000 speculum of bitting problems. Preoperative radiographs and infiltra-
is heavy and can be purchased with a draft horse poll strap. tion of local anesthetic agents are helpful in planning and
If hand floating, long shaft instruments are required to reach successfully carrying out extractions.
the caudal aspect of the cheek teeth. Special 24-inch-long
shafts with bonded or interchangeable blades are available
from at least one instrument manufacturer. Power equip- Correction of cheek teeth and  
ment is especially convenient for working in large, deep incisor overgrowths
mouths. The disk burr floats with long shafts have been
found to be extremely versatile and efficient for working on The process of reducing dental protuberances to adjust the
draft horses (Fig. 17.15). dental arcades has been practiced for centuries. Percussion

269
 17 Treatment

type instruments described as molar cutters or chisels have

been used for at least 200 years. Abnormal wear patterns
develop secondary to poor dental occlusion or altered mas-
ticatory patterns. It is beneficial to explore the cause of the
wear abnormality before corrective action is instituted. It
should be determined whether the wear abnormality render-
ing the table surface uneven is a result of an overgrowth of
a tooth crown or excessive attrition or lack of tooth crown.
The classic types of cheek teeth abnormalities of wear are
described as step mouth (tall teeth), hooks, wave mouth,
exaggerated transverse ridges, and shear mouth. Common
abnormalities of incisor wear include elongated teeth sec-
ondary to overjet, diagonal bite, smile or frown bite, and
isolated tall teeth.13,21
Balancing a horse’s mouth is more than simply reducing
the crown on tall teeth. Dental arcade balancing or equilibra-
tion allows the jaw to move symmetrically through the full
range of mastication.41 The molar arcades, oral soft tissues,
muscles of mastication, and temporomandibular articula- Fig. 17.16  Guarded carbide dental burr used to reduce a dental elongation
tion should function as a unit. Factors such as head confor- on the rostral aspect of 306.
mation, facial asymmetry, previous trauma, dental attrition,
and craniofacial deformity (congenital or developmental)
determine how close to ideal dental balancing can be available today are quite efficient in reducing tall teeth
achieved. Keep in mind, changing the crown shape of a crowns (Fig. 17.16). These instruments should be used with
tooth changes the way the tooth functions in the arcade. caution so as not to overheat the tooth or abrade the soft
With even a small alteration of the dental table, all associ- tissues of the mouth. Some tall teeth, especially those in the
ated structures of mastication (i.e., teeth, bone, muscles, caudal recesses of the oral cavity, may be difficult to reach
tongue, and palate) must adjust. Indiscriminate use of with some power tools. Molar cutters and obstetrical wire
instruments in the mouth by individuals untrained in the may be useful in correcting some caudal elongations, but
principles of dental anatomy, physiology, and pathophysiol- extreme care must be exercised not to fracture the crown or
ogy can cause harm to the dental apparatus. Corrective pro- expose a pulp horn.
cedures dealing with the occlusal surfaces of teeth should be Equipment selection and placement are critical when
conservative until one has a thorough working knowledge using molar cutters to reduce tall teeth. Cutters should be
of not only anatomy and mastication but tools specifically sized to fit the tooth to be reduced, with blades set parallel
developed for correction. The principles in treating all dental to each other when pressure is placed on the buccal and
elongations are the same for any tooth. Reduce the tall tooth lingual edges of the crown. The cutter blades should be
to take the damaged or worn surface of the opposite arcade placed parallel to the normal occlusal surface of the dental
out of occlusion and allow for less restricted rostrocaudal arcade. The tooth should be reduced with quick pressure
and lateral jaw motion.9 Each tooth in the dental arcade taking care not to twist the cutter. The objective is to cleanly
taken out of occlusion by reducing the exposed crown height remove the tall tooth crown without damaging the remain-
places excessive masticatory forces on the teeth that remain ing tooth. Problems seen after molars have been cut include
in occlusion. fissure fractures down the crown and associated periodontal
Hypsodont teeth out of occlusion with teeth in the oppo- pockets, tooth extractions, and pulp exposure. Molar cutters
site dental arcade become tall or protuberant from lack of have either simple or compound action. A simple cutter with
crown wear or attrition. Congenital or developmental condi- B- or C-head works well for most mandibular cheek teeth.
tions resulting in unopposed teeth include supernumerary A compound D-head cutter is more effective in fracturing
teeth or the absence of a tooth or several teeth in a molar or maxillary cheek teeth. The upper molars are wide, and the
incisor arcade. Acquired conditions with this same result upper incisor teeth and speculum plates limit access to a
include teeth that have been surgically removed from one long, straight-handled cutter. An open head cutter with an
arcade or severe crown damage or fracture that has occurred; offset 20° angle works well to reach some maxillary cheek
the unopposed tooth/teeth become elongated due to lack of teeth. After cutting, the affected tooth should be palpated
attrition.50,51 and probed to ensure the intact section has not been loos-
A single unopposed tooth becomes longer over time and ened or fractured. The table surface should be smoothed and
can cause pronounced negative effects on mastication. This leveled with a rasp. If pulp horns have been exposed, a vital
condition is often referred to as ‘step mouth.’ Long crowns pulpotomy and crown sealing are required.
can reach the soft tissues of the opposite jaw and lead to Dental hooks, if present, are located on the rostral or
mucosal ulceration, osteomyelitis, or sinus empyema. It is caudal aspects of the molar arcade. They are typically the
important to detect unopposed teeth early and keep the result of a malocclusion of the upper and lower jaws and
table surfaces even. This is easy to do during regular dental can be associated with congenital or developmental disor-
check-ups. If the teeth are not attended to on a regular basis, ders. Rostral or caudal displacement of the maxillary arcade
great difficulty may be encountered in attempting to reduce or a disparity in length of cheek tooth rows results in a hook.
extremely tall teeth. Many power dental instruments Hooks grow and develop at a variable rate but do so in

270
 Corrective dental procedures

proportion to the eruption rate of the involved tooth. Most lower M3 apical abscesses that were attributed to crown
teeth that develop hooks are in partial occlusion, and supere- reductions that damage the pulp horns.
ruption is seldom a factor in the rate of hook formation. The ‘Wave mouth’ is the term used to describe an undulating
length and table surface of premolar and molar hooks pattern usually involving the central portion of the dental
increase over time. Hooks alter mastication and place abnor- tables. This condition is seen in horses of any age. Waves
mal forces on the teeth and jaws. usually involve elongated lower 08s and 09s with corre-
Close and regular attention to malocclusions and abnor- spondingly worn, cupped-out, or decayed upper 08s, 09s, or
mal wear patterns, with timely correction, keeps elongations 10s. Waves can also form as a result of missing, misplaced,
from forming. Not all horses have routine dental care, and deviate, or rotated teeth in the opposing dental arcade.50 It
some develop large hooks over time. The position, size, and is important to assess the cause of a wave in order to develop
extent of the hook should be assessed, as should its mechan- a plan for management. Long teeth are seldom an isolated
ical effect on periodontal structures of the affected tooth and event in the mouth but they affect the pattern of mastication
opposing teeth. Additionally, the pattern of mastication and wear of all other teeth. It is important to note how many
should be taken into account. Some hooks are bilateral and teeth are involved in the protuberant area. Rarely is only a
symmetric to all four molar quadrants. Large hooks can have single tooth overgrown. The usual rate of dental eruption
a detrimental effect on the alignment of the incisor tables can be increased if the involved tooth is completely out of
from abnormal forces placed on the jaws. Small hooks that occlusion with the opposing teeth. Completely unopposed
consist mostly of enamel can be easily reduced with a carbide teeth have been seen to erupt at a rate of 0.5–2 cm a year,
float. Large hooks that consume a greater portion of the table two to four times the normal rate of eruption. Unopposed
surface contain a high percentage of dentin and are much teeth do not have the normal occlusal surface stimulation to
more difficult to rasp. Hooks can be narrow but quite long, form secondary dentin, so the sensitive pulp is often closer
as is the case in horses with slight malocclusions. Some to the occlusal surface. The most common wave seen is the
hooks comprise almost the entire tooth. This type of hook slowly progressing condition of aged horses. Infundibular
is more common in horses with missing or extra teeth in a enamel loss or central crown attrition reduces the upper
dental row. The hook should not be reduced below the level cheek teeth, and the wave may become quite tall as the
of the normal molar table surface. upper cheek teeth wear down to the root and eventually
Percussion instruments, both cutters and chippers, have become smooth (see Ch. 18).
been used successfully to reduce hooks. These instruments Slight wave formations of the dental table can be corrected
should be used with great caution and precision as teeth with a float or rasp. The horse’s mouth must be held open
have been broken, loosened, and/or repelled as a result. The with either a speculum or wedge to gain access to the table
most efficient and safest way to remove hooks is with the surface of the arcade. The use of tungsten carbide blades
use of motorized dental grinders. These instruments use makes small wave reduction easy, while power floats and/or
high-speed rotary burrs made of tungsten carbide or diamond grinders are often necessary to reduce extremely tall waves.
grit to grind down the tall crown surface of the tooth.32,33,52 When reducing a wave it is important not to take down the
Front hooks in the upper or lower arcade are usually entire molar table but only the portion involved in the elon-
reduced without difficulty. The cheeks and lips should be gation. Keep in mind that by reducing the crown height of
protected from the burr and visualization is aided by a good the involved teeth, this portion of the dental arcade is being
head light. Air or water should be used to reduce the amount taken out of occlusion. Thus, the masticatory forces are
of heat and dental dust generated when burring. Rear hooks increased on the adjacent teeth. Dental waves are easy to
are usually associated with a ramp or wave in the back of manage if the patient is seen on a regular basis and the
the mouth. It is helpful to reduce other elongations rostral crown height is maintained at a normal level.
to the hook before correction is attempted. The majority of Abnormal transverse ridges are actually tall wedges of
rear hooks can be reduced with a solid carbide blade enamel and surrounding hard tissues running buccolin-
mounted on a long-handled, straight float. The blade should gually across the occlusal surface of the tooth. These ridges
be set to cut on the pull stroke. The float is pushed to the are usually opposite a small diastema or narrow areas of
back of the mouth until it rests on the top of the hook. A excessive crown wear or fracture and should be reduced to
pull stroke is used to rasp the crown of the tooth. Small thin aid in therapy of the defect that occurs in the opposing
caudal hooks can be removed with an Equi-Chip. Several arcade. A table float or most any power tool can be used to
motorized instruments with 18–24 inch long guarded heads reduce the elevated portion of the ridge. These should not
have been successfully used to remove back hooks. Once the be confused with regular transverse ridges seen in young
hooks are reduced, forces placed on the jaws and the pattern horses (3–8 years of age).53 Regular transverse ridges serve
of mastication change. a purpose by increasing the surface area of the teeth and are
Incisor occlusion and lateral jaw excursion (EMC) should a normal feature in young horses. Normal ridges are not a
be evaluated before and after corrective procedures. A gradual continuation of the sharp enamel points that form on the
upward sloping at the end of the arcades is referred to as a buccal cingula of the upper cheek teeth. These ridges can be
ramp. Many horses have the caudal lower molars erupt in slightly contoured but no attempt should be made to reduce
the curve of the jaw. This is a normal anatomic feature in or flatten the table surface as this can damage the tooth and
some horses and these ramps should be carefully evaluated reduce its longevity. Excessive reduction of the table surface
before any crown reduction is undertaken. Special precau- has been known to bring the molar arcades completely out
tions should be taken if molar cutters are used to reduce rear of occlusion. Overzealous reduction of transverse ridges con-
hooks. The caudal pulp horns are easily opened when caudal tributes to the unfortunate practice of excessive and repeated
hooks are reduced. This author has seen several cases of incisor reductions.

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 17 Treatment

‘Shear mouth’ occurs when the occlusal table surfaces of between the incisor and molar arcades and the temporo-
the molar arcades are worn at an extremely steep angle mandibular joints. Before the incisor tables can be properly
(greater than 45°). When dental occlusion is symmetric balanced, the molar tables should be floated and wear
through a full range of jaw motion, the molar tables should abnormalities corrected. Horses are usually more sensitive
wear at an even 10–30° slope. When masticatory excursion in the incisor tooth area. Since incisor tooth corrective pro-
is limited on one or both sides, the teeth wear at an abnor- cedures are often the last to be performed, the horse may
mally steep angle. Horses with loose or painful teeth, jaw require sedation or resedation to complete the task of incisor
malalignment, severe periodontal disease, neurological reduction. For minor incisor work, a twitch may be used to
paralysis of the masticatory muscles, or temporomandibular restrain the horse for a short period of time.
joint problems that limit jaw motion in one direction, Horses with long incisor teeth have a malocclusion of the
develop shear mouth. Quite often, horses with shear mouth upper and lower jaws. The congenital defects termed parrot
will also exhibit masseter and temporalis muscle atrophy on mouth, monkey mouth, and wry nose are the most common
one or both sides. reason for these teeth rows to be out of occlusion. Some
Before correcting a shear mouth, the equine practitioner horses may develop a slight incisor overjet or underjet over
should attempt to identify and correct the underlying cause. time due to abnormal forces placed on the jaws from enlarg-
Any attempt at correction of the molar table angle abnormal- ing rostral 06 and caudal 11 hooks. These elongations, if
ity should be addressed only after certain factors are large, can force the lower jaw in a rostral or caudal direction,
considered: which leads to lack of wear on the portion of the incisor
tables that is out of occlusion (Fig. 17.17). The technique to
1. The condition has been present for an extended period
correct overlying long incisors involves reducing the exposed
of time and the muscles, ligaments, and joints have
crown height of the long teeth. It has been shown that no
remodeled to accommodate changed chewing patterns.
more than 3 mm should be removed at one time to prevent
2. Steep table angles may be accompanied by a long outer
pulp exposure and avoid drastic changes in the EMC. A
buccal edge of the upper arcade (up to 4 cm) and a
simple, logical method for determining how much incisor
very short palatal edge that may progress up into the
should be removed has been proposed. Based on this work
gum line. A corresponding long, sharp edge usually
using trigonometry and measuring lateral jaw excursion and
forms on the lower arcade.
incisor elevation, a fairly accurate estimate of incisor reduc-
3. The tall, scissor-like conformation of the dental arcades
tion can be determined.56,57 Another method often used is
may prevent opening the mouth wide enough to allow
estimating the distance in the interocclusal space. This has
visualization or instrumentation in the caudal portion
been defined as the distance between the occlusal surfaces
of the mouth.
of the upper and lower cheek teeth arcades. To estimate the
Correction of shear mouth should be attempted in stages, interocclusal space, the sedated horse’s head is elevated and
working on the horse’s mouth every 1–3 months for three– the cheek retracted. Using a penlight or other transillumina-
six visits. The scissor blade wear pattern on the cheek teeth tion device, the distance between the cheek teeth arcades can
prevents the operator from establishing a normal table angle be estimated.21
even if the tall portion of the crown is reduced to a more It has been shown that each 1 mm shortening of incisor
normal height. Working from the front of the mouth cau- length decreases the lateral jaw excursion to molar contact
dally, the molar tables can be contoured. Over time, the distance (EMC) by about 4 mm. EMC rarely increases fol-
muscles and joints adjust with mastication and many lowing removal of sharp enamel points, but may increase
affected horses enjoy more normal occlusion and comfort- after correction of a severe wave mouth or other major cheek
able masticatory function. This condition is irreversible in tooth elongations. Measuring EMC pre- and post-treatment
some horses, and associated dental pathology may be severe. enables one to return EMC to the original value after cheek
Many of these horses must be managed through dietary teeth corrections. Long incisor reductions have been per-
adjustments. formed using flexible shaft, cable grinding tools with solid
Abnormalities of incisors have been blamed for causing tungsten, carbide grit, or diamond grit burrs (Fig. 17.18).
difficult mastication and decreased performance. The inci- Diamond cut-off wheels, nippers, and forceps have been
sors are easy to observe and can be evaluated with less dif- used to remove large amounts of incisor crown, but these
ficulty than the cheek teeth. The oral examination, prior to tools can prove dangerous to the horse and operator. Rotary
any corrective procedures, should include evaluation of grinders with carbide burrs or fine carbide or diamond files
lateral jaw excursion to molar contact (EMC). Incisor abnor- are the preferred tools for reducing and smoothing incisors.
malities have been separated into five classes:54–56 The occlusal surface should be ground down in thin
(1–2 mm) layers and then checked for molar table contact
1. Excessively long incisor arcades from lack of occlusal
and EMC.56
contact and/or wear
Smile bite has been identified as a normal incisor confor-
2. Smile bite, or dorsal curvature of the incisor arcade
mation in donkeys.58 If it has been found to interfere with
3. Frown bite, or ventral curvature of the incisor arcade
mastication, smile bite can be corrected by reducing the
4. Diagonal bite with or without an offset jaw, and
corner teeth in the lower arcade (303, 403). Leveling the
5. Stepped or irregular incisor bite.
upper incisors should only be performed if it is determined
Most abnormalities can be corrected or at least greatly that reducing them will not create a gap between the upper
improved with relatively simple procedures and basic equip- central (101, 201) and lower central (301, 401) incisors.
ment. When realigning the occlusal surfaces of the incisor Frowning incisors are treated in the opposite manner
arcade, it is important to keep in mind the relationship by reducing the corners of the upper arcade (103,

272
 Corrective dental procedures

Fig. 17.18  A carbide chip rotary drum is used to reduce elongated upper
A incisor teeth.

occlusion and limiting mastication. The incisors can be

leveled from side to side by reducing the tall areas as much
as 3 mm at a treatment.
The treatment of horses suffering from infundibular decay
of the upper cheek teeth is controversial. Through the years,
the belief that cemental hypoplasia and infundibular caries
could be diagnosed from an oral evaluation of the tooth has
led some to advocate filling these defects.60–62 To date, the
only reasonable management tool is to reduce the tall teeth
or wave in the opposite arcade in order to decrease stress on
the decayed tooth.
Dental overgrowth has been associated with 62.5 % of
horses with diastema and is attributed to abnormal occlusal
movements caused by painful periodontal disease.63 Becker
described treating diastemata by enlarging the space between
the teeth to reduce food trapping.64 The type of diastema he
dealt with has been recently defined as a ‘valve’ (or closed)
B diastema.65 In this pathological situation, food material is
able to enter the triangular defect, bounded rostrally and
Fig. 17.17  (A) A horse with a slight incisor overjet. Only the upper 01s and caudally by tooth, distally by gingiva or the periodontal
02s are out of occlusion with the lower teeth. The upper 01s and 02s have defect, and proximally by the occlusal surface of the dental
become elongated from lack of wear. (B) Rostral 106 crown elongation arcade. Egress of feed material from this space is impeded
(hook). This tooth has been blunted during floating but the body of the by the valve effect and the enlarging abnormal wedge or
hook is still mechanically forcing the lower jaw in a caudal direction. When transverse ridge that often forms on the opposing cheek
these elongations and the corresponding lower 11 hooks were reduced, the
tooth. Quality regular dental care, appropriate crown reduc-
incisor arcade came into normal occlusion. The horse could not masticate
feed due to a gap between the upper and lower molar arcades. To correct tions, and necessary extractions should be the first phase of
this problem, the upper incisor arcades were shortened 4 mm. therapy. Many horses respond positively to repeated removal
of dental associated overgrowths.63 Removal of foreign mate-
rial (plant awns, impacted or decayed feed, and calculi) in
the interproximal spaces and gingival sulci speeds healing in
203). Diagonal (or slightly tilted) arcades can be improved many cases (Fig. 17.19). Flushing dental pockets with a
or corrected by shortening the upper or lower long or tall syringe and infusion catheter or elongated water pick has
incisors. It may be impossible to completely level the more been described.20,66 Special long-handled air abrasion units
severely tilted incisors without creating a gap between the deliver water and medical grade baking soda under pressure,
upper and lower arcades. Incremental shortening of the tall to flush periodontal pockets (Fig. 17.20). In cases where
teeth should be performed every 4–6 months until the reimpaction of feed is likely, placement of a perioceutic
incisor occlusal surfaces are closer to level from side to side. within the sulcus and/or dental impression material in the
Recent studies have shown that it is impossible to predict larger interproximal spaces has shown good results.67,68
the long-term benefit of correcting the incisor angles in Special right-angle burrs have been developed to treat valve
many of these cases.59 Stepped (irregular bite) incisors may diastema (Fig. 17.21). They have been used successfully to
be locked, with the horse unable to move the mandible later- grind the dental crown on each side of the valve, opening
ally without opening his mouth, thus reducing cheek tooth an occlusal space allowing it to self-clean.69

273
 17 Treatment

Fig. 17.19  A high pressure water irrigation unit with a right angle nozzle is Fig. 17.21  A right angle 4 mm diameter burr is used to open a valve
used to flush material from a periodontal pocket between 307 and 308. diastema between 407 and 408.

Fig. 17.22  Iatrogenic fracture of 101 caused by incisor nipper used for
crown reduction.
Fig. 17.20  A dental air abrasion unit with an elongated shaft is used to
flush debris from diastema and periodontal pockets.

irritation. Careless or improper use of molar cutters and

chippers or incisor nippers can lead to tooth fracture or
Complications of dental corrective procedures extraction (Fig. 17.22). Overzealous grinding of teeth to
reduce elongations or even in forming bits seats and blunt-
Dental corrective procedures should not be attempted by ing canine crowns can cause complications, such as open
persons unfamiliar with the possible damage improper pulp chambers, tooth decay, or tooth loss (Fig. 17.23).
equipment and/or technique might cause. Simple tooth Reducing canine teeth to gum level can lead to tongue lolling
floating is not an innocuous procedure but can lead to iatro- in some performance horses. Only a licensed veterinarian
genic damage to the horse and its dentition. Coarse float should administer an intravenous sedative or analgesic to a
blades chip and break the coronal structures of the tooth and horse. Interarterial injections have resulted in severe convul-
open dentin tubules.17 Horses chewing on floats or dental sive reactions or death in some cases. Perivascular medica-
spools have been known to fracture or loosen teeth. Floats tion can cause jugular vein phlebitis or thrombosis, which
and other sharp instruments in the mouth can cause soft- can end the career of an elite equine athlete. Improperly
tissue damage that can lead to cellulitis and septicemia. restrained horses (whether sedated or unsedated) have been
Sharp root elevators and dose syringe tips can lacerate the known to injure themselves, the operators, and other persons
roof of the mouth and cause severe hemorrhage.70 Power in the work area. Iatrogenic jaw fracture has been seen fol-
tools must be grounded and have GFI plugs to prevent pos- lowing the use of a full-mouth speculum.
sible electric shock to the horse and/or operator. Disinfect- Post-dental-procedure pain is experienced by some horses,
ing agents used on equipment and for flushing the mouth, especially if aggressive crown reductions are performed with
must be prepared in the proper dilution to avoid caustic power equipment. Affected horses do not eat well for a few

274
 Corrective dental procedures

3) bit lesions. Recommended procedures are to float

teeth and round off the rostral corners of the second
premolars. Extract wolf teeth.
2–3 years. Examine: 1) upper and lower wolf teeth or
blind wolf teeth; 2) deciduous tooth eruption – central
incisors and premolars; 3) bit injuries at the corners of
the mouth and interdental spaces; and 4) points or
hooks on molars and premolars. Recommended
procedures are to float outside of upper and inside of
lower cheek teeth, remove caps, if present and ready for
removal, and extract wolf teeth. Rostral corners of upper
and lower second premolars should be rounded if the
horse wears a bit.
3–4 years. Examine 1) corners of the mouth and
Fig. 17.23  Iatrogenic pulp horn exposure of 106. This tooth had been
interdental space for bit injuries; 2) incisors for retained
reduced with a carbide burr in an attempt to create a ‘bit seat’. deciduous teeth or supernumerary teeth; 3) molars and
premolars for points and retained third premolars
(second cheek teeth); 4) size and shape of the lower jaw;
days to a few weeks after dentistry. Some veterinarians advo- and 5) for presence of blind wolf teeth. Recommended
cate giving prophylactic non-steroidal anti-inflammatory procedures are to remove caps if present, float teeth, and
medication to all dental patients to help prevent this remove wolf teeth.
problem.71 This painful condition has been blamed on tem- 4–5 years. Examine: 1) incisors for eruption; 2) canine
poromandibular joint pain, readjustment of the masticatory teeth for sharp edges or eruption delays; 3) molar arcade
muscles after speculum use, loose teeth post procedure, for proper eruption and alignment of fourth premolars;
leaving the mouth out of balance, thus overloading isolated 4) for presence of upper rostral and lower caudal cheek
teeth in occlusion, or exposed dental tubule pain.17,72 These teeth hooks from malocclusion; and 5) for presence of
problems are enumerated to emphasize the importance that points or sharp edges on cheek teeth. Recommended
only veterinarians and veterinary technicians (under the procedures are to remove deciduous teeth, if ready, grind
direct supervision of a veterinarian) should perform equine or rasp hooks, if present, float teeth, and remove mucosa
dental procedures. The potential for iatrogenic damage must over canines if gingival eruption cysts are present.
be kept foremost when performing equine dentistry. The 5 years and older. Examine: 1) mouth visually and
equine practitioner’s job as steward of the horse must be ‘to digitally, especially noting hooks and uneven wear;
do no harm.’ 2) canines for sharp edges and tartar; 3) oral cavity for
decay or gingivitis; 4) incisors for even wear; and 5)
evaluate lateral jaw excursion. Recommended procedures
Timetable for routine dental examinations
are to float teeth, remove hooks, correct abnormal wear
patterns, and level or shorten the incisors if indicated.
The following timetable is a good reference for scheduling
routine dental examinations and general maintenance.73 Educate owners and trainers of the need for routine dental
examinations. Indicated corrective procedures should be
Birth. Examine for: 1) congenital defects of the lips or
performed before starting any horse in training.
palate; 2) tongue motion and strength; 3) dental
malocclusions; and 4) body system abnormalities.
Recommended procedures are to provide genetic and Summary
orthodontic consultation and perform corrective surgery
if necessary. Look for other problem signs, such as A thorough visual and manual examination of the equine
underdeveloped carpal or tarsal bones, ruptured extensor patient must be performed to identify any abnormalities.
tendons, and hernias. Sedating the horse and using a full-mouth speculum facili-
6–8 months. Examine for: 1) incisor and premolar tate both the examination and corrective procedures. The use
occlusion (all incisors should have erupted); 2) missing of proper dental instruments makes it much easier for both
teeth; 3) sharp enamel points or hooks; and 4) ulcers on the patient and veterinarian. Dental elongations should be
the tongue and buccal mucosa. Recommended reduced in stages, taking care not to remove more than
procedures are to provide orthodontic consultation and 3–4 mm of occlusal surface at one time. A dental form
float teeth, if necessary. should be used to maintain a record of what procedures were
16–24 months. Examine for: 1) upper and lower wolf performed, what needs to be done in the future, and to
teeth eruption; 2) points and hooks on premolars; and itemize the charges.

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58. duToit N, Burden FA, Dixon PM. Clinical In: Handbook of specialized pathological Annual Meeting, New Orleans, 2003
dental examinations of 357 donkeys in anatomy of the horse. Verlag Paul Parey, 72. Johnson TJ. Iatrogenic damage caused by
the UK: part 1 – prevalence of dental Berlin, 1945, p. 146 modern dentistry procedures. In: Current
disorders. Equine Vet J 2008; 138 65. Carmalt JL. Understanding the equine Therapy in Equine Medicine, 6th edn.
59. DeLorey MS. A retrospective study of 204 diastema. Eq Vet Edu 2003; 3(1): 43 Robinson and Sprayberry, Saunders/
diagonal incisor malocclusion corrections 66. Mueller POE, Lowder MQ. Dental sepsis. Elsevier, St Louis, 2009, pp 324–327
in the horse. J Vet Dent 2007; 24: Vet Clinics North Am: Equine Practice 73. Easley KJ. Equine dental development
145–149 1998; 14(2): 349–363 and anatomy. Am Assoc Eq Pract
Proceedings 1996; (42): 1–10

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 Section 5:  Treatment

C H A P T ER  18 
Geriatric dentistry
Nicole du Toit† BVSc, MSc, PhD, MRCVS,
Bayard A. Rucker* DVM
†
Division of Veterinary Clinical Studies, University of Edinburgh, Easter Bush Veterinary Centre, Roslin,
Midlothian EH25 9RG, UK
*309 Overlook Drive, Lebanon, VA 24266, USA

Introduction and perform a complete physical examination. Older horses

may have concurrent disease of other body systems, espe-
Geriatric equine medicine is that part of medicine that relates cially gastrointestinal, musculoskeletal, and respiratory tract
to the prevention and treatment of diseases in aged horses. problems.6 Laboratory analyses, such as complete blood
The age at which an equid requires geriatric care varies counts and biochemistry functions, should be performed on
depending on the breed of the horse (or other equid), man- initial examination to rule out other concurrent medical or
agement practices and type of work. Horses have an increased metabolic conditions. The presence of large or non-healing
prevalence of dental disorders, and in particular of perio- cheek or tongue ulcers should alert practitioners to a possi-
dontal disease, after 15 years of age.1–3 A recent study has ble underlying disease, such as pituitary dysfunction.7 Pitui-
shown that many donkeys start to develop serious dental tary dysfunction should be considered in geriatric equids
related disorders at 16–20 years of age.4 Cheek teeth diastem- exhibiting any related clinical signs as 85 % of horses with
ata, wear abnormalities, overgrowths, displacements, loss of pituitary dysfunction have been shown to be >15 years of
teeth, and other dental disorders, such as periodontal disease, age.8 A dental survey in live donkeys demonstrated that older
wave mouth, step mouth, and smooth mouth have an donkeys are more likely to have dental disease, a low body
increasing prevalence in donkeys older than 20 years of age.4 condition score, and have a need for supplemental concen-
This emphasizes the need for additional preventative dental trate feeding.9 Furthermore, dental disease has been shown
treatment to equids aged 15 years and older, although such to be significantly associated with colic in donkeys.9,10
additional care is needed at an earlier age if the animal has
pre-existing dental disorders.
Clinical signs associated with dental disease vary with the
Anatomic overall tooth changes
severity of dental disease, and up to 24 % of horses that do
Equid teeth are tapered from the occlusal to apical aspect,
not show any dental related clinical signs, have one or more
and as the teeth progressively wear down and erupt, the
dental abnormalities.5 In milder cases, clinical signs may be
erupted (clinical) crown and occlusal surface become
limited to bitting problems or abnormal head carriage
gradually smaller on cross-section. The occlusal surface
during ridden exercise. With more advanced dental disease,
of incisors changes in shape in older equids, initially appear-
equids may display quidding, with boluses of partially
ing oval after eruption, then triangular and eventually
chewed forage found on the stable floor. With painful oral
becoming oval again with extreme age, as described in detail
lesions, equids may exhibit slow deliberate chewing and
in Chapter 7. The rostral orientation of the caudal cheek
make ‘slurping’ noises instead of the normal ‘crunching’
teeth and caudal orientation of the rostral cheek teeth
noises when masticating. Accumulation of forage boluses
compress each cheek teeth row tightly to work as a single
between the cheeks and cheek teeth may cause temporary
functional unit, even despite the initial narrowing of the
cheek swellings. The presence of long forage fibers and un-
reserve crown.11–14 However, eventually the tapering allows
masticated, undigested whole grain particles in the feces is
for the development of diastemata between the cheek teeth
also an indication of dental related problems. Eventually,
(‘senile diastemata’) with food impaction and development
in cases of severe dental disease, equids may have weight
of periodontal disease.13,15 Radiography of such a case is
loss associated with decreased food intake and inefficient
shown in Fig. 13.13.
digestion.
The loss of maxillary cheek tooth infundibular enamel
results in wearing out of the center of the tooth, leaving it
Intercurrent geriatric diseases with a thin, elevated peripheral enamel ridge (‘cupped out
tooth’). The exposure of all three dental tissues (enamel,
When presented with a geriatric equid requiring dental treat- dentin and cementum) is essential for efficient mastication
ment, it is important to acquire a detailed medical history in equids, as the differential wear rate results in prominent

279
 18 Treatment

A B

Fig. 18.1  Loss of the rostral infundibulum and ‘cupping’ of a 106 (A) and loss of peripheral enamel infolding in mandibular cheek teeth (B) in a 31-year-old
donkey. Note the occlusal pulpal exposures in all the cheek teeth.

diet with 14 % protein content fared better than those fed
an 8.5 % protein, textured, sweet feed mix.17 Therefore, the
feeding of a good-quality, pre-digested (addition of enzyme)
or extruded feedstuff with a protein content of 12–14 %
would be beneficial to older equids that do not have hepatic
or renal disease.18 If the maintenance of an adequate body
condition is a problem, the addition of a vegetable oil or
rice bran to the diet will increase the calorific content of the
diet, without increasing the level of concentrate feeding.18 If
the efficiency of mastication is greatly reduced as a result of
‘smooth mouth’ or other dental disorders, the feeding of
moistened pellets or cubes to a liquid consistency will
improve the amount of feed ingested. Commercially pre-
pared dehydrated chopped hay with 15 % crude protein,
which is available in the USA, is a suitable diet for many
geriatric equids. If availability or economic consideration
make this unsuitable, then fiber length may be reduced by
processing hay through a wood chipper, leaf mulcher or a
Fig. 18.2  End stage of ‘smooth mouth’ in a 28-year-old donkey with lawn mower using a bag attachment.
predominantly cemental root remnants of the cheek teeth remaining.  
Also note the loss of cheek teeth 410 and 411.
Sedation and restraint
enamel ridges and acts as a self-sharpening mechanism. As The presence of concurrent diseases, such as cardiac disease,
the teeth are worn to their more apical aspects, the peripheral arthritis, and muscle wasting, needs to be taken into consid-
enamel infolding in mandibular and maxillary cheek teeth eration when sedating and restraining geriatric equids for
becomes less pronounced, before finally wearing out at the dental treatment. In general, lower doses of anesthetic and
junction with the cemental roots (Fig. 18.1). This is charac- sedative agents are required in older horses, as they have
terized by a smooth occlusal surface composed predomi- increased sensitivity and decreased clearance of commonly
nantly of cementum and dentin termed ‘smooth mouth’.13 used agents.19 The type and likely duration of dental treat-
As these teeth no longer have enamel ridges, they are inef- ment need to be determined prior to commencement of any
fective at mastication, and as they have no wear resistance treatments to assist in choosing the appropriate restraint
from enamel, they are quickly worn away (Fig. 18.2). methods. If a painful procedure is to be performed, the use
In older equids, the decreased occlusal surface area and of local nerve blocks will decrease the amount of systemic
reduced length of enamel ridges of cheek teeth result in loss sedation and analgesia that is required.
of efficiency in grinding food. This is further complicated by Low dosages of alpha-2-adrenoceptor agonists, such as
the reduced ability to digest protein and fiber that is exhib- xylazine, romifidine hydrochloride or detomidine hydro-
ited in geriatric horses.16 It is, therefore, essential that geriat- chloride, in combination with low dosage of butorphanol
ric equids have their diet evaluated and adapted according tartrate for pain control, can be sufficient for most dental
to their dental and general health, and body condition. It procedures in geriatric equids. Although butorphanol has
has been shown that geriatric horses on a pelleted/extruded five times the analgesic activity of morphine, the analgesia

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 Geriatric dentistry

persists for only 15–20 minutes. Geriatric equids may be

very fractious to extraction of worn, loose teeth, but butor-
phanol administered just prior to extraction usually provides
sufficient analgesia. A continuous IV drip of detomidine or
detomidine/butorphanol20 may be used instead of repeated
dosing of these drugs. Use of a head support is recom-
mended during dental procedures, but it should be used
with stocks or after backing the horse into a corner to mini-
mize slumping of the forelimbs and over-extension of the
head, with possible atlanto-occipital subluxation.
Another option if significant dental treatment is required,
especially in a fractious patient, is the use of short general
anesthesia.21 The drawback to general anesthesia is the devel-
opment of long bone fractures during recovery if insufficient
assistance is available to help the horse rise. Protracted mal-
nutrition may produce osteoporosis and so increase the risk
of this sequel in older patients.
Heavily sedated geriatric horses, when left alone and
unstimulated following dental procedures, are more suscep-
tible to falling off their feet than younger horses. Judicious
use of tolazoline HCl (100–200 mg in a slow IV injection) Fig. 18.3  The typical ‘smile’ mouth appearance of the incisor occlusal
is indicated to partially reverse the effects of alpha-2- surface observed in most aged donkeys.
adrenoceptor agonists. If the sedation is insufficiently
reversed after 15 to 20 minutes, the tolazoline HCl admin-
istration may be repeated using half to one-third of the
initial dosage. occlusion and then pushing the mandible laterally until the
upper and lower cheek teeth arcades touch and (due to their
angulated occlusal surfaces) the incisors just begin to sepa-
Incisor disorders rate. The distance is measured from the center of the maxil-
The incisor arcades in older equids often have disorders, lary incisor arcade (interproximal space of 101 and 201) to
such as excessive wear, corresponding overgrowths in the the center of the mandibular incisors (interproximal space
opposite teeth, malocclusions, missing teeth, and displaced of 301 and 401). The EMC measurements are made on each
teeth. Excessive wear of an entire incisor arcarde, most com- side. When in centric occlusion, if the center points of the
monly the maxillary incisors, is usually as a result of a behav- incisor arcades do not align with each other, then the offset
ioral problem, such as crib-biting or wind-sucking. With loss distance is either added or subtracted from the center-to-
of teeth or excessive incisor wear, repeated regular floating center point measurement (Fig. 18.4).
of the opposing teeth is required to maintain a level occlusal The average EMC distance for a 450 Kg horse is 12.3 mm.22
surface. Excessive reduction of severely overgrown incisors This distance, coupled with the average maximum excursion
may expose pulp horns, and it is advisable to reduce over- distance of 45 mm ±5 mm,23 demonstrates that a normal
grown incisors, in stages some months apart, to stimulate equid’s masticatory cycle is about 22–25 % incisor occlusion
normal secondary dentin deposition to protect the occlusal and about 75–78 % cheek teeth occlusion. Horses with
aspect of the pulps. The tapering of incisors towards their heads shorter than average (Quarter horse length), have an
apical aspect results in the development of incisor diastem- average EMC distance less than 12.3 mm, while the EMC in
ata with the accumulation of food, in some older horses. longer headed horses is greater than 12.3. The mean EMC
Geriatric equid incisors often have abnormal occlusal sur- in miniature horses is about 4 mm, while the mean value in
faces, such as a ventral convex curvature (‘smile’), a dorsal a draught horse is about 16 mm. This difference in EMC in
convex curvature (‘frown’) or a diagonal (to left or right side) different sized heads is because the pivot point or vertex for
surface (‘slant mouth or slope mouth’). These changes are lateral excursion is the temporomandibular joint (TMJ).
often secondary to disorders of the cheek teeth and a result- Lines drawn from the TMJ to each of the center points
ant abnormal masticatory action. Once cheek teeth disorders diverge more the further they are from the TMJ and diverge
have been corrected, these incisor table abnormalities can be less the nearer they are to the TMJ.
corrected, in stages if severe. ‘Smile’ mouth appears to be Reducing EMC distances within a range of 12–16 mm
very common in donkeys and was present in 96 % of aged should be done carefully, with reduction of tall teeth per-
donkeys with dental disease and 99 % of donkeys without formed in 1-mm thick stages on tall incisors, before re-
dental disease4 (Fig. 18.3). Therefore, smile mouth may be assessing EMC. A 1-mm reduction in incisor height can
regarded as a normal appearance in aged donkeys and decrease the EMC by 4 mm or more. Experience indicates
should not be corrected unless inhibiting normal mastica- that total reduction should be limited to 3 mm in one
tory action. session or no more than a 10 mm change in the EMC.
Functional incisor/molar occlusion in the presence of Horses with incisor malocclusions having reasonably
abnormal incisor occlusal surfaces may be determined by normal or shorter than normal EMC distances do not need
measuring the excursion to molar contact (EMC) distances. incisor correction; they have functional incisor malocclu-
EMC is measured by putting the incisors arcades into centric sions (Fig. 18.5).

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 18 Treatment

403 303

Fig. 18.6  ‘Smile’ malocclusion. Correction is initiated on 303 and 403 by

removing 1 mm at the tallest point and tapering toward 301 and 401.  
(Black wedges). If reduction ceases before 101 and 201 are reduced, incisor
contact will be maintained on the 01s and possibly the 02s.

Correction of a ‘smile’ should begin on the mandibular

incisor arcade, removing 1-mm thick layers until the arcade
is level, or the reduction (3 mm) or EMC (10 mm) limits
Fig. 18.4  In this 20-year-old Saddle bred horse, the mandibular center
point is offset to the horse’s right by 10 mm (distance between the black are reached (Fig. 18.6). The lateral maxillary incisors are also
arrows). EMC to the right is 8 mm (18 mm minus the 10 mm offset; blue to reduced, if needed. ‘Frown’ correction reduction is begun on
adjacent black arrow) and to the left is 24 mm (14 mm plus the 10 mm the maxillary arcade then the mandibular arcade, if needed.
offset; red to adjacent black arrow). Measurement is made from the center Correction should always commence on the 03s (corner
of the maxillary incisors to the center of the mandibular incisors. incisors). If excursion or reduction limits are reached before
reduction of the 01s (central incisors) is needed, incisor
contact will be maintained on the 01s and possibly part or
all of the 02s (intermediates), depending on the severity of
the malocclusion.

Periodontal disease
The formation of senile diastemata in the incisors may lead
to food impaction and periodontal disease. However, as
these teeth are not exposed to any grinding masticatory
forces, these diastemata are very rarely associated with deep
periodontal pockets. These diastemata and associated
(usually) mild periodontal disease can be managed by
regular cleaning of the impacted food by the owner. In more
severe cases of food impaction, which may be difficult to
remove on the caudal aspect of the incisors, these diastemata
can be widened using a diastema burr or rotary saw. The
accumulation of calculus on the canines and 03s may also
cause mild, localized periodontitis, which does not appear
to cause any clinical signs (Fig. 18.7). Accumulation of large
amounts of calculus can result in more severe gingivitis, with
hyperemia and recession of the gingival margin. Removal of
the calculus at every dental examination/treatment tempo-
rarily relieves the associated periodontal disease. Frequent
Fig. 18.5  Horse in Fig. 18.4 after correction. 103 (not visible) was reduced brushing of the canines by the owners using a normal tooth
by 3 mm; this tooth was displaced caudally and was not interfering with brush may slow down re-accumulation of calculus.
cheek teeth occlusion but was making contact with 404. Teeth 402 and 403 More recently, a more severe form of incisor periodontal
were reduced 2.5 mm. EMC to left is now 14 mm and EMC to right has not disease has been recognized in geriatric equids that is associ-
changed. The incisors are not level but are now functional, and the horse
ated with cemental hyoplasia, and hyperplasia and radio-
can chew with more left cheek teeth occlusion.
graphic lytic changes.24–27 The exact etiopathogenesis of this
disease has not been determined, but pathological studies
show it to be an odontoclastic resorption of affected incisors
(also of canine teeth) with subsequent marked deposition

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 Geriatric dentistry

characterized by lysis of the incisors in an apical direction

and an increase in the thickness of the lytic areas to involve
the dentin. Loss of interdental bone and widening of
the periodontal ligament may also be observed on radio-
graphs. Clinically advanced cases may have painful mobile
incisors. Hypercementosis (subgingival nodular enlarge-
ments) of portions or all of the subgingival incisors may
also be observed on radiographs in some advanced cases
(Fig. 18.9).
Due to the predominance of resorptive lesions in this
condition, it has been proposed to be more similar to feline
tooth resorption than to a primary periodontal disease.24
Feline tooth resorption has been shown to start as focal
lesions at the cemento-enamel junction, indicating that local
factors appear to play a role in the etiopathogenesis.28 Feline
tooth resorption has an initial resorptive phase where there
is odontoclastic resorption of dentin and destruction of the
periodontal ligament and alveolar bone.29 This is followed
Fig. 18.7  Calculus accumulation on both mandibular canines and the 203s
in a 28-year-old donkey. There is mild gingival hyperemia associated with by cementum and bone deposition during the reparative
the calculus on 304. phase. Thus far, bone deposition and dento-alveolar anky-
losis, as described in feline tooth resorption, has not been
described in equids. Treatments with long-term antibiotics
and steroids have been unsuccessful and extraction of
affected incisors has been the only treatment to alleviate the
clinical signs associated with this disease.

Canine teeth disorders

The most common abnormality observed in canine teeth is,
as noted, the accumulation of calculus, which may cause
mild local periodontal disease. This calculus is easily removed
with the use of forceps. Excessive calculus accumulation on
the mandibular canines has also been associated with cor-
responding tongue ulcers. Rarely, canine teeth may be dis-
placed or enlarged and interfere with the bit. Canine teeth
have very long, well embedded reserve crowns, and extrac-
tion of these teeth should not be performed without prior
radiography. The canine teeth are often floated, purportedly
to prevent bitting problems or injuries to operators’ hands
and arms during dental procedures. Extreme floating or even
cutting of these canine teeth may expose the pulp cavity and
result in apical infections. Enlargement of the clinical crown,
Fig. 18.8  Enlargement of thickness of reserve crown of 203 and 303 exposure of the alveolar bone or reserve crown, and the pres-
(identical to 103 and 403) due to hypercementosis associated with equine ence of pain if the canine is palpated, percussed or subjected
odontoclastic tooth resorption and hypercementosis. The horse was to a cold substance (piece of ice), are all indications for
asymptomatic, and the disease was identified on oral examination. All the
radiographic evaluation of the canine.
incisors were stable and non-painful to manipulation, but firm palpation of
303 and 403 reserve crowns was painful.
Cheek teeth disorders
Dental abnormalities of wear encountered in geriatric equids
of cement on these teeth, termed equine odontoclastic tooth are the same abnormalities that are recognized in younger
resorption and hypercementosis (EOTRH; discussed in Ch. equids, but they have reached an advanced stage over a
10). Affected animals may present with clinical signs associ- prolonged period of time. These disorders, e.g., shear mouth,
ated with pain, such as masticatory and bitting problems, wave mouth, and focally overgrown teeth, are often compli-
and halitosis (Fig. 18.8). Initially, this condition presents as cated by the lack of reserve crown and hence, instability of
mild gingival inflammation and edema with small lytic teeth within the alveolus, which results in displacement and
changes in the mid reserve crown incisor on radiographic eventually loss of teeth (Fig. 18.10).
examination.25 With progression of the condition, draining A post-mortem survey of dental disease in geriatric donkeys
tracts may develop in the gingiva, and this may be accom- (estimated median age 31 years) showed a very high preva-
panied by gingival recession, or marked subgingival swelling lence (93 %) of dental disease; with diastemata (85 %),
of incisors, reflecting hypercementosis of their reserve crown missing (56 %), displaced (43 %) and worn teeth (34 %)
and apex. Radiographically, progression of the disease is being the most common dental disorders present30

283
 18 Treatment

Fig. 18.9  This 20-year-old Thoroughbred was

reported to refuse to bite carrots for over one
year. Enlargement of all incisor reserve crowns is
prominent with gingival recession, and draining
tracts visible (at arrows). Radiographs showed
extensive lysis and hypercementosis of 103 and
203, typical of equine odontoclastic tooth
resorption and hypercementosis, with
radiographic changes in all the other incisors.

Fig. 18.10  Loss of maxillary cheek teeth 208, 209, and 210 is due to loss of Fig. 18.11  Severe bilateral lateral displacement of the 310 and 410 is
reserve crown in this geriatric donkey. Also note the large, open diastema present in this 38-year-old donkey. There is also moderate lateral
between 107 and 108 and the loss of infundibular enamel in 108, indicating displacement of the 407.
the presence of a high degree of wear in these teeth and the beginning of
‘smooth mouth’.

oral comfort. Sharp enamel overgrowths should be floated

(Fig. 18.11). Studies in horses have also shown an increased to prevent soft tissue trauma to the cheeks (maxillary cheek
prevalence of dental disease in older age groups.1,2,31–33 A teeth) or tongue (mandibular cheek teeth). Cheek teeth
comparison of clinical dental disorders in different age diastemata are often a result of tapering reserve crowns and
groups of donkeys (age range 2–53) showed a significant loss of angulation of the rostral and caudal cheek teeth
increase in the prevalence of dental disease in donkeys over (‘senile diastemata’), and, therefore, the cause of these
20 years of age (≥88 % prevalence) compared to donkeys diastemata cannot be eliminated (Fig. 18.12). As diastemata
younger than 20 years (≤64 %).4 More specifically, a signifi- often involve the caudal cheek teeth,30,34 it is essential that a
cant increase in the prevalence of diastemata, missing teeth, dental mirror and good light source are used to evaluate
overgrown teeth, worn teeth, displaced teeth, and periodon- these. Impacted food should be flushed out, and the severity
tal disease with increasing age has been shown, in particular of associated periodontal disease determined. Very often, the
in donkeys over 20 years of age.4 As expected, the prevalence only treatment for diastemata is to reduce the opposing
of enamel points decreased significantly with age, to a preva- cheek teeth occlusal surface by 2–3 mm to decrease the
lence of less than 20 % in donkeys older than 20 years, impaction of food into the diastema, particularly if there are
as compared to >40 % prevalence in donkeys under 20 years focal transverse overgrowths secondary to the diastemata.34
of age.4 Some clinicians advise filling the base of cleaned diastemata
Treatments of cheek teeth disorders in geriatric equids are with dental impression material (as later described), but no
often limited by the lack of reserve crown. Dental treatment objective studies are available on its efficacy in treating any
should be aimed at preserving as much of the functional type of periodontal disease in the horse. Following removal
occlusal surface for mastication as possible, while ensuring of cheek teeth overgrowths, mild-to-moderate periodontal

284
 Geriatric dentistry

Fig. 18.14  Calculus accumulation on the buccal aspect of 207 and 208 in a
geriatric (33-year-old) donkey. There is also a diastema with food impaction
and periodontal pocketing between 208 and 209, and displacements of 209
and 210 (arrow).

Fig. 18.12  Multiple senile diastemata of both mandibular cheek teeth rows
in a donkey of 27 years. Some of these diastemata have adjacent severe
periodontitis and deep periodontal pockets (arrow).

Fig. 18.13  Slight wave mouth with overgrowths of 410 and 411 and Fig. 18.15  Severely overgrown maxillary cheek tooth resulting in’step
moderate peripheral caries. Diastemata are present in all the interdental mouth’. This overgrown tooth needs to be reduced in stages to prevent
spaces in this cheek teeth row, but the diastema between 408/409 has potential pulpal exposure. Also note the associated periodontal disease and
severe periodontal disease and food pocketing associated with it. gingival recession.

disease may be arrested or its progression slowed by oral where the accumulation of calculus is an important cause of
rinsing with diluted chlorhexidine gluconate (5 ml of 2 % periodontal disease,37 cheek teeth calculus is less common
chlorhexidine added to one liter of water). The owner should in equids and is not a major cause of periodontal disease.
rinse the mouth out once a day for 10 days, then twice Cheek teeth calculus accumulation has been observed in
weekly. Some horses object to the taste of chlorhexidine and 19 % of geriatric donkeys at post mortem, predominantly on
may become briefly anorectic. If this occurs, a flavored the maxillary 07, 08, and 09 cheek teeth30 (Fig. 18.14).
0.12 % chlorhexidine (or human mouthwash) can be used Cheek teeth calculus often accumulates secondary to food
as a rinse, 50 to 100 ml per rinse. The mouth should be stagnation in equids that have painful dental disease and
rinsed with lukewarm water to remove food particles prior subsequent decreased normal masticatory movements.
to the chlorhexidine rinsing. These teeth are beside the salivary duct opening that possibly
Periodontal disease is an important disease in geriatric provides much of the mineral component for calculus.
equids and has been shown to occur in 80 % of horses over Excessive cheek teeth overgrowths resulting in ‘step mouth’
20 years of age2 (Fig. 18.13). If the periodontal disease is should be reduced as much as possible (Fig. 18.15). If over-
severe and associated with periodontal pockets, the applica- growths are more than a few mm high, the initial reduction
tion of an antibiotic oral gel (Doxirobe [doxycycline] Gel, should be done in stages (e.g., 3 mm at a time) at 2–3-
Pfizer Animal Health) with impression material may allow month intervals to prevent potential pulp horn exposure. As
temporary alleviation of the inflammation and allow healing these overgrowths are secondary to missing, displaced, or
of the periodontal pocket.35,36 In contrast to small animals ‘cupped out’ teeth in the opposing cheek teeth row,

285
 18 Treatment

A B

Fig. 18.16  Corresponding maxillary (A) and mandibular (B) cheek teeth rows that illustrate severely overgrown maxillary cheek teeth secondary to worn and
missing mandibular cheek teeth, with mandibular soft tissue trauma. There are also multiple maxillary cheek teeth diastemata with food impaction. Note the
presence of the rudimentary 205 (first premolar, wolf tooth).

treatment needs to be repeated at regular intervals, to prevent

re-development of these overgrowths to an extent that they
are interfering with masticatory movements or causing soft
tissue damage. These overgrowths do not have to be fully
reduced (Fig. 18.16). Severely displaced teeth should be
extracted if they are protruding into the cheeks or tongue
and causing chronic ulceration and pain. Mild to moderately
displaced teeth with focal overgrowths on the displaced and
opposing teeth due to the malocclusion can be managed by
reducing the overgrowths if the teeth are not digitally loose.
Overgrown, slightly loose teeth may re-attach firmly if over-
growths are removed. However, if teeth are very loose or
have marked periodontal disease and diastemata, extraction
is the most appropriate treatment. Oral extraction of dis-
placed teeth, particularly if still well embedded in the alveo- Fig. 18.17  ‘Wave mouth’ in a right mandibular cheek teeth row with a
lus, may be complicated by the limited space between the medially displaced 408 and 406, an overgrown 410, and worn 411. A large
diastema between 407 and 408 with periodontal disease and gingival
cheek and tooth and the inability to satisfactorily apply
recession is also present, as is moderate peripheral caries of the 406 and
molar extractors. Therefore, careful consideration must be 407, most likely secondary to food stagnation due to abnormal masticatory
given to the potential duration of the procedure and the action.
required sedation to a debilitated geriatric equid.
Wave mouth is believed to develop as a result of the oldest
teeth in the mouth (09s) wearing and becoming ‘cupped
out’ prior to younger adjacent teeth, thus causing uneven
wear in a cheek teeth row (Fig. 18.17).38 Treatment of wave Other abnormalities of wear may result in further maloc-
mouth consists of floating excessively overgrown teeth to clusions, with geriatric equids usually presented with multi-
theoretically create a straight (or slightly concave) occlusal ple dental disorders. Prolonged overgrowths of the 106, 206,
surface in the cheek teeth rows in a rostrocaudal direction, 311 and 411 may result in restricted rostrocaudal movement
in mild cases. However, in the usually more severe cases of and contribute to more pronounced generalized cheek teeth
wave mouth, only the area of maximal overgrowth can be overgrowths.
reduced without removal of very significant amounts of the Ultimately, most geriatric equids with dental disease need
reserve crown. The aim is to create maximal occlusal contact to have regular (6-monthly or annually) dental examina-
surface area and allow for the normal range of mandibular tions and treatment as appropriate on welfare grounds to
jaw movement for efficient mastication. The cheek teeth row ensure oral comfort and masticatory efficiency. It is highly
must not be floated to the height of worn teeth, but rather likely that those with significant dental wear or disease will
the overgrowth on the opposing tooth should be floated. require supplemental feeding to maintain a suitable body
When reducing overgrown cheek teeth, it is important to weight, and this is particularly so in the colder months when
remember the normal occlusal angle of mandibular (18– green forage is not available. Owners need to be educated
31°) and maxillary (12–9°) cheek teeth in a lingual-buccal on the long-term management of geriatric equids, with par-
and buccal-palatal direction, respectively.39 ticular emphasis on the formulation of an appropriate diet.

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 Geriatric dentistry

References
1. Baker GJ. Some aspects of equine dental Annual Convention 2002; 421–437 Equine odondoclastic tooth resorption
disease. Equine Vet J 1970; 2: 105–110 14. Dixon PM, Dacre I. A review of equine and hypercementosis. The Veterinary
2. Wafa NS. A study of dental disease in the dental disorders. Equine Vet Educ 2005; Journal 2008; 178: 372–379
horse. MVM Thesis, University College 169: 165–187 28. DeLaurier A, Boyde A, Horton MA,
Dublin, Dublin, 1988 15. Dixon PM, Tremaine WH, Pickles K, et al. Price S. A scanning electron microscopy
3. Kirkland KD, Marretta SM, Inoue OJ, Equine dental disease part 2: a long-term study of idiopathic external tooth
Baker GJ. Survey of equine dental disease study of 400 cases: disorders of resorption in the cat. Journal of
and associated oral pathology. development and eruption and variations Periodontology 2005; 76: 1106–1112
Proceedings of the 40th American in position of the cheek teeth. 29. Gorrel C. Feline odontoclastic resorptive
Association of Equine Practitioners Equine Vet J 1999; 31: 519–528 lesions. In: World Small Animal
Annual Convention 1994; 40: 119–120 16. Ralston SL, Squires EL, Nockels CF. Veterinary Association 23rd World
4. du Toit, N, Burden FA, Dixon, PM. Digestion in the aged horse. Equine Congress Proceedings, Bangkok,
Clinical dental examinations of 357 Veterinary Science 1989; 9: 203–295 Thailand, 2003
donkeys in the UK: Part 1 – Prevalence of 17. Ralston SL, Breuer LH. Field evaluation of 30. du Toit N, Gallagher J, Burden FA, Dixon
dental disorders. Equine Vet J 2009; a feed formulated for geriatric horses. PM. Post mortem survey of dental
41(4): 390–394(5) Equine Veterinary Science 1996; 16: disorders in 349 donkeys from an aged
5. Uhlinger C. Survey of selected dental 334–338 population (2005–2006). Part 1:
abnormalities in 233 horses. Proceedings 18. Pugh DG. Feeding the geriatric horse. In: prevalence of specific dental disorders.
of the 33rd American Association of Proceedings of the 53th American Equine Vet J 2008; 40: 204–208
Equine Practitioners Annual Convention Association of Equine Practitioners 31. Honma K, Yamakawa M, Yamauchi S,
1987; 33: 577–583 Annual Convention, Orlando, Florida, Hosoya S. Statistical study on the
6. Brosnahan MM, Paradis MR. 2007, pp 193–195 occurrence of dental caries of domestic
Demographic and clinical characteristics 19. Donaldson LL. Anesthetic considerations animal: I. Horse. Japanese Journal of
of geriatric horses: 467 cases (1989– for the geriatric equine. In: Bertone JJ, Veterinary Research 1962; 10: 31–36
1999). Journal of American Veterinary eds. Equine geriatric medicine and 32. Miles AEW, Grigson C. Coyler’s variations
Medical Association 2003; 223: 93–98 surgery. Elsevier, St Louis, 2006, and diseases of the teeth of animals,
7. Hillyer MH, Taylor FRG, Mair TS, et al. pp 25–37 Cambridge University Press, Cambridge,
Diagnosis of hyperadrenocorticism in the 20. Goodrich LR, Clark-Price S, Ludders J. 1990, p. 672
horse. Equine Veterinary Education 1992; How to attain effective and consistent 33. Uhlinger C. Common abnormalities of
18: 131–134 sedation for standing procedures in the premolars and molars. Proceedings of
8. Dybdal N. Pituitary pars intermedia the horse using constant rate infusion, the 37th American Association of Equine
dysfunction (equine Cushing’s-like In: Proceedings of the 50th American Practitioners Annual Convention 1991;
disease). In: Robinson NE, ed. Current Association of Equine Practitioners 37: 123–128
therapy in equine medicine. WB Annual Convention, 2004, 34. Dixon PM, Barakzai S, Collins N,Yates J.
Saunders, Philadelphia, 1997, pp 229–232 Treatment of equine cheek teeth by
pp 499–501 21. Carmalt JL. Safety, restraint, and oral mechanical widening of diastemata in 60
9. du Toit N, Burden FA, Dixon PM. Clinical examination of the horse. In: AAEP horses (2000–2006). Equine Vet J 2008;
dental examinations of 357 donkeys in Dental focus meeting, Indianapolis, 40: 22–28
the UK: Part 2 – Epidemiological studies Indiana, 2006 35. Green SK, Basile T. Recognition and
on possible relationship between 22. Rucker BA. Utilising cheek teeth angle of treatment of equine periodontal disease.
different dental disorders, and between occlusion to determine length of incisor Proceedings of the 48th American
dental disease and systemic disorders, shortening. Proceedings of the 48th Association of Equine Practitioners
2009; 41: 395–400 American Association of Equine Annual Convention 2002; 48: 463–466
10. du Toit N, Gallagher J, Burden FA, Dixon Practitioners Annual Convention, 2002, 36. Klugh DO. Equine periodontal disease.
PM. Post mortem survey of dental pp 448–452 Clinical Techniques in Equine Practice
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population (2005–2006): Part 2 – digestibility in horses. B Sc dissertation. 37. Wiggs RB, Lobprise HB. Periodontology.
Epidemiological studies. Equine Vet J Monash University, Victoria, 1994 In: Wiggs RB, Lobprise HB, eds.
2008; 40: 209–213 24. Gregory RC, Fehr J, Bryant J. Chronic Veterinary dentistry: Principles & practice,
11. Dixon PM, Copeland AN. The incisor periodontal disease with cemental Lippincott-Raven Publishers,
radiological appearance of mandibular hyperplasia and hypoplasia in horses. In: Philadelphia, 1997, pp 186–231
cheek teeth in ponies of different ages. AAEP Dental focus meeting, Indianapolis, 38. Leue, G. Zähne. In: Dobberstein J,
Equine Veterinary Education 1993; 5: Indiana, 2006 Pallaske G, Stunzi H, eds. Handbuch der
317–323 25. Baratt RM. Equine resorptive lesions. In: speziellen pathologischen anatomie der
12. Misk NA, Seilem SM. Radiographic Conference proceedings of the 21st haustiere, 3rd edn. Verlag Paul Parey,
studies on the development of cheek Annual Veterinary Dental Forum, Berlin, 1941
teeth in donkeys. Equine Practice 1999; Minneapolis, 2007, pp 123–130 39. Brown S, Arkins S, Shaw DJ, Dixon PM.
19: 27–37 26. Caldwell LA. Clinical features of chronic The occlusal angles of cheek teeth in
13. Dixon PM. The gross, histological, and disease of the anterior dentition in normal horses and horses with dental
ultrastructural anatomy of equine teeth horses. In: Conference proceedings of the disease. Veterinary Record 2008; 162:
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Association of Equine Practitioners 27. Stazyk C, Bienert A, Kreutzer R, et al.

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 Section 5:  Treatment

C H A P T ER  19 
Basic equine orthodontics and
maxillofacial surgery
Jack Easley† DVM, MS, Diplomate ABVP (Equine),
James Schumacher* DVM, MS, MRCVS, Dipl ACVS
†
Equine Veterinary Practice, LLC, Shelbyville, KY 40066, USA
*Department of Large Animal Clinical Sciences, College of Veterinary Medicine, University of Tennessee, Knoxville,
TN 77901-1071, USA

Basic equine orthodontics characteristics. A basic understanding of the growth of the

upper and lower portions of the head is important in the
diagnosis and treatment for many types of malocclusions7
Introduction (see Ch. 5).
The prevention of and treatment for dental malocclusions is Bone is plastic, and its form and capacity for growth are
the field of dentistry known as orthodontics. Orthodontics, affected and modified by environmental forces and factors.
in its most basic form, is the controlled movement of teeth A branch of orthodontic treatment, first referred to as bio-
through alveolar bone. The purpose of equine orthodontics mechanical orthodontics, has developed over the past
is to correct or prevent irregularities and malocclusions of century. Applying the theories of bone plasticity traced back
the teeth and/or jaws through equilibration of dental crowns, to Fouz and Wolff, several techniques have been used to
application of dental appliances, exodontia, and/or surgery. correct dentofacial deformities and malocclusions in the
The orthodontic principles of tooth movement are at work horse using the principles of functional orthodontics.8
on horses that develop abnormal wear patterns on exposed A more descriptive term, functional jaw orthopedics, was
dental crowns. Dental elongations place stresses on the popularized by Karl Haupl, who refined the concepts and
tooth that can result in abnormal movement. The general techniques used today in this branch of human dentistry.9
laws of biomechanics apply to movement of teeth. Alveolar Pressure, whether functional or artificially created, affects
bone is reabsorbed when the root and reserve crown main- bone growth. Cellular growth of bone is constant, occurring
tain compressive force on the periodontal ligament. New in the young horse from an increase in size and change in
alveolar bone is deposited when stretching forces act on form or in the adult from the replacement of dead cells.
bone. However, these laws are subject to numerous varia- Bone metabolism remains constant whether forces acting on
tions and exceptions when factors such as magnitude, direc- the bone are normal or abnormal in direction or amount,
tion, and duration of force are introduced.1 Dental cementum but bone grows in the direction of least resistance. Forces of
has the inherent tendency to resorb when pressure is applied occlusion, when acting incorrectly, therefore, become factors
to it but to a lesser degree than bone. Dental floating and of malocclusion.
equilibration are forms of orthodontic correction used in an Functional orthodontics is the use of appliances, devices,
attempt to reduce abnormal forces placed on teeth and thus or techniques to modify the forces placed on the jaws of
improve occlusion. The application of orthodontic wire, young, growing animals to encourage growth in a way that
springs, coils, arch bars, bands, brackets, incline planes, and corrects or at least limits the extent of malocclusion when
elastics has been used in correcting common malocclusion the animal reaches adulthood. Reduction of hooks and elon-
problems of horses (Fig. 19.1).2–5 gated teeth that interfere with normal jaw growth is the
Extracting deciduous teeth to guide the eruption of the simplest application of functional orthodontics in horses.
permanent teeth into a favorable occlusion has been referred Both fixed and removable appliances have been used
to as preventative or interceptive orthodontics.6 Interceptive in foals, with mixed results, in an attempt to modify jaw
orthodontics, when wisely and judiciously applied to well- growth and the spatial relationship between the dental
selected cases, can prevent dental malocclusions that cause arches (Figs 19.3 & 19.4).
functional problems with dental wear throughout the horse’s Surgical correction of dental malocclusion and dentofacial
life (Fig. 19.2). deformities in the horse has had limited application. The
Many dental malocclusions involve an abnormal skeletal most severe types of deformities, such as wry nose, have
relationship between the upper and lower jaws. General been corrected successfully in a small number of horses
form and capacity for growth of bone are inherited by following the principles of orthognathic surgery.10–13

289
 19 Treatment

A B C

Fig. 19.1  (A) Orthodontic spring device used to spread 307 and 309 to allow room for an impacted 308 to erupt. (B) Intra-oral mirror used to visualize the
orthodontic spring in the 308 position. (C) Lateral radiograph of impacted 308 with orthodontic spring in the dental space. (Courtesy of B.W. Fletcher DVM.)

Fig. 19.2  Crowded lower incisor arch with retained deciduous teeth 701
and 801, causing displacement (labiocclusion) of permanent teeth 301 and
401. Following the principles of interceptive orthodontics, the deciduous
teeth were removed, and the exposed mesial crown portions of 702 and
802 were filed, widening the space for 301 and 401 to migrate forward.

Fig. 19.4  Removable functional orthodontic mouthpiece on a 10-month-

old gelding. This device incorporated a metal incline plane and a restrictive
band labial to the upper incisors. This type of device works well, but owner
compliance with long term care, is a problem.

Osteodistration surgical techniques have been employed to

correct both wry nose and parrot mouth.14
Malocclusion can be categorized according to three etio-
logical types:
1. congenital or genetic malocclusion
2. eruptive malocclusion
3. traumatic malocclusion.
Most horses with reasonable dentofacial alignment and
occlusion and normal jaw function, should be considered to
have normal occlusion. Although a very small abnormality
Fig. 19.3  Removable functional orthodontic device in the mouth of a
5-month-old foal with a parrot-mouth deformity. This device is used to
in occlusal contact can affect dental wear, its impact on func-
improve the dental alignment and encourage growth of the lower jaw.   tion cannot always be predicted by its morphology. Under-
The device must be worn 16 hours daily and requires intensive nutritional standing the concepts of normal occlusion is fundamental
management and husbandry of the foal for a successful outcome. to orthodontic diagnosis. (See Ch. 6, Dental physiology.)

290
 Basic equine orthodontics and maxillofacial surgery

The equine veterinary literature has given little attention Perturbation of growth of the jaw can be induced by trauma
to any type of dental malocclusion with the exception of to the soft tissues.27 In response to the disturbance of optimal
parrot mouth. Although parrot mouth is probably the most occlusal relationships, growth of the jaw can be modified by
common malocclusion of the incisors, many other types of a new functional environment. To modify inherited growth
dental malocclusions of the horse are more commonly of the jaw of human beings, the functional disturbance must
encountered. Many types of malocclusion occur in horses.15 be of sufficient magnitude and duration (e.g., more than 6
Colyer (1935) and Joest (1970) described many variations hours per day for thumb-sucking by children).9 Deviation of
seen in equine teeth that lead to various types of dental the mandible to one side causing dental malocclusion is
malocclusion.16,17 Hypsodont teeth that are not properly common in tethered pigs and is probably due to the pig
aligned in the dental arcade suffer from severe abnormalities pulling on its tether in one direction to reach food and
of wear. Abnormal wear has been shown to be the leading water35 (Fig. 19.5).
cause of dental disease and to adversely affect proper Epidemiological studies are needed to establish breed or
mastication.18 family predisposition to malocclusion. The classification
Surveys of equine dental patients have shown a high per- system of malocclusion (i.e., modified angle) presently
centage of horses with significant dental malocclusions.15,19–22 being used in human and small animal dentistry is not well
Many of these malocclusions were severe enough to cause adapted for use in the horse.6,36,37 Such a classification system
clinical problems, and a certain percentage of affected horses of malocclusion does not exist for horses even though we
were classified as having a handicapping unsoundness.15 use the MAL Class 1–3 system adapted by the AVDC.38 A
Treatment of horses with a dental malocclusion has been well-designed system and its standardized use by a broad
aimed at correcting dental overgrowth and managing peri- base of well-informed observers would be helpful in acquir-
odontal disease.18,21,23,24 Orthodontic techniques have been ing meaningful information about the effect of treatment in
introduced by equine practitioners to correct some of the horses suffering from dental malocclusion. Additionally,
more severe dental malocclusions.25,26 Dentofacial deformi- cephalometric measurements and studies of jaw interrela-
ties, such as wry nose, parrot mouth, and monkey mouth, tion during craniofacial growth in the horse are essential for
involve both the dental complex and the facial skeleton. orthodontic therapy of horses to progress.
The genetic and functional environment work closely to
determine the growth of all bones.27,28 The genetic factors Sequelae of malocclusion
that are at play and the veterinary literature pertaining to
craniofacial deformity in domestic animals have been Malocclusion of the continually erupting and wearing hyp-
reviewed.29 The intrauterine environment has a known effect sodont teeth of horses leads to abnormal wear patterns of
on facial growth and development. Intrauterine molding the exposed dental crowns. Mechanical forces placed on
occurs when growth of the fetus is greater than that of the teeth that are wearing abnormally can cause teeth to move
uterus, causing pressure from the uterus to distort the devel- within their alveolus. The teeth may tip, rotate, or shift,
oping face. Intrauterine molding has been documented to depending on the angle of force applied, leading to forma-
occur in human beings and may be the cause of some facial tion of diastemata (i.e., periodontal pocketing), the leading
and skeletal limb deformities seen in foals.30,31 Postnatal cause of periodontal disease.39,40 Most malocclusions cause
environmental factors affecting morphology include all non- teeth to wear in such a fashion that abnormal forces are
genetic influences brought to bear on the developing indi- applied to the teeth and jaws, exacerbating malocclusion.
vidual. These include the environmental effects of muscle These abnormally worn teeth alter the masticatory pattern
function and neuromuscular adaptation.32,33 Force placed on of some horses. They can also lead to secondary abnormali-
the teeth and jaws of the growing horse from abnormal wear ties of wear, such as alteration of the angle of the molar
of the exposed dental crowns is another factor to consider. tables and inadequate wear of the buccal edges of the upper
The scientific basis of environmental causes of malocclu- arcades and lingual edges of the lower arcades. The most
sion rests primarily on findings of experiments performed severe form of this type of altered wear pattern is referred to
on animals.27 Under certain experimental conditions, growth as shear mouth.
can be extensively stimulated or stunted. The duration of
pressure has a greater effect on growth than does the mag- Examples of altered wear causing
nitude. Environmental factors that are recognized as leading
to dentofacial abnormalities include:
tooth movement
Long enamel points and exaggerated transverse ridges may
• habits of long duration, such as sucking
form due to malalignment of the upper and lower jaws.
• posture of the head, mandible, tongue, and lip because
Exaggerated transverse ridges wedge between the teeth in the
posture determines the resting pressure on soft-tissue
opposite arcade, forcing the teeth apart to create diastemata
• eruption of the tooth and wear of the crown into which food becomes packed. Misplaced teeth develop
• trauma, either osseous, soft tissue, articular, or dental. abnormal wear of their occlusal surface with the unopposed
The current theory for explaining growth of the craniofacial portion of the crown becoming protuberant and developing
bones states that growth of the face occurs in response to an excessive angle. Mechanical forces placed on the protu-
functional needs and is mediated by the soft tissue in which berant crown force the tooth further out of alignment and
the jaw is embedded.34 That is, the soft tissues grow, and can cause tipping or increased malalignment of the crown,
both the bone and cartilage follow this growth. which leads to periodontal packing of feed around the dis-
Function plays an important role in normal growth of the placed crown. The tooth in the opposing arcade does not
jaw and is closely related to inherited patterns of growth. wear normally and may become protuberant or develop

291
 19 Treatment

Fig. 19.6  Prominent hooks on 106 and 206 due to malocclusion of the
upper and lower dental arcades. The rostral pressure placed on the 106 has
moved it forward causing a space or diastema between 106 and 107
(arrow). This condition can lead to severe periodontal disease and eventual
tooth loss.

excessive enamel points or ridges that mirror the defect in

the opposite arcade.
A missing or displaced tooth in one dental arcade leads to
abnormal wear of the opposing teeth. The mesial and distal
teeth in the same arcade tend to drift into the space that is
unoccupied. This abnormal interproximal drifting can open
spaces between adjacent teeth in the same dental arch,
leading to formation of diastemata and periodontal pocket-
ing between teeth and inspiring sequential drifting.41,42 This
B is not a consistent feature, and sometimes all the teeth in
the dental arch move simultaneously to close the gap. This
closure shortens the dental arcade and predisposes dentition
to abnormal patterns of wear (e.g., hooks) on the ends of
the opposite arcade. Some drifted teeth become angled
medially or laterally so that the side of the crown develops
occlusal wear. These angled teeth can have a smooth occlusal
surface and excessive attrition of the crown, often associated
with a step or wave in the opposing arcade.
Formation of a hook on the rostral aspect of the first cheek
tooth (Triadan 06) or caudal aspect of the last cheek tooth
(Triadan 11) places force on the crown of the tooth with
the protuberance, forcing that tooth away from the rest of
the arcade, resulting in a diastema. Packing of feed into the
diastema leads to periodontal disease, which if left uncon-
trolled, may lead to formation of an abscess, loosening of
the tooth, and eventually expulsion of the tooth (Fig. 19.6).
C A rostral or caudal hook can also result in mechanical forces
applied to the jaw that affect growth, mastication, shedding
Fig. 19.5  (A) Foal developed unilateral hypoglossal nerve paralysis 24 hours of deciduous teeth, head carriage, and function of the tem-
after birth. The tongue can be seen protruding out of the left side of the poromandibular joint. As the protuberant portion of the
mouth. (B) Same foal at 5 months of age. The tongue protrudes from the crown at the end of the dental arcade becomes more promi-
left side of the mouth except when it is stimulated. (C) The incisor teeth no nent, it tends to limit rostrocaudal motion of the jaw and
longer meet on the left side due to ventral deviation of the rostral mandible
place mechanical forces on both the upper and lower jaws.
from constant tongue pressure. This foal regained full function of the
tongue by 10 months of age, but retained a diagonal incisor arcade. A hook on the first upper or lower cheek tooth of the growing
foal works mechanically to restrict the growth of the shorter
jaw. In the adolescent horse with mixed dentition, mechani-
cal forces placed on the jaws and teeth from hooks inhibit
growth of the shorter jaw and compress the crowns of the

292
 Basic equine orthodontics and maxillofacial surgery

deciduous teeth, limiting the space for the deciduous teeth Parrot mouth
to shed and predisposing erupting permanent teeth to
impaction. In the adult horse, hook formation can lead to An overjet of the incisor teeth is seen in most mammals,
several pathological processes depending on the size, shape including man. This condition is abnormal in the horse and
and position of the hook and the demands for performance commonly referred to as parrot mouth, brachygnathism,
placed on the horse. overshot maxilla, or buck tooth, but officially is classified as
The position of the jaw changes slightly as the horse moves a type 2 malocclusion (MAL2). When this malocclusion is
its head up and down. With the head elevated, the lower jaw slight, the labial aspect of the lower incisors rests on the
retracts caudally in relation to the upper jaw. This can be lingual aspect of the uppers. When the condition is more
demonstrated by elevating the head high in the air and severe, the incisors are completely out of occlusion, and the
noticing the occlusion of the incisor teeth. The cheek tooth premaxillae tend to be deviated downward causing the lower
arcades also shift with head position. Some clinicians specu- incisors to rest on the hard palate caudal to the upper inci-
late that this positional shifting is the reason that horses that sors. The parrot mouth syndrome in horses can involve the
eat from an elevated hay rack or net have a higher incidence incisor portion of the dentition alone, or it can occur in
of hooks on the rostral aspect of the 06s than do horses that combination with varying degrees of malocclusion of the
eat in the normal position off the ground. upper and lower cheek teeth. The mismatch in length of the
As a horse flexes its neck, the lower jaw tends to move upper and lower jaws can be either from brachygnathism of
forward in relation to the upper jaw.43 This becomes impor- the mandible or from prognathism of the maxillae and
tant when dealing with horses that are asked to perform with premaxillae.17
the neck flexed in collection, such as dressage horses, gaited Mandibular brachygnathism has been reported to occur
horses, or harness horses worked in an overcheck with their with other types of congenital deformity involving the
necks forced into flexion. Hooks on the rostral aspect of the musculoskeletal system.44,45 Without cephalometric norms,
upper 06s or caudal aspect of the lower 11s inhibit the determining whether an affected horse has a short lower jaw
rostral motion of the lower jaw when the horse’s mouth is or a long upper jaw is impossible. Some observations of
closed. Some horses tend to open their mouths when col- horses with parrot mouth show that the lower jaw is shorter
lected, but often, trainers use various types of nosebands to (by 1.5–9.3 %), while others show that the upper jaw is
force the mouth closed, thus preventing relief from the longer (by 11.15–18.1 %).17 Some observers conclude that
forces placed on the jaws and limiting the amount of flexion the lower jaw of some horses with parrot mouth is under-
the horse can exhibit. Secondary problems, such as soreness developed.16,46 It is not unusual for the upper canines of
in one or both temporomandibular regions or in the muscles adult male horses affected with severe parrot mouth to be
of the neck or back, can be associated with the horse’s inabil- positioned rostral to the lower canines.
ity to freely move its jaw rostrally and caudally. Cattle inspected for breeding soundness show an inci-
dence of parrot mouth ranging from 2–13 %. This percent-
Documentation of malocclusion and age is similar to the 2–5 % incidence of parrot mouth
reported in several equine studies.15,47 The degree to which
craniofacial deformities this condition is expressed at birth, and the progression
The clinician should document the history and clinical find- of the condition throughout growth and development of
ings of all horses that may require any type of orthodontic the horse have not been scientifically documented. The
treatment. A complete history, including the horse’s pedigree parrot mouth condition can be acquired by avulsion injury
and an oral examination of its parents, is helpful in coun- to the incisor teeth or premaxillae, compression fracture
seling the client about the heritability of the malocclusion. of the mandible, or illness immediately prior to a growth
Historical information also allows the clinician to determine spurt.48,49
whether the condition was noticed at birth or soon after and Equine parrot mouth is most often a result of breeding
if it is becoming progressively worse as the horse grows. The two horses with normal dental occlusion but extremely dif-
proposed use of the horse and knowledge of the rules of its ferent head types. The degree of malocclusion seems to
breed’s registry are necessary to make ethical decisions depend on many factors. Some horses are only affected in
regarding treatment of the horse when the deformity may the region of the cheek teeth, some are affected only in the
have a hereditary component. region of the incisors, and some are affected in both areas.
The clinical assessment should begin with a general physi- Because horses have hypsodont teeth that depend on normal
cal examination of the horse and a complete, detailed, oral occlusal contact for wear, horses suffering from parrot mouth
examination. Photographs and skull measurements are are more seriously affected by the condition at all stages in
useful in monitoring clinical progress. Radiographic evalua- life than are similarly affected members of other species with
tion of the skull sometimes allows for more precise assess- brachydont teeth.
ment of the problem and is another source of permanent, Few foals are born with the full expression of parrot mouth
measurable documentation for monitoring improvement. (Fig. 19.7). Foals born with a slight incisor overjet (i.e.,
Dental impressions and stone castings are helpful in the upper incisor arcade labial to the lower incisor arcade) soon
documentation of deformities as well as in planning treat- develop an overbite (i.e., the occlusal surface of the upper
ment. Stone castings can also be used in the fabrication and incisor arcade is dropped ventral to the occlusal surface of
fitting of removable or fixed dental appliances (see Ch. 21). the lower incisor arcade). As the upper incisors elongate, the
Bite impressions using a sheet of base plate wax allow for palate and incisive bones are pulled downward by gravity,
proper alignment of upper and lower stone models and for causing the lower incisors to become trapped as they begin
following progress of treatment.6 to contact the palate behind the upper incisors (Fig. 19.8).

293
 19 Treatment

multiple genes (polygenetic). Each breeding horse has a dif-

ferent propensity to pass the deformity on to its offspring.
Breeding a horse that has a congenital defect, or breeding a
horse that has previously produced offspring with a congeni-
tal defect is risky. The breeder’s long-term goals and philoso-
phy should dictate breeding decisions. One should consider
the horse’s good traits and the seriousness of the defect.
Breeding horses with any type of congenital defect probably
increases the incidence of that defect in the breeding popula-
tion and may eventually lead to an intolerable concentration
of affected horses in the gene pool. An extreme approach
would be to neuter horses with congenital defects and to
remove their sires and dams from the breeding population.
Although this would prevent horses with a congenital defect
from passing it on, it would also prevent them from repro-
ducing their good conformational and behavioral traits, and
ability to perform. One good strategy would be to not
re-mate two horses that have previously produced defective
offspring. Another approach would be to re-mate these
horses but to retain in the breeding program only offspring
that do not exhibit the defect. A good breeding practice is to
mate horses with similar virtues but different faults.
A
Orthodontic management of a horse with parrot mouth
should follow four basic principles:
1. abnormal wear of the teeth should be prevented or
reduced
2. downward, gravitational drift of the premaxillae and
upper incisor teeth should be prevented or corrected
3. rostral growth of the maxillae and premaxillae should
be inhibited, and
4. rostral growth of the mandible should be stimulated.
The most important management tool used to correct parrot
mouth is to reduce or prevent abnormal dental wear because
abnormal dental wear patterns inhibit rostral and lateral
movement and growth of the mandible. Rostral hooks on
the upper 06s and caudal ramps or hooks on the last lower
cheek teeth (08s, 09, 10s, or 11s, depending on the horse’s
age) should be reduced. Excessive transverse ridges and
enamel points on the cheek teeth should be reduced, and
vaulted ceiling of occlusion corrected. Incisors excessively
B long from lack of wear should be reduced to bring the lower
incisors out of contact with the soft tissues of the palate and
Fig. 19.7  (A) Lateral view of newborn foal with an incisor overjet (parrot to allow free lateral motion of the mandible. Care must be
mouth). (B) Intra-oral view of foal showing incisor overjet. Only the central taken to not expose pulp chambers or to damage teeth when
deciduous incisors have erupted. reducing crowns.
Foals with minor overjet (i.e., less than 5 mm) and with
This places caudal pressure on the mandible, inhibiting its no overbite or malocclusion of the cheek teeth benefit from
growth and creating a cascade of events that worsen the wiring of the upper teeth.25,26 This technique is used to
deformity. As the growth of the lower jaw is stunted, the inhibit rostral growth of the upper jaw from the second
cheek teeth malocclusion worsens, causing hooks to form cheek tooth rostrally while allowing the growth of the man-
on the rostral aspect of the upper first cheek teeth (Triadan dible to proceed unimpeded. This wiring technique used
506 and 606). The unopposed incisor teeth continue to alone is biomechanically unsound for use in horses with
erupt and elongate. The elongated, unopposed lower inci- overbite or malocclusion of the cheek teeth.
sors trapped between the wider, upper incisor arcade inter- Horses with a more severe malocclusion of the incisors
fere with the normal masticatory cycle and limit free lateral (i.e., overbite) have been improved or corrected by applying
motion of the jaw, leading to more abnormal wear of the a functional, orthodontic device early in their life, when they
cheek teeth. are in a rapid stage of growth.4 Orthognathic surgery and
When advising an owner about managing a horse with osteodistraction of a few foals has been attempted.14 Foals
parrot mouth, one should keep in mind that the mode of born with no contact between the upper and lower incisor
inheritance of malocclusion is not clear. Parrot mouth is teeth have an incisor overjet but no overbite, but within 3–6
a complex conformational trait and is the outcome of months, gravity and soft-tissue tension on the upper lip

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 Basic equine orthodontics and maxillofacial surgery

A B

Fig. 19.8  (A) Measuring a parrot-mouth foal’s overjet in millimeters. (B) Measuring the overbite in millimeters.

cause the premaxillae and incisive bones to tip downward. situations that requires detailed evaluation and careful
This downward curve is evident during oral examination as planning.5
a bow in the palate midway between the cheek teeth and the The primary advantage of a fixed dental appliance is that
incisors. This downward movement of the upper incisors, in it can be permanently attached in the mouth, making com-
combination with lack of attrition or wear, leads to an over- pliance by the owner and by the foal less of a factor in
bite. Removable or fixed, functional, orthodontic devices success of treatment. To apply a fixed appliance, however,
combined with retention wires can be used to correct the the foal must be anesthetized, and special equipment is
overbite and allow free movement and rostral growth of the required. Because foals grow rapidly, and because they tend
mandible. to put their mouths in and on things that can damage fixed
Tension band wires have been used to inhibit rostral devices, repair and reapplication of the appliance are all too
growth of the upper jaw of foals less than 6 months old that frequent occurrences. Fixed acrylic appliances that incorpo-
have sufficient potential for growth of the lower jaw to rate an aluminum or stainless steel incline plate can be
correct the deformity. Stainless steel wire (18- to 20-gauge, attached to orthodontic retention wires.
AISI 316L) can be used as a tension band device. A wire The earlier correction is initiated, the better the results.
placed caudal to each second upper cheek tooth and brought Treatment is best initiated when the intermediate upper inci-
rostrally around the upper incisors inhibits growth of this sors (Triadan 502 and 602) are in wear (i.e., when the foal
portion of the upper jaw. The lower jaw continues to grow is 6–12 weeks old) so that interference with the eruption of
normally, correcting the overjet. these teeth is avoided. Prior to orthodontic correction, a full
If no portion of the upper and lower incisor arcades is in set of skull radiographs and occlusive measurements should
contact, a combination of tension band wires and a func- be obtained. The cheek teeth should be floated to reduce tall
tional orthodontic device is used. Such a device in the most transverse ridges and rostral or caudal hooks. The incisor
simple form consists of a removable plate, attached to a bit, plate opens the bite, thus separating the occlusal contact
that extends rostrally between the incisor arcades. When the between the upper and lower cheek teeth. ‘Overfloating’ of
mouth is closed, the plate places upward pressure on the the occlusal surface, therefore, is discouraged because it
upper incisors discouraging their ventral drift. A removable results in loss of contact between the upper and lower
orthodontic device can be applied with the foal standing and arcades during mastication when the incline plate is in place.
unsedated. Because the device must be worn 16 hours per Primiparous mares and dams with small nipples on the
day to be effective, owner compliance is the most common udder can present a problem for foals attempting to nurse
problem associated with the use of the removable appliance, after surgery. Foals should be fed a diet consisting of a pel-
and compliance of the foal is the second limiting factor. leted complete foal ration before and after surgery.
Without an educated, enthusiastic, and committed owner Preoperatively, the foal receives antimicrobial and non-
and/or groom, the use of a removable appliance is doomed steroidal anti-inflammatory drugs, and the mouth is rinsed
to failure. completely with a dilute chlorhexidine solution. General
A more sophisticated, fixed acrylic appliance can be fash- anesthesia is induced with xylazine and ketamine and main-
ioned to fit in the roof of the mouth. Acrylic is molded on tained with a triple drip (i.e., a combination of xylazine,
a plaster model of the upper jaw or fashioned on the anes- ketamine, and guaifenesin). The foal is positioned in lateral
thetized foal in dorsal recumbency. A metal inclined plane recumbency, and an oxygen tube is inserted nasally. Oxygen
can be incorporated in this device to place rostral force on is delivered at 10 l/min during the procedure. Using a rasp
the lower jaw when the mouth is closed. Application of these or power grinder, the exposed crowns of the upper and lower
devices cannot be ‘cook-booked’ because each case presents incisors are reduced and leveled almost to the gingival
a slightly different set of anatomical and biomechanical margin, taking care not to expose the pulp (Fig. 19.9).

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Fig. 19.10  Parrot-mouthed foal in lateral recumbency for placement of

Fig. 19.9  Power grinder being used to level and shorten the incisors
orthodontic wires. A Steinmann pin is used to make a hole between the
(3 mm) prior to surgery.
reserve crowns of 607 and 608, and a 14-gauge needle is placed in the hole
and used as a guide for the 18-gauge, orthopedic retention wire. The
needle is pulled over the free end of the wire. A longer free end of the wire
A small area just ventral to the facial crest is clipped and is placed back through the same skin incision just below the facial crest,
pushed through the mucosa into the buccal recess and brought rostrally.
prepared for surgery. With one hand in the mouth, the junc-
tion between upper 3rd and 4th premolars (Triadan 07 and
08) on the arcade is identified as an indentation in the hard
palate. A small, longitudinal, skin incision is made below on itself in the interdental space. Including the occlusal
the facial crest at a level just opposite this junction, avoiding surface of the upper 2nd premolar in the twists is avoided
branches of the facial nerve, maxillary artery, and salivary by keeping the wire close to the hard palate and pulling
duct. A 3 32 -inch diameter Steinmann pin is introduced downward on the buccal wire and upward on the palatal
through the skin incision and directed between the reserve wire while twisting. The twisted strands from both sides are
crowns of upper 3rd and 4th premolars just above the buccal pulled rostrally and brought around the labial edge of the
gingival margin so that the pin emerges in the mouth 1 8 – 1 4 upper incisor arcade and twisted together. The wires should
inch above the palatal gingival margin. Care should be taken lie across the labial surface of the incisors at the gingival
to avoid the palatine artery. Intra-operative radiographs and/ margin. The ends of the wires are cut and tucked between
or fluoroscopy are helpful and sometimes necessary to prop- two incisors. An 1 8 -inch-thick plate of aluminum with several
erly position the pin between the teeth without damaging 3.5 mm perforations is sized so that it fits over the occlusal
dental roots. The pin is removed, and a 14-gauge, 1.5-inch surface of the upper incisors and extends caudally over the
hypodermic needle is carefully placed in the hole created by hard palate 1 4 inch caudal to the point at which the lower
the pin to act as a wire guide. A section of 18-gauge, stainless incisors contact the hard palate (Fig. 19.11A). Paraffin rope
steel, orthopedic wire is cut to a length at least three times is placed around the gingival margin of the upper incisors,
the distance from 4th premolar to the central incisors. One pulled under the wires on each side, and extended several
end of the wire is inserted into the dorsal aspect of the oral centimeters caudally on the hard palate to form a dental dam
cavity through the needle, and the needle is removed over to contain the unset acrylic (Fig. 19.11B). Hard-setting
the other end of the wire, which is then doubled back and dental acrylic is mixed and formed into the roof of the
passed through the buccal incision into the buccal space of mouth, within the confines of the paraffin rope, incorporat-
the oral cavity (Fig. 19.10). Care should be taken not to catch ing the wires and labial surface of the upper incisors. The
soft tissue with the wire or to damage a branch of the facial acrylic should cover the knot in the wire on the labial aspect
nerve during this process. The end of the wire in the buccal of the upper incisors to prevent the knot from irritating soft
space is grasped with forceps inserted into the mouth, and tissue. Splinting of the upper incisor arcade with acrylic
it and the palatal portion of the wire are pulled rostrally to stabilizes the teeth and prevents the force of the orthodontic
form a loop around the distal aspect of the reserve crowns wires from spreading or twisting the incisors. The acrylic
of the upper 2nd and 3rd premolars. Kinks should be band wrapping around the labial surface of the upper inci-
avoided because they hasten stress fatigue of the wires. The sors and the orthodontic wires hold the acrylic firmly in the
small skin incision is left open to heal by second intention. roof of the mouth. The acrylic is formed with the curved,
The foal is repositioned in lateral recumbency on the oppo- rostral edge of the metal plate resting on the occlusal surface
site side, and the procedure is repeated. of the upper incisors and the caudal, straight edge of the
With both wire loops extending out of the oral cavity, the plate level or slightly more ventral in the mouth than its
foal is placed in dorsal recumbency with a pad placed caudal rostral edge. This creates a flat or inclined surface for the
to the poll to hyperextend the neck so that the roof of the lower incisors to contact (Fig. 19.11C). This inclined plate
mouth lies parallel to the ground. The loop wire around the frees the mandible from caudal force imposed on it by the
first two cheek teeth is pulled tight and twisted several times upper incisors and creates a slight rostral pull on the

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 Basic equine orthodontics and maxillofacial surgery

Fig. 19.11  (A) Parrot-mouthed foal placed in dorsal recumbency with orthodontic retention wires in place. An aluminum plate is cut and sized to fit the
occlusal surface of the upper incisors while projecting caudally to contact the occlusal surface of the lower incisor arcade. A dam of paraffin rope has been
built to retain the acrylic mouth piece. (B) Acrylic and thin plate in place. (C) Lateral view showing final placement of wires and acrylic mouth piece.

mandible as the lower incisors slide over the plate during The appliance eventually loosens, so that by 3–6 months
chewing. As the foal chews, upward pressure is applied to the appliance and wires must be removed. If correction is
the upper incisors and premaxillae, forcing them into a more not complete by this time, the wires and acrylic appliance
normal position (Fig.19.12). are reapplied and maintained until desirable results are
The foal is allowed to recover from anesthesia after the achieved. The gap between the upper and lower incisors
acrylic sets and is returned to the dam. Most foals quickly decreases, for most horses, by about 5 mm every 3–6 months.
learn to nurse with the appliance in place. Foals that do not The most rapid correction is noticed when the procedure is
nurse well should be supplemented with a complete foal performed when the horse is 2–8 months old; improvement
ration and weaned. is slow after the horse is 8 months old and ceases by the time
Postoperative care consists of keeping the skin wounds the horse is 19 months old. Complications from orthodontic
clean until healing is complete. Most foals are administered wiring and bite plate application are rare. They can include
omeprazole orally for 4–5 days, while they adjust to the trauma to the dorsal buccal nerve, damage to the greater
orthodontic appliance, to help prevent gastric ulcers. Most palatine artery, postoperative pain and nursing problems,
foals begin to eat and nurse well within 1–2 days after and nasal curvature from unilateral wire breakage.50
surgery. The plate and wires should be checked daily by Adult horses suffering from parrot mouth experience long-
personnel at the farm to determine if the wires are loose or term adverse effects on dentition and mastication. The molar
broken or if the acrylic appliance has loosened. The foal arcades may develop a hook on the rostral aspect of the
should be examined monthly by a veterinarian to ensure upper 06s and/or a hook and/or ramp on the caudal aspect
that the appliance is secure and is not causing oral lesions. of the lower 11s, and the cheek teeth of both the upper and
At the same time, the cheek teeth should be inspected so that lower jaws may develop abnormal, exaggerated transverse
abnormal wear patterns can be detected and corrected by ridges. The combination of abnormalities of the cheek teeth
careful floating. and elongated incisors tends to limit free, lateral excursion

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 19 Treatment

Fig. 19.13  Four-week-old foal with a monkey mouth or Mal 3 deformity.

Monkey mouth
The term monkey mouth refers to the condition where the
premaxillae/maxillae are shorter than the mandible, leading
to an incisor underbite. This condition has also been termed
sow mouth, hog mouth, undershot jaw, underjet, underbite,
or mandibular prognathism, but the official term is a Class
3 malocclusion (MAL3). Retrognathism is a term defined,
using human anatomical nomenclature, as a condition
where the mandible is located posterior to its normal posi-
tion in relation to the premaxillae/maxillae or a condition
where one or both jaws lie posterior to normal in their
craniofacial relationship.
B The forward projection of one or both jaws in relation to
the craniofacial skeleton has been referred to as prognath-
Fig. 19.12  (A) Lateral radiograph of the rostral skull of a 4-month-old foal ism. This condition is seen more commonly in miniature
with an overjet and overbite just prior to surgery (B) Lateral skull radiograph horses and has been associated with achondroplastic dwarf-
of foal with orthodontic retention wires placed behind the upper third ism in cattle.51–53 Prognathism is also seen in other breeds of
premolar and encircling the upper incisor arcade. The metal incline plate horses, especially those with a dished face, such as the
has not been sloped for this first application of retention wires because Arabian breed. This congenital anomaly has been reported
creating a slope would have caused a gap in the premolar arcades. The
to occur with other deformities of the head and muscu-
second appliance will have a slope or mechanical incline to encourage
rostral growth of the mandible. loskeletal system. Owners should receive genetic counseling
before therapy is undertaken to correct monkey mouth
(Fig. 19.13).
of the jaw, which can lead to a steep angle of the occlusal
Principles of therapy in the young, growing horse should
surface of the cheek teeth or, in some cases, to bilateral
consist of:
shear mouth.
Some parrot-mouthed horses function quite well if they • encouraging or accelerating growth of the maxillae and
receive regular dental equilibration and if their diet is modi- premaxillae
fied. Dental equilibration entails reduction of rostral and • supporting the nasal bones and nasal septum
caudal hooks, abnormal exaggerated transverse ridges, and • slowing rostral growth of the mandible
steep molar angles. Unopposed upper and lower incisor • preventing the upper incisor arcade from interfering
arcades should be shortened to allow more normal, unob- with the lower incisor arcade, and
structed motion of the lower jaw. Deciduous incisors can be • preventing abnormal wear of the cheek teeth.
shortened with little risk of damaging the pulp chambers. Adult horses with a hook on the rostral aspect of the lower
Permanent incisors, especially long ones, should be reduced 06s can develop a slightly undershot lower jaw. This abnor-
in stages. mality can be corrected by periodically floating the cheek
In addition to having its teeth equilibrated, a parrot- teeth to remove the hooks and by reducing the incisors.
mouthed horse should also have its diet altered or modified.
Some parrot-mouthed horses have difficulty foraging short
grass; others have difficulty masticating any type of roughage,
Wry nose
and so, to maintain these horses in good body condition, Wry nose, or campylorrhinus lateralis, is a congenital
feeding processed or extruded feeds may be beneficial. deviation of the maxillae, premaxillae, and nasal septum

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 Basic equine orthodontics and maxillofacial surgery

supported by scientific evidence. The authors are aware of a

mare that produced two foals affected with wry nose, during
successive pregnancies, when bred to the same stallion
(Dr Chris Johnson, personal communication, 2008).
Mildly affected foals have been managed using unilateral
orthodontic wiring with good results. More severely affected
foals have been treated successfully using principles of
orthognathic surgery, as detailed later in this chapter, and
many of these treated foals have developed into successful
athletes and productive breeders.11,13,55,56
Foals should be evaluated carefully for aspiration pneu-
monia and to rule out associated congenital defects. The
degree of the deformity can be determined by oral radio-
A
graphic examination, and computed tomography of the
skull might be useful to confirm the position and degree of
premaxillary/maxillary deviation and nasal obstruction
(Fig. 19.15). Dental impressions of the upper and lower
arcades from the premolars to the incisors can help the
surgeon determine the amount of space created on the
concave side of the premaxillae/maxillae when the deform-
ity is corrected and the upper and lower incisor arcades are
brought into proper occlusion (Fig. 19.16). Occlusal abnor-
malities of the premolars causing wear should be corrected
prior to surgery. This involves re-establishing a normal
occlusal angle on the premolar arcades and leveling the inci-
sors (Fig. 19.17).

Conclusion
All undesirable traits and pathologic conditions present at
birth were at one time thought to be entirely genetic in
origin. Our knowledge of birth defects has evolved to the
point that we now know that many, if not most, congenital
defects are the result of intrauterine events that result from
extrauterine influences. Congenital defects do not indicate
inheritance but simply that the defect was present at birth.
Some characteristics of horses are genetically influenced,
and horses have been selectively bred for centuries to
promote or discourage these characteristics. The selection for
B or against inherited tendencies is the basis for our current
breed registries. Size, power, color, speed, conformation,
Fig. 19.14  (A) Four month old wry nose foal. (B) Dorsoventral radiograph and many other characteristics that are genetically influ-
of a wry nose foal. The maxilla is deviated at a 65° angle to the mandible. enced, are selected for or against by certain breed registries.
Variations from ideal may be undesirable, but they are not
genetic defects.
(Fig. 19.14). It is an infrequently reported condition some- The American Veterinary Medical Association (AVMA)
times associated with other congenital anomalies, such as recently restated a policy saying that surgical correction of
cleft soft palate (palatoschisis), umbilical herniation, and ‘genetic defects’ for the purposes of concealing the defect is
contracted tendons of the limb.54 Affected foals may have unethical.57 This AVMA statement refers specifically to cor-
difficulty suckling, but most seem to thrive until dyspnea rection of genetic defects. By definition, a genetic defect is a
appears when they are several months old. The degree of pathologic condition of proven genetic origin.
dyspnea is related to the severity of the nasal septal devia- Although equine practitioners should support the intent
tion. Severely affected foals may require a permanent trache- of the AVMA statement, the policy should be applied only
ostomy or a nasal dilation tube to ventilate properly. Horses to horses with a genetic defect and not misapplied to horses
affected with wry nose usually encounter difficulty prehend- with a congenital defect for which a genetic cause has not
ing and masticating grass forage when they are weaned. been proven or to horses with inherited tendencies. Equine
Lateral excursion of the lower jaw is usually limited to move- practitioners should considered surgical treatment of horses
ment to the convex side of the deformity, causing abnormal with a debilitating condition if the condition is amendable
wearing of cheek teeth, which may lead to shear mouth. by surgical correction. There is no doubt that correction of
Wry nose is thought by some to be a heritable condition debilitating dental malocclusions and facial deformities is in
because it seems to be seen most often in the Arabian and the best, long-term interest of the horse’s oral health. Some
miniature horse breeds,52–54 but these claims are not equine breed registries require certain undesirable traits and/

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 19 Treatment

Fig. 19.15  Computed tomography images

of transverse scans through the head of a
7-month-old Thoroughbred filly with wry  
nose. The filly is positioned in dorsal recumbency,
and serial images, beginning at the second
premolar and advancing rostrally, demonstrate
the premaxillary curvature and progressive
narrowing of the right nasal cavity.

Equine orthodontic principles are at work in the mouth

starting in utero and continuing well into old age. Changes
occur as the deciduous teeth erupt, the jaws grow and
develop, deciduous teeth are shed, permanent dentition
erupts, and the hypsodont teeth wear. The equine practi-
tioner who is familiar with the principles of diagnosis and
documentation of malocclusion is better able to use the
controlled movement of teeth and adjustments of jaw
growth for treatment. Knowledge obtained through observa-
tion, diagnosis, documentation, and appropriate adjust-
ments provides the equine dental patient with the best
possible occlusion and helps maintain proper oral health.

Surgery of the paranasal sinuses

Fig. 19.16  Plaster of Paris dental model of the upper arcade from a
wry-nosed foal. The model has been cut and straightened to bring the Sinusotomy
upper and lower incisor arcade into proper occlusion. The white wedge
indicates the angle of rostral and lateral displacement required to correct Surgery of the paranasal sinuses is performed most com-
the deformity. monly to determine the cause of clinical signs of disease
referable to the paranasal sinuses, such as facial deformity
or chronic, unilateral nasal charge. It is also performed to
or conditions commonly considered to be a ‘genetic defect’ excise or biopsy abnormal tissue, such as an osteoma, cyst,
to be indicated on the affected horse’s registration certificate. progressive ethmoidal hematoma, fungal granuloma, or
This requirement should be brought to the attention of an neoplasm, or to evacuate inspissated exudate, usually from
owner or breeder when a severe malocclusion is diagnosed. the ventral conchal sinus. It is sometimes performed to
An attempt to correct a known genetic defect to allow an expose the apex of a diseased tooth so that the tooth can be
owner to misrepresent the horse in the show ring or breed- repulsed into the oral cavity or receive endodontic treat-
ing shed should be considered unethical. ment. The paranasal sinuses can be exposed through one or
Clinical observation and detailed documentation promote more trephine openings or through an osteoplastic flap.
understanding of why and how malocclusions and malrela- Although the paranasal sinuses can be examined endoscopi-
tionships between the jaws occur and how they can be pre- cally through one or more trephine holes, treatment of the
vented or treated. The equine practitioner can benefit greatly horse for a disease identified endoscopically is often not
from the new human biomedical discoveries. Genetic studies possible, unless the trephine opening is huge, in which case
to detect the chromosomal factors that play a role in head the horse may be left with facial deformity. Surgery of the
shape could influence genetic consultation and mating engi- paranasal sinuses is, therefore, usually performed through
neering. Such studies and/or research may help reduce the one or more large osteoplastic flaps that are replaced at the
incidence of equine dental malocclusions. end of surgery.

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 Basic equine orthodontics and maxillofacial surgery

Fig. 19.18  To create a medially hinged, osteoplastic frontonasal flap,

a three-sided incision extending through periosteum is created within  
the confines of the boundaries of the conchofrontal sinus.

boundaries and anatomical features of the paranasal sinuses

before performing sinusotomy.

A Frontonasal flap
To create a medially-hinged, osteoplastic frontonasal flap, a
three-sided incision through the skin, subcutaneous tissue,
and periosteum, with rounded corners, is created within the
confines of the boundaries of the frontal and dorsal conchal
sinuses (i.e., the conchofrontal sinus; Fig. 19.18). The caudal
portion of the incision begins on the dorsal midline, at a
point midway between the supraorbital foramina and the
medial canthi of the eyes, and extends laterally, perpendicu-
lar to the long axis of the head, to a point about 1.5–2 cm
medial to the most medial aspect of the rim of the orbit. The
rostral portion of the incision also begins on the dorsal
midline, at a point 1–2 cm caudal to the plane where the
nasal bones begin to diverge, and extends laterally, perpen-
B dicular to the long axis of the head, to an imaginary line
extending from the medial canthus of the eye to the nasoin-
Fig. 19.17  (A) and (B) Twelve-year-old Thoroughbred mare with a wry cisive notch. The lateral portion of the incision connects the
nose. A ‘permanent’ tracheostomy as a yearling allowed the mare to lateral extent of the rostral and caudal portions of the inci-
breathe with no signs of respiratory distress. She had produced six normal sion and courses parallel to the midline. The incision should
foals while being bred to six different stallions. The uncorrected dental and
facial deformity caused the mare difficulty with prehension and mastication.
not cross the path of the nasolacrimal duct, which courses
She had a severe shear mouth on the concave (right) arcades. between the medial canthus of the eye and a point midway
between the infraorbital foramen and the nasoincisive
notch. The rostral aspect of the lateral segment of the inci-
The two types of osteoplastic flaps are the frontonasal flap sion can be angled medially, if necessary, to avoid crossing
and the maxillary flap. The frontonasal flap is the most ver- the duct. Periosteum is reflected several millimeters from
satile because it is easy to create and provides direct or the underlying frontal and nasal bones with a periosteal
indirect access to all compartments of the ipsilateral parana- elevator.
sal sinuses. The maxillary flap is more difficult than the The incision is extended through bone using an oscillating
frontonasal flap to create and provides poor access to the bone saw, a motorized cast cutter with a sharp, oscillating
ventral conchal sinus, at least in horses less than 6 years old. blade, or a mallet and osteotome. The blade of the saw
The maxillary flap provides good access to the rostral and should be cooled with sterile, normal saline solution, while
caudal maxillary sinuses, however, and is most commonly cutting, to avoid overheating bone. The bone is cut at a 45°
used to expose the apex of the first or second maxillary molar angle so that the flap’s external lamina is slightly larger than
(Triadan 09 and 10). The apex of the third maxillary molar its internal lamina. The flap is elevated sufficiently, using a
(Triadan 11) is often best exposed through a frontonasal chisel or osteotome, to allow the fingers of one hand to be
flap. The surgeon should have a good understanding of the introduced beneath the flap, and the flap is fractured at its

301
 19 Treatment

Fig. 19.20  A progressive ethmoidal hematoma exposed through a

conchofrontal, osteoplastic flap created with the horse sedated.

threading a 5- to 8-Fr, male dog urinary catheter into the

caudal opening of the nasomaxillary aperture, located
between the floor of the dorsal conchal sinus and the bulla
of the ventral conchal sinus at the rostral aspect of the fron-
tomaxillary aperture. The end of the catheter exits the
Fig. 19.19  The bulla of the ventral conchal sinus is seen protruding into
ipsilateral external naris. Threading a catheter through the
the caudal maxillary sinus beneath the rostral margin of the frontomaxillary
aperture. The bulla structure is sometimes obscured by the caudal portion nasomaxillary aperture can sometime be difficult or even
of the floor of the dorsal conchal sinus. impossible, but blood or lavage fluid seen exiting the nasal
cavity can also be used as evidence that the nasomaxillary
aperture is patent. Rarely is the nasomaxillary aperture
base, close to the dorsal midline. The flap remains attached obstructed.
to the skull by skin, subcutaneous tissue, and periosteum. A portal to remove gauze packing or to allow lavage of the
Elevating the flap exposes the conchofrontal sinus, which sinuses can be created in the frontal bone, adjacent to flap,
communicates ventrally with the caudal maxillary sinus through a 2-cm, longitudinal, skin and periosteal incision,
through the large frontomaxillary aperture. Provided that the using a 9.5-mm (3 8-inch) Galt trephine. Alternatively, the
architecture of the sinuses is not distorted by disease, the portal can be created in the maxillary bone about 2 cm
bulla of the ventral conchal sinus, which forms a portion of ventral and 2 cm rostral to the medial canthus of the eye.
the maxillary septum, is usually seen protruding into the After returning the flap to its normal position, at the end
caudal maxillary sinus beneath the rostral margin of the of surgery, the subcutaneous tissue is apposed with 4–6,
frontomaxillary aperture (Fig. 19.19). Occasionally, this widely-spaced, simple interrupted, absorbable sutures.
structure is obscured by the caudal portion of the floor of Because the bone in the flap is beveled, it need not be
the dorsal conchal sinus. To expose the rostral maxillary and attached to surrounding bone, and suturing the fragile, ine-
ventral conchal sinuses, a portion of this bulla is excised with lastic periosteum is difficult to impossible. The margins of
scissors. After creating a hole in the bulla, the ventral conchal the skin incision are apposed with staples, and the surgical
sinus is seen medial to the infraorbital canal, and the rostral site is compressed with a Stent bandage or with gauze swabs
maxillary sinus is seen lateral to the canal. The infraorbital anchored by elastic, adhesive tape placed in a figure-of-eight
canal is supported by a thin plate of bone that separates fashion around the head. Gauze packed into the sinuses can
these two compartments. All or a portion of the reserve be removed through the trephine hole, usually within 12
crowns of the 3rd, 4th, and 5th cheek teeth (Triadan 08–10) hours, and the Stent or elastic bandage is removed at 5–7
completely fill the rostral maxillary sinus of horses less than days. The portal created for lavage of the sinuses or to remove
4 years old. To better expose the ventral conchal and rostral the gauze packing can be closed with staples or sutures after
maxillary sinuses, the rostrolateral portion of the floor of the the portal is no longer required.
conchofrontal sinus and the closely associated dorsolateral Surgery of the paranasal sinuses is usually performed with
portion of the ventral conchal bone can be excised using a the horse anesthetized and recumbent, but most surgeries of
scissors or a bone rongeur. the paranasal sinuses that can be performed through a fron-
The medial wall of the dorsal or ventral conchal sinus is tonasal flap can also be performed with the horse standing,
often perforated, or a portion of it is excised, to establish a thereby eliminating the risks and expense of general anesthe-
portal for drainage of the paranasal sinuses into the nasal sia (Fig. 19.20). Repulsion of a tooth, however, is most safely
cavity, and creating this portal is generally accompanied by performed with the horse anesthetized. Creating a fronto­
substantial hemorrhage. A portal for drainage need not be nasal flap causes minimal hemorrhage, regardless of the
established if the nasomaxillary aperture is patent, provided position of the horse, but performing surgery within the
that the mucosa of the sinuses is not grossly thickened. sinuses with the horse standing seems to cause less hemor-
Patency of the aperture can sometimes be determined by rhage than surgery performed with the horse anesthetized

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 Basic equine orthodontics and maxillofacial surgery

and recumbent.58 Performing surgery of the horse’s sinuses

with the horse standing and its head elevated may result in
less venous congestion in structures of the paranasal sinuses,
and hence less hemorrhage, than if the same surgery were
performed with horse recumbent. Another advantage of per-
forming surgery of the sinuses with the horse standing is that
the structures within the sinuses are oriented in a normal
position.
A horse selected to receive surgery of the sinuses while
standing should be compliant and should not resent move-
ment of hands and instruments about its head. When per-
formed with the horse standing, surgery of the paranasal
sinuses is most safely and conveniently performed with the
horse restrained in stocks; cross-tying the horse’s halter to
the stocks provides added restraint. The horse is sedated with
detomidine HCl (0.01–0.02 mg/kg IV or 0.03–0.04 mg/kg
Fig. 19.21  The infraorbital foramen is located by placing the thumb (or
intramuscularly) and butorphanol tartrate (0.02–0.05 
middle finger) in the nasomaxillary notch, and the middle finger (or thumb)
mg/kg IV) or morphine (0.15 mg/kg IV). When adminis- on the rostral end of the facial crest. The foramen is located with the index
tered intramuscularly, detomidine should be administered finger halfway between 1.5 and 2.5 cm caudal to an imaginary line between
15–20 minutes before surgery. The horse can be re-sedated these points.
during surgery with xylazine (0.5 mg/kg IV) or detomidine
(0.01 mg/kg IV), when needed, to minimize movement.
If a long procedure is anticipated, constant rate infusion anesthetizes the infraorbital nerve, which courses through
of detomidine (0.02 mg/kg/hour) and butorphanol the canal, as far caudally as the maxillary foramen. To locate
(0.012 mg/kg/h) can be administered to provide a pro- the infraorbital foramen, the thumb (or middle finger) is
longed, constant state of sedation, after first administering a placed in the nasomaxillary notch, and the middle finger (or
loading dose of detomidine (0.008 mg/kg IV) and butor- thumb) is placed on the rostral end of the facial crest. The
phanol (0.02 mg/kg IV).59 The horse can also be sedated foramen is located with the index finger halfway between
using constant-rate infusion of morphine (0.15 mg/kg/h) and 1.5 to 2.5 cm (0.5–1 inch) caudal to an imaginary line
after first administering a loading dose of morphine between these points (Fig. 19.21). The bony ridge of the
(0.15 mg/kg IV). After the horse is sedated, its head should foramen can be palpated by pushing the ventral edge of the
be supported on a stand or small table so that the site of levator nasolabialis muscle dorsally. A 20- or 22-gauge,
sinusotomy is at a comfortable level for the surgeon. 3.8 cm (1.5 inch) needle is inserted through the skin about
The proposed site of incision is infused subcutaneously 2.5 cm (1 inch) rostral to the foramen after elevating the
with local anesthetic solution, and the paranasal sinuses are levator nasolabialis muscle. The shaft of the needle is inserted
desensitized, either by infusing 30–40 ml of local anesthetic about 1 inch into the canal. Although anesthetizing the
solution into the sinuses or by anesthetizing the ipsilateral infraorbital nerve is easier and more reliable than anesthetiz-
maxillary nerve. Instilling local anesthetic solution into the ing the maxillary nerve, the infraorbital nerve block is not
paranasal sinuses usually desensitizes the mucosa suffi- tolerated well by the horse, and so great care should be
ciently to permit most procedures to be performed without taken during its administration. Anesthesia of the infraor-
causing severe discomfort to the horse. The local anesthetic bital nerve or maxillary nerve at the maxillary foramen
solution is infused through a small hole created several cen- desensitizes the paranasal sinuses on that side of the head,
timeters medial to the medial canthus of the eye with a but desensitization of the skin at the proposed site of inci-
Steinmann pin in a Jacob’s chuck or with a steel 14- or sion by subcutaneous infiltration of local anesthetic solution
16-gauge hypodermic needle driven through a stab incision is still required.
in the skin and frontal bone with a mallet. A plug of tissue After the horse’s paranasal sinuses and skin at the pro-
is often retained within the shaft of the needle and can be posed site of incision are desensitized, the surgical site is
extruded into the sinuses with a smaller gauge, spinal needle prepared for surgery. The surgical site should not be draped,
inserted through the shaft of the larger needle. so that the horse’s reactions to the procedure can be moni-
The paranasal sinuses can be desensitized more effectively tored. A twitch should be applied to the horse’s upper lip
by anesthetizing the maxillary nerve at the pterygopalatine when the bone is cut to prevent the horse from moving, but
fossa, where it passes through the maxillary foramen to enter the twitch can usually be removed after the flap is fractured.
the infraorbital canal as the infraorbital nerve. To anesthetize The paranasal sinuses are inspected, and the horse is treated
the maxillary nerve, a 20-gauge, 8.9-cm (3.5-inch) spinal for disease encountered. If the maxillary nerve was not
needle is inserted just ventral to the zygomatic process at the desensitized with local anesthetic solution before surgery,
level of the lateral canthus of the eye, perpendicular to the the horse may react to manipulations within the sinuses,
long axis of the head until the needle strikes bone. Ten– especially if the infraorbital canal is touched with
fifteen milliliters of local anesthetic solution is deposited at instruments.
this site. An alternative method of exposing the paranasal sinuses
The paranasal sinuses can also be desensitized by deposit- with the horse standing is to create a hole into the concho­
ing 10 ml or more of local anesthetic solution into the frontal sinus through a cutaneous, periosteal flap, using
rostral aspect of the infraorbital canal. This large volume a 5-cm (2-inch) diameter trephine (Arnolds Veterinary

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 19 Treatment

Products Ltd, Harlescott, Shrewsbury, UK), as described by the ventral boundary extends along the facial crest to below
Quinn et al (2005).60 The site of trephination is centered the middle of the eye. The rostral boundary is a line that
5 cm axial to an imaginary line between the medial canthus extends from the infraorbital foramen to the rostral border
of the eye and the nasoincisive notch, 2 cm below a line of the facial crest, and the dorsal boundary is a line that
drawn between the medial canthi, and 4 cm lateral to the extends from the medial canthus of the eye to the infraor-
dorsal midline. Bone of the forehead is exposed through an bital foramen.
abaxially based, curved, cutaneous incision created 1–1.5 cm The caudal portion of the cutaneous incision begins at a
axial to the intended site of trephination. This incision is point about 1 cm rostral to the eye, slightly below the medial
extended through the periosteum, and the cutaneous, perio- canthus, and extends ventrally to a point about one centim-
steal flap is reflected abaxially. The edge of the trephine is eter dorsal to the facial crest. The incision is extended ros-
aligned 10 mm inside the skin incision. The disc of bone trally, parallel to the facial crest to a point about one
excised with the trephine is discarded. At the end of surgery, centimeter caudal to the rostral end of the facial crest. The
four or five, simple-interrupted, widely-spaced sutures are incision is turned dorsally and extended to a point about
placed to approximate the skin and periosteum in a single one centimeter caudal to the infraorbital foramen. The
layer, and the skin incision is stapled. Using a large trephine, rostral portion of the incision extends into the nasolabialis
rather than an oscillating saw, to expose the sinuses simpli- and levator labii superioris muscles and may transect the
fies surgery, while still providing adequate exposure for angularis oculi artery and vein. Periosteum is reflected about
removal of diseased tissue, but removing the large section of 3 mm to the inside of the three-sided incision, and the max-
bone sometimes imparts a marked concavity to the horse’s illary bone is cut along the incision using an oscillating saw
forehead. or a mallet and an osteotome. The bone is cut at a 45° angle,
so that its external lamina is slightly larger than its internal
Maxillary osteoplastic flap lamina. Care should be taken when cutting the bone at the
dorsal, rostral end of the incision to avoid damaging the
The apex of a maxillary molar is often exposed through an infraorbital canal and the infraorbital nerve contained
osteoplastic maxillary flap. Creating a maxillary flap, rather within. After the rostral, caudal, and ventral sides of the flap
than a trephine hole, to expose the apex of a maxillary molar have been cut, the flap is pried upward until it fractures
provides opportunity for visual examination of a large extent dorsally to expose the interior of the rostral and caudal
of the paranasal sinuses and permits easier manipulation of maxillary sinuses. Septal attachments on the interior surface
dental instruments within the sinuses. The most common of the bone flap sometimes must be severed with the oste-
indication for creating a maxillary osteoplastic flap is repul- otome before the flap can be pried dorsally. The flap is
sion of a tooth. hinged dorsally by skin, subcutis, and periosteum. Besides
To create a dorsally hinged, osteoplastic maxillary flap, a repelling a tooth through a maxillary flap, inspissated
three-sided incision through the skin, subcutis, and perios- exudate in the ventral conchal sinus can also be removed
teum, with rounded corners, is created within the confines through a portal into this compartment created below the
of the boundaries of the rostral and caudal maxillary sinuses infraorbital canal, provided that the horse is more than 6
(Fig. 19.22). The caudal boundary of the maxillary sinuses years old (Fig. 19.23). The sagittal bony plate beneath the
extends from the middle of the eye to the facial crest, and

IOC

RMS
VCS

Fig. 19.23  Inspissated exudate in the ventral conchal sinus can also be
removed, through a portal in the sagittal bony plate and the lateral wall of
the ventral conchal sinus located beneath the infraorbital canal, provided
that the horse is older than 6 years. The reserve crowns of the first and
Fig. 19.22  To create a dorsally hinged, maxillary flap, a three-sided incision second maxillary molars of horses less than 6 years old obscure this bony
extending through the periosteum is created within the confines of the plate and lateral wall of the sinus. VCS, ventral conchal sinus; RMS, rostral
boundaries of the rostral and caudal maxillary sinuses. maxillary sinus; IOC, infraorbital canal.

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 Basic equine orthodontics and maxillofacial surgery

infraorbital canal and the lateral wall of the ventral conchal

sinus are penetrated using a small trephine or a bone rongeur.
The reserve crowns of the first and second maxillary molars
of horses less than 6 years old obscure this bony plate and
lateral wall of the sinus. The ventral conchal sinus can be
exposed by deforming the conchomaxillary aperture, located
medial to the infraorbital canal, with a finger.61 The ventral
conchal sinus of horses less than 6 years old is most easily
penetrated at its bulla, which is exposed through a fronto-
nasal, osteoplastic flap. Inspissated exudate in the ventral
conchal sinus most commonly results from primary bacte-
rial sinusitis, but it can also accompany sinusitis secondary
to dental infection.
If the sinuses require lavage after maxillary sinusotomy,
the portal for lavage can be created over the frontal bone
into the conchofrontal sinus or through the maxillary bone
into the caudal maxillary sinus, caudal to the flap, about
1.5 cm ventral to the most ventral aspect of the orbit. Packing
the paranasal sinuses to achieve hemostasis after repelling a
tooth is seldom, if ever, necessary. A trephine portal large
enough to accommodate a 24 Fr Foley catheter is created
into the conchofrontal sinus through a 3- or 4-cm longitu-
dinal cutaneous incision created over the frontal bone,
2–3 cm medial to the medial canthus of the eye. Fluid Fig. 19.24  The juvenile ossifying fibroma is the most commonly
encountered mandibular neoplasm and is most commonly found on  
instilled into the conchofrontal sinus through the Foley the mentum.
catheter exits the sinuses into the nasal cavity through the
nasomaxillary aperture.
After returning the flap to its normal position, after the
tooth has been repelled, the subcutaneous tissue is apposed
with 4–6, widely spaced, simple interrupted, absorbable
sutures. Attaching the flap of bone to surrounding bone is
not necessary, because the flap is beveled. Only the subcutis
and skin are sutured, because the inelastic periosteum is dif-
ficult to appose. The cutaneous margins of the flap are
apposed with staples, and the surgical site is compressed
with a Stent bandage or with gauze swabs anchored by
elastic, adhesive tape placed in a figure-of-eight fashion
around the head. The Stent or elastic bandage is removed at
5–7 days. The portal created for lavage of the sinuses can be
closed with staples or sutures after the portal is no longer
required.

Partial mandibulectomy
Fig. 19.25  Laterolateral radiograph of the skull of a horse with a carcinoma
of the mandible. The rostral portion of the mandible of this horse was
The most common indication for partial mandibulectomy
amputated caudal to the symphysis.
is to remove a neoplastic lesion of the rostral aspect of the
mandible. The most commonly encountered mandibular
neoplasm is the juvenile ossifying fibroma, and this
neoplasm is most commonly found on the mentum (Fig. using gas anesthesia, the endotracheal tube should be
19.24). Consequently, the mentum is that portion of the inserted into the trachea through a nasal cavity so that the
mandible that is most frequently amputated. Other neo- oral cavity is maximally exposed. Administering a bilateral
plasms sometimes encountered on the mentum include the mental nerve block after the horse is anesthetized allows the
carcinoma (Fig. 19.25) and ameloblastoma. Another indica- horse to be maintained at a lighter depth of anesthesia. To
tion for amputation of the rostral aspect of the mandible is perform the surgery with the horse standing, the mandibular
fracture of the mentum not amenable to repair. alveolar nerves are desensitized by injecting local anesthetic
The rostral portion of the mandible can be amputated solution through a needle inserted through the mental
with the horse anesthetized and in dorsal recumbency or foramen into the mandibular canals. If deformity of the
with the horse sedated using local or regional anesthesia to mentum from disease makes inserting a needle into the
desensitize the mentum. The horse should receive an anti- canals difficult, the mentum can be desensitized by infusing
microbial and an anti-inflammatory drug prior to surgery. If the submucosa around the site at which the mandible is to
the procedure is performed with the horse anesthetized be amputated with local anesthetic solution.

305
 19 Treatment

The horse’s mouth is maintained in an opened position the rostral portion of the mandible must be amputated
with a wedge speculum inserted between the cheek teeth, caudal to the symphysis, fixing the right and left hemimandi-
and the rostral aspect of the mandible prepared for surgery. bles to each other may be necessary, using a spacer, such
The gingiva is incised horizontally at the ventral margin of as a portion of rib, at the site of amputation to maintain
the abnormal bone, and the incision is extended through the the proper relationship of the dentition of each hemimand-
periosteum. Each end of the incision is directed dorsally to ible to its opposing maxillary dentition. However, one of us
the center of the right and left interalveolar spaces. At the (JS) amputated the rostral portion of a horse’s mandible
dorsal aspect of the horizontal ramus of each hemimandi- caudal to the symphysis, without fixing the hemimandibles
ble, each end of the incision is redirected rostrally to the to each other, and this horse suffered no postoperative
corner incisor and then medially until the ends of the inci- complications.
sion meet on the midline caudal to the central incisors. The
mucoperiosteal flaps created are reflected 15–20 mm beyond
the margin of the abnormal bone using a curved, periosteal
elevator.
The mandible is transected caudal to the lesion but rostral
to the caudal margin of the symphysis using an oscillating
saw or obstetrical wire (Figs 19.26 & 19.27). If necessary,
hemorrhage from the mandibular stump can be ameliorated
by applying bone wax to the cut edge of the bone. Sharp
edges of bone are smoothed with a rongeur. The submucosa
and periosteum of the lingual flap are apposed to the sub-
mucosa and periosteum of the labial flap, using 2-0 or
0-absorbable suture in a simple-continuous or cruciate
suture pattern, and the mucosal margins of the flaps are
apposed with simple-interrupted, cruciate, or vertical mat-
tress sutures using the same suture material (Fig. 19.28).
Inserting a Penrose drain into the space between the two
flaps through a stab incision created on the ventral aspect of
the mentum prevents formation of a hematoma between the
two flaps. Phenylbutazone should be administered twice
daily for at least several days after surgery to provide
analgesia.
The appearance of a horse that has had the rostral aspect
of its mandible amputated in this fashion is nearly normal,
Fig. 19.27  Transected portion of the jaw containing a juvenile, ossifying
but the procedure imparts slight flaccidity of the lower lip fibroma.
(Fig. 19.29). Horses are able to prehend grain and grass
normally.62 Initially, the tongue may protrude intermittently
between the lips.
If a portion of the symphysis is left intact, the need
for internal fixation of the mandibles is avoided, but if

Fig. 19.26  The mandible is transected caudal to the lesion but rostral to
the caudal margin of the symphysis using an oscillating saw or obstetrical Fig. 19.28  The lingual flap and labial mucoperiosteal flaps are apposed in
wire. two layers using absorbable sutures.

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 Basic equine orthodontics and maxillofacial surgery

Fig. 19.30  In preparation for premaxillectomy, the upper lip is retracted

with a towel clamp to expose the vestibule. The horse’s mouth is
maintained in an opened position with a wedge speculum inserted
between the maxillary and mandibular cheek teeth.

Fig. 19.29  The facial appearance of a horse that has had the rostral aspect
of its mandible amputated is nearly normal, except for slight flaccidity of the
lower lip.

Premaxillectomy
Indications for premaxillectomy are the same as those for
partial mandibulectomy, but the procedure is not performed
as frequently as is partial mandibulectomy because ossifying
fibroma is not as commonly encountered on the premaxillae
as it is on the mandible.
Premaxillectomy is performed in a manner similar to that
described for partial mandibulectomy, but the procedure is
best performed with the horse anesthetized because, with
this procedure, the large palatine arteries are transected.
Administering a bilateral infraorbital nerve block after the Fig. 19.31  The palatal and labial, mucoperiosteal flaps are apposed in two
horse is anesthetized allows the horse to be maintained at a layers with absorbable sutures.
lighter depth of anesthesia. The horse should receive antimi-
crobial and anti-inflammatory drugs prior to surgery. To
perform premaxillectomy, the horse is anesthetized, and an surface of the premaxillae and maxillae to at least 1 cm
endotracheal tube is inserted nasally, rather than orally, so beyond the intended site of transection. The palatine,
that the oral cavity is maximally exposed. Anesthesia is best mucoperiosteal flap is also elevated to its base at the inter-
maintained using gas anesthesia. The horse is positioned in alveolar space to expose the palatine surface of the prema­
dorsal recumbency, and the oral cavity and surrounding skin xillary and maxillary bones and the palatine processes of
are prepared for surgery. The upper lip is retracted and the premaxillae.
attached to the skin over the nasal bones with a towel clamp The exposed bone of the upper jaw is then excised, caudal
to expose the vestibule. The horse’s mouth is maintained in to the lesion, using obstetrical wire or an oscillating saw.
an opened position with a wedge speculum inserted between The palatine arteries are ligated, and hemorrhage from the
the maxillary and mandibular cheek teeth (Fig. 19.30). maxillae is ameliorated, if necessary, by applying bone
A horizontal incision through the gingiva and periosteum wax to the cut edge of bone. If the canine teeth were
is made on the labial surface of the premaxillae at the dorsal transected, the portion of each tooth that remains embedded
border of the mass, and each end of the incision angled within the maxillae is removed by using a bone gouge. Sharp
caudoventrally to the right and left interalveolar spaces edges of bone are smoothed with a rongeur, and the submu-
aiming toward the caudal border of the canine teeth. Both cosa and periosteum of the labial, mucoperiosteal flap are
ends of the incision are redirected rostrally from the alveolar apposed to the submucosa and periosteum of the palatine,
border of the hard palate to the corner incisors and then mucoperiosteal flap with 2-0 or 0-absorbable suture in a
medially until the ends of the incision meet on the midline simple-continuous or cruciate suture pattern, and the
caudal to the central incisors. Hemorrhage is controlled by mucosal margins of the flaps are apposed with simple-
ligating or cauterizing blood vessels. Using a periosteal ele- interrupted, cruciate, or vertical mattress sutures using the
vator, the upper lip and nostrils are elevated from the labial same suture material (Fig. 19.31). Phenylbutazone should

307
 19 Treatment

Fig. 19.32  The facial appearance of a horse that has had a premaxillectomy Fig. 19.33  Wry nose is a congenital deviation and shortening of the rostral
is nearly normal, but the horse’s tongue may protrude intermittently aspect of the nose.
between its lips.

be administered twice daily for at least several days after Wry nose may be accompanied by other abnormalities, such
surgery to provide analgesia. Removing a lesion that extends as cleft palate (i.e., palatoschisis) and abnormal arching of
beyond the canine teeth using this technique is difficult the nasal bones and hard palate.
without entering the nasal cavities or removing a portion of Most affected foals are capable of nursing and can survive
the nasal septum. without treatment, but severely affected foals may be unable
The facial appearance of a horse that has had a premaxil- to nurse and may require immediate, intensive manage-
lectomy performed in the manner described is nearly normal ment. A slightly deviated nose may straighten as the horse
(Fig. 19.32). Horses can prehend hay and grain, and can matures,31 but for horses with moderate or severe deviation,
graze tall grass without difficulty but may have difficulty surgical treatment is required to improve respiratory capac-
grasping short grass.63 Initially, the horse’s tongue may pro- ity, occlusion of the incisors, and cosmetic appearance. To
trude intermittently between its lips. surgically correct the deviated nose, the maxillae/premaxil-
lae and nasal bones are transected at their point of maximum
curvature and stabilized in proper alignment, and a portion
Wry nose of the nasal septum is excised. The nasal bones can be
straightened and a portion of the septum removed 2 or 3
Wry nose, or campylorrhinus lateralis, is a congenital deviation months after the premaxillae/maxillae are straightened,13
and shortening of the rostral aspect of the bones of the nose but to decrease time of convalescence and expense associ-
(i.e., maxillae, premaxillae, nasal bones, vomer bone, and ated with the procedure, the entire deviation can be cor-
nasal septum; Fig. 19.33). Wry nose has been reported to rected during one anesthetic period.11
occur in a wide variety of horse breeds, but the malformation The deviation is corrected with the horse anesthetized,
may be most prevalent in the Arabian breed, causing specu- preferably using gas anesthesia, and positioned in dorsal
lation that the condition may be genetic.64 Inheritance of wry recumbency. The gas anesthetic agent should be delivered
nose, however, has not been reported. Failure of the uterus, through an endotracheal tube inserted through a temporary
particularly that of primiparous mares, to expand to accom- tracheostomy, rather than orally, to provide maximal expo-
modate the fetus as it grows has also been hypothesized to sure of the oral cavity. The horse should receive an antimi-
be responsible for the anomaly.31 crobial and an anti-inflammatory drug prior to surgery. The
The nose of the affected horse may be deviated mildly or horse can be administered a bilateral infraorbital nerve block
severely (e.g., up to 90°) causing all or some of the premaxil- after anesthetic induction, so that it can be maintained at a
lary incisors to fail to contact the mandibular incisors, but lighter depth of anesthesia.
the deviation typically does not involve the maxillary cheek Before straightening the maxillae/premaxillae, a section of
teeth. An affected foal may have trouble nursing,65 and its rib to be grafted at the site of maxillary/premaxillary oste-
nasal septum may be so severely deviated that it has sterto- otomy is harvested. After preparing the right or left aspect of
rous respiration, even when resting. The nasal cavity on the the thorax for aseptic surgery, a 10 cm long, cutaneous inci-
convex side of the deviation is the most severely obstructed. sion is created over one of the most caudal ribs. The incision

308
 Basic equine orthodontics and maxillofacial surgery

begins at the costochondral junction and extends dorsally, retracted and attached to the skin over the bridge of the nose
through the skin, subcutaneous tissues, and periosteum, with a towel clamp to expose the vestibule, which is cleansed
along the longitudinal axis of the rib. Periosteum is reflected with an antimicrobial soap and rinsed with water. A 3-cm,
from the exposed rib, and a 2- to 4 cm long section of rib is longitudinal, mucosal incision centered at the point of great-
transected using obstetrical wire or an oscillating saw. The est curvature is created in each interalveolar space over the
section of rib is stored in gauze sponges soaked in normal ventral aspect of each premaxilla/maxilla (Fig. 19.34). The
saline solution (0.9 % NaCl) until it is inserted later, at the incision extends through the periosteum, which is elevated
site of premaxillary/maxillary osteotomy, as a graft. Instilla- from the medial and lateral surfaces of the premaxilla/
tion of bupivacaine around the surgical site to desensitize maxilla using a periosteal elevator.
the intercostal nerve of the rib may diminish pain associated The premaxillae/maxillae and palatine processes of the
with the rib resection after the horse recovers from anesthe- premaxillae are transected though the mucoperiosteal inci-
sia. The periosteum, musculature, and subcutaneous tissue sions using an oscillating saw (Fig. 19.35). The oral specu-
are sutured separately with 2-0 absorbable suture placed in lum is removed, and the transected, rostral portion of the
a simple-continuous pattern, and the skin is stapled. A Stent upper jaw is rotated toward the sagittal plane of the head
bandage sutured over the site of surgery may decrease swell- until the premaxillary and mandibular incisors are properly
ing associated with the resection of the rib. aligned. A piece of bone, 1–3 cm long, that corresponds in
To straighten the premaxillae/maxillae, the horse’s mouth length to the length of the gap created on the concave side
is maintained in an opened position with a wedge speculum of the jaw when the maxillae/premaxillae are straightened is
inserted between the cheek teeth or with a Guenther oral cut from the harvested section of rib using an oscillating saw,
speculum inserted between the incisors. The upper lip is and this piece of bone is inserted tightly into the gap.

Fig. 19.34  The ventral border of each

premaxilla/maxilla is exposed through a
longitudinal mucosal incision at the interalveolar
space centered at the site of greatest curvature.
(From Schumacher J, Brink P, Easley, J, et al.
Surgical correction of wry nose in four horses.  
Vet Surg 37:142–148, 2008. Illustrations by D.K.
Haines © 2007 the University of Tennessee.)

Interalveolar space
mucosal incision

©2007 The University of Tennessee

Fig. 19.35  Dashed lines indicate sites of

transection of the premaxillae/maxillae and nasal
bones. (From Schumacher J, Brink P, Easley, J,  
et al. Surgical correction of wry nose in four
horses. Vet Surg 37:142–148, 2008. Illustrations by
D.K. Haines © 2007 the University of Tennessee.)

A B
©2007 The University of Tennessee

309
 19 Treatment

Wedge osteotomy

©2007 The University of Tennessee

Fig. 19.37  The transected end of each nasal bone can be fixed to its
parent nasal bone using a dynamic compression plate or a reconstruction
plate. (From Schumacher J, Brink P, Easley J, et al. Surgical correction of wry
nose in four horses. Vet Surg 37:142–148, 2008. Illustrations by D.K. Haines  
© 2007 the University of Tennessee.)

two deviated nasal bones. The nasal bones are exposed using
©2007 The University of Tennessee a self-retaining retractor, and the periosteum is incised long­
itudinally, along the midline of each nasal bone, and the
Fig. 19.36  Rostral view. Dashed lines show path of Steinmann pins for
fixation of the transected premaxillae/maxillae. Stippled pattern shows gap
margins of the periosteal incisions are reflected.
in premaxillae/maxillae and nasal bones created by transection and The nasal bones are transected perpendicular to their long
realignment of the bones. The gap created when the transected nasal axis at their point of maximum curvature by using an oscil-
bones are realigned along the longitudinal axis of the skull is eliminated by lating saw, being careful not to penetrate the underlying
performing a wedge osteotomy at the convex side of the nasal bones at the parietal cartilage. The gap created on the concave side of the
site of transection. (From Schumacher J, Brink P, Easley J, et al. Surgical deviation when the bones are rotated into proper alignment
correction of wry nose in four horses. Vet Surg 37:142–148, 2008. Illustrations
can be eliminated by inserting a wedge-shaped segment of
by D.K. Haines © 2007 the University of Tennessee.)
one of the cortices of the harvested section of rib into the
gap, or the gap in the nasal bones can be eliminated by
The transected segment of the upper jaw is stabilized with performing a wedge osteotomy at the convex side of the
2, trocar-point Steinmann pins (6-mm diameter), using a nasal bones at the site of transection by using an oscillating
high-speed, pneumatic drill (Figs 19.36 & 19.37). Each pin saw (Fig. 19.36).
is inserted between the reserve crowns of the deciduous The transected end of each nasal bone is fixed to its parent
central and intermediate incisors, dorsal to the gingival bone using a 2.7 mm reconstruction plate (Fig. 19.38). The
margin, and driven through the medullary cavity of the plates are fixed with 8-mm long, 2.7-mm cortical screws. The
transected segment of the ipsilateral premaxilla into the transected segments of the nasal bones can also be fixed to
medullary cavity of the ipsilateral maxilla. The pin inserted the parent nasal bones with 1-mm diameter Kirschner wires
on the concave side of the jaw also penetrates the medullary by using a high-speed drill. These Kirschner wires are
cavity of the rib graft. Pins are cut flush with the gingiva inserted, caudal to rostral, between the internal and external
using a hacksaw or a bolt cutter, and the pins are driven laminae of the thin, transected end of each nasal bone so
beneath the gingiva using a mallet and a punch. The sites of that each emerges through the dorsal surface of the nasal
gingival penetration of the pins are left unsutured to heal by bone and skin at the level of the external nares. The wires
second intention. The gingival incisions at the interalveolar are then inserted retrograde, between the internal and exter-
space are closed with 2-0 absorbable suture placed in a nal laminae of the parent nasal bones. The exposed ends of
simple-interrupted or simple-continuous pattern. the wires are cut flush with skin. The Kirschner wires are
To straighten the nasal bones and remove the nasal more difficult to implant because the thickness of the nasal
septum, either during the same anesthetic period or 6–8 bones is not much more than the diameter of the pins,
weeks later, the horse is positioned in lateral recumbency, making insertion of the pins between the internal and exter-
with the concave side of the deviation uppermost. The dorsal nal laminae of the bones, without penetrating the nasal or
aspect of its head is tilted 45° using a sand bag. After prepar- facial surface of the bone, difficult. The subcutaneous tissue
ing the bridge of the nose for surgery, a 6- to 10 cm, longi- is sutured with 2-0 absorbable suture in a simple continuous
tudinal, curved, cutaneous incision, centered over the site of pattern, and the skin is stapled. A Stent bandage, composed
maximum deviation of the nasal bones, is made between the of gauze swabs, is sutured over the surgical site.

310
 Basic equine orthodontics and maxillofacial surgery

Fig. 19.38  (A) Rostral view. Dashed lines denote

position of Steinmann pins. Thin lines in the nasal
bones denote Kirschner wires. (B) Lateral view.
Kirschner wires in nasal bones (denoted by thin
lines) and Steinmann pins in the premaxillae and
maxillae. Kirschner wires are inserted, caudal to
cranial, through the transected end of each nasal
bone, so that each pin emerges through the
dorsal surface of the bone and skin at the level  
of the external nares. The wires are then inserted
retrograde into the parent nasal bones. (From
Schumacher J, Brink P, Easley J, et al. Surgical
correction of wry nose in four horses. Vet Surg
37:142–148, 2008. Illustrations by D.K. Haines  
© 2007 the University of Tennessee.)

A B

©2007 The University of Tennessee

The nasal septum is removed with the horse in lateral additional stability provided by wiring incisors together is
recumbency with the dorsal aspect of its head elevated 45° not necessary for healing, and horses can be returned to their
with a sand bag, using a guarded chisel, a cartilage scissor, normal diet as soon as they recover from anesthesia.
or obstetrical wire, using any one of various published tech- Distraction osteogenesis may be another effective method
niques.66,67 Two–three centimeters of the rostral aspect of the of correcting wry nose.69 Using this technique, the premaxil-
septum are retained by the horse to provide support for the lae/maxillae are partially transected at their point of
soft tissues at the rostral aspect of the nose. The caudal cut maximum curvature, and a monolateral distraction external
edge of the septum should lie within the nasopharynx. skeletal fixator applied to the concave side of the deformity
When only the rostral, deformed portion of the nasal septum is used to periodically distract pins inserted rostral and
is removed, the airways become obstructed if the caudal, cut caudal to the osteotomy.69 Using this technique, the nasal
edge of the septum thickens, because this edge lies between bones and nasal septum, in addition to the premaxillae/
the conchae. The nasal chamber is packed tightly with rolled maxillae, apparently also straighten. A disadvantage of using
gauze, and the nostrils are sutured closed to retain the distraction osteogenesis to correct wry nose is that the horse
packing. The endotracheal tube is removed, either before or must be hospitalized for a prolonged time so that the exter-
after the horse recovers from anesthesia, and replaced with nal fixator can be frequently adjusted to maintain a distrac-
a tracheotomy tube. tive force. Danger of injury to the dam from the protruding
Gauze packing can usually be removed safely after 24 pins may prohibit use of the device to correct wry nose of a
hours, after which the tracheostomy tube is no longer nursing foal.
required. Phenylbutazone should be administered twice
daily for at least 5 days after surgery to provide analgesia.
Steinmann pins can be removed after 6 weeks, and plates or Oromaxillary sinus fistula
Kirschner wires can be left in situ. Because the upper jaw of
most horses affected with wry nose is foreshortened, the A relatively common complication of repulsion of one or
horse is likely to require periodic dental care tailored to more of the caudal four maxillary cheek teeth is formation
horses affected with prognathism. of an oromaxillary sinus fistula (orosinus or oro-antral
Excising the nasal septum has been reported to result in fistula) resulting in contamination of the paranasal sinuses
collapse of the nasal bones into the nasal chamber, and col- with feed.70,71 This complication occurs in up to 33 % of
lapse seems most likely to occur if the horse is <1 year old.67 horses suffering apical dental infection of one or more of the
Support of the nasal bones by anchoring each transected caudal maxillary cheek teeth (Triadan 09–011) treated by
segment of nasal bone to its parent bone with either Kir- repulsion of the infected tooth into the oral cavity.71An oro-
schner wires or plates and screws prevents collapse of the maxillary sinus fistula can also develop secondary to an
nasal bones. Collapse of the alar folds and ventral aspect of acquired or developmental diastema between two of the
the nasal diverticula resulting in abnormal respiratory noise caudal maxillary cheek teeth.72 During mastication, food is
or partial obstruction of the nasal passage may be evident compressed into the diastema, causing destruction of the
after surgery.11 Resecting the alar folds may be necessary to periodontium that may eventually result in formation of an
resolve the abnormal respiratory noise and partial obstruc- oromaxillary sinus fistula, especially if the horse is old,
tion of the nasal passage. because old horses have short cheek teeth.
Fixing the premaxillary incisors to the mandibular incisors Repulsing a maxillary molar or the fourth maxillary
with wire to increase stability at the sites of premaxillary/ premolar creates a large communication between the oral
maxillary osteotomy has been recommended,68 but the cavity and the paranasal sinuses, and the coronal aspect of

311
 19 Treatment

this communication is usually plugged with gauze or acrylic structures should be clean and dry. The fistula should be
until its apical aspect fills with tissue. An oromaxillary sinus surrounded by a tooth both rostrally and caudally because
fistula results if this communication fails to fill with tissue. the acrylic requires a hard surface to attach to. The plug can
The communication may fail to heal if the alveolus becomes be applied per os or through a sinusotomy. The plug should
chronically infected, usually from sequestration of dental or not extend into the apical aspect of the fistula. If an over-
osseous fragments that were either left in the alveolus at the growth or exaggerated transverse ridge is present on oppos-
time of surgery or from osseous sequestra that formed later ing cheek teeth, it should be reduced.
due to damage to the blood supply of the alveolus caused Horses with an oromaxillary sinus fistula that is refractory
by surgical trauma. to treatment by plugging the coronal aspect of the fistula
Premature loss of the alveolar plug or overfilling the alveo- with acrylic can be treated by occluding the lumen of the
lus so that the plug extends into the sinuses can also result alveolus with the end of a transposed muscle, such as the
in formation of an oromaxillary sinus fistula.70,71,73 When the levator nasolabialis muscle74 or levator labii superioris
alveolus is overfilled with the plug, the entire alveolus epi- muscle.75 The levator nasolabialis muscle is difficult to mobi-
thelializes around the plug, so that when the plug is removed lize, and because it is flat, it fits poorly into the oromaxillary
or lost, the sinuses communicate with the oral cavity through sinus fistula.75 The levator labii superioris muscle is ellipsoid
an epithelialized alveolus. The alveolus of old horses is more in its transverse plane, making it ideal for filling an
likely to be overfilled than that of young horses because the alveolus.
alveoli of old horses are short. To transpose the levator labii superioris muscle to the
Most horses with oromaxillary sinus fistula can be treated oromaxillary sinus fistula, as described by Brink (2006),75
while sedated by lavaging feed and exudate from the sinuses the horse is anesthetized, positioned in lateral recumbency
through a trephine portal and temporarily plugging the with the affected side of the head uppermost, and prepared
coronal aspect of the vacant alveolus with gauze or acrylic for surgery of the oral cavity and face.
until the apical aspect of the alveolus fills with tissue.72 The skin over the maxilla is incised longitudinally, with
Before sealing the oral aspect of the alveolus, epithelium that the incision centered over the apex of the oromaxillary sinus
lines the alveolus and infected granulation tissue that fills it fistula, and the paranasal sinuses and the opening of the
are removed by curettage. Horses with an oromaxillary sinus fistula into the sinuses are exposed through a trephine hole.
fistula that has occurred secondary to a diastema may also The epithelial lining of the alveolus is removed by curettage,
respond to plugging the oral aspect of the diastema with an and the sinuses and fistula are lavaged with isotonic saline
acrylic, without removal of an adjacent tooth.72 The primary solution.
complication associated with this form of treatment is loos- The palpable tendon of the levator labii superioris muscle
ening or loss of the plug during the 2 to 3 weeks that it takes is exposed through a 2-cm longitudinal skin incision created
for granulation tissue to fill the fistula. The most effective directly over the tendon and transected 2 cm rostral to its
plug is one composed of polymethylmethacrylate.72 To musculotendinous junction (Fig. 19.39). A locking-loop
prevent the acrylic plug from loosening, the plug should not suture with long tails is placed in the tendon. The muscle
be in contact with the cheek teeth in the opposing arcade, and tendon are bluntly separated from the underlying maxil-
and when the acrylic is applied, the surrounding dental lary and nasal bones and overlying subcutaneous tissue,

Fig. 19.39  This figure shows the site incisions

created to expose the levator labii superioris
muscle. (From Brink P. Levator labii superioris
muscle transposition to treat oromaxillary sinus
fistula in three horses. Vet Surg 35:596–600, 2006.)

312
 Basic equine orthodontics and maxillofacial surgery

Fig. 19.40  Using a hand placed in the oral

cavity, the levator labii superioris muscle is
transposed through the maxillary sinus and
orosinus fistula. (From Brink P. Levator labii
superioris muscle transposition to treat
oromaxillary sinus fistula in three horses. Vet Surg
35:596–600, 2006.)

using scissor dissection through the small incision created slight tension to the skin and musculature at the ventral
to expose the tendon and through the dorsal margin of the buccal incision with several, simple interrupted sutures.
cutaneous incision over the maxilla, to the muscle’s origin A drain tube is placed in the space formerly occupied by
rostral to the eye. the levator labii superioris muscle (Fig. 19.43). One end of
A grasping forceps is inserted subcutaneously at the dor- the drain exits a stab incision created about 1 cm rostral
sorostral margin of the incision over the maxilla and to the end of the incision created over the tendon of the
advanced rostrally beneath the levator nasolabialis muscle levator labii superioris. Another drain is placed subcutane-
until it emerges at the incision created to expose the tendon ously at the maxillary incision. One end of this drain exits a
of the levator labii superioris muscle. The ends of the suture stab incision created 1–2 cm ventral to the rostral end of the
in the tendon are grasped with the forceps, and by pulling maxillary incision, and the other end exits a stab incision
them caudoventrally, the muscle and its tendon are retro- created 1–2 cm ventral to the caudal end of the maxillary
verted into the incision over the maxilla (Fig. 19.40). A 2-cm, incision (Fig.19.43). Each end of each drain is secured with
longitudinal, buccal skin incision is created adjacent to the a simple-interrupted skin suture. If the sinuses must be
oral aspect of the oromaxillary sinus fistula, and the jaws of lavaged, a Foley catheter is placed into the ipsilateral caudal
a mosquito forceps are forced into the oral cavity through maxillary sinus or conchofrontal sinus through a small tre-
this incision. The suture ends are inserted through the oro- phine portal.
maxillary sinus fistula into the oral cavity, and using hand The ventral buccal incision, through which the tendon of
assistance through the mouth, the suture ends are grasped the levator labii superioris muscle protrudes, is left unsu-
with the forceps. By placing traction on the suture with the tured to heal by second intention. The other incisions are
forceps, the tendon and muscle of the levator labii superioris closed in two layers. A Stent bandage, composed of sterile
are pulled into the oromaxillary sinus fistula and through gauze sponges, is sutured over the maxillary incision with
the buccal incision so that the muscle completely occupies heavy, non-absorbable suture. Any space at the oral aspect
the oromaxillary sinus fistula (Fig. 19.41). of the alveolus unoccupied by muscle is filled with a dental
A 5-mm, longitudinal skin incision is made about 2–4 cm acrylic.
ventral to the buccotomy, and using a curved mosquito The drains in the rostral wound and the maxillary wound
hemostat inserted through the incision, the skin between are removed when drainage ceases. The Stent bandage is
this incision and the buccotomy is undermined. The ends of removed after 3 or 4 days, and skin sutures are removed at
the suture in the tendon are grasped with the forceps and 2 weeks. The paranasal sinuses are lavaged once or twice
pulled subcutaneously, causing the tendon to emerge at the daily until lavage is no longer required. The portion of
ventral incision (Fig. 19.42). The tendon is secured under muscle located within the oral cavity sloughs at about a

313
 19 Treatment

Fig. 19.42  The tendon of the levator labii superioris is tunneled

subcutaneously beneath the buccotomy, exited through the buccal skin,  
and secured with sutures. (From Brink P. Levator labii superioris muscle
transposition to treat oromaxillary sinus fistula in three horses. Vet Surg
Fig. 19.41  Cross-section of head showing the position of the transposed 35:596–600, 2006.)
levator labii superioris muscle and tendon through the maxillary sinus,
orosinus fistula, and cheek. (From Brink P. Levator labii superioris muscle
transposition to treat oromaxillary sinus fistula in three horses. Vet Surg
35:596–600, 2006.)

Fig. 19.43  This figure shows surgical drains

placed subcutaneously and a Foley catheter
placed into the paranasal sinuses for lavage of  
the sinuses. (From Brink P. Levator labii superioris
muscle transposition to treat oromaxillary sinus
fistula in three horses. Vet Surg 35:596–600, 2006.)

week, and is removed through the oral cavity, after cutting and nasal function, but care should be taken when perform-
the sutures anchoring the tendon to the ventral buccal inci- ing a lateral buccotomy to avoid damaging the dorsal buccal
sion. The portion of muscle within the alveolus remains branch of the facial nerve because permanent damage to this
vital. branch of the facial nerve results in permanent flaccidity of
Transposing the levator labii superioris muscle and its the lip. Care should also be taken to avoid damage to the
tendon does not appear to have deleterious effects on labial duct of the parotid salivary gland.

314
 Basic equine orthodontics and maxillofacial surgery

Sinocutaneous fistula expose the muscle or tendon, and through the margin of the
sinocutaneous fistula. A grasping forceps is inserted and
A sinocutaneous fistula is a permanent defect that extends advanced subcutaneously at the margin of the fistula until it
from the skin into the paranasal sinuses (Fig. 19.44). Those emerges at the incision created to expose the muscle to be
that occur in horses are most commonly the result of transposed. The ends of the suture in the muscle or tendon
an open, comminuted fracture involving facial bones, but are grasped with the forceps, and by placing traction on
they can also result when a sinus flap or trephine portal fails them, the muscle is pulled beneath skin interposed between
to heal. its transected end and the sinocutaneous fistula. The fistula
Full-thickness defects over the sinuses decrease in size after is covered with the transposed muscle, and the muscle is
injury by centripetal movement of the tissue surrounding the sutured to fascia surrounding the fistula. The muscle is
defect. When the defect is large, the skin heals to the mucosa covered with a rotational skin flap or a free, full-thickness or
of the sinus, forming a completely epithelialized surface that split-thickness, meshed or non-meshed skin graft.
prevents the defect from closing completely. The size of the A sinocutaneous fistula can be healed with one large perio-
defect can sometimes be decreased by incising the mucocu- steal flap that covers the fistula or two, small periosteal flaps
taneous margin of the fistula and elevating the surrounding that are joined over the center of the fistula.78 This surgery is
skin to initiate contraction of the wound. A sinocutaneous best performed with the horse anesthetized and in lateral
fistula that cannot be healed in this manner can be healed recumbency with the side of the head containing the fistula
using transposed muscle, such as the temporalis muscle,76 uppermost. The dorsal aspect of the head is tilted 45° using
the levator nasolabialis muscle,77 or the levator labii superi- a sand bag, and the skin around the defect is prepared for
oris muscle,75 or by covering the fistula with periosteum aseptic surgery. The mucosa is separated from the skin
reflected from the margin of the fistula.78 around the mucocutaneous border of the fistula with a
Muscle transposed to cover a sinocutaneous fistula pro- scalpel, and skin surrounding the fistula is freed from its
vides vascularized tissue to the wound that is capable of underlying subcutaneous tissue. The periosteum adjacent to
accepting a rotational skin flap or a free skin graft. The tem- the fistula is exposed by creating a rotational skin flap adja-
poralis muscle is in close proximity to a sinocutaneous cent to the fistula. A curved incision is made through the
fistula involving the conchofrontal sinus, and the levator periosteum on opposite sides of the fistula, unless perios-
nasolabialis and levator labii superioris muscles are in close teum is available on only one side. Each incision is slightly
proximity to a sinocutaneous fistula involving the rostral or longer than the length of the fistula and curved away from
caudal maxillary sinuses. To heal a sinocutaneous fistula by the fistula. The periosteum within the curved incision on
transposing a muscle, the horse is anesthetized and posi- each side is elevated toward the fistula, creating two flaps,
tioned in lateral recumbency with the side of the head con- each of which remains attached at its base, which is the
taining the sinocutaneous fistula uppermost. The dorsal border of the fistula. The periosteal flaps are sutured together
aspect of its head is tilted 45° using a sand bag. The muco- with the inner, or osteogenic, layer outermost over the
cutaneous margin of the fistula is incised, and the margin of defect, using simple interrupted, absorbable sutures. The
the skin surrounding the fistula is elevated. A skin incision rotational skin flap is sutured over the periosteal flap. Sub-
is made over or close to the insertion of the muscle to be cutaneous tissue exposed by covering the defect with the
transposed, and through this incision the muscle or its rotated skin flap can be covered with a full-thickness or split-
tendon is transected. A locking-loop suture with long tails is thickness, meshed or non-meshed skin graft (Fig. 19.45).
placed in the severed end of the muscle or tendon, and the The full-thickness graft is harvested from the pectoral region
muscle is bluntly freed from its fascial attachments, using and the split-thickness skin graft is harvested from the ventral
scissor dissection through the small incision created to

Fig. 19.45  Same horse as in Fig. 19.44 after sinocutaneous fistula was
closed using periosteal and rotational skin flaps. Subcutaneous tissue
Fig. 19.44  This horse has a permanent defect (i.e., sinocutaneous fistula) exposed by the rotational skin flap has been covered with a full-thickness,
that extends from the skin into the paranasal sinuses. meshed skin graft procured from the pectoral region.

315
 19 Treatment

aspect of the abdomen. A non-adherent dressing is placed bone, harvested from the sternum or wing of the ilium, can
over the surgery site, and the dressing is covered with a Stent be used to augment periosteal bone formation, but is not
bandage or gauze pads and elastic adhesive tape. The site necessary for the successful closure of the defect. Creating
from which the full-thickness graft was obtained is sutured two small periosteal flaps, rather than one large flap, is more
in two layers. effective at preserving the blood supply to the edges of the
The osteogenic, or cambium, layer of the periosteal flaps flaps, but creating two flaps may be difficult if the fistula is
forms new bone, and bone denuded of periosteum to create in an area where periosteum is available on only one side of
the periosteal flaps forms new periosteum.78 Cancellous the lesion.

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deviated nasal septum and premaxilla in AN, Moore JN, Lippincott JB, eds. 38. Academy of Veterinary Dentistry. Dental
a colt. J Am Vet Med Assoc 1978; 173: Current practice of equine surgery, abbreviations, Equine dental
1001–1004 Philadelphia, 1990, pp. 469–472 abbreviations Suppl, 2007, pp 15–17

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39. Carmalt JL. Understanding the equine 52. Mitz C, Allen T. Dentistry in miniature in a horse. Australian Veterinary Journal
diastema. Equine Veterinary Education horses. In: Allen T, ed. Manual of equine 1993; 70: 112–114
2003; 5(1): 43–44 dentistry. Mosby, St Louis, 2003, 66. Doyle AJ, Freeman DE. Extensive nasal
40. Greene S, Basile JP. Recognition and pp 175–192 septum resection in horses using a 3-wire
treatment of equine periodontal disease. 53. Pence P, Mitz C. Miniature horse method. Veterinary Surgery 2005; 34:
In: Proceedings of the 48th Annual dentistry. In: Pence P, ed. Equine 167–173
Convention of the American Association dentistry: a practical guide. Lippincott, 67. Tulleners EP, Raker CW. Nasal septum
of Equine Practitioners, 2002, Williams, and Wilkins, Baltimore, 2002, resection in the horse. Veterinary Surgery
pp 463–466 pp 191–199 1983; 12: 41–47
41. Vlaminck L. Post-extraction molariform 54. Baker GJ . Problems involving the mouth. 68. Auer JA. Craniomaxillofacial disorders.
tooth drift and alveolar grafting in In: Reed S, Bayly W, eds. Equine internal In: Auer JA, Stick JA, eds. Textbook of
horses. PhD thesis. University of Ghent, medicine. WB Saunders, Philadelphia, equine surgery, 3rd edn. Elsevier,
Ghent, 2007, pp 209–223 1998, p. 605 Philadelphia, 2006, pp 1341–1362
42. Vlaminck L, Hays L, Maes D, et al. Use of 55. Easter JL, Watkins JP. Diseases of the 69. Puchol JL, Herrán R, Durall L, et al.
a synthetic bone substitute to retard head and neck. In: Colahan PT, Merritt Use of distraction osteogenesis for the
moliform tooth drift after maxillary tooth AM, Moore JN, Mayhew JG, eds. Equine correction of deviated nasal septum and
loss in ponies. Vet Surg 2006; 35 (7): Medicine and Surgery. Mosby, St Louis, premaxilla in a horse. J Am Vet Med
587–588 1999, p. 1669 Assoc 2004; 224: 1147–1150
43. Carmalt JL, Townsend HGG, Allen LA. 56. Stashak TS. Equine wound management. 70. Baker GJ. Some aspects of equine dental
Effect of dental floating on the Lea and Febiger, Philadelphia, 1991, disease. Equine Vet J 1970; 2:
rostrocaudal mobility of the mandible of pp 139–144 105–110.
horses. J Am Vet Med Assoc 2003; 23: 57. American Veterinary Medical Association 71. Orsini PG, Ross MW. Retrospective study
666–669 Membership Directory. Principles of of tooth root abscesses in 110 horses.
44. Lear TL, Cox JH, Kennedy GA. Autosomal veterinary medical ethics of the AVMA Proceedings of the 16th Annual
trisomy in a thoroughbred colt: 65, XY, (1999 revision) IV. Therapies, Genetic Veterinary Surgical Forum, 1988
+31. Equine Vet J 1997; 31(1): 85–88 Defects, 2003, 36 72. Dixon PM, Hawkes C, Easley J. Standing
45. McLaughlin GB, Doige LE. Congenital 58. Schumacher J, Dutton DM, Murphy DJ, treatment of oronasal and orosinus
musculoskeletal lesions and hyperplastic et al. Paranasal sinus surgery in sedated, fistulas. Proceedings of the American
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Journal 1981; 22: 130 173–177 Symposium Equine and Small Animal,
46. Becker E. Zähne. In: Handbuch der 59. Doherty T, Valverde A. Management of 2007
speziellen pathologischen Anatomie der sedation and anesthesia. In: Doherty T, 73. Prichard MA, Hackett RP, Erb HN.
Haustiere, 3rd edn. Vol 5, Valverde A, eds. Manual of equine Long-term outcome of tooth repulsion in
Digestionsapparat. Verlag Paul Parey, anesthesia and analgesia. Blackwell, horses: a retrospective study of 61 cases.
Berlin, 1970, pp 83–313 Ames, Iowa, 2006, pp 206–208 Vet Surg 1992; 21: 145–149
47. Duke A. Equine bit analysis. Annual 60. Quinn GC, Kidd JA, Lane JG. Modified 74. Orsini P, Ross M, Hamir A. Levator
Conference of American Veterinary frontonasal sinus flap surgery in standing nasolabialis muscle transposition to
Dental Society, Handout notes. New horses: surgical findings and outcomes of prevent an orosinus fistula after tooth
Orleans, 1989 60 cases. Equine Vet J 2005; 37: 138–142 extraction in horses. Vet Surg 1992; 21:
48. Boero M. Correction of brachygnathism 61. Schumacher J, Honnas C, Smith B. 150–156
in foals. In: Allen T, ed. Manual of Paranasal sinusitis complicated by 75. Brink P. Levator labii superioris muscle
equine dentistry. Mosby, St Louis, 2003, inspissated exudate in the ventral conchal transposition to treat oromaxillary sinus
p. 173 sinus. Vet Surg 1987; 16: 373–377 fistula in three horses. Vet Surg 2006; 35:
49. Pence P, Wilewski K. Newborn, weanling 62. Richardson DW, Evans LH, Tulleners EP. 596–600
and adolescent horse dentistry. In: Pence Rostral mandibulectomy in five horses. 76. Campbell ML, Peyton LC. Muscle flap
P, ed. Equine dentistry: a practical guide. J Am Vet Med Assoc 1991; 199: closure of a frontocutaneous fistula in a
Lippincott, Williams and Wilkins, 1179–1182 horse. Vet Surg 1984; 13: 185–188
Baltimore, 2002, pp 115–139 63. Schumacher J, Kemper DL, Helman RG, 77. Dart A, Best P, Peatfield J. Reconstruction
50. Dixon PM, Hawkes C, Townsend W. Edwards JL. Removal of the premaxillae of a maxillary sinus defect in a horse
Complications of equine oral surgery. of a horse. J Am Vet Med Assoc 1996; using a levator nasolabialis muscle flap.
Vet Clin North Am Equine Pract 2009; 209: 118–119 Australian Veterinary Journal 1994; 71:
24: 499–514 64. Baker GJ. Abnormalities of development 379–380
51. Jayo M, Leipold HW, Dennis SM, and eruption. In: Baker GJ, Easley J, eds. 78. Schumacher J, Auer J, Shamis L. The use
Eldridge FE. Brachygnathia superior and Equine dentistry. WB Saunders, of periosteal flaps to repair facial defects
degenerative joint disease, a new lethal Philadelphia, 1999, pp 49–59 in two horses. Vet Surg 1985; 14:
syndrome in Angus calves. Veterinary 65. McKellar GM, Collins AP. The surgical 235–239
Pathology 1987; 24: 148–155 correction of a deviated anterior maxilla

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 Section 5:  Treatment

C H A P T ER  20 
Exodontia
W. Henry Tremaine† BVet Med, M Phil, Cert ES, Dip ECVS, MRCVS,
James Schumacher* DVM, MS, MRCVS, Dip ACVS
†
Senior Lecturer, Department of Clinical Veterinary Sciences, University of Bristol, Langford House, Langford, Bristol BS40 5DU, UK
*Department of Large Animal Clinical Sciences, College of Veterinary Medicine, University of Tennessee, Knoxville,
TN 77901-1071, USA

Introduction and the preference of the veterinary surgeon performing the

procedure. Regardless of the technique used, the principle
A tooth should be removed only when it is proven to be rule of removing a tooth, summarized by Lane,3 ‘to remove
diseased and only after other more conservative treatments the tooth, the whole tooth and nothing but the tooth,’
to salvage the tooth have failed or are likely to fail. Because remains valid in all situations, excluding those where exten-
of technical limitations of preserving a hypsodont tooth by sively diseased bone surrounds the tooth. The principles of
endodontic treatment, removing a severely diseased cheek dental extraction in human beings, summarized by Shira, are
tooth often remains the only effective treatment for horses valid for the horse.4 These principles are:
with a diseased tooth. Extraction of a cheek tooth from 1. to obtain adequate access to the periodontium
horses was described early in the veterinary literature1 and, 2. to create an unimpeded pathway for removal of the
after the advent of anesthesia, was one of the first surgical tooth
procedures to be performed with the horse anesthetized. 3. to use controlled force to remove the tooth.
It remains the most frequently performed oral surgery of
When a diseased cheek tooth can be removed by an intra-
the horse.
oral approach, using a dental extractor, complications are
few and the horse requires little aftercare, but despite its
advantages, extraction per os of a diseased tooth along its
Indications for dental extraction natural path of eruption is often not feasible, and other
methods of removal must be considered. Removing a
The most common indication for removing a tooth is apical tooth using an intra-oral approach is difficult or impossible
dentoalveolar infection, which results most commonly from when the tooth’s clinical crown cannot be grasped with a
periodontal disease, infundibular caries of a maxillary cheek dental extractor (e.g., when a portion of the clinical crown
tooth, or hematogenous deposition of bacteria into the pulp is missing), when its reserve crown is fractured, when its
(i.e., anachoretic infection). Other indications for removing clinical crown is brittle because of extensive dental caries,
a tooth include: a retained deciduous incisor or premolar; a or when the reserve crown of the tooth is so large from
tooth affected by severe, irreversible periodontal disease; hyperplasia of the cementum or a dental tumor that it
a loose tooth; a tooth whose clinical crown has fractured; a cannot traverse the alveolus. When the tooth cannot be
supernumerary, displaced, or misaligned tooth causing clini- removed using an intra-oral approach, the tooth must
cal signs of disease; an impacted tooth; a tooth that has be removed by an extra-oral approach, which entails
become non-vital because of fracture of the jaw; a tooth with either repulsing the tooth into the oral cavity, using a
an overgrowth so severe that it has caused severe, soft-tissue mallet and a punch, or prying the tooth from the alveolus
trauma; a tooth that interferes with orthodontic surgery; and through a buccotomy after removing the lateral plate of
a tooth that has become neoplastic. alveolar bone.
Evidence that a tooth is diseased is usually obtained from Removal of a tooth, regardless of the technique used, has
clinical signs and oral and radiographic examination, but historically been thought of as a straightforward, unsophis-
other imaging techniques, such as computed tomography, ticated procedure, but the high incidence of complications
magnetic resonance imaging, or nuclear scintigraphy, must reported, particularly that associated with repulsion, shows
sometimes be used to determine if a tooth is diseased. Dental that removing a tooth can be a technically difficult procedure
extraction to resolve signs of dental disease is contraindi- that demands careful preparation, specialized equipment,
cated when the identity of the tooth causing these signs is and meticulous attention to technique to avoid complica-
not firmly established.2 tions. Before embarking on this potentially complicated pro-
The technique used to remove a tooth depends on the cedure, the veterinarian should discuss the potential costs
tooth involved, the nature of the disease affecting that tooth, and complications with the owner.

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 20 Treatment

Removal of incisors
Deciduous incisors, especially the middle (Triadan 02) and
corner (Triadan 03) incisors, are often involved in an
avulsion fracture of the mandible or an incisive bone (pre-
maxilla). Whenever possible, and whenever soft-tissue
attachments remain, the teeth should be salvaged by incor-
porating them into the fracture repair. Many incisors that
may initially appear to be devitalized can be salvaged, pro-
vided that they can be immobilized and that they remain at
least partially attached to their alveolus. Removing a com-
pletely devitalized deciduous incisor has minimal effect on
eruption of its permanent counterpart.
Failure of one or more deciduous incisors to shed when
their permanent counterparts erupt can result in misalign-
ment of the permanent teeth as they erupt (Fig. 20.1). These Fig. 20.2  Small periodontal elevators, such as these, are suitable for
retained incisors, which usually reside rostral to the perma- elevating incisors and ‘wolf teeth.’
nent incisors, rarely interfere with prehension of food, and
usually present a problem only with cosmesis. A deciduous
incisor can easily be removed with the horse sedated after
infiltrating the surrounding gingiva with local anesthetic
solution, such as mepivacaine or lidocaine. A deciduous
incisor has a short reserve crown, and its periodontal attach-
ments are easily loosened using a small, periodontal elevator
(Fig. 20.2). Once loosened, the tooth can be extracted using
a pair of small, wolf tooth extracting forceps (Fig. 20.3). The
alveolus fills rapidly with a blood clot, which is soon replaced
by granulation tissue, then by fibrous tissue, and finally
by bone.

Removal of supernumerary,
permanent incisors
Supernumerary, permanent incisors occur frequently and Fig. 20.3  Small dental extractors, such as these, are suitable for removing
vary in number from one to several. The supernumerary retained deciduous incisors.
permanent incisor usually has an occlusal surface that
appears similar to that of a normal incisor and has a reserve
crown that is often equal in length and shape to that of a
normal incisor (Figs 20.4 & 20.5). Supernumerary teeth that

Fig. 20.1  Retained middle upper deciduous incisor. A retained incisor

usually resides rostral to the permanent incisors. These shallow-rooted teeth Fig. 20.4  Supernumerary incisors are difficult to distinguish from the
can usually be removed without difficulty with the horse sedated, using normal incisors by their occlusal appearance and are usually of no clinical
local analgesia. significance.

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 Exodontia

Fig. 20.5  Temporary and permanent supernumerary incisors removed from

a pony.
Fig. 20.7  These avulsed mandibular incisors have been salvaged by
reducing the fracture and immobilizing it with cerclage wire.

permanent incisor may necessitate that the horse be anes-

thetized, especially if more than one tooth is to be removed,
because most horses are more sensitive to concussion of the
incisors than to concussion of the cheek teeth. If the horse
is compliant, however, a single, supernumerary, permanent
incisor can usually be removed with the horse sedated after
providing analgesia with an alpha-2 agonist and an opiate
and desensitizing the tooth and associated structures with a
maxillary or mandibular nerve block. (See Ch. 15).
A supernumerary, permanent incisor can be removed by
gradually elevating its periodontal attachment around the
entire circumference of the tooth until the tooth is loose
enough that it can be extracted with minimal force. Teeth
that are difficult to loosen can be extracted after raising a
Fig. 20.6  Their deep reserve crowns and their close proximity to each gingival flap by making two parallel, gingival incisions along
other make supernumerary incisors difficult to extract. The remaining teeth the peripheral margins of the reserve crown to expose the
align to provide a normal or near normal appearance to the incisors. The labial alveolar plate, which is removed using a narrow (e.g.,
benefit of removing supernumerary incisors is usually only cosmetic. This 1 cm wide) osteotome. The periodontal ligament is gradu-
picture shows an incisor arcade after permanent supernumerary incisors ally severed using a periodontal elevator until the incisor is
were removed.
loose enough to be extracted with a small incisor extraction
forceps.
resemble teeth of the normal series in crown and root mor-
phology are sometimes referred to as supplemental teeth. Removal of incisors after trauma
Radiographic examination is often useful to detect non-
Incisors that have separated totally from their gingival
erupted permanent incisors, but despite careful physical and
attachments as a result of avulsion of a portion of the inci-
radiographic examination of the incisors, distinguishing a
sive bone or rostral aspect of the mandible should be
supernumerary tooth from the usually identical surrounding
removed. Avulsed incisors that retain some gingival attach-
normal teeth can often be impossible. A supernumerary per-
ments may remain vital and can often be salvaged by debrid-
manent incisor imparts an asymmetric appearance to the
ing the wound and reducing and immobilizing the fracture
incisor arcade but usually causes minimal signs of disease,
(Fig. 20.7).
and affected horses rarely suffer any difficulty in prehending
feed. Removing a supernumerary incisor is usually unneces-
sary and serves only to improve the cosmetic appearance of Removing canine teeth
the horse. Although removing a supernumerary incisor
leaves a large gap between the remaining teeth, this gap The few indications for removing canine teeth include severe
disappears as the teeth realign (Fig. 20.6). periostitis, often associated with bit injuries, and pulpitis,
Removing a supernumerary incisor can be difficult because often resulting from fracture of the tooth or its alveolus.
these incisors have an extensive reserve crown and are in Canine teeth severely affected by the odontoclastic resorp-
close proximity to other teeth. Removing a supernumerary tion and hypercementosis syndrome may also require

321
 20 Treatment

Fig. 20.8  This canine, which was sensitive to percussion, was desensitized Fig. 20.9  This picture shows a range of equipment used to elevate gingival
with a mandibular alveolar nerve block before its gingival attachments were and periodontal attachments to a wolf tooth before the tooth is extracted
elevated. Canines have an extensive reserve crown, and so, to extract a with small forceps.
canine, a lateral alveolar ostectomy is often required.

infrequently displaced toward the buccal or palatal aspect of

extraction. Pulpitis can result in a painful, focal, apical
that tooth and may erupt far rostrally, close to the canine.
abscess, which in some cases discharges through a gingival
Some remain subgingival and are often detected as a hard,
tract. Removing the entire canine to prevent injury to other
subgingival nodule in the interdental space. An unerupted
horses or to facilitate dental examination is contraindicated
wolf tooth may occasionally be associated with gingival
and may result in spillage of the tongue from the mouth,
ulceration and may cause the horse to show signs of discom-
which may affect the horse’s performance, if the horse is a
fort when it is contacted by the bit. Radiographic examina-
show horse. Excessively sharp canines can be reduced slightly
tion of the tooth is useful to demonstrate the size and
and profiled using a rotating diamond burr.
direction of the embedded portion of the tooth before
Loose canines can be extracted using an incisor forceps or
attempting to extract the tooth. An erupting canine in the
a small animal dental forceps after elevating the periodon-
interdental space of a young horse (i.e., 2- to 4-year-old)
tium. The long, curved alveolus in which the apical portion
should not be mistaken for a displaced wolf tooth.
of the canine is embedded makes removing a canine with
Extracting the wolf teeth to resolve bitting problems was
an intact periodontium difficult. Removing a canine is facili-
described in the 18th century,6 and wolf teeth are still
tated by desensitizing the surrounding gingiva with local
removed today for this same reason, and sometimes because
anesthetic solution and raising a gingival flap to expose the
they are perceived to interfere with other dental procedures,
labial aspect of the alveolar bone, which is removed with an
even though scientific evidence of the benefit of extracting
osteotome (Fig. 20.8). The periodontal ligament surround-
them is lacking. Pain or sensitivity associated with the wolf
ing the reserve crown can then be severed with a periodontal
teeth, especially those that are extremely large, molarized or
elevator until the tooth is loose enough to be extracted.
aberrantly placed, may result in a problem with bitting or
When extracting a mandibular canine, care must be taken to
performance. Entrapment of the buccal, mucosal fold of the
avoid damaging the mandibular alveolar nerve when elevat-
commissure of the lips between the bit and the wolf tooth
ing the gingival flap. An apically infected canine can some-
or the rostrolateral aspect of the 2nd premolar has been cited
times be salvaged using endodontic treatment.
as a cause of discomfort and, consequently, a lack of respon-
siveness to the bit. Reducing the rostral and buccal aspect of
Extracting wolf teeth the 2nd premolar (i.e., 1st cheek tooth, Triadan 06) with a
rasp can be hindered by the presence of a large wolf tooth.
The first premolar (Triadan 05), commonly referred to as the Because of these problems associated with the wolf teeth,
‘wolf tooth’, is highly variable in position, shape, and size. real or imagined, wolf teeth have traditionally been removed
Wolf teeth are commonly present in the maxillae but are from young horses. This tradition may eventually slide into
present far less frequently in the mandible. The size of the obsolescence.
clinical crown of a wolf tooth is a poor indicator of the size Wolf teeth can usually be extracted in toto with the horse
of the embedded portion of the tooth. Maxillary wolf teeth sedated and standing; administrating local anesthetic solu-
are present in 40–80 % of horses, but often only one wolf tion subgingivally may ease extraction. A wolf tooth with a
tooth is present.5 The time at which the wolf teeth erupt is normal configuration can be extracted easily by circumfer-
variable, but most erupt when the horse is between 6 and entially elevating its gingival and periodontal attachments
18 months old. using a traditional, circular ‘Burgess-type’ extractor, but a
Most wolf teeth are located immediately rostral to the small, curved periodontal elevator can be used with much
maxillary 2nd premolar (Triadan 106, 206), but they are not more precision and effectiveness (Fig. 20.9).

322
 Exodontia

Fig. 20.10  A small, gingival incision exposes a subgingival wolf tooth for Fig. 20.12  This deciduous premolar was removed with cap extracting
extraction. forceps.

position where it can be more easily removed. Mandibular

wolf teeth (Triadan 305, 405) occur rarely, but if present
they can usually be palpated rostral to the first cheek tooth.
They vary in size and position, but commonly they are quite
small. They may be responsible for discomfort with the bit
and are a noteworthy observation during a pre-purchase
examination. The technique for their removal is similar to
that described for removing maxillary wolf teeth.

Extracting deciduous premolars

The permanent premolars erupt, displacing the remnants of
their temporary counterparts, when the horse is between
approximately 2.5 and 4 years old. The age at which each
permanent tooth erupts varies among breeds and among
individuals within a breed. For instance, the permanent
teeth of miniature horses often erupt later than those of
Fig. 20.11  Large, subgingival wolf tooth being extracted using a narrow
horses of other breeds. A deciduous premolar can become
osteotome placed between the tooth and the hard palate and directed
caudally. retained if it becomes impacted between adjacent teeth, and
if impacted, it can occasionally contribute to impaction or
maleruption of the emerging permanent tooth.
Young horses sometimes develop a transient periodontitis
The size and position of the apical portion of an aberrant
caused by retention of feed between the exfoliating tempo-
or a very large wolf tooth should be assessed radiographi-
rary tooth and the erupting permanent tooth. Periodontitis
cally before attempting to extract the tooth. After its perio-
and entrapment of food around a deciduous tooth are indi-
dontium has been elevated, the loosened tooth can be
cations that the temporary tooth should be removed. Occa-
extracted using a small incisor extractor or a specialized wolf
sionally, a remnant of a deciduous tooth becomes retained
tooth extractor. A wolf tooth located subgingivally can be
at an interproximal space, causing pain.
exposed through a small incision in the overlying gingival
If the gingival attachments of a deciduous premolar are
mucosa (Fig. 20.10). The apex of an unerupted, rostrally
intact, the deciduous premolar should not be removed
located, wolf tooth often extends caudally, and an oste-
because development of the underlying permanent tooth
otome or gouge placed between the tooth and palate can be
may be incomplete. An exfoliating, deciduous premolar, or
used to separate the periodontium from its underlying bone
‘cap’, is easily extracted using a shallow-jawed, cap extractor
(Fig. 20.11).
(Figs 20.12 & 20.13).
Failure to sufficiently loosen the periodontium surround-
ing a wolf tooth can result in fracture of the tooth. The
retained dental fragment should be elevated and removed to Extracting a permanent cheek tooth per os
assure healing of the alveolus, but an apical fragment located
subgingivally rarely causes a clinical problem. After several Extraction of a tooth per os, performed with the horse con-
days, a loose fragment may migrate to a more superficial scious, has been practiced since the turn of the 20th century,

323
 20 Treatment

Fig. 20.14  This horse is sedated, and its head supported in a sling prior to
dental extraction.
Fig. 20.13  The underside of this shed deciduous premolar contains some
of the gingival epithelium that surrounded the emerging permanent
premolar.
Extraction per os should not be attempted, however, with the
horse conscious if the horse’s temperament puts the horse
but the technical difficulties encountered when extracting a or personnel at risk of injury.
tooth from a poorly restrained horse and the development Extracting a tooth per os with the horse standing is best
of improved anesthetic agents during the past century performed with the horse restrained in stocks, with its head
brought about the development of surgical techniques of supported in a rigid halter or head-stand (Fig. 20.14).
extraction, and consequently, dental repulsion became Extracting a cheek tooth constitutes a major surgical proce-
widely practiced. The technical problems and the high inci- dure, especially when the horse is young, and effective seda-
dence of complications associated with dental repulsion, tion and good analgesia are prerequisites for a successful
such as dental or osseous sequestra and oro-antral fistula, outcome. (See Ch. 15.) A tooth can be extracted successfully
reported in major studies,7,8 stimulated development of an without the use of regional analgesia,7 but administering the
alternative surgical technique of extraction, namely extrac- appropriate regional nerve block greatly improves the ease
tion through a buccotomy, which was reported to be associ- of the extraction per os and reduces the time required to
ated with a lower incidence of complications than was perform the procedure and the quantity of sedation that
extraction by repulsion.9,10 The technique of extraction by must be administered.14 Administering a nerve block, even
buccotomy was found by many to be technically compli- when extraction is performed with the horse anesthetized,
cated, necessitated that the horse be anesthetized, and not allows the procedure to be performed with the horse in a
without complication, such as iatrogenic damage to branches lighter plane of anesthesia.
of the dorsal buccal nerve or to the parotid salivary duct.11
Because of complications associated with extraction by
repulsion and by buccotomy, extraction per os again became
Selecting a horse for extracting a cheek
the technique of extraction preferred by most practitioners tooth per os
and remains so today. Teeth with a short reserve crown and those with weakened
Extraction per os, originally described by Merillat (1906),12 periodontal attachments caused by advanced periodontal
is associated with a low incidence of complications and is disease can be extracted per os without difficulty, but extract-
more economical than is extraction by repulsion or by buc- ing a tooth with a long reserve crown and little periodontal
cotomy.7,13 The ease of the technique has been enhanced by destruction presents a challenge. O’Connor (1942) observed
the evolution of better instruments, development of more that ‘to extract a molar tooth from a sound alveolus in a
effective sedatives and analgesic drugs, and more wide- young horse is almost an impossible task.’15 However, by
spread use of regional analgesia of dental structures. using modern techniques, sedatives and analgesic drugs, the
appropriate regional nerve block, and appropriate instru-
Restraining a horse for extracting mentation, difficulties of extraction per os are no longer
insurmountable.
a cheek tooth per os Extracting the most caudal cheek teeth (i.e., Triadan 010s
Although a small proportion of nervous or fractious horses and 011s) is technically more difficult because the caudal
must be anesthetized for extraction of a tooth per os, the aspect of the mouth cannot be opened wide, impairing accu-
procedure can usually be performed with the horse sedated. rate placement of instruments on these teeth. Extraction of
Extracting a cheek tooth with the horse sedated, rather than teeth with long reserve crowns is hindered by the narrow
anesthetized, offers considerable advantages because of the confines of the caudal aspect of the mouth and interference
costs and risks associated with anesthetizing a horse. from the opposing dental arcade.

324
 Exodontia

A fractured cheek tooth can sometimes be extracted orally

if the parent fragment is sufficiently large that it can be
grasped with an instrument, but many fractured teeth need
not be extracted if apical infection is not clinically evident.
A fractured tooth, most commonly the maxillary 1st molar
(Triadan 09),7 is commonly composed of a parasagittal,
lateral slab fragment, which nearly always can be removed
without difficulty, and a larger, non-displaced, stable, parent
fragment, that need not be removed, provided that the two
exposed pulps have been sealed off, and clinical signs of
apical infection are not present.
Although a diseased maxillary tooth responsible for
causing secondary bacterial sinusitis can be extracted per os,
lavage of the affected sinuses is often necessary after the
tooth has been extracted, and if the sinuses contain inspis-
sated exudate, an osteoplastic flap must be created to remove A
the exudate. (See Ch. 19.)

Technique of extracting a cheek tooth per os

The techniques of oral extraction described below are slight
modifications of those first described by O’Connor (1942)15
and Guard (1951).16 The horse is sedated, and the appropri-
ate regional nerve block is administered using mepivacaine
or bupivacaine. Which of these two local anesthetic agents
is used depends on the anticipated duration of the proce-
dure. The horse should receive a broad-spectrum, antimicro-
bial drug and a non-steroidal, anti-inflammatory drug before
the procedure. The speculum is inserted into the mouth and
opened sufficiently to allow visualization and digital palpa-
B
tion of the dental arcades so that the tooth to be removed
can be identified. The veterinary surgeon must have good
Fig. 20.15  Flat-bladed periodontal elevators are used to elevate the
access to the oral cavity so that the bulky instrumentation
gingival and periodontal attachments from the buccal and lingual aspects
required to extract a tooth can be manipulated. A bright of the tooth.
head-light is necessary to illuminate the mouth so that
instruments can be placed accurately.
The gingiva on the buccal and palatal or lingual aspects of
the affected tooth is elevated from the tooth using a right-
angled, flat-bladed, dental pick or a small periodontal eleva-
tor (Fig. 20.15). The jaws of a molar separator (Fig. 20.16)
are placed into the interproximal space rostral and then
caudal to the affected tooth to strain the tooth’s rostral and
caudal periodontal attachments (Fig. 20.17). The jaws are
held in place for approximately 5 minutes at each site. When
extracting a 3rd premolar (Triadan 07), the molar separator
should not be applied with great force between the 2nd and
3rd premolars (Triadan 06 and 07) to avoid inadvertent
damage to the periodontal attachment of the 2nd premolar
(Triadan 06). Similarly, when removing the 2nd molar
(Triadan 010), the molar separator should not be applied
with great force between the 2nd and 3rd molars (Triadan
010 and 011). Aggressive use of the molar separator is
unnecessary and increases the risk of inadvertently loosening
a healthy tooth or fracturing the crown of the affected tooth Fig. 20.16  Molar spreaders with varied head designs achieve different
or that of an adjacent tooth. degrees of separation.
After the gingiva has been elevated and the molar separa-
tor used, the molar extractor is placed on the tooth to be extractor fits the tooth to which it is applied (Fig. 20.19).
extracted (Fig. 20.18). Because cheek teeth vary in size and Mandibular cheek teeth are narrower than their maxillary
configuration between horses and according to their loca- counterparts, and therefore require an extractor with a nar-
tion within the oral cavity, a variety of molar extractors of rower space between the jaws when the handles are closed.
different sizes should be available to ensure that the Good instrument–tooth contact is essential, and to achieve

325
 20 Treatment

Fig. 20.17  Molar separators are used to strain the periodontium on the
rostral and caudal aspects of the tooth, as shown in this cadaver specimen.

this contact, the extractor should have a high-quality, box

hinge and finely machined, toothed jaws. After the extractor
is applied, the oral cavity should be inspected visually to
ensure that the correct tooth has been grasped and that the
jaws of the extractor do not overlap onto an adjacent tooth.
The handles of the extractor are fixed using the locking
mechanism found on some extractors, a rubber bandage, or
adhesive tape (Figs 20.20 & 20.21).
The handles of the extractors are moved with slow, low-
amplitude, horizontal, to-and-fro oscillations along the
longitudinal axis of the cheek tooth. The tooth should B
be inspected visually during the first few oscillations to
ensure that the extractor has maintained its grip on the Fig. 20.18  The molar extractor selected to best contact the clinical crown
tooth and that the tooth is moving slightly. Incorrect or is applied to the tooth, ensuring that it does not overlap onto an adjacent
loose placement of the extractor can result in attrition of tooth.
the clinical crown, causing the crown to become rounded
and impossible to grip. Torsional movement along the
axis of the extractor’s handles early in the procedure can
result in fracture of the clinical crown and should be avoided.
The amplitude of the oscillations is increased, but only extractors is advanced along the occlusal surface of the
slightly, as the tooth loosens. Excessive force or attempts to arcade until it lies between the box hinge of the extractor
oscillate the extractors in a wide arc can result in shearing of and the occlusal surface of the cheek tooth rostral to the
the clinical crown before periodontal attachments of tooth being extracted (Fig. 20.23B). The mechanical advan-
the reserve crown are disrupted. The elasticity of the bony tage provided by the fulcrum is maximized by advancing the
alveolus is slight, and so the arc of movement must also fulcrum as far caudally as possible along the row of cheek
remain slight. teeth. While keeping the molar extractors firmly gripped on
When the periodontal attachments are loosened, a distinc- the affected tooth, steady, firm pressure is applied to the
tive ‘squelching’ sound can be heard, and the resistance to handles so that the tooth is levered from the alveolus over
movement of the extractor decreases. The squelching sound the fulcrum in a straight line, along its natural pathway of
is frequently accompanied by foamy hemorrhage around the eruption (Fig. 20.24). After the tooth has been partially
gingival margin (Fig. 20.22). In addition to disrupting the extracted, re-grasping a more apical portion of the tooth with
periodontal ligament, the repetitive movement of the tooth the extractors may be necessary to extract the rest of the
may stretch the alveolus, facilitating extraction of the tooth tooth. Axial twisting of the extracting forceps should be
(J. Easley, personal communication). Hundreds of oscilla- avoided until the tooth has been totally freed from perio-
tions, sometimes taking an hour or more to perform, may dontal attachments. Re-directing the clinical crown axially,
be required before the periodontium is disrupted sufficiently after the tooth has been partially extracted, may be necessary
to allow the tooth to be extracted. to avoid impingement of the tooth by the opposing arcade
After the tooth feels loose enough to be extracted, a dental (Fig. 20.25). Loosening a 2nd or 3rd molar (Triadan 010 or
fulcrum (Fig. 20.23A) appropriate to the size of the 011) of a young horse (i.e., <7 years old) can be particularly

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 Exodontia

Fig. 20.19  A variety of molar extractors of different sizes should be

available to ensure that the extractor fits the tooth to which it is applied.

Fig. 20.21  The handles of an extractor can be fixed, after the extractor is
correctly positioned, using a rubber band or adhesive tape.

fragments. If fragments are palpated, the alveolus should

be carefully curetted, using an angled curette, until the
alveolus feels smooth and no osseous or dental fragment
remains.
Fig. 20.20  A self-locking mechanism can be found on some molar Removing dental fragments can be difficult because often
extractors. no portion of the tooth is visible supra-gingivally, and
because access to the apical aspect of the alveolus, especially
one of a young horse, is poor using an oral approach. The
dental fragments should be clearly identified on radiographs
(Figs 20.26 & 20.27) and then, if possible, elevated per os
frustrating, due, at least in part, to the tooth’s oblique, cau- using long, right-angled elevators (Fig. 20.28). After the frag-
dally angled reserve crown. The crown of such a tooth may ments are loosened, they can be extracted with right-angled
need to be reduced with a burr, while partially extracted, so forceps; endoscopic guidance greatly facilitates their removal.
that it can be manipulated from the alveolus without it being When dental fragments or fractured teeth cannot be extracted
impinged by the opposite arcade. Sectioning a cheek tooth orally, they can be repulsed using a special root fragment
so that it can be extracted is rarely necessary, and sectioning punch or Steinmann pin (Figs 20.29–20.31). Radiographic
a mandibular cheek tooth risks the loss of the apical portion or fluoroscopic guidance may aid the approach to the
of the sectioned tooth into the alveolus from where its retained fragments. A 4-mm osteotomy is created over the
removal, without surgery, is difficult or impossible. retained fragment using a Steinmann pin or drill bit, and
After the tooth is extracted from the alveolus, it is with- the Steinmann pin or a root fragment punch is inserted into
drawn from the mouth and inspected, paying close attention the osteotomy so that it contacts the fragment. If the pin or
to its apical aspect, to ensure that it has been removed in its punch is positioned properly, the fragment can usually be
entirety, which is usually the case. The alveolus should then repulsed into the oral cavity with little force. The alveolus is
be carefully palpated for the presence of dental or osseous cleaned of debris, using a spoon curette, and irrigated. The

327
 20 Treatment

skin incision over the osteotomy is left unsutured to heal by cheek at the level of the affected alveolus, and a narrow
second intention. elevator is inserted into the coronal aspect of the alveolus
A dental fragment can also be extracted with the aid of an through the incision to elevate the fragment. After the frag-
elevator inserted through a small buccotomy (Fig. 20.32). ment is elevated, it can be retrieved per os. The stab incision
The surgical site is identified, a stab incision is created in the is left to heal by second intention. This technique facilitates
periodontal elevation of the fragment, allowing it to be
extracted without the destructive forces sometimes required
when repulsing a dental fragment. Branches of the facial
nerve and parotid salivary duct can be damaged using this
technique, and the subcutaneous tissues can be inoculated
with oral bacteria, resulting in painful cellulitis.
After extracting a cheek tooth, the alveolus can be tempo-
rarily loosely packed with polysiloxane putty, dental wax, or
a gauze swab impregnated with an antibacterial drug, such
as metronidazole paste, but care must be taken to avoid
sealing dental or osseous fragments within the alveolus. If
dental infection has produced a draining tract, the tract
should be irrigated with isotonic saline solution, after remov-
ing its epithelial lining with a curette, before the alveolus is
packed. The packing is gradually extruded as the alveolus fills
with organizing granulation tissue. Infected paranasal
sinuses may need to be debrided through an osteoplastic,
maxillary or frontonasal flap or through a large trephine hole
or lavaged through a catheter inserted into the sinuses
through a small trephine hole. If the alveolus communicates
with paranasal sinuses, it should be sealed from the sinuses
with a material likely to be retained until the communica-
tion no longer exists, such as polysiloxane putty or polymeth-
ylmethacrylate bone cement.17
The alveolus should be cleaned and dried with gauze
swabs before the plug is inserted. The plug is pressed into
the coronal third of the alveolus, while still malleable. The
surface of the plug should lie flush with the gingival margins
of the alveolus (Fig. 20.33), and formation of a large flange
that protrudes from the gingival margin should be avoided
(Fig. 20.34). Creating a slight flare on the plug at the gingival
margin facilitates removal of the plug when a seal is no
longer needed, but an excessively large flare may facilitate
Fig. 20.22  Foamy hemorrhage can be seen around the gingival margin early loosening of the plug by the horse’s tongue. Filling
of the tooth when the tooth loosens. This hemorrhage is accompanied by a
more than the distal third of the alveolus with the seal may
squelching sound.

A B

Fig. 20.23  (A) The dental fulcrum enables the extractor to elevate the tooth from the alveolus. (B) Fulcrums of different thickness may be required so that
the force of extraction can be directed appropriately.

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 Exodontia

Fig. 20.24  After the fulcrum is optimally positioned, the handles of the
forceps are pressed on the fulcrum, extracting the tooth from its alveolus.
Fig. 20.27  Radiograph showing dental fragment in the apex of a
mandibular alveolus. The tooth was fractured during an attempt at
extraction per os. Dental fragments in the alveolus of a young horse can be
difficult to remove, but with careful perioperative imaging to ensure
accuracy of the placement of the punch, the fragment can be repulsed into
the oral cavity with the horse sedated after desensitizing the affected region
with a regional nerve block.

result in delayed healing of the alveolus, and filling the

entire alveolus of a maxillary molar is likely to result in
formation of an oro-antral fistula.

Care of the horse after extracting a cheek

tooth per os
Horses require only minimal aftercare after a tooth has been
successfully extracted per os. The horse should receive a non-
steroidal, anti-inflammatory drug for 24–72 hours to provide
analgesia, and feeding a soft or soaked feed for a few days
Fig. 20.25  A caudal cheek tooth of a young horse often has a reserve
crown so long that the crown must be directed axially, so that its postoperatively may be indicated. Lavaging the paranasal
movement is not impinged by the opposing arcade. sinuses daily or twice daily may be necessary if the horse
suffers from dental sinusitis. The alveolus should be
inspected digitally, after the seal is removed, usually at
12–14 days, to detect if alveolar sequestra have formed. After
a tooth has been removed, that portion of the arcade that
opposes the empty alveolus erupts faster and without attri-
tion from mastication (Fig. 20.35). Consequently, the
opposing arcade should be rasped frequently (e.g., biannu-
ally) to avoid development of ‘step-mouth’. Teeth caudal
and rostral to the empty alveolus drift toward that alveolus,
but development of diastemata caudal to the empty alveolus
is apparently rare.18

Complications of extracting a cheek

tooth per os
Complications from dental extraction per os are rare.7 In one
survey, 93 % of horses that underwent dental extraction
per os had no complications. Nevertheless, serious problems
can occur. Fracture of the tooth may result in retention of
the tooth’s apical portion, necessitating its removal by repul-
Fig. 20.26  The reserve crown of the 1st maxillary molar (Triadan 09) was sion. A tooth can easily be fractured during its extraction if
fractured during attempted extraction per os. The fragments were elevated incorrect technique is used or if the tooth is fragile because
and retrieved using an oral approach. of advanced caries, and incorrect placement of instruments

329
 20 Treatment

A B

Fig. 20.28  (A) Root elevators and picks of various sizes and shapes are required to elevate root fragments. (B) Dental fragment forceps with long jaws to
facilitate extraction of dental fragments.

Fig. 20.29  If a fractured root cannot be retrieved using a root elevator, it Fig. 20.31  Fragment of a tooth retained at the apex of the alveolus.
can be repulsed into the mouth using a Steinmann pin or small punch The tooth was fractured during an attempt at extraction per os and was
inserted through a small osteotomy created over the apex of the alveolus. extracted retrograde using a Steinmann pin.

Fig. 20.30  A small Steinmann pin is in position to repulse a dental

fragment into the oral cavity. The pin was positioned using radiographic Fig. 20.32  A dental fragment can be extracted by inserting an elevator into
guidance. the alveolus through a small buccotomy.

330
 Exodontia

Fig. 20.35  A portion of the right mandibular 4th premolar (Triadan 408)
Fig. 20.33  The plug, which is pressed into the coronal third of the alveolus, and a portion of the right mandibular 1st molar (Triadan 409) have erupted
should lie flush with the gingival margins of the alveolus. Large flanges into the vacant alveolus of the 4th premolar (Triadan 208). After a tooth has
should be avoided. been removed, that portion of the arcade that opposes the vacant alveolus
erupts faster and without attrition. The opposing arcade should be rasped
biannually to avoid this complication. Note the unerupted supernumery
maxillary molar (Triadan 12).

alveolus to heal and often causes pain and swelling of soft

tissue surrounding the alveolus. The sequestered bone is best
removed by curetting the alveolus, which is performed most
easily between 2 and 6 weeks after the tooth was extracted.
Sequestra may be less likely to form if the alveolus is allowed
to fill with clotted blood after the tooth has been extracted.
Persistent, purulent nasal discharge after one or more of
the ipsilateral caudal four maxillary cheek teeth have been
removed could indicate the presence of an oro-antral fistula,
usually the result of osseous or dental sequestra within the
alveolus that cause failure of the alveolus to heal. The affected
horse commonly has inspissated exudate or feed trapped
within the paranasal sinuses. Persistent discharge of puru-
lent exudate and feed from a naris after one or more of the
ipsilateral maxillary premolars has been extracted could
indicate the present of an oro-nasal fistula. A horse with an
Fig. 20.34  Care must be taken when molding the plug to avoid excessively oro-antral or oro-nasal fistula is treated by sealing the
large flares, which may cause discomfort and may facilitate premature loss oral aspect of the affected alveolus with an acrylic plug
of the plug.
(Fig. 20.36), a mucoperiosteal flap, or a transposed muscle
belly after dental or osseous fragments are removed from
the alveolus by curettage and irrigation, and after feed
can result in damage to a healthy, adjacent tooth.7 Applying and exudate have been removed from the paranasal sinuses.
excessive forces while loosening a tooth can result in fracture (See Ch. 19.)
of the jaw, especially when extracting a caudal mandibular Extracting a tooth per os is preferred to surgical techniques
tooth from a young horse. An ill-fitting alveolar seal can be of removing a tooth because it can usually be accomplished
lost prematurely, resulting in impaction of feed within the with the horse standing, has a low incidence of complica-
alveolus or, if the alveolus communicates with a maxillary tions, and the horse recovers rapidly. When extraction per os
sinus (i.e., Triadan 108–111, 208–211), an oro-antral fistula. is unsuccessful, subsequent removal of the tooth by repul-
A loose alveolar seal may allow feed to become trapped sion or by buccotomy is greatly facilitated because attempts
between the seal and the alveolus, causing discomfort. at extraction per os weaken the periodontal attachments, thus
Dental fragments may prevent the alveolus from healing reducing the enormous forces needed to remove the tooth.
and should be removed at the time of extraction. Occasion-
ally, a portion of the alveolar bone becomes devitalized and
subsequently sequestered after extraction, possibly as a result Extracting a cheek tooth using a
of microfracture that occurred during extraction. These surgical approach
sequestra develop after the tooth has been extracted and are
not visible during intra-operative radiographic examination Surgical removal of teeth usually involves either a retrograde
of the alveolus. The sequestered bone results in failure of the (i.e., via the apex) approach or creation of a mucoperiosteal

331
 20 Treatment

Fig. 20.37  The clinical crown of the first cheek tooth (i.e., 2nd premolar;
Triadan 06) is about one-third longer in a rostral to caudal plane than is the
Fig. 20.36  Persistent discharge of feed and purulent exudate from a naris clinical crown of the other five cheek teeth in that arcade.
after one or more of the ipsilateral maxillary premolars has been extracted
could indicate the presence of an oro-nasal fistula. This horse was treated
for an oro-nasal fistula by occluding the oral aspect of the fistula with an
acrylic plug. osteoplastic flap if it resides completely within the maxillary
sinuses (i.e., the maxillary molars, Triadan 209–211 and
309–311). The osteotomy must be created precisely over the
tooth’s apex to avoid damage to an adjacent, healthy tooth.
flap with a partial alveolar osteotomy to expose the reserve The location of the apex varies according to the tooth
crown of the tooth. Retrograde removal of a tooth by repul- involved and the age of the horse.
sion became fashionable during the late 19th and early 20th The optimum site of exposure can be identified using
centuries, when general anesthesia of the horse became pos- several techniques, one of which is to first locate the clinical
sible, and the technique has changed little since this time. crown of the diseased tooth and then, by knowing the incli-
Complications associated with retrograde removal of a tooth nation and length of the tooth, to estimate the location of
by repulsion resulted in the development of an alternative the tooth’s apex. Using this technique, the clinical crown of
surgical technique for removal, the buccotomy approach, the diseased tooth, including its mesial and distal contact
which entails exposing the reserve crown of the tooth by surfaces, is identified by sight during oral examination. The
removing its lateral alveolar wall through an incision into contact surface of two contiguous teeth is recognized by a
the oral cavity and then removing the tooth after dividing it palpable depression at the gingival sulcus. (N.B. The clinical
into segments. crown of the first cheek tooth, i.e., 2nd premolar, Triadan
06, is about one-third longer in a rostral to caudal plane than
Technique of extracting a cheek tooth is the clinical crown of the other five cheek teeth in that row;
Fig. 20.37). After the clinical crown has been identified, the
by repulsion location of the apex of the tooth to be removed must be
Repulsion of diseased teeth remains a commonly performed estimated. Its location can be estimated by placing one of
surgical procedure in equine practice despite the widely two identical dental picks, held in contact at the handles,
reported, high incidence of complications associated with it into the mouth so that its tip rests buccal to the center of
and its mechanical inefficiency. Regardless of what surgical the diseased tooth. The other pick is placed adjacent and
technique of exodontia is used (i.e., repulsion or extraction parallel to the first pick but on the outside of the cheek to
via buccotomy), the tooth’s periodontium must be disrupted demarcate the site of the center of the clinical crown of the
to avoid damage to surrounding alveolar bone, and there- affected tooth on the buccal skin.19
fore, attempting to disrupt some of the periodontium, using To expose the apex of a mandibular or maxillary 2nd (i.e.,
extraction forceps per os, before embarking on a surgical Triadan 06 ) or 3rd (i.e., Triadan 07) premolar, the center of
course of dental extraction is prudent. Disrupting some of the osteotomy should be on a line perpendicular to the
the periodontal ligament greatly reduces the time of surgery occlusal surface of the arcade at the center of the clinical
and the likelihood of collateral tissue damage that can occur crown, regardless of the age of the horse (Fig. 20.38).20 The
when the tooth is repulsed. reserve crowns of the mandibular and maxillary 4th premo-
To repulse a tooth, the tooth’s apex must be exposed to lars (i.e., Triadan 08) and that of all the mandibular and
allow correct alignment of the dental punch on the apex of maxillary molars (i.e., Triadan 09–11) curve caudally, in a
the tooth so that force can be delivered along the natural coronal to apical direction until the horse is about 8 or 9
eruption pathway of the tooth. The apex of a cheek tooth is years old,21 and so, to expose the apex of one of these teeth
exposed by creating an osteotomy in the overlying mandible in horses less than 8 or 9 years old, the center of the oste-
or maxillary bone, created using a trephine, drill bit, oscil- otomy should be approximately level with the caudal contact
lating bone saw, or chisel (or osteotome). The apex of the surface of that tooth, on a plane perpendicular to the occlu-
tooth can also be exposed through a frontonasal or maxillary sal surface of the dental arcade.20,21 For horses older than

332
 Exodontia

and inaccurate identification of the site for osteotomy. To

see the interproximal dental spaces, the X-ray beam can be
deviated slightly rostrally or caudally from perpendicular
to the longitudinal axis of the head so that the beam is
aligned perpendicular to arcades. Multiple views should be
taken until the precise position for the surgical approach is
identified with confidence. (See Ch. 13, Dental imaging, for
more detail.)
Although a tooth can be repelled with the horse sedated
and the surgical site desensitized using regional anesthesia,
a cheek tooth is usually repulsed with the horse anesthe-
tized. When extraction is to be performed with the horse
anesthetized, a cuffed endotracheal or nasotracheal tube
should be inserted into the trachea to prevent inhalation of
fluid. The tube should be large enough to permit adequate
ventilation, but small enough to provide sufficient space to
allow extraction of the tooth. The horse is placed in lateral
Fig. 20.38  The center of the osteotomy to expose the apex of a recumbency with the affected side of the head uppermost.
mandibular or maxillary 2nd (Triadan 06) or 3rd (Triadan 07) premolar should The horse is administered a broad-spectrum antimicrobial
be on a line perpendicular to the occlusal surface of the arcade at the drug and a non-steroidal, anti-inflammatory drug before
center of the clinical crown, regardless of the age of the horse. To expose surgery. Anesthetizing the arcade of the affected tooth with
the apex of a mandibular and maxillary 4th premolar (Triadan 08) or that of a regional nerve block after the horse is anesthetized allows
a mandibular and maxillary molar (Triadan 09–11) of a horse less than 8 or 9
surgery to be performed with the horse in a lighter plane of
years old, the center of the osteotomy should be approximately level with
the caudal contact surface of that tooth, on a plane perpendicular to the anesthesia and provides analgesia during the immediate
occlusal surface of the dental arcade. (Image is courtesy of Luis Velazquez, postoperative period (see Ch. 15). A full-mouth speculum
University of Mexico.) (e.g., a Guenther or Bodamer oral speculum) is inserted to
provide safe access to the oral cavity. After the horse is anes-
thetized, but before it is prepared for surgery, the gingiva
should be separated from the buccal and lingual or palatine
aspects of the tooth to the cortex of the alveolar rim of the
tooth to be removed using a long-handled, right-angled peri-
odontal elevator, so that as the tooth is repulsed, the gingiva
is not avulsed (Fig. 20.15).
The maxillary or mandibular bone overlying the apex of
the tooth can be exposed for osteotomy through a straight,
longitudinal skin incision, approximately 5–7 cm long, or
through a dorsally or ventrally directed cutaneous flap. A
cutaneous flap must be sutured after the tooth is repulsed,
but a straight incision can be left unsutured to heal by
second intention. Because of the contaminated nature of the
surgery, one of us (WHT) prefers to leave the incision unsu-
tured. A straight skin incision extends through the perios-
Fig. 20.39  The proper site for osteotomy can be identified radiographically teum, which is reflected, using a periosteal elevator, to
by placing radio-opaque markers, such as skin staples, in the region expose bone for trephination. The curvilinear or rectangular
estimated to be near the tooth’s apex. incision of a cutaneous flap extends through the subcutane-
ous tissue, and after elevating the cutaneous flap, a straight,
longitudinal incision is created in the subcutaneous tissue
9 years, the center of the osteotomy created to expose the and periosteum, which are then reflected. Reflecting perios-
apex of any cheek tooth should be approximately level with teum, rather than removing it, avoids damage to nerves and
the center of that tooth, on a plane perpendicular to the vessels that overly it, and because the periosteum is spared,
occlusal surface of the dental arcade. healing of the osteotomy proceeds more rapidly.
Rather than approximating the location of the tooth’s When exposing bone overlying the apex of the mandibular
apex, using the guidelines described above, the exact site of 1st molar (i.e., Triadan 309 or 409), care should be taken to
the apex of the diseased tooth can be identified radiographi- avoid damaging the facial artery and vein and the parotid
cally by placing radio-opaque markers, such as skin staples, salivary duct, which cross the lateral surface of the mandible
in the region estimated to be near the tooth’s apex (Fig. along the rostral border of the masseter muscle close to the
20.39) or by placing a blunt metallic probe into a discharg- site of osteotomy (Fig. 20.40). Reflecting these structures
ing tract at the tooth’s apex.22 The primary X-ray beam must away from the site of trephination may be necessary. When
be approximately perpendicular to the longitudinal and exposing bone overlying the apex of a maxillary premolar
transverse axes of the head because even slight deviation of (i.e., Triadan 106–108 or 206–208), care should be taken to
the beam from a plane perpendicular to these axes markedly avoid damaging the infraorbital nerve and facial artery and
distorts the image, which could result in parallax distortion vein, which lie in close proximity to the site of osteotomy.

333
 20 Treatment

Fig. 20.40  Computed tomographic image of a head showing the facial

artery and vein and salivary duct that course along the rostral border of the
masseter muscle. (Image is courtesy of Luis Velazquez, University of Mexico.)

Fig. 20.42  Trephines and bits suitable for creating an osteotomy for
repulsion.

Fig. 20.41  Computed tomographic image of a head showing the

relationship between the paranasal sinuses and the maxillary molars Fig. 20.43  Galt trephine. The brace attached to one of these trephines
(Triadan 109–111 and 209–211). (Image is courtesy of Luis Velazquez, decreases the amount of effort required to create the osteotomy.
University of Mexico.)

ventral aspect of the osteotomy should be close to the facial

The apex of any one of the three maxillary premolars is crest if the horse is old. The mandibular cheek teeth of young
exposed by removing the external lamina of the maxilla horses often extend to the ventral border of the mandible,
overlying it, usually with a trephine. The apices of the maxil- and so, if the horse is young, the ventral aspect of the oste-
lary molars (i.e., Triadan 109–111 or 209–211) reside within otomy should also extend to the ventral border of the
the paranasal sinuses (Fig. 20.41) and can be exposed mandible.
through a trephine hole or through an osteoplastic flap into After incising and reflecting the periosteum, the apex of
the paranasal sinuses. the tooth is exposed through an osteotomy, which is com-
Regardless of where the apex of the tooth is determined to monly created using a 1.5- to 2-cm ( 1 2 - to 3 4 -inch) diameter
reside, the osteotomy created to expose the apex of a maxil- Galt trephine or a 0.95-cm to 2.7-cm ( 3 8 - to 1 2 -in) drill bit
lary cheek tooth should be ventral to an imaginary line that rotated in a hand drill or by hand (Figs 20.42 & Fig. 20.43).
marks the course of the nasolacrimal duct. This duct courses To create a hole in the external lamina of a maxilla or the
between the medial canthus of the eye and a point slightly mandible with a trephine, the center-pin of the trephine is
dorsal and rostral to the infraorbital foramen.23 The dorsal extended and seated perpendicular to the exposed bone and
aspect of the osteotomy should be close to this line if the the trephine is rotated to and fro until the center-pin pene-
horse is less than 8 years old because the cheek teeth of trates the bone and the barrel of the trephine cuts a circular
horses less than 8 years old have undergone little attrition groove in the bone. The center-pin is retracted or removed,
of length.24 To avoid damaging the infraorbital nerve when and the circular osteotomy is continued until the disc of
removing a maxillary 3rd (Triadan 107 or 207) or 4th bone is completely transected. If the transected disc of bone
(Triadan 108 or 208) premolar, the dorsal aspect of the is not removed with the barrel of the trephine, it can be pried
osteotomy should be ventral to the infraorbital foramen. The from its attachments with a bone gouge.

334
 Exodontia

Caudal

Ventral
Fig. 20.44  A bone gouge and mallet can be used to enlarge the trephine
hole.

The apex of the tooth is completely exposed by removing Fig. 20.45  This figure shows the creation of an osteoplastic maxillary flap,
overlying cancellous alveolar bone with a bone curette. To using an oscillating saw, to expose the rostral and caudal maxillary sinuses.
avoid damaging an adjacent, healthy tooth, the entire apex The apices of maxillary molars can be exposed through this flap. The 1st or
of the tooth should be exposed, and both contact surfaces 2nd maxillary molars (i.e., Triadan 109 or 110 or 209 or 210) or sometimes
of the diseased tooth identified before the tooth is repulsed the 3rd maxillary molar (Triadan 111 or 211) are repulsed into the oral cavity
into the oral cavity. Suction is helpful at this point in the using this approach.
procedure to aid visibility, which is usually obscured by
constant capillary bleeding. If the trephine hole has not
adequately exposed the apex of the tooth, the hole can be triple trephine technique).3 Using this approach, one hole is
enlarged using a bone rongeur or a bone gouge and mallet created dorsomedial to the medial canthus of eye for place-
(Fig. 20.44). The apical end of the tooth can be transected ment of the punch on the apex of the tooth. A second hole,
perpendicular to the long axis of the tooth, using a chisel created ventrorostral to the medial canthus, allows the
(or osteotome) and a mallet or a diamond cutting wheel, punch to be guided onto the apex of the tooth and allows
and removed to provide a flat platform for a punch to be the alveolus to be inspected postoperatively. The third hole,
seated and aligned properly along the long axis of the created at the angle formed by the orbit and the facial crest
tooth. Transecting and removing the apex of the tooth provides a portal for placing a catheter into the caudal maxil-
may also provide space to maneuver the punch into proper lary sinus for postoperative lavage of the paranasal sinuses.
alignment. Alternatively, reasonable access to the 2nd maxillary molar
The maxillary 1st or 2nd molar (i.e., Triadan 09 or 010) of mature horses (i.e., >8 years old) can be gained through
can be removed through a trephine hole created into the either a maxillary or frontonasal, osteoplastic flap.
paranasal sinuses over the apex of the tooth. To repulse To create a dorsally hinged, osteoplastic maxillary flap, a
the maxillary 1st molar (i.e., Triadan 109 or 209), which is three-sided incision through the skin, subcutis, and perios-
the most commonly diseased maxillary tooth, the trephine teum is created within the confines of the boundaries of the
hole is usually centered at a point midway between the rostral and caudal maxillary sinus (Fig. 20.45). A technique
rostral end of the facial crest and a point on the facial crest to create and close a maxillary osteoplastic flap is described
at the level of the medial canthus of the eye, 1 cm ventral to in detail in Chapter 19, Basic equine orthodontics and max-
an imaginary line drawn between the infraorbital foramen illofacial surgery. The osteoplastic, maxillary flap provides
and the medial canthus of the eye. the operator opportunity to visually examine a large extent
To remove the 2nd maxillary molar (i.e., Triadan 110 or of the paranasal sinuses and permits manipulation of dental
210), the trephine hole is centered more caudally over the instruments within the sinuses.
caudal maxillary sinus, rostroventral to the ventral orbital A disadvantage to creating an osteoplastic maxillary flap,
rim; but the site varies between horses and is affected by the rather than a trephine hole, to repulse a maxillary molar, is
age of the horse. Selection of the optimal site for trephina- that unless the flap is reopened, access to the apical aspect
tion should be guided by radiographic examination. One of the alveolus is no longer accessible to monitor healing of
author has suggested an approach to the 2nd maxillary the alveolus or to curette the alveolus, should the need arise.
molar that involves creating three trephine holes (i.e., the Access to the apical aspect of the alveolus after surgery is

335
 20 Treatment

Fig. 20.46  Aligning a dental punch along the eruption path of a tooth is A
made much easier using an off-set, or double-curved, punch. Note that the
shanks are different in length. Two or three off-set punches, each with a
different length of shaft, may be required to completely repulse a tooth.

easier if the apex of the tooth was accessed through a tre-

phine hole, provided that the skin over the hole is left unsu-
tured to heal by second intention. If the cutaneous incision
over the trephine hole was sutured or stapled, the incision
can be re-opened to inspect the apical end of the alveolus
and then re-sutured or stapled when access is no longer
required. If the apex of the tooth was accessed through an
osteoplastic flap into the sinuses, the apical end of the alveo-
lus can be inspected endoscopically through the trephine
hole created to provide a port for lavage of the sinuses. B
Because the apex of the maxillary 3rd molar (i.e., Triadan
111 or 211) lies beneath the eye, it must be exposed either Fig. 20.47  To remove the 2nd and 3rd mandibular molar (Triadan 310, 311,
410, or 411) and sometimes the mandibular 1st molar (i.e., Triadan 309 or
through a trephine hole in the frontal bone or through a
409), the masseter muscle is reflected dorsally to expose the underlying
frontonasal, osteoplastic flap. The punch is inserted through lateral lamina of the mandible overlying the apex of the tooth. (A) The
the frontomaxillary aperture into the caudal maxillary sinus ventral aponeurosis of the masseter muscle has been incised. (B) After
to engage the apex of this tooth, which lies ventral to the creating a trephine hole over the apex of the tooth to be removed, the
infraorbital canal. Aligning a dental punch along the erup- punch is aligned along the long axis of that tooth.
tion path of a maxillary 3rd molar is difficult because of the
tooth’s position below the orbit and its caudal curvature.
Using an off-set (i.e., a double-curved) punch (Fig. 20.46)
to repel the maxillary 3rd molar may be helpful because masseter muscle. The incision is extended through the inser-
obtaining proper alignment between the punch and tooth tion of the muscle, and the muscle and the periosteum to
without damaging the infraorbital canal is often difficult which the muscle is attached are elevated to expose the
using a straight or curved punch. external lamina of the mandible. The site for osteotomy to
Removing a mandibular 2nd (Triadan 310 or 410) or 3rd expose the apex of the diseased tooth is then located using
(Triadan 311 or 411) molar is particularly difficult because one of the methods described above.
the bone over the apices of these teeth is covered by the The lateral plate of bone overlying the apex of the 3rd
masseter muscle and because the apices of these teeth are mandibular molar (i.e., Triadan 311 or 411) can also be
distant from the ventral border of the mandible, even in exposed through an incision in the masseter muscle. Using
young horses. To remove one of these teeth, and sometimes this approach, the skin is incised obliquely in a plane that
the mandibular 1st molar (i.e., Triadan 309 or 409), the extends from the occlusal surface of the tooth to the angle
ventral aponeurosis of the masseter muscle is incised so that of the mandible.25 This incision exposes the fibers of the
the muscle can be reflected dorsally to expose the underlying masseter muscle, which traverse the lateral lamina of the
thin lateral lamina of the mandible overlying the apex of the mandible in the same dorsorostral to ventrocaudal direction
tooth (Fig. 20.47). as the skin incision. The masseter muscle is split bluntly,
To elevate the masseter muscle, skin is incised along the along the course of its fibers, being careful not to damage
ventrocaudal border of the mandible, ventral to the masseter the dorsal and ventral buccal branches of the facial nerve
muscle, from the angle of the mandible rostrally, taking care that lie superficial to the muscle. The thin bone over the apex
to avoid the parotid salivary duct and facial artery and vein of the 2nd molar (i.e., Triadan 210 or 410) can be exposed
where they cross the mandible at the rostral aspect of the through a similar but more rostral incision. Aligning the

336
 Exodontia

properly aligned and seated on the tooth intended to be

removed. The operator or assistant can detect percussion
transmitted through the tooth and movement of the tooth.
Striking the punch when it is in contact with the tooth pro-
duces a higher pitched sound than when the punch is struck
when in contact with bone. A better feel for proper align-
ment of the punch can be appreciated if the operator with
the hand in the mouth also controls the alignment of the
punch with his or her other hand while a trustworthy,
second operator wields the mallet. Numerous, vigorous
blows with the mallet are usually required to dislodge the
tooth from its alveolar and gingival attachments, but when
movement of the tooth can be felt with the hand in the
mouth, the force of the blows to the punch is decreased. A
long tooth of a young horse, especially a tooth located cau-
dally on the arcade, must often be deviated axially with an
extractor as the tooth is repulsed so that the tooth does not
become impinged by the opposing arcade. Transverse sec-
tioning of a partially repulsed tooth to facilitate its repulsion
Fig. 20.48  When repulsing a tooth into the oral cavity, the punch should is awkward to perform, risks creating subgingival dental frag-
be aligned in the direction of the tooth’s path of eruption. Confirming the ments, and despite being widely advocated by others, is
position of the punch radiographically ensures that the punch is properly seldom or never necessary. Wedged teeth can usually be
aligned. The punch seen in this radiographic projection is in close alignment
maneuvered after minor profiling using a rotary burr. After
with the longitudinal axis of the tooth.
the tooth has been repulsed, the operator whose hand was
in the mouth must re-glove before proceeding with the
surgery.
Because the tooth is usually fragmented while being
punch along the long axis of the tooth, so that the tooth can repulsed, it should be examined to determine if pieces are
be repulsed efficiently, is difficult using this approach, espe- missing, and the alveolus should be inspected visually and
cially if the masseter muscle is thick. digitally for osseous and dental fragments. Dental fragments
After the apex of a diseased cheek tooth has been exposed still attached to the alveolus may be difficult to detect. The
using techniques described above, the tooth is repulsed into tooth of a young horse is more brittle than that of an old
the oral cavity by striking a dental punch applied to the apex horse, and therefore, is more likely to be fragmented. After
of the tooth and aligned in the direction of the tooth’s path the alveolus is curetted, irrigated, suctioned, and dried, it
of eruption. Confirming the position of the punch radio- should be examined radiographically to detect osseous or
graphically ensures that the punch is properly aligned dental fragments that may remain within it. A ventrodorsal
(Fig. 20.48). Failure to align the punch correctly may result radiographic projection of the alveolus, obtained with the
in damage to a neighboring tooth, the palatine bone, if the cassette in a sterile sleeve, provides a good view of the
tooth is maxillary, or to the internal or external lamina of vacated alveolus (Fig. 20.49). Pulling the mandible laterally
the mandible, if the tooth is mandibular. When the punch may allow a view of the entire vacated alveolus unobstructed
is aligned obliquely to the long axis of the tooth, more force by superimposition of teeth in the opposing arcade.
is required to repulse the tooth because the periodontium is The alveolus is sealed from the oral side using polysi-
not disrupted as efficiently as when the punch is properly loxane putty (President Putty, Henry Schein, UK), bone wax,
aligned. The extra force required is more likely to result in polymethacrylate (PMMA) bone cement (Palacos R, Glaxo-
bony or dental sequestra. Because the reserve crowns of the SmithKline), gutta percha,3 or plaster of Paris,26 to prevent
cheek teeth curve axially in a coronal to apical direction, and feed and saliva from contaminating the alveolus. Plugs of
because the mandibular and infraorbital nerves lie slightly PMMA provide the best long-term security against alveolar
medial to the center of the teeth, applying the punch slightly contamination, but PMMA has the disadvantage of generat-
lateral to the central axis of the tooth reduces the risk of ing considerable heat as it sets.
damaging these nerves. The plug should fill no more than the coronal third of the
An off-set punch is often easier to properly align than is a alveolus so that the bulk of the alveolus is able to fill first
straight or angled punch, but two or three off-set punches, with a blood clot and then with granulation tissue. The plug
each with a different length of shaft, may be required to should not extend past the gingiva. A plug that protrudes
completely repulse the tooth (Fig. 20.46). Continuing to past the gingiva is prone to loosening by the tongue or from
strike to the punch with the mallet after the horizontal arm mastication. Care should be taken when molding a plug to
of the off-set punch has contacted bone at the margin of the the alveolus to avoid forming sharp projections that can
trephine hole results in damage to the bone and is ineffective cause discomfort to the horse by traumatizing the tongue or
in repulsing the tooth. Off-set punches with shafts of various gingiva. Care should be taken to ensure that the plug’s apical
lengths can be made by a farrier for little expense. end is narrower than its coronal end and that the plug fits
By inserting a hand in the horse’s mouth and palpating tightly within the alveolus. The plug should be examined
the clinical crown of the affected tooth, the operator or a after the horse recovers from anesthesia, using digital palpa-
non-scrubbed assistant can determine if the punch is tion, to ensure that it is seated tightly within the alveolus. A

337
 20 Treatment

If maintaining the implant in the alveolus is likely to be

difficult, such as when the tooth removed was the 1st cheek
tooth (2nd premolar, Triadan 06), the plug can be molded
around a small section of screen to which a loop of stainless
steel wire has been attached (Fig. 20.50).20 The ends of the
wire loop are inserted through the oral entrance to the alveo-
lus and exited through the osteotomy and a cutaneous stab
incision created adjacent to the site of osteotomy. The plug
and screen embedded within it are pulled into the oral
aspect of the alveolus, and the ends of the wire loop are
secured under tension over a gauze roll. The gauze roll is
changed when it becomes soiled.
A straight skin incision over the site of osteotomy is often
left open to heal by second intention because contamination
A of the surgical site with oral pathogens is inevitable. Leaving
the incision unsutured allows the alveolus to be inspected
and loose, osseous or dental debris retained within the alve-
olus to be easily retrieved. The alveolus can be irrigated and
monitored daily, visually and by palpation, for healing
through the open incision. The leakage of saliva contami-
nated with ingesta from the incision or escape of fluid into
the mouth during irrigation of the alveolus indicates that the
alveolar plug should be replaced. Packing gauze swabs into
the skin incision until the alveolus has filled with granula-
tion tissue, usually at 2–3 weeks, prevents gross contamina-
tion of the surgery site from the environment.
If the skin incision at the osteotomy is to be sutured, the
surgical site should be irrigated vigorously. If the likelihood
of infection at the surgical site is high, a drain can be placed
into the depths of the wound and exited through another
B
small incision. The subcutaneous tissue is sutured with
absorbable monofilament suture, and the skin incision is
Fig. 20.49  (A) A ventrodorsal radiographic projection of the alveolus apposed with non-absorbable suture or staples (Fig. 20.51).
provides a good view of the alveolus. Pulling the mandible laterally may
The inelastic periosteum holds sutures poorly and need not
allow a view of the entire vacated alveolus unobstructed by superimposition
of teeth in the opposing arcade. (B) A dorsoventral radiographic projection be sutured. Gauze swabs are placed over the incision and
showing a dental fragment within an alveolus (arrow points to fragment). held in place with sutures or with adhesive, elastic tape
applied to the head in a figure-of-eight fashion to minimize
swelling at the surgical site and to prevent the horse from
mutilating the site. The head is generally left bandaged for
at least 5 days. If the incision was sutured, it should be
loose plug should be removed with extraction forceps and inspected periodically for signs of subcutaneous infection.
replaced after irrigating debris from the alveolus; this can The incision should be opened if signs of infection, such as
usually be accomplished with the horse sedated and its drainage through the incision, are observed.
mouth held open with an oral speculum. Granulation tissue surrounding the plug epithelializes
Because the alveoli of old horses are shallow, care must be within several weeks. The plug may eventually be lost spon-
taken to avoid over-packing the alveolus. The pack placed taneously, but if not, it can be removed, usually at about 2
into the alveolus of an old horse should be shallow so that weeks after surgery, with the horse sedated (Fig. 20.52). The
granulation tissue can form unimpeded through most of the portion of alveolus occupied by the plug fills completely
alveolus. An alveolar plug that extends into a maxillary sinus with granulation tissue after the plug is removed. Permanent
results in a persistent, oro-antral fistula (see Ch.19). Over- retention of a plug is desirable only when the horse is at
packing the alveolus can be avoided by packing gauze swabs increased risk of developing an oro-antral fistula. If the plug
into the apical end of the alveolus, and then removing them is attached to a wire loop, both the plug and the wire must
after the alveolar plug, placed orally into the coronal aspect be removed.
of the alveolus, has set. If the skin incision is to be sutured, If the paranasal sinuses are to be lavaged after a maxillary
it should be sutured only after the plug has been inserted, molar has been repulsed, a 0.95-cm ( 3 8 -inch) trephine hole,
so that the depth to which the plug has been packed in the which is large enough to accommodate a 26- or 24-Fr
alveolus can be determined accurately. If the incision is to Foley catheter, is created, through a straight cutaneous inci-
be left open, rolled gauze impregnated with a dilute solution sion into the conchofrontal or caudal maxillary sinus
of povidone-iodine can be packed concertina fashion into through a small incision. A trephine hole into the concho­
the apical aspect of the alveolus, prior to inserting the plug frontal sinus is created 2–3 cm medial to the medial canthus
orally into the coronal aspect of the alveolus. The gauze can of the eye, and a trephine hole into the caudal maxillary
then be gradually removed over the next 4–5 days. sinus is created, through a straight incision, 1.5 cm ventral

338
 Exodontia

Fig. 20.50  Maintaining the plug in the alveolus

is sometimes difficult if the alveolus is that of a
2nd premolar or if 2 teeth adjacent to each other
were removed. (A & B) To keep a plug secure in
the alveolus, it can be molded around a small
section of screen to which a loop of stainless
steel wire has been attached. (C) The ends of the
A wire loop are inserted through the oral entrance
to the alveolus, exited through the osteotomy
and a cutaneous stab incision, and the acrylic and
embedded screen are pulled into the oral aspect
of the alveolus. (D) The ends of the wire loop  
are secured under tension over a gauze roll.  
(E) Radiograph of a dental arcade showing  
the implant sealing two alveoli from which  
the teeth were repulsed.

B C

D E

to the ventral rim of the eye. Warm, isotonic saline solution complications serious enough to necessitate a second
or a solution of povidone-iodine instilled into the sinuses surgery.10
through the Foley catheter exits the sinuses into the nasal The most serious complication associated with extracting
cavity through the nasomaxillary aperture. The sinuses are a cheek tooth by repulsion is unintended damage to other
lavaged for 1–7 days; the frequency and duration for which structures, such as adjacent, healthy teeth, the infraorbital
the sinuses are lavaged depends on the degree to which the or mandibular nerve (Fig. 20.53), and palatine bone
sinuses were contaminated. The cutaneous incision over the (Fig. 20.54) or medial or lateral lamina of the mandible or
osseous portal can be sutured or stapled after the catheter is maxilla (Fig. 20.55). Other complications associated with
removed, or the incision can be allowed to heal by second dental repulsion include early loss of the alveolar plug
intention. causing contamination of the alveolus and paranasal sinuses
with feed; formation of an oro-antral fistula; damage to the
nasolacrimal duct, parotid salivary duct, infraorbital nerve,
Complications associated with extracting
or palatine artery; and most commonly, a chronic draining
a cheek tooth by repulsion tract caused by sequestration of alveolar bone or dental
The owner should be advised that a horse that has lost a fragments.8 The more caudal the tooth, the more likely is the
cheek tooth requires life-long, prophylactic dental care and horse to suffer one or more of these serious postoperative
should be forewarned that serious complications of dental complications.10
extraction by repulsion are common and often result in the The owner should be forewarned that even when the
need for additional surgery. In a report of 220 horses that alveolus is determined to be free of bony fragments at the
had undergone surgical removal of a cheek tooth, 165 had time of surgery, the severe trauma to which the alveolus was
undergone extraction by repulsion, and of these, 65 had subjected when the tooth was repulsed can result in the

339
 20 Treatment

Fig. 20.53  The horse may mutilate its nose if the infraorbital nerve is
damaged.

Fig. 20.51  The apex of a diseased premolar of this horse was approached
through a straight skin incision for repulsion of the tooth into the oral cavity.
Because the likelihood of infection at the surgical site is high, the stapled
incision should be inspected periodically for signs of subcutaneous
infection. The incision should be opened if signs of infection are observed.

NS

SP

HP
Fig. 20.52  The alveolus can be carefully inspected visually and digitally
after removing the implant to ensure that it has commenced to granulate. Fig. 20.54  Endoscopic view of the right nasal cavity of a horse after
Bone not covered with granulation tissue may be devitalized and repulsion of a maxillary molar showing a large hole (arrows) in the hard (HP)
sequestered. and soft palates (SP) from injury from the dental punch. The nasal septum
(NS) is on the right.

formation of osseous sequestra within the alveolus, causing

failure of the alveolus to heal. The large concussive forces and sequestered. Partially disrupting the periodontium
required to repulse a tooth may create minute alveolar frac- before embarking on repulsion greatly reduces the concus-
tures that are not visible during postoperative radiographic sive forces required to repulse the tooth and, therefore,
examination of the alveolus. These fractures may result in reduces the likelihood of creating osseous sequestra.
formation of alveolar sequestra in subsequent weeks, leading Contamination of the alveolus from premature loosening
to resumption of clinical signs of apical dental infection and or loss of the implant usually results in nothing more serious
an alveolus that fails to heal. Bone not covered by granula- than delayed granulation of the alveolus, but if the alveolus
tion tissue encountered when palpating the alveolus 2 to 3 is one that communicates with the paranasal sinuses, loss of
weeks after surgery should be suspected of being devitalized the implant can result in formation of an epithelialized

340
 Exodontia

Fig. 20.55  A fracture of the lateral alveolar wall after repulsion of a

maxillary tooth is evident on this ventrodorsal radiographic projection.
Fig. 20.56  Vertical buccotomy approach for extracting the right 2nd
mandibular molar (Triadan 410). The vertical incision is created caudal to  
the facial vein and artery and the parotid salivary duct.

oro-antral fistula, signs of which include chronic, purulent,

nasal discharge.
If clinical signs of apical dental infection fail to resolve
after the infected tooth has been repulsed, the alveolus space on either side of the tooth to be removed from within
should be examined carefully, radiographically and using a the oral cavity. The incision should not be made until
mirror or an endoscope, for the presence of dental or osseous the interproximal margins of the tooth to be removed have
sequestra or an oro-antral fistula. The relationship between been positively identified by an unscrubbed assistant whose
a draining tract, the nasal cavity, and the alveolus can some- hand is within the mouth. Placing a small-gauge, hypoder-
times be elucidated by infusing fluorescein dye into the tract mic needle through the skin at each interproximal space
and observing for the presence of dye in the nasal or oral helps define the site of incision. For the horizontal buccot-
cavity. Radiographic examination of the alveolus with a fine omy approach, a curvilinear skin incision, centered over the
radio-opaque probe inserted into a draining tract over the diseased tooth, is made at the level of the tooth’s gingival
alveolus may help demonstrate the relationship between a reflection in the buccal cleft. For the vertical buccotomy
discharging tract and a sequestrum. Small sequestra can be approach, the incision is made parallel to the linguofacial
removed by curettage using an oral approach or a retrograde artery and vein (Fig. 20.56). By using a vertical incision
approach through the osteotomy. to extract the 1st or 2nd mandibular molar (Triadan 309,
310, 409 or 410), rather than a horizontal incision, trauma
to the linguofacial artery and vein and the parotid salivary
Extracting a cheek tooth using a horizontal duct is avoided. To extract the first mandibular molar
(Triadan 309 or 409), the incision lies rostral to the linguo-
or vertical buccotomy approach facial artery and vein, and to extract the second mandibular
A transalveolar approach to the infected tooth through a molar (Triadan 310 or 410) the incision lies caudal to the
horizontal or vertical buccotomy has been used successfully linguofacial artery and vein at the rostral border of the mas-
to remove any one of the mandibular or maxillary cheek seter muscle. Retracting the masseter muscle caudally pro-
teeth except the 3rd molar (Triadan 011).9,10 The horizontal vides a good view of the lateral mandibular cortex overlying
or vertical buccotomy approach to dental extraction offers the 1st and 2nd mandibular molars (Triadan 309 and 310
the advantages of precision and accuracy and good visualiza- or 409 and 410).
tion of the tooth to be removed, which precludes the pos- During the buccotomy approach, extreme care is taken to
sibility of iatrogenic damage to unaffected teeth. Exposing avoid damage to the dorsal buccal branch of the facial nerve
the buccal aspect of the tooth permits a more controlled when removing a maxillary tooth, and to the ventral buccal
disruption of the periodontal ligament than does repulsion branch of the facial nerve when removing a mandibular
of the tooth, but the procedure must be performed with the tooth. These branches lie superficial to the musculature.
horse anesthetized. The lateral aspect of the alveolus of max- These nerves can be identified and reflected atraumatically
illary or mandibular premolars (Triadan 06–08) is accessed from the surgical site (Fig. 20.57). The incision for a maxil-
through a horizontal incision, and that of the 1st or 2nd lary buccotomy is made dorsal to the parotid papilla located
mandibular or maxillary molar (Triadan 09 and 010) is at the rostral aspect of the 4th maxillary premolar (Triadan
accessed through a vertical incision created parallel to the 108 or 208), and the incision for a mandibular buccotomy
long axis of the tooth.3 is made ventral to it. As the dissection to the lateral dental
The tooth to be removed, using the buccotomy approach, alveolus deepens, the ventral buccal glands and the buccal
is identified with the assistance of radiography or fluoros- venous plexus, which is composed of the labialis communis,
copy, using skin markers, and by locating the interproximal labialis maxillaris, and labialis mandibularis veins, are

341
 20 Treatment

Fig. 20.57  For the buccal approach to dental extraction, vital structures, Fig. 20.59  Extraction through a buccotomy. The alveolar bone over the
such as the dorsal or ventral buccal branch of the facial nerve, must be buccal aspect of the cheek tooth is being removed with a burr.
identified and retracted carefully. The suture surrounds the ventral buccal
branch of the facial nerve.

Fig. 20.60  Extraction through a buccotomy. The buccal aspect of the

alveolus has been removed, allowing sectioning of the periodontium.
Fig. 20.58  Extraction through a buccotomy. The oral mucosa is incised to
expose the buccal alveolar bone.

encountered. After dissecting through these structures, aspect of the reserve crown of the tooth. At least two-thirds
paying extreme attention to detail and hemostasis, which is of the lateral alveolar wall is removed to completely expose
assisted by suction, the tough, oral mucous membrane is the apical end of the tooth.
encountered. By incising it, the clinical crown of the tooth The periodontium on the rostral and caudal surfaces of
to be removed is exposed (Fig. 20.58). the tooth is disrupted using a fine elevator or curved gouge
A gingival flap is raised on the lateral aspect of the alveolus (Fig. 20.60). Space for extraction can be created by splitting
of the tooth with a periosteal elevator to expose the lateral the tooth longitudinally, using a burr. The tooth can also
alveolar cortex of the maxilla or mandible. The periosteum be removed by transecting it transversely with a chisel, in
is incised at the center of the tooth, parallel to the long axis which case, the occlusal fragment is advanced into the oral
of the tooth, and reflected to either side. The buccal alveolar cavity, where it is removed, to provide access to the apical
bone that spans the rostral and caudal contact surfaces of portion of the tooth, which can then be elevated intact or
the tooth is incised parallel to the long axis of the tooth at piecemeal from the alveolus using a gouge or curved peri-
the rostral and caudal interproximal margins of the tooth odontal elevator (Fig. 20.61). Radiographic examination at
using an oscillating saw, a surgical fissure burr, or a sharp this point in the procedure is necessary only when the
chisel (Fig. 20.59). This plate is elevated and removed using surgeon has doubt as to whether the entire tooth has been
an osteotome or periodontal elevator to expose the buccal removed.

342
 Exodontia

Fig. 20.61  Extraction through a buccotomy. The tooth is being sectioned Fig. 20.63  Extraction through a buccotomy. The oral aspect of the alveolus
with a chisel before it is removed. is sealed with a plug of polysiloxane.

Fig. 20.62  Extraction through a buccotomy. The empty space at the apical
Fig. 20.64  The incision is sutured in three layers, and the end of the rolled
aspect of the alveolus is packed with rolled gauze impregnated with a dilute
gauze is exited through a separate incision.
solution of povidone-iodine.

After the tooth has been removed, the empty alveolus is Complications associated with extracting
packed concertina fashion with rolled gauze impregnated a cheek tooth using a horizontal or vertical
with a dilute solution of povidone-iodine (Fig. 20.62). One buccotomy approach
end of the gauze exits through a stab incision created adja-
cent to the original incision so that the gauze can be with- The most serious complications associated with extracting a
drawn a few inches at a time during the next 5–10 days. A cheek tooth by buccotomy are irreversible, iatrogenic damage
plug of acrylic, such as polysiloxane, is placed into the to the ventral or dorsal buccal nerve and parotid salivary
oral aspect of the alveolus over the gauze packing duct. In one study, only 1 of 44 horses that had undergone
(Fig. 20.63), but because the buccal portion of the alveolus removal of a cheek tooth by buccotomy had a complication
has been removed, this implant often soon loosens. The that necessitated a second surgery.10 Complications arising
gingival flap can be sutured but, because of inevitable con- from extraction by buccotomy included temporary facial
tamination of the surgery site, is often left to heal by second paralysis from trauma to the dorsal buccal branch of the
intention. The buccotomy incision is closed in three layers, facial nerve (2 horses) and partial wound dehiscence (6
using monofilament absorbable suture to close the incision horses). Transection and subsequent anastomosis of the
in the oral mucosa and subcutaneous tissue, and parotid salivary duct was required to access the diseased
non-absorbable suture or staples to close the skin incision tooth of 2 horses.
(Fig. 20.64).

343
 20 Treatment

References
1. Blundeville T. The fower chiefyst offices 10. Lane GJ. Equine dental extraction- 19. MacDonald MH, Basile T, Wilson WD,
belonging to horsemanshippe. London, Repulsion vs Buccotomy: Techniques and et al. Removal of maxillary tooth
1566 results. Proceedings World Veterinary fragments and root remnants in standing
2. Lane JG. A review of dental disorders of Dental Congress, Birmingham, 1987, horses. Proceedings AAEP-Focus on
the horse, their treatment and possible pp 135–138 Dentistry 2006, 148–155
fresh approaches to management. Equine 11. Easley J. Equine tooth removal. In: Baker 20. Wheat J. Sinus drainage and tooth
Veterinary Education 1994; 6: 13–21 G, Easley J, eds. Equine dentistry, eds. repulsion in the horse. Proceedings AAEP
3. Lane JG. Exodontia: Part 2: surgical WB Saunders, London, 1999, 1973; 19: 171
extraction of equine molars and pp 228–229 21. Frank E. Veterinary surgery, 7th edn.
premolars (cheek teeth). In: Baker GJ, 12. Merillat MA. Equine dentistry and Burgess, Minneapolis, 1964,
Easley J, eds. Equine dentistry, 2nd ed. diseases of the mouth. Veterinary Surgery, pp 156–159
Elsevier, Edinburgh, 2005, pp 279–294 Vol. 1, Alex Eber, Chicago, 1906 22. Lane J, Gibbs C, Meynink S, et al.
4. Shira RB. Principles of exodontia. In: 13. Tremaine WH. Oral extraction of equine Radiographic examination of the facial,
Guralnick WC, ed. Textbook of Oral cheek teeth: a Victorian technique nasal and paranasal sinus regions of the
Surgery, Little, Brown and Co, Boston, revisited. Proceedings World Veterinary horse: I. Indications and procedures in
1968, p. 79 Dental Congress, Birmingham, 1987, 235 cases. Equine Vet J 1987; 19:
5. Nickel R, Schummer A, Seifarle E. The pp 139–143 466–473
anatomy of domestic animals, 2nd edn. 14. Tremaine WH. Local analgesic techniques 23. Sissons S, Grossman J. The anatomy of
Verlag Paul Parey, Berlin and Hamburg, for the equine head. Equine Veterinary the domestic animals, 4th edn. WB
1979 Education 2007; 19: 495–503 Saunders, Philadelphia, 1953, pp 387,
6. Markham G. Markham’s masterpiece. G 15. O’Connor JJ. Operations. In: Dollar’s 882
Conyers, London, 1723 Veterinary surgery, 3rd edn. Baillière, 24. Mueller P. Equine dental disorders:
7. Dixon PM, Tremaine WH, Pickles K, et al. Tindall and Cox, London, 1942, Cause, diagnosis, and treatment.
Equine dental disease Part 4. A long-term pp 250–261 Compendium of Continuing Education
study of 400 cases: apical infections of 16. Guard WF. Equine operations. In: Surgical for the Practicing Veterinarian 1991; 13:
cheek teeth. Equine Vet J 2000; 32: principles and techniques. WF Guard, 1451
182–194. Columbus, Ohio, 1951, 25. McIlwraith C, Turner A. Equine surgery:
8. Prichard M, Hackett R, Erb H. Long-term pp 78–89 advanced techniques, 2nd edn. Williams
outcome of tooth repulsion in horses: a 17. Dixon PM. Dental extraction and and Wilkins, Philadelphia, 1987,
retrospective study of 61 cases. Vety Surg endodontic techniques in horses. pp 289–292
1992; 21: 145–149 Compendium of Continuing Education 26. Trostle S, Juzwiak J, Santschi E. How to
9. Evans LH, Tate LP, LaDow CS. Extraction for the Practicing Veterinarian 1997; 19: use antibiotic impregnated plaster of
of the equine 4th upper premolar and 1st 628–637 Paris for alveolar packing after tooth
and 2nd upper molars through a lateral 18. Townsend N, Barakzai S. Abstracts of the removal. Proceeding AAEP 2000; 46:
buccotomy. Proceedings AAEP 1981; 28: 17th scientific meeting of the ECVS, 180–181
249–252 Veterinary Surgery 2008, 95–98

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 Section 5:  Treatment

C H A P T ER  21 
Dental materials
Stephen S. Galloway† DVM, Melanie S. Galloway DVM
†
Fellow, Academy of Veterinary Dentistry (Equine)
Animal Care Hospital, 8565 Hwy 64, Somerville, TN 38068, USA

Introduction characteristics. To select and apply the appropriate cement,

practitioners must be familiar with the bonding mechanism
Throughout recorded equine dental history, exodontia has for each material (Box 21.1). Since luting applications are
been the only treatment option for diseased teeth. The goal rarely practiced in equine dentistry, dental cements will be
of equine dentistry is to preserve functional dentition in discussed with respect to their use in the other dental
order to promote the general health, longevity, and pro­ disciplines.
ductivity of the horse. In an effort to preserve functional
dentition, clinicians have begun to apply accepted dental
technologies and to adapt dental materials from human and
small animal dentistry. This cross-species extrapolation is
Restorative dentistry
common in both human and veterinary dentistry since all
Restorative dentistry is the dental discipline concerned with
mammalian dental tissues are similar; however, the equine
the treatment, repair, and conservation of teeth broken
clinician must understand the differences between brachy­
down by trauma or decay. The goals of restorative dentistry
dont and hypsodont teeth when applying materials designed
include returning the diseased tooth to its original shape and
for use in human teeth.
function, preventing breakdown of the remaining tooth
The purpose of this chapter is to serve as a general resource
structure, protecting the pulp from thermal, mechanical, and
for equine practitioners to facilitate the incorporation of
bacterial insult, and creating an esthetic tooth appearance.
dental materials into their practice. It includes a basic discus­
The indications for restorative dentistry include dental decay,
sion of dental cements, restorative, endodontic, and perio­
resorptive lesions, crown fractures, attrition, congenital
dontal materials, and impression materials. Specific material
anomalies, enamel hypoplasia, and access closure of an
brand recommendations have been purposely omitted since
endodontically treated tooth.1 Restorative dentistry can be
hundreds of materials are available in each category and
divided into two sub-disciplines: direct placement restora­
since the dentist’s preferences are a major factor in the final
tions and laboratory-assisted restorations (prosthodontics).
selection of a specific brand. However, many experienced
The scope of this discussion will be limited to direct place­
dentists advise using a single line of materials for each cat­
ment restorations.
egory. The general clinical application steps for each category
Regardless of the disease etiology, the restoration of a
of materials is presented, but every dental material has
tooth includes two equally important procedures: 1) cavity
unique properties, handling characteristics, and an applica­
preparation and 2) selection and application of the restora­
tion protocol based on the ratios of essential components
tive materials. Treatment planning for any restoration must
and the addition of proprietary components. To optimize
include radiographic evaluation of the affected tooth and its
the clinical properties of any material, the manufacturer’s
surrounding tissues. Radiographic evaluation of the diseased
instructions for storage, mixing, and application must be
tooth includes evaluation of the pulp, the specific location
followed exactly.
of the lesion, and the depth and extent of the lesion. Radio­
graphic findings consistent with pulp disease would indicate
Dental cements root canal therapy before tooth restoration. The location of
the lesion on each specific tooth determines the forces that
Dental cements are primarily used for bonding prosthetics will be applied to the restoration. Restorations on the occlu­
(luting agents) and orthodontic appliances to teeth. Zinc sal surface of a tooth must be designed to withstand com­
phosphate, zinc oxide eugenol, and polycarboxylate cements pressive loading and wear, whereas restorations on the
are available and still used in dentistry. However, glass apical aspect of the clinical crown might experience tension
ionomer and resin composite cements are primarily used or bending stresses. Regardless of the present location of the
today because of their superior properties and handling lesion, all restorations have the potential for eventual occlusal

345
 21 Treatment

Box 21.1  Types of bonding

1. Mechanical retention: Non-adhesive bonding where the dental
material infiltrates the surface irregularities of the dental tissue
and cures to interlock with the dental tissue. All cements exhibit
mechanical bonding.
A. Macromechanical retention – involves instrumented under-
cuts (retention grooves) in the dental tissues (usually dentin).
The bonding mechanism with non-bonded amalgams and
self-curing resin composites (Fig. 21.1).
B. Micromechanical retention – involves surface preparation
(acid etching) and the use of bonding agents that microscopi-
cally interlock in the enamel porosities (Fig. 21.2), dentinal
tubules (Fig. 21.3), and other microscopic surface irregularities.
The bonding mechanism with resin composite and resin mod-
ified glass ionomer cements and light-cured resin composite
and bonded amalgam restorations.
2. Chemical bonding: Glass ionomer and polycarboxylate Fig. 21.3  Demineralized dentin that has been kept moist. The collagen
cements form a chemical crystal bond between the carboxyl structure is preserved. (From van Noort R 2002. Introduction to dental
groups in the polyacid of the cement and the calcium ions of the materials, 2nd edn. Mosby, St Louis.)
apatite crystals in the enamel and dentin.

cavity preparation. Consideration of these factors will deter­

mine the required properties of the restorative materials
needed to fill the cavity.
During treatment planning, the clinician should also try
to identify and eliminate the cause of the lesion, especially
Bevel in traumatic cases. Failure to eliminate the cause often leads
to subsequent destruction of the restoration. Finally, a
Undercut
client’s esthetic demands may influence the practitioner’s
A B choice of the final restorative material and its finish.

Fig. 21.1  Placement of small retention groove in dentin using a small

round burr. (Courtesy of K-J. Söderholm.)
Cavity preparation
Cavity preparation is the surgical operation involving the
debridement of decayed or diseased dental tissues in order
to shape the tooth to receive and retain the restorative mate­
rial.2 Regardless of the etiology or location of the lesion, the
operator must adhere to the following principles. First, the
cavity must be prepared so that all diseased and damaged
dental tissues are removed without weakening the tooth’s
structure. Inherent in this principle is that as much tooth as
possible must be preserved so that the restoration does not
compromise the structural integrity of the tooth. Secondly,
the cavity is extended to prevent further decay or damage to
the restoration. The focus of this extension is the removal of
any unsupported or undermined dentin and enamel. To
achieve this, the walls of the cavity are formed parallel to the
enamel rods, which are usually oriented perpendicular to the
tooth surface (Fig. 21.4). Finally, the cavity is configured to
facilitate filling, retention, and finishing of the restorative
Fig. 21.2  Surface of etched enamel in which the centers of enamel rods material. This step may include dentinal undercutting for
have been preferentially dissolved by the phosphoric acid. (Courtesy of K-J. mechanically retained materials and marginal beveling to
Söderholm.) increase the enamel surface bonding area.3 Advances in
modern restorative materials make the necessity of dentinal
wear due to hypsodontic tooth eruption; therefore, the strength undercutting debatable.4 Since cementum, not enamel, is the
and wear resistance of restorative materials must be considered peripheral tissue on the crown of equine teeth and since the
during material selection. The depth and extent of the lesion bonding of restorative materials to cementum has not been
must be evaluated to determine the dental tissues involved studied, the value of marginal beveling of the cavity prepara­
in the lesion, as well as the proper size and shape of the tion is also debatable.

346
 Dental materials

A B

Fig. 21.4  (A) Decay of the mandibular right 3rd incisor (403). (B) Cavity preparation using a diamond burr on a high-speed handpiece. Note that the walls
of the preparation are perpendicular to the surface of the tooth. The author elected not to instrument retention grooves (dentinal undercuts) or marginal
beveling since this shallow preparation was designed for a resin composite filling.

Bases and liners eugenol chemically react to form a chelate. The setting time
is accelerated by humidity, elevated temperature, and
Cavity preparations, in which less than 2 mm of dentin
increasing the powder-to-liquid ratio. Therefore, ZOE is typi­
remains between the pulpar wall and the pulp (indirect pulp
cally mixed on a cooled glass slab to slow the setting reaction
exposure), require the application of a pulp protecting mate­
(Fig. 21.5). Condensation (humidity) on the cooled pad will
rial.5 Cavity varnishes, liners, and bases are used to protect
accelerate the setting reaction and negate the cooling effect.
the pulp. Cavity varnishes are organic solvent and resin solu­
The powder-to-liquid ratio for the mix is dictated by the use
tions that seal dentinal tubules. They do not prevent acid
of the cement. When mixing a ZOE base material, sufficient
penetration or thermal conductivity, and are losing popular­
powder must be incorporated to produce a stiff, putty-like
ity since the organic solvent can interfere with the polymeri­
consistency (Box 21.2).
zation of resin composites.
Zinc phosphate (ZP) cements are the oldest and least
Cavity liners are non-irritating materials that are placed in
expensive cements. They have high compressive strength and
a thin layer to protect the pulp and decrease dentinal sensi­
good thermal insulation properties and historically have
tivity. They provide no thermal or mechanical protection
been used as a restoration intermediate layer between gutta
and are inadequate as a sole protecting medium. Calcium
percha (GP) and the final composite restoration. Due to the
hydroxide (CaOH), the most popular liner, is supplied as a
acidic nature of the material, ZP is not recommended as a
powder or as commercially prepared pastes. The powder can
base in cases with direct or near pulp exposure.6
be applied directly into a cavity or mixed into a paste with
Glass ionomer (GI) cement is currently the most popular
water, saline, or an anesthetic. The strong alkalinity (pH 12.5
base material. The properties of GIs are discussed below,
when mixed with saline) of CaOH is bactericidal, neutralizes
under Direct placement restorative materials.
acids, and induces reparative dentin formation. CaOH dis­
solves if contaminated with oral fluids and must be covered
by another restorative material. Direct placement restorative materials
Cavity bases are used in deep cavities to provide structural
support for the final restoration and chemical and thermal The ideal restorative material would allow for conservative
protection of the pulp. Dental cements are typically used as cavity preparation, be easy to apply, bond to the substrate
bases. Reinforced zinc oxide-eugenol (ZOE) cement (Inter­ (dental tissues), have the similar strength, thermal, and wear
mediate Restorative Material, IRM)a has been a historically characteristic to the tooth, and be the same color as the
popular cavity base. This material is losing popularity tooth. No material has all of these ideal characteristics.
because eugenol interferes with the bonding of resin com­ Therefore, a material, or combination of materials, must be
posites. ZOE cements have a pH of approximately 7, which selected based on its specific advantages in a specific situa­
is thought to have protective and soothing properties on the tion. Three basic groups of restorative materials are used in
pulp. In cases of direct or near pulp exposure, a liner should veterinary dentistry: amalgam, glass ionomers, and resin
be used since ZOE cements can cause pulp inflammation. composites. These materials have also been combined to
ZOE cements are dispensed as zinc oxide powder and produce materials (e.g., resin modified glass ionomers) in
eugenol liquid or as a two paste system. Zinc oxide and an attempt to gain the advantages and minimize the disad­
vantages of the base materials.
Dental amalgam is the alloy of mercury mixed with other
a
Caulk IRM, DENTSPLY International Inc., York, PA, USA. metals (usually silver, tin, and copper). This material has

347
 21 Treatment

A B

Fig. 21.5  Mixing dental cement. (A) The zinc oxide powder and the eugenol liquid are placed on a glass slab for mixing. (B) Properly mixed cement has a
uniform creamy consistency that can be pulled approximately 1 cm.

Dental composites are the most commonly used restorative

Box 21.2  Preparation of dental cement (zinc oxide-eugenol) materials in veterinary dentistry. They are easy to apply,
provide acceptable strength and wear resistance, and are
• A small amount of powder is placed on a mixing slab or pad. A
esthetically pleasing. Modern composite bonding systems to
few drops of liquid are placed onto the slab beside the powder.
dentin and enamel require limited cavity preparation and
• Approximately 14 of the powder is pulled into the liquid and
greatly reduce marginal leakage. A composite is a solid mate­
mixed with a spatula to a creamy consistency.
rial formed from multiphased materials that have been com­
• Another 14 of the powder is incorporated into the mixture and
bined to produce properties superior to the individual
spatulated.
constituents.9 Dental composites contain three major
• The remainder of the powder is pulled into the mixture and
components:
spatulated.
• The final consistency of the mixture is dictated by the cement’s 1. Matrix: an acrylic resin consisting of monomers
intended use; however, for most applications, the cement is polymerized using free radical initiators to form a solid
properly mixed when a one-cm string can be pulled between the material
mixing pad and the spatula. 2. Fillers: glass, ceramic, or composite particles that
reinforce the resin matrix
3. Coupling agents: an organosilane, coats the filler
particles, and covalently bonds to the matrix resin.
been the primary direct restorative material in human den­ Other components in dental composites include tooth
tistry for over a century due to its ease of use, low technique colored pigments, the polymerization activator-initiator
sensitivity, ability to maintain cavity form, and wear resist­ system, and polymerization inhibitors to control the
ance. Amalgam is considered the gold standard for load- working time.
bearing (occlusal) restorations. This material is losing favor All commercial dental composites use free radical initia­
among human dentists and has seen minimal veterinary use tors to start an addition polymerization reaction. These free
due to its material disadvantages and also due to the popu­ radicals are activated either chemically, by an external energy
larity of modern composite materials. The toxicity of mercury source (e.g., a curing light), or by a combination of the two
requires special handling. Current evidence does not support mechanisms.
the popular concerns about systemic toxicity secondary to Light-activated resins (light-cured) are packaged as a single
dental fillings.7 Amalgam corrodes over time, and the metal­ paste in a light-proof container (i.e., syringe or compule).
lic color is esthetically displeasing. Amalgam does not bond Light in the visible blue range (450–475 nm) excites a pho­
to dental tissues and is retained by macromechanical forces, tosensitizer, commonly camphorquinone, which reacts to
which necessitates additional cavity preparation steps, such the amine activator to produce free radicals. The advantages
as dentinal undercutting, and makes the restoration suscep­ of light-activated resins are an unlimited working time for
tible to marginal leakage. Finally, the applicability of material placement and a short, ‘on demand’ set time (usually
amalgam in equine teeth is uncertain due to the enamel/ 30–60 seconds). The depth of cure for light-activated resins
cementum configuration on the occlusal surface of equine is accepted to be approximately 2 mm; therefore deep res­
hypsodontic teeth.8 torations must be applied using a layering technique

348
 Dental materials

(incremental buildup).10,11 In addition to ensuring maximum particles (8–12 µm) and are rarely used because newer
polymerization conversion, the layering technique mini­ composites outperform them. Although they are strong,
mizes resin shrinkage. The curing light should be held within their surface is notably rough, discolors, and wears
1 mm of the restoration to optimize light exposure, or the unevenly.
activation time should be extended. Light-activated resins are • Microfilled composites. These composites were designed
initiated by visible light and must be protected from room for superior polishability and contain filler particles in
lights, especially surgical lamps. The minimum energy the 0.04–0.4 µm range. They are indicated for low-
requirement to initiate the photosensitizer is 300 mW/cm2. stress, esthetic restorations and are not popular in
Curing lamps should be tested periodically with a radiometer veterinary medicine because they lack strength and
to ensure adequate emission. Because of the intensity of wear resistance.
the light produced by curing lamps, operators should never • Hybrid composites. These composites have a high filler
look at the blue light and should use an orange protective content and contain various sizes of particles ranging
shield or glasses to protect against retinal damage. from 0.2–3 µm. They are currently the preferred
Chemically activated resins (self-cured, auto-cured) are pack­ restoration material in human and veterinary dentistry
aged as two paste systems. One paste contains a benzyl because of their wide range of uses, their superior
peroxide initiator, and the other paste contains an aromatic clinical properties, wear resistance, and acceptable
tertiary amine activator. Upon mixing, polymerization polishability. They are used in stress-bearing and
begins, and the composite sets into a solid state within 3–5 esthetic restorations. The following hybrid composites
minutes. Heat increases both the rate and degree of polym­ are further grouped into subcategories.
erization. Chemically activated resins are usually used for • Microhybrid composites. This subcategory of hybrid
large, bulk fill restorations or restorations with limited light composites combines filler particles of submicron
access. (0.04 µm) and small (0.1–1.0 µm) sizes. They were
Dual-cure resins are chemically activated resins in which a developed to offer a composite for high stress as well
light activation system has been added to each paste and are as esthetic restorations. In general, they have superior
indicated in restorations where light cannot penetrate the strength, but polishability is not better than traditional
entire depth of the restoration. Light activation attains the hybrids. This is the most popular category of compos­
initial set of the restoration, and the chemical activator com­ ites because of their versatility.
pletes the polymerization. Whether the composite is light or • Flowable composites. This subcategory of hybrid
chemically activated, the polymerization reaction continues composites consists of low viscosity (syringeable)
for at least 24 hours before the resin is completely cured. An composites with reduced filler content that flow and
unfilled resin coating is applied to protect the restoration adapt intimately to the cavity walls. They are only
from air and oral fluids during this curing period. This tech­ recommended in low stress restorations and restora­
nique is referred to as ‘rebonding.’ tions with poor accessibility because they lack strength
Historically, the most significant problem with dental and wear resistance.
composites has been shrinkage of the matrix material during • Packable composites. This subcategory of hybrid
polymerization. This shrinkage creates a gap between the composites is highly viscous and was designed to be
restoration and the cavity wall referred to as marginal leakage. placed similarly to amalgam. They are strong, wear-
In order to reduce the volumetric change within the matrix, resistant, and polishable. Packable composites have no
high molecular weight monomers, which covalently bond to superior properties to other hybrid composites and
other polymer chains, are used. Most contemporary dental adaptation to the cavity walls is very technique
resins use a combination of bisphenol A epoxy and glycidyl­ sensitive.
methacrylate (Bis-GMA) and triethylene glycol dimethacr­ • Nanofilled composites. Recent advances in sol-gel
ylate (TEGDMA) monomers to limit matrix shrinkage. These technology have made submicron-sized particle
monomers also cross-link between polymerization chains to production possible. The nano-particle size (0.005–
produce a composite with increased physical and mechanical 0.01µm) allows for increased filler loading, which
properties.12 Additionally, high levels of filler particles reduce improves strength and wear resistance, as well as
the amount of matrix in the composite, which also limits the minimizing shrinkage.
polymerization volumetric change. Increased filler loading • Nanohybrid composites. These composites combine
increases the restoration hardness, fracture strength, and nano particles and conventional fillers to produce a
wear resistance and reduces thermal expansion and contrac­ microhybrid composite with the strength and wear
tion. While the combination of high levels of Bis-GMA and resistance of a traditional composite and the polish­
filler loading minimizes marginal leakage and improves the ability of a microfilled composite.
mechanical properties of the restoration, it also results in a • Core (buildup) composites. These high-strength compos­
viscous material with poor handling characteristics. There­ ites were designed for placement under prosthodontic
fore, numerous composite materials are manufactured in an crown restorations where significant tooth structure has
attempt to maximize the physical, mechanical, and handling been lost. Filler particle sizes vary from micro to macro,
properties required for different restorative applications. and polishability is poor. Anecdotal success in restora­
Dental composites are commonly classified by the filler tions of incisor fractures and extensive decay has been
particle size: reported.
• Compomers (polyacid modified resin composites). These
• Conventional (traditional, macrofilled) composites. composites have a polyacid modified resin matrix with
These stress-bearing composites have the largest composite and glass ionomer fillers. They release low

349
 21 Treatment

levels of fluoride and are indicated for low-stress

restorations in patients at risk for caries. Since they Box 21.3  Acid-etch technique
exhibit poor physical properties and wear resistance 35 % phosphoric acid is the ‘gold standard’ etchant, although other
and release lower levels of fluoride than traditional or acids (e.g., polyacrylic acid) and varying acid concentrations are avail-
resin modified glass ionomers, compomers have seen able. Etchants are available in liquid and gel forms, with the gel being
little clinical use. the most popular because it is easier to dispense and because it retains
its placement during vertical applications.
No clinical trials have been performed to study the use of The etching procedure includes the following steps:
any restorative material in equine hypsodontic teeth. 1. The preparation is isolated to prevent contamination from blood
However, clinical success using microhybrid composites to or oral fluids.
restore infundibular cavities was first reported in 2001.13 The 2. The tooth and cavity preparation are cleaned with non-fluoride
use of core composite material in large defects has also been flour pumice to remove the organic pellicle, plaque, food, and
reported.14 The use of flowable composites in equine teeth other oral fluids. The pumice is mixed with water into a thick
has become a common practice because of the material’s paste and applied with a prophy cup on a low-speed handpiece.
handling characteristics and the adaptability of the material Fluoride polishing paste is contraindicated because it interferes
to the cavity; however, this application must be questioned with the etching reaction.
due to the poor mechanical properties of the material. Nano­ 3. The cleaned area is rinsed and gently air dried.
composites have the potential to make a significant improve­ 4. The etchant is applied to the preparation for appropriate contact
ment over the available composite materials in both human time, and then thoroughly rinsed off with water. The standard
and veterinary patients but have seen limited clinical use. contact time for dentin is 10–15 seconds and for enamel is 30–40
seconds. The etching time for coronal cementum has not been
established; however, the author (SSG) allows 20–30 seconds
Dentin-enamel adhesives (bonding agents) contact time for cementum. Over-etching should be avoided
Except for compomers, composite restorative materials are since a contact time over 120 seconds leaves insoluble calcium
precipitates on the surface of enamel.
hydrophobic and will not bond to hydrophilic dental tissues.
5. The etched surface is dried according to the adhesive material
Therefore, composite restorations require an adhesive appli­
instructions. Most enamel bonding systems require a dry etch
cation to which the composite resin can copolymerize.
surface, and properly conditioned enamel has a chalky-white or
Adhesion is the bonding or attachment of dissimilar materi­ frosty appearance. If this appearance is not achieved, the surface
als so that the materials resist separation and transmit should be re-etched. Most dentin bonding systems require a
mechanical forces across the bond. Regardless of the moist surface with a glistening appearance. Drying the dentin
substrates being joined, adhesion promotion follows a desiccates and collapses the collagen fibrils, which prevents
prescribed generic methodology: 1) substrate preparation; proper bonding.
2) surface priming; and 3) placement of application-specific 6. The conditioned tooth is protected from contamination until the
overlayers that react with the primer. With the exception of restoration material is applied. In the sedated horse, this often
glass ionomers, which chemically bond to dental tissues, all necessitates that an assistant cover the prepared tooth with
modern adhesive systems follow this generic adhesive sterile gauze while the operator prepares the restorative material.
methodology.15
Substrate preparation dissolves the barrier layers that inhibit
primer interaction with the substrate. In heterogeneous agent interlocks the primer into the microporosities and
substrates, such as dentin and enamel, selective removal of forms a micromechanical bond. In dentin, the primer infil­
substrate components also enables more efficient surface trates the dentinal tubules (micromechanical bonding) and
reactions, alters surface conformation, and changes the entangles the collagen fibers exposed during etching, which
surface energy. Acid etching (also called conditioning) is the upon polymerization, forms the hybrid layer. Hybrid
required surface preparation technique for bonding of layer formation is the primary bonding mechanism in
restorative materials to dental tissues. Acid etching enamel dentin bonding systems (Fig. 21.6). Finally, interfacial resin
removes the smear layer created by instrumentation, dis­ overlayers, with extensive crosslinking capabilities, are
solves apatite crystals to create a microporous surface, and applied which copolymerize with both the primer and
lowers the surface energy, which facilitates spreading composite resin.
(wetting) of the primer. In addition to the surface prepara­ Bonding agents have traditionally been classified based on
tion effects noted for enamel, acid etching dentin increases generational sequencing, chronologically based on market
permeability by widening the dentinal tubules and exposes introduction (Box 21.4). Advances in this classification
acid insoluble type 1 collagen fibers, which represent approx­ system are generally indicative of a reduction in the number
imately 90 % of the organic phase of dentin (Box 21.3). of application steps in the bonding procedure and are not
After a substrate is prepared, a primer is applied to the indicative of improved bonding performance. Since the gen­
substrate. The primer consists of molecules with chemically erational classification system has no correlation to improved
functional terminal groups that react to the adherends. bonding strength, Stangel et al proposed a contemporary
Dental primer monomers have an adhesive hydrophilic bonding system classification based on whether the acid
group, which reacts with the enamel or dentin, and a hydro­ conditioner (etchant) is rinsed off the dental tissue or left
phobic polymerizable group that cross-links with the restor­ in situ.15
ative resin. The primer is carried in acetone, ethanol, or The ‘etch and rinse’ (ER) category is divided into two- or
water. The function of the primer on enamel is to completely three-step systems in which the first application step is always
wet the surface of the enamel and to penetrate the micropo­ the etching step (Step 1). In the Two-Step ER system (One
rosities created by the etchant. Polymerization of the bonding Bottle System), the primer and adhesive resin overlayer is

350
 Dental materials

applied in a single application (Step 2). In the Three-Step ER

system, the primer and adhesive resin overlayer is applied
separately (Steps 2 and 3). Within the ‘etch and rinse’ cate­
gory of bonding agents, the Two-Step (One Bottle) system
is the most popular. While both the Two- and Three-Step ER
systems produce acceptable bonding strengths to both
enamel and dentin, the Three-Step ER system has superior
bonding to dentin (Fig. 21.7).
The ‘no rinse’ (NR) (self-etch, self-priming) category is
divided into one- or two-step systems. In the One-Step NR
system, the conditioner, primer, and adhesive resin overlayer
is applied together from a single bottle. In the Two-Step NR
system, the combined conditioner and primer components
(first bottle) are applied, followed by the application of the
adhesive resin overlayer (second bottle). The NR bonding
systems have failed to produce clinically acceptable bonding
Fig. 21.6  The bonded composite resin. Resin flags are formed from the
strength when compared to the ER systems due to poor
flow of the dentin bonding agent into the dentinal tubules. A hybrid layer  
is formed by the interaction of the resin and the collagen fibers of the removal of the dentin smear layer. If a ‘no rinse’ bonding
decalcified dentin. The composite resin is bonded to this hybrid layer agent is used for bonding to enamel, a preparatory ‘etch and
interface. (From Gladwin M and Bagby M 2000. Clinical aspects of dental rinse’ step has been recommended.16 However, this addi­
materials. Lippincott, Williams and Wilkins.) tional step defeats the entire purpose for the ‘no rinse’ system.
In 2005, a review of 85 performance trials evaluated the
clinical effectiveness of six dental adhesives systems (2-Step
ER, 3-Step ER, 1-Step NR, 2-Step NR, and glass ionomers
(GI) with and without conditioning).17 The study found a
Box 21.4  Generational classification of bonding agents high degree of variability within each group but made several
general conclusions about contemporary bonding systems
Since dentists commonly refer to bonding agents with respect to the
(Box 21.5).
generational classification system, the following outline is included:
1st generation:
• Introduced in the 1950s Glass ionomer cements
• Poor clinical success.
Glass ionomer (GI) cements are a group of materials based
2nd generation:
on the reaction of silicate glass powder and polyacrylic acid.
• Introduced in the late 1960s and early 1970s
GIs chemically bond to dentin and enamel by crystal forma­
• Poor clinical success. tion when the GI’s carboxyl group chelates with the calcium
3rd generation: in the apatite in dentin and enamel. Although this bond is
• Introduced in the early 1980s not as strong as that formed by resin-based dentin bonding
• Application of the dentin conditioner (etchant), primer and systems, the clinical retention of GIs in low-stress applica­
adhesive in distinct steps. tions is excellent.18 Additional bond strength can be attained
4th generation: by conditioning the walls of the cavity with 34–37 % phos­
• Introduced in the mid-1980s phoric acid or 10–20 % polyacrylic acid to remove the smear
• The Total-Etch Technique (simultaneous aggressive etching of layer to allow for micromechanical bonding to the dentin
enamel and dentin with phosphoric acid) and the dentin ‘Wet and enamel.19 The chemical bonding of GIs allows for con­
Bonding’ process were introduced servative cavity preparation and placement into moist fields,
• Acceptable bonding strength and GIs have shown clinical success when placed in incom­
• Numerous procedural steps. pletely debrided cavities (atraumatic restorative treatment).20
5th generation: GIs have a modulus of elasticity similar to dentin and a
• Introduced in the early1990s coefficient of thermal expansion comparable to tooth struc­
• The ‘Etch and Rinse’ systems ture, which minimizes marginal microleakage and thermal
conduction. The unique property of GIs is the release of high
• Developed to reduce the number of procedural steps
levels of fluoride ions over the life of the restoration, which
• Improved clinically consistent results
is known to strengthen enamel, decrease dentin sensitivity,
• These systems are the most commonly used.
and provide an antibacterial and cariostatic effect to the sur­
6th generation:
rounding tissues. Finally, GIs are relatively biocompatible
• Introduced in the early 2000s
with pulp.
• ‘No Rinse’ system GIs also have several disadvantages that must be consid­
• Single-Step Bonding ered during treatment planning. Their use is limited to low-
• Low bonding strength to enamel and poor clinical trials. stress applications because low compression and flexural
strength make them brittle and susceptible to fracture and
cause poor wear resistance. GIs are technique sensitive
during preparation and placement and must be mixed
and applied exactly according to the manufacturer’s

351
 21 Treatment

A B C

Fig. 21.7  Placement of an ‘Etch and Rinse’ (5th generation) bonding agent (BA) after incisor odontoplasty. (A) The occlusal surface is acid etched, and then
rinsed and left damp. (B) The BA is applied and brushed onto the surface. (C) The BA is light cured, and then a second application is made.

Box 21.5  Conclusions about contemporary bonding systems Box 21.7  Classifications of glass ionomer cements
based on a review of clinical trials17
Type I: Luting cements used to bond crowns and orthodontic
1. The 3-Step ER systems out-performed the 2-Step ER systems due appliances
to phase separation and incomplete infiltration into the Type II: Restorative materials
demineralized zone with the latter system Type III: Bases and liners used under composite materials
2. Several NR systems required selective enamel etching to be Type IV: Admixes, light-curing bases, and liners.
effective; therefore, they are not a true NR system
3. 2-Step NR systems showed clinically reliable performance in
non-load-bearing restorations
4. 1-Step NR systems had ineffective clinical performance and had
the highest failure rate of all systems specifications for handling and working time. GIs should be
5. Resin Modified GIs performed comparably to 3-Step ER systems manipulated as little as possible during the initial setting
and better than conventional GIs period, usually four to five minutes. GIs are often provided
6. Although anecdotal reports may support the use of these as a liquid and a powder which are mixed and applied as a
bonding systems in load-bearing restorations, no systematic data tacky liquid, which lumps upon placement into a cavity. The
exist to recommend this application. consistency of the prepared material often necessitates the
use of a mylar strip to hold the material in place during
initial setting when the cavity is located on a vertical wall
(i.e., a peripheral cavity on an incisor) and makes applica­
Box 21.6  The basic technique for a composite restoration tion into an occlusal maxillary cavity difficult (i.e., incisor
1. The cavity or endodontic access is prepared (cavity preparation; root canal therapy restoration) or impossible (i.e., cheek
Fig. 21.4). tooth infundibulum). To improve handling sensitivity, some
2. In deep cavity preparations and endodontic access restorations, a GIs are packaged in syringes that dispense a premeasured
liner and/or base material (e.g., calcium hydroxide, glass ionomer, volume of two gels, which are then mixed or in capsules
and Reinforced Zinc Oxide-Eugenol Cement) may be applied. which are mixed with an amalgamator and dispensed
3. The walls of the cavity are conditioned (Acid Etch Technique; directly into the cavity. Resin modified glass ionomers have also
Fig. 21.8). been developed to allow for instant light-cured initial setting
4. A bonding agent is applied to all etched surfaces with a of the material, as well as improving strength. The final dis­
disposable brush and light cured. Most manufactures suggest two advantage of GIs is their extended curing time (months),
applications of the bonding agent (Fig. 21.8). which necessitates protection of the restoration surface from
5. The resin composite is applied into the cavity and shaped with a desiccation. Protection during curing is commonly provided
plastic instrument. Chemical cure composites are typically applied by the placement of an unfilled resin on the restoration
in bulk, while light-curing and dual-curing composites are applied surface and peripheral dental tissues (enamel and cementum
and cured in 2 mm increments to allow for proper curing of in the horse; rebonding technique).
composite and to minimize the shrinkage of the restoration
Because of the unique chemical bonding and fluoride
(incremental buildup). Low viscosity materials in vertical
restorations can be held in place with a mylar strip (Fig. 21.9).
releasing properties, GIs are formulated for many dental
6. The cavity is filled to the coronal margin, or slightly overfilled.
applications (Box 21.6, 21.7 and 21.8). Although GIs are
very popular in human dentistry in luting applications (Fig.
7. The restoration surface is contoured with a diamond finishing burr
on a high-speed water-cooled handpiece and then finished with
21.12) and in restorative applications in patients with high
finishing stones and discs on a low-speed hand piece (Fig. 21.10). risk for caries (Fig. 21.13), in veterinary medicine GIs are
8. The restoration surface and marginal tissues are sealed by primarily used as liners under composite restorations to
re-etching and applying two coats of bonding agent (Rebonding; protect the pulp and to augment marginal sealing (Fig.
Fig. 21.11). 21.14). This application is commonly referred to as the
‘sandwich technique.’21 Before using a GI, practitioners must

352
 Dental materials

A B

Fig. 21.8  Conditioning and bonding of the cavity. (A) The cavity preparation is conditioned with 37 % phosphoric acid, and then rinsed and left damp.
(B) Two layers of an ‘Etch and Rinse’ bonding agent are applied to the cavity preparation. Note the shiny appearance of the bonded dentin.

A B

Fig. 21.9  Incremental filling of the cavity with a light-cured resin composite. (A) The first layers are placed and adapted to the walls of the cavity.
(B) The remainder of the cavity is filled in 2-mm increments.

consider that the hypsodontic eruption of equine teeth Irrigation during root canal therapy is required to remove the
might eventually put a restoration into an occlusal, load- smear layer of dentin shavings, cellular debris, and pulp
bearing location, for which a GI is inappropriate. remnants created during instrumentation and to disinfect the
pulp canal. The chemical debridement provided by endo­
Endodontic materials dontic irrigants during equine root canal therapy is critical
since the shape of equine pulp canals rarely allows for com­
plete instrumentation. While the type and the concentration
Endodontic irrigants of endodontic irrigants are continuously debated, a SEM
Endodontic therapy involves the preparation, sterilization, study concluded that the volume of the irrigant was the most
and obturation of a diseased pulp canal (see Ch. 22). important factor in removing debris from the canal.22

353
 21 Treatment

Box 21.8  The basic technique for glass ionomer restoration

1. The tooth and cavity preparation are cleaned with non-fluoride,
flour pumice.
2. If the manufacturer recommends, or if increased bonding strength
is required, condition the cavity with polyacrylic acid (acid etch
technique).
3. Mix, or activate (encapsulated GI), exactly according to the
manufacturer’s instruction. Remove one level scoop of powder
and place it on a mixing pad. Divide the powder into three to four
aliquots. Dispense the liquid next to the first aliquot and rapidly
mix with a mixing spatula. Continue by drawing each aliquot into
the liquid until the material is thoroughly mixed. The typical
mixing time is approximately 30 seconds; however, mixing on a
chilled surface extends the working time. The prepared material
should have a uniform, tacky, glossy liquid consistency (Fig.
21.15).
4. Apply the GI to the restoration with a plastic instrument or a
compule syringe. In vertical restorations, a mylar strip is usually
required to hold the material in place. The initial setting time for
GIs is approximately 4 minutes, during which time the material
can be manipulated; however, overworking the material should
be avoided.
Fig. 21.10  Contouring and finishing the restoration. Once the cavity is 5. The GI must be protected from contamination and drying during
completely filled, the restoration is contoured to approximate the tooth the initial setting period (about 20 minutes) by covering the
margins, and then finished to a smooth appearance. Note the dull restoration surface with a varnish or unfilled resin.
appearance of the restoration. 6. After the initial set, the restoration surface is contoured with a
diamond finishing burr on a high-speed, water-cooled handpiece,
and then finished with finishing stones and discs on a low-speed
hand piece.
7. The restoration surface and marginal tissues are sealed by
re-etching and applying a bonding agent (rebonding).

should improve irrigation of the irregularly-shaped equine

pulp canals.24
Liquid irrigants are delivered into the pulp canal using a
blunt needle on a syringe to prevent extrusion into the peri­
apical tissue. Needles with a closed tip and a side port should
be used when irrigating with caustic irrigants (see sodium
hypochlorite). Irrigants are removed by suction, with a paper
point, or by flushing with sterile saline solution. Compressed
air should not be used to evacuate irrigants from the root
canal since air may be extruded through the apex. Fatalities
secondary to air embolism have been reported in a human25
and in dogs.26
The most commonly used irrigant is sodium hypochlorite
(NaOCl). It has broad-spectrum antimicrobial efficacy and
is a proteolytic solvent that dissolves the organic portion of
Fig. 21.11  Rebonding the restoration. The finished restoration and the smear layer and the predentin layer of the dentin. Free
marginal tissues are re-etched, and two coats of a bonding agent are Cl− ions are responsible for NaOCl’s antimicrobial effects.
applied. Note the shiny appearance of the rebonded tooth and restoration. Proteolytic reactions deplete free Cl− ions; therefore, NaOCl
must be replenished frequently to maintain chemical effi­
cacy. Concentrations from 1 to 5.25 % (household bleach)
have been shown to be clinically effective.27 At room tem­
The effectiveness of all endodontic irrigants is limited by perature, a total contact time of 20–30 minutes is required
their ability to penetrate to the apex of the canal and into to completely dissolve the pulp.28 However, heating increases
the dentin tubules; therefore, all irrigants should be replen­ both the tissue solvent and antimicrobial effects.29,30 The
ished frequently to ensure effective chemical concentrations effervescence created by mixing sodium hypochlorite and
and removal of debris. Replenishment after each instrument hydrogen peroxide was once a popular flushing technique
change, or at least every two minutes, is commonly accepted. but this method has been shown to be ineffective.31 During
Ultrasonic activation of endodontic irrigants augments pen­ conventional root canal therapy (coronal access), slow irri­
etration into small pulp canal spaces23 and, theoretically, gation with light pressure through a non-binding or side-

354
 Dental materials

A B

Fig. 21.12  Application of Type I glass ionomer cement. (A) A resin modified glass ionomer was used to cement an orthodontic appliance to the cheek teeth
of a young horse. (B) After appliance failure, the glass ionomer cement remains bonded to the cheek tooth peripheral cementum. (Bonding to cementum
has not been scientifically evaluated.)

port endodontic needle is advisable since injection of NaOCl Chlorhexidine, 2 % solution, (CHX) is used as an endo­
through the apical foramen into the periradicular tissue is dontic disinfectant because of its antimicrobial properties,
extremely caustic and causes severe pain, periradicular hem­ and like sodium hypochlorite, heating enhances this prop­
orrhage, swelling, and possible abscess. During retrograde erty;34 however, CHX has no tissue solvent properties.
procedures, the periapical tissues should be protected and The use of CHX has had mixed acceptance. Some dentists
rinsed frequently with saline solution, and the endodontist irrigate with alternating flushes of NaOCl, EDTA, and CHX
should consider using a lower concentration of NaOCl. for increased disinfection, while others support the use of
During procedures on maxillary incisors in the sedated CHX as the final canal rinse before obturation because CHX
horse, gravity evacuates the irrigant from the root canal. For binds to dental tissues and has persistent antimicrobial
this reason, higher concentrations of irrigant should be effect.35
considered. When using multiple irrigants the root canal is typically
Ethylenediaminetetraacetic acid (EDTA) is a decalcifying rinsed with sterile saline solution between irrigants, and this
agent that is commonly used to dissolve the inorganic com­ is especially important when using CHX. CHX is incompat­
ponent of the smear layer. EDTA also increases the diameter ible with NaOCl and decomposes into a potentially carcino­
of the dentinal tubules to allow penetration of disinfectants. genic precipitate, parachloroaniline,36 and when CHX is
A 17 % solution is the most common endodontic concentra­ mixed with EDTA, a CHX/EDTA salt precipitates.37 The com­
tion and removes the smear layer in less than one minute of bination of NaOCl and EDTA inactivates the NaOCl, while
contact time. Another popular formulation of EDTA adds the EDTA remains active for a few minutes.38
urea peroxidase for its antibacterial properties in propylene
glycol base (RC Prep).b Although the use of gel and paste
formulations as a file lubricant is commonly practiced, the
solvent efficacy of these preparations is questionable. Since
Intracanal medicaments
the chemical efficacy of EDTA is self-limiting, it also must Since instrumentation and irrigation of non-vital pulps often
be intermittently replenished. For maximum clinical effi­ leaves viable bacteria in the pulp canal, some endodontists
cacy, EDTA should have a total contact time of at least 15 perform staged root canal therapy (multiple visits) to ensure
minutes.32 NaOCl and EDTA are most effective if their use disinfection of the canal. Antimicrobial intracanal medica­
is alternated.33 ments are used between treatments. Historically, volatile
medicaments (i.e., formocresol and phenol derivatives) were
used for their strong antibacterial properties, but these mate­
b
RC Prep, Stone Pharmaceuticals, Philadelphia, PA, USA. rials have lost popularity due to their potential toxicity.

355
 21 Treatment

A B C D

E F

Fig. 21.13  Application of Type II glass ionomer (GI) cement restoration. GI restorations should only be applied after careful and cautious planning because
of the hypsodontic eruption of equine teeth. (A) Tooth resorption on the vestibular aspect of the 3rd incisor of a senior horse. (B & C) Cavity preparation of
the lesion involved osteoplasty and extensive subgingival debridement of all three dental tissues (Modified Honma Stage 3 lesion). (D & E) A glass ionomer
restoration was selected due to the uncertain etiology of the lesion and based on extrapolated applications in human and small animal patients. (F) 1-year
follow-up demonstrates retention of the restorative with surface pitting and possible marginal leakage.

A B C D

Fig. 21.14  Application of Type III glass ionomer cement (Sandwich Technique). (A) Non-vital pulp exposure of a mandibular 3rd incisor in a teenage horse.
(B) Gutta percha (orange) and ZOE obturation of the root canal. (C) Glass ionomer liner application over the gutta percha. (D) The final resin composite
restoration of the root canal access.

356
 Dental materials

A B

Fig. 21.15  Mixing a glass ionomer (GI). (A) The GI powder and liquid are placed upon a glass mixing block. (B) The powder and liquid are rapidly mixed into
a uniform, tacky, glossy liquid consistency.

Calcium hydroxide (CaOH) has both scientific and compared to GP, and may strengthen the root.40 However,
popular support in several endodontic applications. CaOH no clinical successes using resin-based obturation systems in
has traditionally been the material of choice for the treat­ the horse have been reported.
ment of exposed pulp tissue (direct pulp capping) and for GP is the oldest, least cytotoxic, and most commonly used
apexification of non-vital pulp canals in immature teeth obturation material. It is also the only solid obturation
(Fig. 21.16) because of its biocompatibility and reparative material with reported use in equine endodontics. Natural
dentin induction property; however, Mineral Trioxide Aggre­ rubber and GP are the cis and trans isomers, respectively, of
gate (discussed below) is rapidly replacing CaOH in these the isoprene monomer, which is extracted from the juices
traditional applications. Because of its potent bactericidal of trees in the sapodilla family. Dental GP typically consists
properties, CaOH is also the material of choice for intracanal of approximately 20 % GP, 75 % zinc oxide, metallic sulfates
medicaments during staged (multiple visits) root canal for radio-opacity, and other waxes and resins. GP is supplied
therapy. In addition to the bactericidal effect of strong alka­ in cones of various shapes and lengths, but also in cones
linity, CaOH also hydrolyzes the lipid component of the tapered to match standardized endodontic files. 60-mm
lipopolysaccharides in bacterial cell walls.39 In equine den­ lengths are appropriate for most equine application
tistry, CaOH has been routinely used as a stand-alone pulp (Fig. 21.17). Most manufacturers package sterilized cones;
capping material after iatrogenic pulp exposures during however, the most common sterilization technique for GP
occlusal equilibration. As discussed above (Bases and liners), is soaking the cone in 5.25 % sodium hypochlorite (NaOCl)
this application is inappropriate. for 1 minute.41 After NaOCl sterilization, the cone is typi­
cally rinsed with sterile saline solution. Some dentists believe
NaOCl sterilized GP must be rinsed with ethyl alcohol to
Obturation materials remove NaOCl crystals, which interfere with the obturation
Obturation is the complete filling and hermetic sealing of seal.42 GP oxidizes if exposed to air, light, and elevated tem­
the prepared and sterilized root canal. Obturation systems peratures; therefore, refrigeration is recommended for pro­
typically require the combination of a solid obturation longed storage. GP is incompressible but can be compacted
material and a sealer. Endodontic sealers bond to dentin to under pressure, and heating it to a temperature above 147°
provide a hermetic seal, but excessive shrinkage during F (64° C) softens GP to facilitate mechanical packing.43 GP
curing can cause seal failure; therefore, the solid obturation dissolves in organic solvents (e.g., chloroform, halothane,
material provides a base for the sealer to minimize shrink­ xylene), and a GP cone can be softened with a solvent to
age. Solid obturation materials include gutta percha (GP), facilitate placement into irregularly shaped canals by dipping
silver, and synthetic polymers. Compared to GP, silver has the apical 2–4 mm of the GP cone into the solvent for 1–6
poor sealing properties, and corrosion produces cytotoxic seconds (chloroform dip technique).44 GP alone has no
salts. Consequently, the use of silver as an obturation mate­ adhesive properties and cannot hermetically seal a canal.
rial is below the current endodontic standard of care. A Endodontic sealer cements are always used in combination
polyurethane based obturation material (Resilon)c is being with the solid obturation material.
used in both human and small animal dentistry in resin- Endodontic sealers are classified as zinc oxide-eugenol-
based obturation systems. This material is non-toxic, non­ based, calcium hydroxide-based, glass ionomer cements,
mutagenic, and biocompatible, has superior coronal sealing and polymers. Calcium hydroxide-based sealers are pro­
moted for their therapeutic effects, but have low adhesion
to dentin, low water solubility, and have not passed scientific
c
Resilon, Resilon Research, LLC. scrutiny. Glass ionomer endodontic cements have excellent

357
 21 Treatment

A B

C D

Fig. 21.16  Calcium hydroxide apexification of an equine incisor. (A) Traumatic crown fracture with pulp exposure of an immature 2nd maxillary incisor (202)
in a 5-year-old horse. Note the mucosal draining tract. (B) Radiograph demonstrating an apical lucency associated with the open apex of 202. (C) At the
five-month follow-up examination, the apex of the 2nd maxillary incisor has mineralized. (D) At the 1-year follow-up examination, the apical periodontium of
202 has re-attached, and root canal therapy was subsequently performed. (Case by permission from Robert M. Baratt DVM.)

biocompatibility and chemical bonding to dentin but are and introduced into the pulp canal with a spiral filler on a
technique sensitive. Polymer sealers are very popular in low-speed handpiece or on an endodontic file. Additionally,
small animal and human endodontics because of their han­ each GP cone is usually coated with sealer before placement
dling characteristics and dentin bonding, but their use in into the canal.
equine endodontics is unreported. Zinc oxide-eugenol-based Thermaplasticized GP obturation systems are widely used
sealers are ZOE cements that have been modified with germ­ in small animal and human endodontics, but no clinical
icides, rosins, resin acids, and other chemicals for endodon­ successes in horses have been reported. The small size of
tic application. They have a long history of success, are the the system instrumentation and the complex equine endo­
most commonly used sealers, and are the ‘gold standard’ for dontic anatomy limit the application of the thermaplasti­
scientific comparison. They are mixed as previously described, cized systems in horses. A cold filling obturation system

358
 Dental materials

gluconate did not inhibit its sealing properties.49 MTA has a

high alkalinity (pH 10.5–12) but is less cytotoxic than
calcium hydroxide and induces the formation of a higher
quality of and greater amount of reparative dentin than
CaOH.50,51 Finally, MTA produces minimal periradicular
tissue inflammation and is cementogenic.52–54 This unique
final property establishes the ideal healing environment for
the periodontium. In the horse, initial clinical successes have
been reported using MTA as a retrograde filling material in
a mandibular cheek tooth;55 however, this report lacks long-
term follow-up.

Periodontal materials

Oral and periodontal irrigants

The treatment of periodontal disease requires the debride­
ment of the periodontal pocket or, in advanced cases, peri­
Fig. 21.17  Gutta percha, which is supplied in a variety of diameters and odontal surgery. Several dental materials are used to augment
lengths. 30-mm and 60-mm lengths are commonly used in veterinary the effects of periodontal debridement. Pocket irrigation is
medicine, with the latter being more appropriate for equine applications. an important procedure following periodontal pocket deb­
ridement to remove the loose debris created by the scaling
and root planing procedures. Water, saline solution, and
(GuttaFlow)d has been introduced, which might facilitate chlorhexidine are commonly used oral irrigants in both
the filling of irregularly shaped equine pulp canals. The human and veterinary dentistry. Chlorhexidine has several
system combines particulate GP with a silicon-based sealer advantages including: 1) adherence to dental tissues, oral
in a prepackaged capsule. After mixing with an amalgama­ soft tissues, and the pellicle, which prevents bacterial and
tor, the material is injected into the pulp canal, and has a plaque adherence; 2) a broad antimicrobial spectrum with
30 minute curing time before a restoration can be applied. no reported antimicrobial resistance; and 3) a residual anti­
The manufacturer claims that the product expands upon microbial effect.56 Chlorhexidine concentrations between
curing. However, this expansion is probably clinically insig­ 0.02 and 0.12 % have been shown in clinical trials to be
nificant. Research is needed to validate this product, but effective oral irrigants.57 A 0.05 % solution has also been
initial use in equine incisors and canine teeth has produced reported to be effective and non-toxic to tissues as a surgical
inconsistent results. (R Baratt, L Kimberlin, S Galloway, per­ wound irrigant,58 and a concentration of 0.12 % was shown
sonal communication.) to have synergistic antibacterial properties with locally
Endodontic treatment of equine cheek teeth requires api­ administered tetracycline.59 However, if chlorhexidine is
coectomy and retrograde obturation of the tooth. Histori­ used as a surgical irrigant during periodontal surgery (i.e.,
cally, amalgam has been the preferred material for apical guided tissue regeneration), it should be thoroughly rinsed
sealing, but it has lost popularity due to toxicity concerns from the periodontal pocket at the conclusion of the proce­
and the availability of superior materials. Glass ionomer dure because chlorhexidine can devitalize periodontal cells
cements, resin composites, and reinforced ZOE cements and interfere with reattachment to cementum.60
(Super EBAe and IRM) have demonstrated better sealing
properties than amalgam, while the latter is noted for less Local antibiotic administration (perioceutics)
technique sensitivity.45 Mineral Trioxide Aggregate (MTA)f is (Box 21.9 and 21.10)
an endodontic material that has recently shown superior
performance in numerous endodontic applications, includ­ In cases of Stage 2 periodontitis (up to 25 % attachment
ing pulp capping, orthograde apical closure (apexification), loss),61 local antibiotic administration (LAA) may be indi­
perforation repair, and retrograde root-end filling. MTA con­ cated as an ancillary treatment after completion of pocket
tains approximately 75 % Portland cement, and upon hydra­ debridement and irrigation. In human dentistry, tetracycline
tion with water or saline solution, forms a colloid gel that impregnated fibers and doxycycline, minocycline, and met­
hardens over a 4-hour period. MTA can be placed in a wet ronidazole gels are commercially prepared for LAA. A bio­
environment and is not affected by blood contamination.46 degradable, polymerized 8.5 % doxycycline gel (Doxirobe
The material properties of MTA have withstood extensive Gel)g is labeled for veterinary use in dogs and has been
scientific testing. Compared to amalgam and reinforced ZOE empirically used in other species, including horses (Fig.
cements, MTA showed significantly less marginal leakage47 21.18). Doxycycline has a broad spectrum of antibiotic activ­
and superior marginal adaptation,48 and a recent in vitro ity against several known bacteria associated with periodon­
study showed that mixing MTA with chlorhexidine tal disease, and the degradation of doxycycline gel provides
localized, sustained release of antibiotic for approximately 2

d
GuttaFlow, Coltène/Whaledent, Raiffeisenstraße 30, 89129 Langenau, Germany.
e
Super EBA, Harry J. Bosworth Company, Skokie, IL, USA.
f g
ProRoot MTA, DENTSPLY Tulsa Dental Specialties, Tulsa, OK, USA. Doxirobe Gel, Pfizer Animal Health, Exton, PA, USA.

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 21 Treatment

Box 21.9  Application of a local antibiotic (perioceutic) Box 21.10  The basic technique for fabricating a reinforced
composite splint
Doxirobe Gel is supplied in a premeasured (1 ml) two-syringe system.
For the product to be effective, the periodontal pocket must be debri- 1. Excessive peripheral cementum is removed from the crowns of
ded and should be dried. the incisors to allow for enamel bonding. This can be
1. The product is mixed according to the labeled instructions using accomplished with a whetstone on a low-speed handpiece or a
the two-syringe system. diamond burr on a high-speed handpiece.
2. A blunt needle is placed onto syringe A for delivery into the 2. The teeth are aligned, and a tin foil template is made by molding
periodontal pocket. the foil to the contours of the teeth in the desired application
3. The pocket is filled to the level of the gingival margin. Many stage site. The template is then used to cut the reinforcing material to
2 periodontal pockets in horses exceed the 1 ml prepackaged the appropriate length and width. The material should not be
volume, and multiple syringes are often required for treatment. handled with bare hands.
4. Upon contact with crevicular fluid, the gel begins to polymerize. 3. The teeth are polished with a non-fluoride pumice paste and
Water drops are typically administered to any exposed gel to acid etched.
accelerate the setting reaction. 4. A bonding agent is applied to the teeth and light cured.
5. A plastic instrument can be used to pack any escaping gel back 5. The mesh is coated with an unfilled resin, and the excess resin is
into the periodontal pocket. blotted off.
6. Covering Doxirobe with an impression material has been 6. A thin layer of filled composite is applied to the bonded surface
described; however, the authors believe that this step is of the teeth but is not cured.
unnecessary since properly placed gel is well retained. Premature 7. The wetted mesh is applied to the splint site and contoured to
dislodging of a local antibiotic administration is probably the the surface of the teeth with a plastic instrument. Excess
result of poor handling technique. composite material is removed.
8. The splint over each tooth is light cured. Curing the entire splint
requires multiple curing increments.
9. An additional layer of a filled composite is added to the splint,
contoured, and cured.
weeks. Additionally, doxycycline binds to dentin, cemen­ 10. The final composite layer of the splint can be shaped or polished
tum, and bone for prolonged antibiotic release, inhibits the to avoid abrasion.
collagenase enzyme (an enzyme that slows the healing of
the periodontal tissues), and stimulates fibroblast activity to
re-establish the periodontium.62,63 The polymer gel also pro­
vides a physical barrier for reinfiltration of food and debris Bone grafting materials
into the periodontal pocket, which is an important goal in
the treatment of cheek tooth periodontal disease. Although In human and veterinary dentistry, bone grafts are used for
the use of LAAs has become a popular practice in equine guided tissue and bone regeneration (GTR, GBR) in the
dentistry, this ancillary procedure has received no critical surgical treatment of advanced periodontal osseous lesions
evaluation and, in the authors’ opinion, has limited indica­ (stage 2–4 periodontitis, >25 % bone loss) and of selected
tions in the equine patient. Other less expensive materials periradicular (endodontic) lesions, and for bone augmenta­
have shown clinical effectiveness as temporary barrier mate­ tion in association with implant surgery. Although the filling
rials (e.g., impression materials, calcium sulfate, calcium of deep post-extraction alveoli with synthetic bone grafting
alginate). material has been practiced in veterinary dentistry in order
to increase the rate of bony healing and to preserve the
alveolar ridge, this practice has limited scientific support and
Periodontal splinting is a source of debate amongst veterinary dentists.
Periodontal splinting is a temporary adjunct appliance used Bone grafting materials are classified by their source and
in combination with aggressive periodontal therapy to sta­ by the type of bone growth that they promote. Material can
bilize diseased permanent teeth with mobility or to stabilize be obtained from the same patient (autogenous bone graft),
mobile teeth during healing after trauma.64 Splinting creates from a different patient of the same species (allograft), from
a stable platform for osseous regeneration by redistributing a patient of a different species (xenograft), or from artificial
the forces applied to the diseased teeth to the adjacent or manufactured materials (synthetic grafts/alloplastic
healthy teeth. Before splinting, odontoplasty should be per­ grafts). The bone growth potential of a graft material is
formed on the affected teeth to take them out of occlusion described as osteogenic, osteoinductive, or osteoconductive.
since excessive occlusal loading is a frequent cause of tooth Osteogenic materials contain living osteoblasts that produce
mobility.65,66 Splinting materials include acrylics and resin new bone within the graft itself. Osteoinductive materials
composites used alone or reinforced with interdental wire possess bone morphogenic proteins (BMP) that induce the
or fiber mesh (Ribbond).h Since the accumulation of plaque differentiation of osteoblasts in the recipient tissue (which
and debris around the splint promotes periodontal disease, does not have to be bone). These osteoblasts then produce
periodontal splinting is best suited to the incisors where the new bone. Osteoconductive materials, when placed into
appliance can be cleaned daily (Fig. 21.19). bone, provide physically favorable scaffolding for osteob­
lasts from the recipient tissue to penetrate and form new
bone.
Autogenous bone grafts are transferred from one site to
h
Pepgen P-15, DENTSPLY Friadent, Postfach 71 01 11, 68221 Mannheim, Germany. another within the same patient. They can consist of

360
 Dental materials

A B C

D E

F G

Fig. 21.18  Application of a local antibiotic (perioceutic). (A & B) A 12-mm periodontal pocket (PP) on the vestibulodistal aspect of the right mandibular
canine tooth (404) of a young gelding. (C) Radiographs reveal horizontal bone loss of the associated alveolar bone (Stage 2 periodontitis). (D) The blue arrow
shows the applied Doxirobe Gel in the PP. (Note that the perioceutic material fills the entire pocket.) (E) At the 2-week follow-up visit, the PP depth measured
4 mm. (F & G) At the 6-month follow-up visit, probing of the PP produced negligible depth and radiographs revealed alveolar bone regrowth.

cancellous or cortical bone and are the gold standard bone Allografts are typically collected from cadavers. Although
grafting material. These grafts are usually considered osteo­ not routinely used in veterinary medicine, in human medi­
inductive but are potentially osteogenic if tissue remains cine, grafts are collected, commercially prepared, and banked
vital. They rapidly revascularize and lack antigenicity. for future use. Preparation of the graft degrades the tissue’s
The collection of autogenous bone graft is also associated BMPs; therefore, allografts are osteoconductive. The disad­
with the inherent complications and expense of general vantages of the materials are antigenicity and the potential
anesthesia and significant morbidity. Therefore, the other for disease transmission.
classifications of bone grafting materials have been Xenografts are prepared materials of bovine origin and
developed. have had extensive clinical use in human periodontics. Like

361
 21 Treatment

Fig. 21.19  Periodontal splinting. Ribbond is used to stabilize a 2nd

mandibular incisor after a traumatic injury. (Courtesy of Edward T. Early,
DVM.)
Fig. 21.20  Alloplastic (synthetic) bone graft materials. A granular synthetic,
bioactive ceramic (Consil) on the left and powdered β-calcium sulfate
hemihydrate (plaster of Paris) on the right.

A B

Fig. 21.21  Calcium sulfate used as an alloplastic graft in a post-extraction alveolus. (A) Calcium sulfate placed into the alveolus of the maxillary 1st cheek
tooth (106) in a young mare. (B) Gingival healing at 6 weeks postoperatively.

allografts, they are osteoconductive and have the potential coated with hydroxylcarbonate apatite (Fig. 21.20) and,
for antigenicity and disease transmission. when placed in contact with tissue fluids, incorporates
Several alloplastic (synthetic grafts) materials have been ground proteins and attracts osteoblasts.68 This bioactive
investigated for use in periodontal surgery. All are inert and ceramic is mechanically hemostatic69 and has bacteriostatic
osteoconductive, with the exception of Pepgen P-15,i a syn­ properties secondary to its high pH.70 The material is easy to
thetic amino acid sequence (P-15) mixed with a calcium- use and can be prepared by mixing with sterile saline solu­
phosphate matrix, which has demonstrated osteoinductive tion, sterile water, or the patient’s blood to form a wet sand
potential.67 The use of this product has not been reported in consistency before placing the material into the host site, or
an equine patient. the material can be placed directly into the host site for
A synthetic, bioactive ceramic derived from calcium incorporation with blood.
salts, phosphates, and silica is labeled for veterinary Due to the large size of the bony defects associated with
use ‘in infraboney pockets caused by periodontal disease, periodontal disease and dental extraction in the horse, many
endodontic-periodontic lesions, traumatic defects, or intra­ practitioners use calcium sulfate (plaster of Paris, Dental
osseous flaws’(Consil Bioglass)j. The granular material is Stone) as an osteoconductive bone grafting material (Fig.
21.21). Calcium sulfate has been used historically in both
i
Consil Dental Bioglass, Nutramax Laboratories Inc., Edgewood, MD, USA. human and veterinary medicine in dental and orthopedic
j
Ribbond, Ribbond Inc., Seattle, WA, USA. applications, and has shown significant regeneration of

362
 Dental materials

bone and cementum in the dog.71 Calcium sulfate is readily

available, inexpensive, and biocompatible. The material is Box 21.11  The basic technique for making a dental
supplied as a powder (calcium sulfate hemihydrate), which impression with alginate
when rehydrated with water, sets into a solid form (calcium 1. A rigid tray is designed so that the teeth and gingival margins
sulfate dehydrate, gypsum). The mixing/working time of the are covered and so that 3–4 mm of material remains between
material is usually 2–5 minutes, but varies based on the the oral tissues and the tray. Overflow holes are drilled into the
specific product. The mixed material can be applied into a tray to allow material relief as the tray is placed.
bony defect through a curved-tip syringe as a viscous liquid 2. The patient should be sedated to provide at least 10 minutes of
during the early phase of the setting reaction or later during access into the mouth without interference from the tongue or
the setting reaction by hand or with a dental spatula as putty. cheeks.
Once set, the material is porous enough to allow fluid 3. The mouth is thoroughly rinsed to remove feed material and to
exchange while dense enough to exclude epithelial and gin­ wet the teeth.
gival connective tissue migration. The porosity of the mate­ 4. The impression tray is test-fitted.
rial also provides for sustained local release of incorporated 5. The impression material is mixed according to the
antibiotics, especially doxycycline, and for the localized manufacturer’s directions using a rubber bowl and spatula and
then is spatulated into the impression tray.
release of calcium ions.72 Calcium sulfate resorbs completely
over a 2-week period.73 Although calcium sulfate has been 6. The tongue, lips, and cheeks are retracted and controlled.
used as a bone graft material for over a hundred years, 7. The tray is placed onto the teeth and held in position until the
impression material sets. Setting can be approximated by
further controlled studies are needed to evaluate its
leaving a small amount of material in the mixing bowl and
efficacy. observing the setting reaction.
In 2008, the first study reporting the use of bone grafting
8. The impression is gently removed and inspected for accuracy.
material in the mouth of a horse was published.74 A meth­
9. At least two impressions, preferably 3 or 4, should be made. You
ylmethacrylate-based, non-resorbable bone substitute was will want study and backup models in addition to the two
placed into the post-extraction maxillary alveolus in five working models sent to the dental laboratory.
ponies. Although the material in this study demonstrated 10. Impressions should be wrapped in a damp cloth and stored in
excellent biocompatibility and osteoconductivity, it per­ an air-tight container until the casts are poured.
formed inferiorly to the control alveoli with respect to bone 11. Stone casts should be poured as soon as possible.
mineral density and bone volume at the one-year follow-up
evaluation.

Dental impression and cast materials accurately measure and mix the pastes, on demand, and
(Box 21.11) facilitate delivery into the impression tray or into the mouth.
EIM have a working time of 2.5–7 minutes and a set time
Dental impression materials are used to make accurate of 3–10 minutes. The expense of EIM is rarely commensurate
molds of the oral hard and soft tissues. The impression is with the degree of accuracy required for equine impressions;
the negative reproduction of the tissues. Casting materials are however, some equine practitioners commonly use EIM as
poured into the impression mold to fabricate the dental cast temporary bandages to prevent food contamination of
or model, the positive reproduction, of the oral tissues. Study extraction site alveoli and periodontal pockets. EIM adapt
models are used for treatment planning and for treatment well to the oral hard tissue walls and can be removed more
documentation. Working models are used to fabricate ortho­ easily than rigid acrylics, such as polymethylmethacrylate
dontic appliances and prosthodontic restorations. Two (PPMA). Condensation silicones (silicone, silicone rubber)
general categories of elastic impression materials are com­ have significant limitations compared to the other EIM and
monly used in veterinary dentistry: alginate hydrocolloids have lost popularity. The clinical properties of the other EIM
and elastomeric impression materials. Dental casts are will be briefly discussed.
molded from epoxy resin or gypsum. Typically, the impres­ The addition silicones (AS) (polyvinyl siloxanes, polyvinyls,
sion is sent to a dental laboratory that fabricates both the vinyls) are currently the most popular impression materials
cast and the prescribed appliance. for fixed prosthetics (Fig. 21.22). AS impressions have excel­
lent detail and remain dimensionally stable for weeks. They
are hydrophobic, and moisture (e.g., saliva, blood) can sig­
Elastomeric impression materials nificantly degrade impression accuracy; therefore, AS must
Elastomeric impression materials (EIM) are primarily used be used in a dry field. AS are thermally sensitive, and the rate
for prosthodontic impressions. Four types of EIM are avail­ of cure is accelerated by heating and decelerated by cooling.
able: polysulfides, condensation silicones, addition sili­ Several materials can contaminate AS, retarding polymeriza­
cones, and polyethers. These products are usually dispensed tion and creating unacceptable impressions; therefore,
as two pastes or putties, which upon mixing begin to set into rinsing the mouth with 2 % chlorhexidine to remove con­
a firm, but elastic consistency. All EIM are set by catalyst- taminants before placing an AS impression is recommended.
initiated polymerization and have been formulated to mini­ The most common contaminant is the sulfides in latex
mize shrinkage. The appropriate ratio of the pastes must be gloves; therefore, polyethelene gloves should be worn when
measured and spatulated in a manner that minimizes air handling AS. Other sources of contamination are recently
entrapment to produce accurate impressions; therefore, placed restorative resins and the residual films left on the
many EIM are supplied in auto-mixing cartridges that teeth by polyether and polysulfide impression materials.

363
 21 Treatment

A B

Fig. 21.22  Polyvinyl siloxane (PVS) is the most popular elastomeric impression material. (A) A generic material supplied in an auto-mixing cartridge. (B) PVS
used as a mold for a resin composite restoration of a mandibular incisor. (Courtesy of Edward T. Early, DVM.)

A B

C D

Fig. 21.23  Alginate hydrocolloid impression materials. (A) Improvised incisor impression trays (right) and alginate impressions (left). (B) Making an alginate
impression of the mandibular incisors in a sedated horse. (C) Improvised cheek teeth impression trays. (D) The alginate impressions of the mandibular cheek
teeth.

364
 Dental materials

A B

Fig. 21.24  Dental stone casts of the impressions from Fig. 21.23. (A) Casts of the incisors. (B) Working models of the mandibular cheek teeth used to
construct an orthodontic appliance. (C) Study models of the mandibular cheek teeth used for treatment planning and for monitoring case progression.

Polyethers (PE) are the second most popular EIM, and the PE. These materials are both temperature and moisture sen­
preferred material for full bite registrations. They produce sitive, and heat and humidity accelerate polymerization.
impressions of excellent detail and retain dimensional sta­
bility for one to two weeks. PE are hydrophilic and make
accurate impressions in a moist environment. The ‘snap-set’
Alginate hydrocolloid impression materials
behavior of PE allows the material to flow into an area Alginate hydrocolloid impression materials (AHIM) are
during the entire working time and then rapidly set. inexpensive and appropriate for dental impressions in
Polysulfides (PS) are also used for full-bite registrations in equine patients. AHIM are dispensed as a powder containing
human dentistry. They are relatively inexpensive and make soluble alginate (derived from marine plants), calcium
accurate impressions in a moist environment; however, the sulfate dihydrate, and sodium phosphate. Upon mixing with
dimensional stability of PS is inferior to that of both AS and water, alginic acid reacts with calcium sulfate to form an

365
 21 Treatment

insoluble elastic gel. Sodium phosphate retards the reaction smaller, regularly shaped rods and prisms. Stone produces
and provides for the working time of the material. Tap water more detailed casts. However, both produce enough detail
with high mineral content also retards the setting time. Fast- for orthodontic models and bite registrations in equine
setting alginates (Type 1) have a 1–2 minute working time patients (Fig. 21.24).
and are appropriate for use in sedated equine patients.
Regular setting alginates (Type 2) have a 2–4.5 minute
working time. AHIM are highly hydrophilic and should be
Summary
applied in a moist field. Drying or polishing the pellicle off
Equine dentistry saw minimal change through most of the
the teeth may cause the alginate to stick to the teeth. AHIM
20th century, with the disciplines of occlusal equilibration
are easily removed from the mouth; however, their dimen­
and exodontia being the standard of equine dental care. The
sional stability is short, and usually only one cast can be
resurgence of veterinary dental care in the 1990s stimulated
made from each impression. Ideally, casts should be poured
practitioners to practice other dental disciplines (endodon­
within 15 minutes of making the impression; however,
tics, orthodontics, periodontics, and restorative dentistry) in
casting can be delayed until returning to the laboratory if the
order to preserve the dentition of their patients. These disci­
impressions are wrapped in a damp cloth and stored in an
plines require the application of dental materials.
air-tight container. Although AHIM lack the detailed accu­
The first decade of the 21st century has seen exponential
racy and the auto-mixing systems of EIM, they produce
changes in the practice of equine dentistry. Accepted dental
impressions of acceptable accuracy for diagnostic bite regis­
procedures and material applications have been extrapo­
trations and orthodontic models, at a fraction of the cost of
lated from human and small animal veterinary dentistry for
EIM. Only gypsum casting materials can be used with algi­
use in the equine patient, and anecdotal reports of success
nate impressions (Fig. 21.23).
support the continuation of these practices. However, fail­
ures and the inappropriate application of dental materials
Cast materials demonstrate the need for scientific investigation. With con­
Dental plaster (plaster of Paris) and dental stone are used to tinued case reporting by practitioners and clinical research
fabricate dental casts from alginate impressions. Orthodontic by universities, our dental materials decisions will become
casts are typically referred to as models. Both of these casting evidence-based.
materials are made from gypsum (calcium sulfate dihy­
drate). The physical properties of the materials vary greatly
based on the dehydration processes used to manufacture Acknowledgments
each material’s base powder, calcium sulfate hemihydrate.
The crystals of dental plasters (β-calcium sulfate hemihy­ Robert M. Baratt DVM (Salem, CT) and Edward T. Early
drate) are large, irregularly shaped, and porous, whereas the DVM (Williamsport, PA) for critical review of the manu­
crystals of dental stone (α-calcium sulfate hemihydrate) are script and for photographs.

Further reading
Anusavice KJ. Phillips’ Science of Dental Newman MG, Takei HH, Klokkevold PP, Wiggs RB, Lobprise HB, eds. Veterinary
Materials, 11th ed. Saunders, St. Louis, Carranza FA. Carranza’s Clinical Dentistry: Principles and Practice.
2003 Periodontology, 10th ed. Saunders Lippincott-Raven, Philadelphia, PA, 1997
Cohen S, Hargreaves KM, eds. Pathways of the Elsevier, St. Louis, 2006 Zardiackas LD, Dellinger TM, Livingston M,
Pulp, 9th ed. CV Mosby, St. Louis, Powers JM, Sakaguchi RL, eds. Craig’s eds. Dental Clinics of North America,
2006 Restorative Dental Materials, 12th ed. Dental Materials. Saunders Elsevier,
Mosby Elsevier, St. Louis, 2006 Philadelphia, PA, 2007

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eds. Pathways of the pulp, 4th edn. CV Instruments, materials, and devices. In: Equipment, Materials and Techniques.
Mosby, Washington, DC, 1987, Cohen S, Hargreaves KM, eds. Pathways Blackwell, Ames, Iowa, 2004, p. 134
pp 397–440 of the pulp, 9th edn. CV Mosby, St Louis, 57. Jahn C. Supragingival and subgingival
27. Mentz TCF. The use of sodium 2006, p. 263 irrigation. In: Newman MG, Takei HH,
hypochlorite as a general endodontic 43. Goodman A, Schilder H, Aldrich W. The Klokkevold PP, Carranza FA, eds,
medicament. Int Endod J 1982; 15: thermomechanical properties of gutta- Carranza’s Clinical periodontology,
132–136 percha. IV. A thermal profile of the warm 10th edn. Eslevier, St Loius, 2006, p. 842
28. Ruddle CJ. Cleaning and shaping the root gutta-percha packing procedure. Oral 58. Stashak TS. Equine Wound Management.
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59. Morrison SL, Cobb CM, Kazakos GM, 65. Klugh DO. A review of equine 71. Kim CK, Kim HY, Chai JK, et al. Effect of
et al. Root surface characteristics periodontal disease. In Proceedings, a calcium sulfate implant with calcium
associated with root surface placement AAEP Annual Convention, 2006; 52: sulfate barrier on periodontal healing in
of monolithic tetracycline-impregnated 551–558 3-wall intraboney defects in dogs.
fiber. J Periodont 1992; 63: 137 66. Spear FM, Cooney JP. Restorative J Periodontol 1998; 69: 982
60. Wiggs RB, Lobprise HB. Periodontology. interrelationship. In: Newman MG, Takei 72. Wiggs RB, Lobprise HB. Basic materials
In: Wiggs RB, Lobprise HB, eds. HH, Klokkevold PP, Carranza FA, eds, and supplies. In: Wiggs RB, Lobprise HB,
Veterinary dentistry: principles and Carranza’s clinical periodontology, 10th eds. Veterinary dentistry: principles and
practice. Lippincott-Raven, Philadelphia, edn. Elsevier, St Louis, 2006, p. 1065 practice. Lippincott-Raven, Philadelphia,
1997, p. 225 67. Precheur HV. Bone graft materials. In: 1997, p. 38
61. Klugh DO. Equine periodontal disease. Zardiackas LD, Dellinger TM, Livingston 73. Carranza FA, Takei HH, Cochran DL.
Clin Technique Equine Pract 2005; 4: M, eds. Dent Clin N Am 2007: 51(3): Reconstructive periodontal surgery. In:
135–147 734 Newman MG, Takei HH, Klokkevold PP,
62. Bellows J. Small animal dental 68. Jahn C. Supragingival and subgingival Carranza FA, eds, Carranza’s Clinical
equipment, materials and techniques. irrigation. In: Newman MG, Takei HH, periodontology, 10th edn. Elsevier,
Blackwell, Ames, Iowa, 2004, p. 136 Klokkevold PP, Carranza FA, eds, St Louis, 2006, p. 982
63. Wiggs RB, Lobprise HB. Periodontology. Carranza’s Clinical periodontology. 10th 74. Vlaminck L, Cnudde V, Pieters K, et al.
In: Wiggs RB, Lobprise HB, eds. edn. Elsevier, St Louis, 2006, p. 982 Histologic and micro-computed
Veterinary dentistry: principles and 69. Deforge DH. Evaluation of Bioglass/ tomographic evaluation of the
practice. Lippincott-Raven, Philadelphia, PerioGlas (Consil) synthetic bone graft osseointegration of a nonresorbable bone
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et al. Combined technique with 70. Allen I, Newman H, Wilson M. 604–610
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teeth. Dent Traumatol 2004; 20: bacteria. Biomaterials 2001; 22:
172–177 1683–1687

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C H A P T ER  22 
Endodontic therapy
Hubert Simhofer
University for Veterinary Medicine Department IV, Clinical Department for Companion Animals and Horses, Veterinaerplatz
1,A-1210, Vienna, Austria

Introduction develop acute masticatory problems, fever, or swelling of

the supporting bones. When recent dental fractures are diag-
Endodontics, from the Greek endo (inside) and odons (tooth), nosed, the resultant pulp exposure can be managed as
is a specialist sub-field of dentistry that deals with the treat- described below. At present, dental extraction is still the
ment of the tooth pulp and the tissues surrounding the apex therapy of choice in the majority of sub-acute or chronic
of a tooth. In contrast to exodontia, endodontic treatment apically infected cheek teeth.12 In selected cases, affected
is aimed at the preservation of teeth affected with pulp or teeth may be preserved with endodontic techniques, such as
apical infection. In man, dental caries and dental trauma are vital pulpotomy, where a sufficiently viable pulp is saved, or
the most common causes of acute pulpitis.1 Because equine alternatively, by apical resection with pulpectomy (extirpa-
dentition is anatomically very different from human, tion of pulp).1,12,13
canine or feline teeth,2–5 endodontic techniques that are As noted above, acute pulp exposure can occur acciden-
well established in such brachydont species have to tally during routine dental procedures, in particular during
be critically evaluated before they can be applied in equine the reduction of incisor overgrowths, including mandibular
(hypsodont) teeth. or maxillary pro- or brachygnathism overgrowths, ‘slant-
Anachoresis, fissure and gross idiopathic fractures; external mouth’ (diagonal bite), and during reduction of canines
traumatic fractures; extension of periodontal disease, and (Fig. 22.1) or cheek teeth overgrowths (‘hooks’, ‘ramps’, ‘tall
extension of infundibular caries have been described as the teeth’, wave- and step-mouth formation). Such iatrogenic
most common causes of apical infection in the horse,1,6,7 and pulp exposure actually occurs more often than is currently
the etiopathogenesis of these disorders is discussed more assumed.1 It has been claimed that pulp exposure under such
fully in Chapters 9 and 10. Direct exposure of pulp, or reduc- conditions does not require treatment because the normal
tion of dentin so close to the pulp as to effectively expose it, deposition of reparative dentin is adequate, and no compli-
can occur during equine dental procedures. Excessive heat cations result from pulp exposure in equine teeth. These
production by power equipment during routine dental cor- suppositions are due largely to lack of observation.1 A recent
rections or diastema widening can also cause thermal pulpi- study found the depth of secondary dentin in equine cheek
tis or even pulp necrosis.8 teeth to be highly variable, ranging from 2.5 to 15 mm, and
consequently the distance from the occlusal surface to the
vital pulp is unpredictable in normal teeth.14
Acute pulp exposure The consequence for the equine dental practitioner is that
pulp exposure may be detected at any time, especially when
As noted above, vital pulp can be exposed secondary to performing dental procedures. It is desirable that some
dental fractures9–11 or iatrogenically during dental proce- equine veterinarians have a theoretical knowledge of
dures. Dental fractures are not always recognized by horse endodontics as well as the practical skills and adequate
owners because some affected horses do not show obvious equipment to enable satisfactory management of pulpar
signs of dental pain. Whether the equine species is less sus- exposure.
ceptible to dental pain or the suppression of pain is a simple
phylogenetic necessity in horses, in order not to stand out
as prey, remains unclear. Due to absence of signs of dental Diagnosis
pain in some horses, idiopathic fractures with pulp exposure
are often not detected or treated immediately, and some The diagnosis of iatrogenic pulp exposure can be difficult in
fractured teeth spontaneously heal by deposition of tertiary some cases, especially when it occurs in caudal cheek teeth.
dentin on the occlusal aspect of the exposed pulps, as dis- Nevertheless, the detection and adequate management of
cussed in Chapter 10. Any deficits in this natural repair iatrogenic pulp exposure are the responsibility of all equine
mechanism result in extension of the pulpitis with probable dental practitioners. A final examination at the end of
development of apical abscess formation, or pulp necrosis. any dental correction using a mirror or an endoscope15,16 is
Only a small percentage of horses with idiopathic fractures mandatory to detect iatrogenically exposed pulp cavities.

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 22 Treatment

Fig. 22.2  Contaminated traumatic fractures of 202, and 203.

Fig. 22.1  An open pulp cavity in a left lower canine (Triadan 304) caused
by excessive reduction of the tooth, following debridement and
probe is then retracted, and the distance between the occlu-
hemorrhage control. sal surface of the fracture and the underlying viable pulp is
measured. High-speed dental burrs or spoon excavators
should now be used to enlarge the pulp cavity1 in order to
create better access to the diseased pulp. Simultaneously,
Bleeding from freshly opened pulp cavities may subside contaminated dentin lining the walls of the pulp chambers
quickly, especially in older animals with narrow pulp horns. is removed with a dental burr. This procedure can be difficult
Consequently, major dental reductions should be performed in curved incisor root canals. In this instance, the pulp cavity
slowly in stages, interrupted by examinations of the occlusal can be accessed from an opening in the intact labial aspect
surface with a mirror or endoscope. The use of power equip- of the clinical crown, which enables a straight drill plane
ment for dental correction creates a dough-like, viscous layer path to be achieved.12
of wet dental dust which can temporarily occlude pulp cavi- The tooth should be thoroughly disinfected, and the burr
ties, thus masking pulpar exposure. Consequently, dental should be sharp and clean (new – preferably sterile). When
debris should be flushed from the occlusal surface before the surgeon is drilling into an exposed pulp, bleeding indi-
examining the occlusal surface. cates that the vital pulp has been reached, and drilling
should be extended for some additional millimeters if pos-
sible to remove any adjacent diseased pulp.
Management of pulpar exposure The exposed pulp canal should be shaped like an inverse
In the case of dental fractures, X-rays should be taken to cone (undercut) close to the occlusal surface to prevent later
evaluate the full extent of the fracture, including assessment loss of filling material. The exposed canal is then carefully
of the supporting bones. If the extent of the fracture does cleaned using Ringer’s solution and sterile paper points.
not preclude dental preservation, preparations for endodon- Clean (preferably sterile) compressed air can also be used to
tic surgery, (that can be performed in the standing, sedated dry the pulp canal, but drying of the pulp must be avoided.
horse) can proceed. Local analgesia via blocking of the ipsi- Hemostasis is subsequently performed using small cotton
lateral maxillary or mandibular nerve significantly facilitates pellets or paper points soaked in adrenaline (Fig. 22.3). A
these endodontic procedures.17 General anesthesia is only couple of minutes after the bleeding has stopped, the pellets
required in a minority of cases, including those occasions are removed carefully, and the pulp can now be capped with
when adequate local analgesia cannot be obtained. calcium hydroxide or similar materials. Calcium hydroxide
Initially, loose dental fragments are removed from frac- (Ca(OH)2), which is used in paste form (calcium hydroxide
tured teeth (Fig. 22.2), and then 2–3 mm of the clinical and sterile water) in this situation, has a strong anti-
crown should be removed if the affected tooth is still in microbial effect18 (due to its basic pH) and also acts as a
occlusal contact, to avoid occlusal pressure from the oppos- tertiary dentin stimulant. It is preferable to cover softer,
ing teeth for a minimum of 2–3 months.1 Bleeding resulting water-based calcium hydroxide with resin-containing
from these procedures can be controlled using locally calcium hydroxide such as Dycal, but it is inadvisable to
applied hemostyptic drugs (e.g., adrenaline) or electro­ place resin-containing preparations directly on to pulp. In
surgical devices. human dentistry, other products, such as MTA (mineral tri-
A fine, sterile dental pick should now be used to gently oxide aggregate) are used.19 MTA is a biocompatible endo-
probe the open pulp cavity. Bleeding indicates the likely dontic cement that is also capable of stimulating healing and
presence of vital (may be inflamed or infected beyond dentogenesis and sets in the presence of moisture.20
redemption) pulp tissue and thus a chance of preserving the In the horse, provided occlusal contact is avoided, addi-
tooth. In order to avoid additional trauma to the pulp, the tional restorative covers may not be necessary over the

370
 Endodontic therapy

Fig. 22.3  Same horse as in Fig. 22.2. The fracture fragments and debris Fig. 22.5  Same horse as in Fig. 22.4. All visible infected and discolored
have been removed; the pulp canal of 202 has been drilled and curetted, dental tissues have been removed with a diamond burr. The pulp canals
and a paper point soaked in 0.8 % adrenaline solution is inserted into its have also been debrided and pulpotomy has been performed. Calcium
pulp cavity for hemostasis. Filling with calcium hydroxide paste will now be hydroxide paste will now be applied.
performed.

Fig. 22.6  Parapulpar pins have been placed into the dentin of the
Fig. 22.4  Longstanding (note necrosis of circumpulpar dentin) traumatic endodontically treated incisors to facilitate partial reconstruction of the
fractures of 101 and 201 in a 7-year-old horse. The fractured teeth have crowns.
been cleaned. An isolated fracture fragment lying between 101 and 102 has
been left in situ in order to prevent excessive local hemorrhage prior to
endodontic therapy.
advised not to feed hay from nets, in order to reduce forces
on the incisor restorations.
calcium hydroxide,1 especially if covered with a resin-
containing calcium hydroxide preparation. Alternatively, the Endodontic procedures in apically infected
more occlusal endodontic calcium hydroxide cement can be cheek teeth
removed, and a few millimeters of the root canal close to
the masticatory surface can be sealed with glass ionomere21
or a resin-composite endodontic material. In show horses,
Oral approach
incisors that are fractured at gingival level can be recon- Whilst the technique described above can easily be per-
structed using parapulpar pins and composite (Figs 22.4– formed in equine incisors, pulp canal treatment of infected
22.7) to avoid protrusion of the tongue. The owners should cheek teeth using an intraoral approach is significantly more
be informed that the reconstructed crown has to be reduced demanding due to difficulties in visualization and limited
at intervals to prevent occlusal contact with the opposite access to the equine oral cavity. Long-handled instruments
incisor; otherwise the artificial crown will inevitably break and long-shafted, angled dental drills are required, as well
as human parapulpar pins and composite cannot withstand as dental mirrors or, preferably, a 90° oral endoscope to
the forces of equine prehension. Owners should also be visualize the surgical site. A skilled assistant is needed to

371
 22 Treatment

Fig. 22.7  Partial reconstruction of the crowns. Several layers of self curing
composite have been attached to the parapulpar pins. The artificial crowns
do not reach the occlusal surface of the opposing mandibular incisors.
Finally the composite is polished and the dental fracture fragment is
removed. Fig. 22.8  Apicoectomy is demonstrated in the following figures using an
extracted maxillary cheek tooth to allow better visualization. The apices are
removed with a diamond-coated burr. (Reproduced from Simhofer H, Stoian
direct the endoscope, if the procedure is performed under C, Zetner K. A long-term study of apicoectomy and endodontic treatment of
apically infected cheek teeth in 12 horses. Vet J 2008; 178: 411–418. With
direct video control. If the procedure is performed by a single
courtesy of the editor.)14
surgeon, the use of a dental burr has to be alternated with
use of other instruments and/or visual control.
Although the endodontic treatment of cheek teeth using
an intraoral approach is often discussed anecdotally at mandibular and rostral maxillary cheek teeth, or via a maxil-
dental conferences, no scientific studies or objective long- lary bone flap for more caudal maxillary cheek teeth. Bacte-
term reports on the outcome of such attempts appear to have riological samples should be taken from the infected
been published to date on this technique. Indeed, when one periapical regions to allow effective postoperative antimicro-
considers the length (up to 10 cm) which might be required bial therapy. The infected apical region is then debrided, and
to instrument an equine pulp canal, in relation to the space infected tissue is removed using curettes. The surgical site
available when the mouth is fully open, such an approach can be obscured by hemorrhage, and even moderate bleed-
is often likely to be impracticable. ing significantly prolongs surgery and can compromise the
quality of root canal sealing. Packing the hemorrhaging area
with gauze or bone wax,25 the use of local vasoconstrictors,
Apical approach (apicoectomy) such as adrenaline solution (0.8 %), and continuous
Apicoectomy (radiculectomy) of equine cheek teeth has suction13 can keep the apical area blood-free during endo-
been described by several authors.1,13,22–25 Apicoectomy dontic treatment.
involves the resection of the tooth apex, followed by removal Diamond burrs mounted on a sterile, high-speed dental
of the affected pulps and sealing of the pulp canal system to drill are used to resect the apex of the affected tooth. Con-
remove any possible communication between the oral cavity stant irrigation with sterile Ringer’s solution throughout the
and the periapical tissues.25 Careful case selection of cases procedure is essential to prevent heat damage of adjacent
for such endodontic surgery is mandatory. A thorough oral dental tissues. The apex is cut at an angle of 15°–20° in a
examination (see Ch.12) in conjunction with high quality buccolingual (or buccopalatal) plane, so that the cut surface
radiographs26 and/or computed tomography (Ch. 13) are faces buccally (Fig. 22.8). All five (or six) pulp canals are
required to identify suitable cases. Teeth showing signs of then visualized and enlarged with a conical diamond burr.
extensive periodontal disease, large fractures, evidence of The contents of the pulp canals (necrotic, infected, or healthy
dental decay, multiple pulpar exposure or long-standing pulps, or food material) are then removed as completely as
apical infection (with subsequent tooth demineralization) possible using barbed broaches (Fig. 22.9). In contrast to
are unsuitable for endodontic surgery.13 In such cases, dental vital pulps, which are easily removed in one piece, debride-
extraction should be recommended. ment of necrotic pulp debris and cleansing of infected pulp
The apicoectomy technique used by the author has been canals are frequently time-consuming and technically diffi-
recently described.13 Surgery is usually performed under cult. Nevertheless these procedures must be meticulously
general anesthesia with the patient in lateral recumbency. performed on all affected root canals. The empty canals are
To definitively identify the site of the affected apex, intra- then filed with Hedstrøm files of ascending diameter to
operative radiography, using surface or sinus tract metallic remove infected and carious circumpulpar dentin, and the
markers should be performed. Access to the affected pulp canals are alternately flushed with 2.5 % sodium
cheek teeth apices is gained, either via trephination27 for hypochlorite and 3 % hydrogen peroxide solutions until no

372
 Endodontic therapy

Fig. 22.9  The pulps are extracted using a barbed broach. (Reproduced Fig. 22.11  The pulp canals are dried using paper points and compressed
from Simhofer H, Stoian C, Zetner K. A long-term study of apicoectomy and air. (Reproduced from Simhofer H, Stoian C, Zetner K. A long-term study of
endodontic treatment of apically infected cheek teeth in 12 horses. Vet J apicoectomy and endodontic treatment of apically infected cheek teeth in
2008; 178: 411–418. With courtesy of the editor.)14 12 horses. Vet J 2008; 178: 411–418. With courtesy of the editor.)14

Fig. 22.10  The pulp horns are flushed with sodium hypochlorite. Fig. 22.12  Gutta percha points are used to compress endodontic cement
(Reproduced from Simhofer H, Stoian C, Zetner K. A long-term study of deep into the pulp canals. (Reproduced from Simhofer H, Stoian C, Zetner K.
apicoectomy and endodontic treatment of apically infected cheek teeth in A long-term study of apicoectomy and endodontic treatment of apically
12 horses. Vet J 2008; 178: 411–418. With courtesy of the editor.)14 infected cheek teeth in 12 horses. Vet J 2008; 178: 411–418. With courtesy of
the editor.)14

further debris or discolored dentin shavings are extracted the procedure. Teeth on which apicoectomy has been per-
from the canal (Fig. 22.10). The final pulp canal flush is formed continue to erupt (dental eruption is unaffected by
performed with 70 % ethyl alcohol. The pulp canals are then endodontic procedures) and are consequently subjected to
dried using pressurized air and paper points (Fig. 22.11). normal attrition. As all pulps have been removed during
A variety of materials, such as human dental eugenol-based surgery, these teeth have lost the ability to produce secondary
or eugenol-free cements, gutta percha or composite endo- dentin which normally prevents occlusal pulpar exposure.
dontic materials have been used for filling empty pulp Consequently, with continued eruption of the treated tooth,
canals13,20–24,28 (Fig. 22.12). The choice of endodontic filling the endodontic filling material eventually appears at the
material in equine teeth influences the long-term success of occlusal surface after the remaining subocclusal secondary

373
 22 Treatment

Fig. 22.13  An undercut is created in the apical aspects of the pulp canals Fig. 22.14  Apical sealing is performed using glass ionomer cement.
using a diamond-tipped burr on a high-speed dental drill. (Reproduced (Reproduced from Simhofer H, Stoian C, Zetner K. A long-term study of
from Simhofer H, Stoian C, Zetner K. A long-term study of apicoectomy and apicoectomy and endodontic treatment of apically infected cheek teeth in
endodontic treatment of apically infected cheek teeth in 12 horses. Vet J 12 horses. Vet J 2008; 178: 411–418. With courtesy of the editor.)14
2008; 178: 411–418. With courtesy of the editor.)14

dentin (if present) is worn away. Human endodontic filling

materials are not designed to withstand any abrasion what-
soever and so cannot withstand the abrasive forces of equine
mastication and so are gradually lost when the material is
occlusally exposed. Consequently, food material becomes
compressed into the pulp canals which eventually can cause
dental decay, secondary fractures, or apical re-infection. The
use of filling materials with higher abrasive resistance, such
as resin-composite endodontic materials, should lead to
better long-term results. Such materials are not designed for
obturation of pulp canals, so their performance when so
used, especially in the high volume of the equine pulp canal,
has yet to be established. In particular, shrinkage which
breaks the initial seal may be a problem. The best choice of
material for equine apicoectomy is as yet uncertain.
Adequate sealing of the resected apex has also been
reported to have a major influence on the outcome of equine
apicoectomies.21,28 To prevent the loss or disintegration of
the apical seal, it is strongly recommended that an undercut
Fig. 22.15  Postoperative X-ray of a 5-year-old Quarterhorse gelding after
is made with diamond-coated burrs on the apical aspect of apical resection and endodontic treatment of 109. (Reproduced from
each root canal (Fig. 22.13). Apical sealing can then be per- Simhofer H, Stoian C, Zetner K. A long-term study of apicoectomy and
formed with self-curing, glass ionomer cement, amalgam, endodontic treatment of apically infected cheek teeth in 12 horses. The Vet
MTA or, less satisfactorily, with a resin-based calcium J 2008; 178: 411–418. With courtesy of the editor.)14
hydroxide cement (Fig. 22.14). Postoperative radiographs
should be taken at this stage (Fig. 22.15) to ensure adequate
pulp canal sealing is present.29 The surgical wound is closed to surgery, and so all pulp should be removed. In the future,
in routine fashion. Antibiotic and anti-inflammatory drugs magnetic resonance imaging may provide precise informa-
are administered for 3–5 days postoperatively. tion on the health status of individual pulps.31
With careful case selection, success rates of about 80 % Despite the fact that equine endodontic surgery is a sophis-
have been described.1,13 Reasons for failure of this technique ticated, costly, and currently controversially technique, the
include spread of infection from infected to unaffected pulps successful outcome of a comparatively high percentage of
via communicating pulp canals, especially in young horses.30 cases treated to date warrants further objective long-term
No current diagnostic technique appears to enable a clear studies in vitro and in vivo to increase our knowledge of this
differentiation between infected and uninfected pulps prior potentially useful technique.

374
 Endodontic therapy

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 Section 5:  Treatment

C H A P T ER  23 
The temporomandibular joint
Neil Townsend† BSc, BVSc, Cert ES (Soft Tissue), MRCVS,
Renate Weller* Dr.vet.med, PhD, MRCVS
†
Royal (Dick) School of Veterinary Studies, University of Edinburgh, Easter Bush Veterinary Centre, Roslin, Midlothian, EH25 9RG, UK
*Department of Veterinary Clinical Sciences, The Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield,
Hertfordshire AL9 7TA, UK

Introduction The transverse facial vessels pass ventral to the TMJ, and the
superficial temporal artery and vein run caudal to the TMJ.
Disorders of the temporomandibular joint (TMJ) are The zygomatic branch of the auriculopalpebral nerve passes
common in human beings, having a reported prevalence of caudal and dorsal to the TMJ to reach the zygomatic arch.5,6
up to 80 %.1 In contrast, reports of horses affected with The caudal aspect of the TMJ is covered by the rostrodorsal
disease of the TMJ are sparse and are limited to reports of aspect of the parotid salivary gland, which also covers the
horses with advanced disease, perhaps not because the prev- superficial temporal artery, vein, and auriculopalpebral
alence of the disease is low, but because definitively diagnos- nerve.5,6
ing disease of the TMJ of horses is difficult. In this chapter,
we describe the anatomy and function of the TMJ, diseases Function
of the TMJ, and options for medical and surgical manage-
ment of horses affected with disease of the TMJ. The primary function of the TMJ is to permit mastication.
Unlike ruminants, which regurgitate their food, horses only
Anatomy have one cycle to masticate feed to a small particle size to
allow efficient microbial digestion.10 Unlike carnivores,
The equine TMJ is a synovial joint formed by the zygomatic whose power stroke of mastication is primarily vertical, the
process of the temporal bone and the condylar process, or equine masticatory cycle has three distinct phases that allow
condyle, of the mandible (Fig. 23.1).2,3 It is an incongruent for effective grinding of feed: the opening, vertical stroke; the
joint and is divided completely into two separate compart- closing, vertical stroke; and the powerful, lateral power
ments by an L-shaped, centrally concave, fibrocartilagenous stroke, during which feed is ground.4,11–13 The configuration
disc (Fig. 23.1).2,4–7 The disc attaches circumferentially to the of the TMJ allows this lateral movement of the mandible,
mandibular condyle, temporal bone, and joint capsule.5,6 which is initiated by the pterygoideus muscle. The side-
The dorsal, discotemporal compartment is wider than the to-side movement of the mandible within the joint capsule
ventral, discomandibular compartment and apparently does is coupled with rostrocaudal movement, with one side of the
not usually communicate with it,2,4–8 though in one study, mandible gliding rostrally, and the other side of the mandi-
communication between the compartments was demon- ble gliding caudally.4,11–13 Dental occlusion13 and type of
strated in three of seven cadaver heads injected with dye, feed12 have been found to have a significant influence on
indicating that in at least a small percentage of horses, they motion of the TMJ.
do communicate.9 Each compartment has a rostral and a
caudal recess. The caudal recess of the discotemporal com- Diseases of the TMJ
partment is larger than the rostral recess, and the rostral
recess of the discomandibular compartment is larger than The equine TMJ is afflicted by the same diseases that afflict
the caudal recess.5,6,8 The joint capsule is reinforced by the other synovial joints and include acute septic arthritis,14–17
lateral and caudal ligaments.5,6,8 (sub)luxation,18,19 osteoarthritis,16,20 and congenital dyspla-
Muscles of mastication associated with the equine TMJ sia (H. Gerhards, personal communication). Tearing of the
include the temporalis muscle, which attaches to the medial intra-articular disc has been reported.16
and rostral aspects of the joint capsule, the masseter muscle,
which attaches rostrally and laterally to the joint capsule,
and the lateral and medial pterygoid muscles, which attach
Septic arthritis
laterally and medially to the joint capsule.3,5,6 Septic arthritis of the TMJ has occurred in association with
The blood supply to the TMJ arises from the transverse open fractures and wounds that communicate with the joint
facial, superficial and deep temporal, and tympanic arteries.5 or from spread of infection from surrounding tissue (e.g.,

377
 23 Treatment

Fig. 23.1  Anatomy of the temporomandibular

joint (TMJ). The image on the left shows the
T skeletal components of the TMJ and a corrosion
cast of the dorsal and ventral compartments with
the fibrocartilagenous disk wedged between
T D
them. The right image shows a transverse section
through the TMJ in a frozen cadaver specimen.  
M T, temporal bone; M, mandibular bone;  
D, intra-articular disc.

A B

Fig. 23.2  A horse affected with infectious osteoarthritis of the TMJ. The horse had a marked swelling of its left TMJ, which when palpated caused the horse
to show signs of pain. A teat cannula was positioned in the caudal recess of the discotemporal compartment of the TMJ for lavage of this compartment
performed with the horse sedated. The picture on the right shows the placement of a Penrose drain into a distal portal.

from tissue infected with Streptococcus equi var. equi in horses Streptococcus zooepidemicus is often cultured from an
suffering from strangles).15 In many cases, an underlying infected TMJ.14,17,22
cause cannot be established, and the horses are presented
because of a masticatory problem, swelling of the TMJ, or a
discharging tract.14,17,21,22
(Sub)luxation
Horses suffering from sepsis of the TMJ are presented for The TMJ can become luxated or subluxated, with or without
examination because they have a swelling, often painful, over fracture of the mandible.18,19,24 Affected horses usually have
the affected TMJ and are dull and have difficulty eating evidence of trauma to the head. Clinical signs depend on the
(Fig. 23.2).14,17,21,22 In some cases, a fistulous tract may be degree of luxation and may include acute swelling of the
evident.17 Typically, the demeanor and masticatory function region of the TMJ, rostral displacement of the mandible,
of horses suffering from sepsis of the TMJ improves while decreased lateral range of movement of the mandible, an
the horse is receiving antimicrobial therapy, but dullness and inability to open the mouth, difficult mastication, and
difficulty eating recur when antimicrobial therapy ceases. rupture of an eye. Horses with a luxated or subluxated TMJ
Unless sepsis is accompanied by fracture, luxation, or sub- may develop osteoarthritis regardless of whether or not they
luxation, radiographic examination of the TMJ is often are treated.
inconclusive, and another imaging modality, such as ultra-
sonography, scintigraphy, or computed tomography, is
needed to diagnose septic osteoarthritis.17,23 Arthrocentesis
Osteoarthritis
of a septic TMJ typically yields abnormal-appearing synovial Clinical signs of disease displayed by horses with osteoar-
fluid that contains an increased nucleated cell count.14 thritis of the TMJ are often similar to signs of disease

378
 The temporomandibular joint

Fig. 23.3  Ultrasonograms of a horse with

osteoarthritis of the left TMJ. The right TMJ is
normal, whereas the left has extensive formation
of new bone at the surface of the joint, joint
effusion, and thickening of the joint capsule.  
D D T, temporal bone; M, mandibular bone;  
T M D, intra-articular disc.
T
M

left right

displayed by horses with septic arthritis of that joint, though

the clinical signs displayed by horses with osteoarthritis are
often less severe and their onset is more insidious.16,23,24
Affected horses typically show a decreased range of man-
dibular motion and masticate preferentially on the non-
affected side of the mandible. Joint distension and bony
swelling are usually present over the affected TMJ, and if the
disease is chronic, atrophy of the masseter muscles may be
evident.
A strong association between disorders of the TMJ and
dental malocclusion has been demonstrated in human
beings,25 and this same association is noted in horses chroni-
cally affected with osteoarthritis of the TMJ. The incisor Fig. 23.4  Post-mortem specimen of a donkey with osteoarthritis of the left
TMJ. Note the extensive new bone formation on the medial surface of the
arcades of horses chronically affected may become slanted, mandibular condyle (arrows).
and the molar arcade on the affected side of the head may
wear at an extremely steep angle, causing shear mouth. Deter-
mining whether disease of the TMJ is a result or a cause of body systems may be necessary before the TMJ is incrimi-
abnormality of the incisor arcades may be difficult. Osteoar- nated as the source of these vague signs.
thritis has occurred secondary to rupture of the articular disc, Examination of a horse suspected of having a disorder of
but most commonly, no underlying cause is identified.16 the TMJ should include careful inspection of the horse while
Identifying arthritis of the TMJ radiographically is often it masticates rough feed, and special attention should be
difficult, and other methods of imaging the joint, such as paid to the symmetry of the side-to-side movement of the
ultrasonography or scintigraphy, may be more useful. Ultra- jaw. The TMJs work as a functional unit, and in normal
sonographic features of an arthritic TMJ include an irregular horses, the grinding motion is symmetrical. Pain or mechan-
contour to both the temporal and mandibular components ical impairment at the TMJ results in a reduced range of
of the joint and an abnormally large volume of synovial motion of the mandible on the affected side. If disease of a
fluid (Fig. 23.3). Typical scintigraphic findings include a TMJ is suspected, the dental arcades should be examined
mild to moderate increase in radiopharmaceutical uptake because disease of one or both TMJs commonly results in
over the affected joint compared to the unaffected, contral- malocclusion.20,26
ateral TMJ. Arthrocentesis of the arthritic TMJ yields synovial Systematic palpation of the TMJ region may cause the
fluid that is less viscous than normal and that has a normal horse to demonstrate signs of pain or may reveal a swelling
nucleated cell count and a normal or mildly elevated con- of soft tissue or bony consistency (Fig. 23.2). The TMJ is
centration of protein. Proliferative new bone formation and located by following the mandibular ramus dorsally. The
cartilage loss are features observed during arthroscopic palpable depression representing the neck of the mandibular
examination of the joint (Fig. 23.4). condyle should not be mistaken for the TMJ. The joint space
lies dorsal to the mandibular condyle, the lateral aspect of
Diagnosis of disease of the TMJ which can be palpated as a smooth projection lying halfway
between the lateral canthus of the eye and the base of the
ipsilateral ear. Making the horse move its mandible while
Clinical examination palpating this region helps to locate the mandibular condyle.
Clinical signs associated with disorders of the TMJ range In our experience, findings during palpation vary widely
from very specific (e.g., swelling over the joint, a discharging between horses, depending on the breed and condition of
sinus tract from the joint, or displacement of the mandible) the horse. In some horses, the pouches of the joint capsule,
to non-specific (e.g., headshaking, head-tilt, reluctance to be especially the caudal pouch of the discotemporal com­
ridden, and weight loss). Clinical examination should start partment, are very prominent, but the pouches of the disco-
with observing the horse for signs of disease reported by the mandibular compartment cannot be palpated. The lateral
owner. If signs of disease are vague, examination of multiple aspect of the mandibular condyle of some horses is very

379
 23 Treatment

prominent, but that of others is very difficult to palpate. Recently, two oblique projections have been described
Even though the palpable portion of the TMJs varies in mor- that allow evaluation of the TMJ and surrounding osseous
phology, the left and right regions of the TMJ should be structures without superimposition of contralateral struc-
symmetrical. To better appreciate function of the joint, the tures.32,33 For one of these projections, the X-ray cassette is
joint can be palpated while the horse chews. placed above the horse’s poll in a horizontal position, with
the horse’s head fully extended, and the X-ray beam centered
on the ipsilateral TMJ and directed caudally at a 35° angle
Intra-articular anesthesia and arthrocentesis to the long axis of the head and 50° dorsally.32 For the other
Because the TMJ is separated completely into two compart- projection, the horse’s head is held in a neutral position, and
ments by the articular disc, each compartment probably the cassette is placed parallel to the sagittal plane next to the
must be injected separately to completely desensitize the TMJ of interest. The X-ray beam is directed caudodorsally to
entire joint. No studies have examined the likelihood of rostroventrally, from the contralateral side, to the TMJ of
local anesthetic solution diffusing in a high enough concen- interest (Fig. 23.6).33 If the TMJ of interest is the left TMJ,
tration from one compartment to the other to result in this projection is termed a right, caudodorsal-to-left, rostro-
desensitization of both compartments. Centesis of the TMJ ventral oblique (Rt15Cd70D-LeRVO). Both projections
performed directly over the joint is difficult because articular allow evaluation of subchondral bone, a feature not allowed
cartilage and the meniscus primarily occupy this space, and by other radiographic projections.
consequently centesis is most reliably performed over the A luxation or subluxation of the TMJ, with or without a
caudal pouch of the dorsal compartment. The technique of fracture(s), is usually easily identified on radiographs as an
arthrocentesis was thoroughly described by Rosenstein et al incongruence of the bony surfaces of the TMJ and an incon-
(2001)9 and Weller et al (2002).27 Using the approach to gruence of the occlusal surfaces of the incisors and cheek
the caudal pouch of the dorsal compartment (i.e., the teeth. Osteoarthritic changes are much more difficult to
discotemporal compartment) described by Rosenstein et al appreciate radiographically. If osteoarthritis is severe, an
(2001),9 the mandibular condyle is identified as a smooth irregular outline of the bones forming the joint, as well as
protrusion approximately midway between the lateral periarticular new bone formation and changes in the width
canthus of the eye and the base of the ear. The zygomatic of the joint, can be appreciated. In our experience, the major-
process of the temporal bone is palpated 1–2 cm dorsal to ity of old horses have some degree of osteophyte formation
the condyle, and a line is imagined between these structures. on the caudal aspect of the mandibular condyle (Fig. 23.5)
The site of centesis is a depression midway between these yet show no clinical signs of disease of the TMJ, indicating
structures and 1 2 to 1 cm caudal to the imagined line. The that osteophytes in this area may not be clinically significant.
discotemporal compartment is desensitized with 2–2.5 ml Mild changes of osteoarthritis are difficult to appreciate
of local anesthetic solution (Fig. 23.2). The ventral compart- during radiographic examination of the TMJ.
ment (i.e., the disc­omandibular compartment) is injected
with 1–1.5 ml of local anesthetic solution by walking the
needle off the rostral aspect of the mandibular condyle.
Scintigraphy
Although the capsule of both pouches is relatively super- Scintigraphy is an imaging modality that portrays function
ficial, care must be taken not to inject the anesthetic solution rather than morphological changes. It is the most sensitive
outside the joint capsule where it may anesthetize branches of all imaging modalities for a variety of diseases, including
of one of the cranial nerves in this area. In some cases, per- dental disorders.27 To examine the TMJs of a horse scinti-
forming the procedure under ultrasonographic control may graphically, the horse is injected intravenously with 5 MBq/
be beneficial. In our experience, the clinical signs of disease kg 99mTc-phosphonate. This dosage equates to half the dose
displayed by the majority of horses with TMJ disorders, such usually used for imaging other parts of the horse, but in our
as decreased range of mandibular motion, resolve while the experience, this reduced dose is sufficient to evaluate the
TMJ is temporarily desensitized. If the joint has advanced head. We have found that the vascular and soft tissue phases
osteoarthritis, mobility of the mandible may be mechani- are not useful for this area, and therefore we perform only
cally impaired. a bone phase, usually about three hours after injection. Left
and right lateral projections and a dorsal projection, each
centered over the TMJ of interest, are acquired. Both TMJs
Radiography should be adjacent to the camera during acquisition of
Radiographic evaluation of the TMJ is challenging, largely images to avoid differences in radiopharmaceutical uptake
because the complexity of this area results in numerous caused by distance attenuation of the gamma radiation.
superimpositions over the joint.28–30 To alleviate the problem The resulting images should be evaluated visually, as well
of superimposition, the TMJ can be examined radiographi- as quantitatively, by defining regions of interest (ROI) over
cally using special projections. To obtain the radiographic the TMJs. On the dorsal projection the ROIs are compared
projection described by Pommer (1948),31 the X-ray cassette directly, whereas on the lateral projections reference ROIs
is placed 120 cm lateral to the TMJ of interest, and the X-ray are defined over the ramus of the mandible (Fig. 23.7). The
beam is directed toward the contralateral TMJ (Fig. 23.5). ratio between the ROI over the TMJ and the reference ROI
Using this technique, the TMJ of interest is magnified to such is calculated and compared between sides. Radiopharmaceu-
a degree that evaluation of that joint is enhanced. This tech- tical uptake by structures of the head, including the TMJs,
nique exposes the horse to a high concentration of radiation varies with the age of the horse. The TMJs of young horses
and consequently, the eye of the horse nearest the X-ray tube take up considerably more of the radiopharmaceutical drug
should be protected with a lead shield. than does the relatively inactive rest of the mandible, whereas

380
 The temporomandibular joint

Fig. 23.5  Radiographic projection of the TMJ. The image shows a projection of the left TMJ of a 23-year-old horse. This projection, described by Pommer
(1948),31 allows evaluation of the TMJ of interest by magnifying the superimposed contralateral TMJ. Note the osteophyte on the caudal aspect of the
mandibular condyle (arrows), which is commonly seen in old horses.

the TMJs of old horses often cannot be differentiated from rotated as the joint is examined. To examine the TMJ ultra-
the surrounding tissues (Fig. 23.8). In our experience, a dif- sonographically, we follow the mandible dorsally with the
ference in radiopharmaceutical uptake by a TMJ of more transducer orientated approximately parallel to the dorsal
than 25 % is indicative of disease of that joint. outline of the horse’s nose until the caudal aspect of the joint
The left and right TMJs are structurally linked and, there- can be imaged. To image the medial aspect of the joint, the
fore, function as a unit. Disorders of the TMJ of human transducer is rotated dorsorostrally by 45°. To image the
beings resulting from malocclusion are often bilateral, and rostral part of the joint, the transducer is rotated another
we believe disorders of the TMJ of horses are likewise bilat- 30°in the same direction while applying slight rostroventral
eral. Marked radiopharmaceutical uptake over both TMJs in translation. A stand-off is usually not required, but may be
an old horse may be suggestive of disease of both TMJs. useful if the horse is thin.
The ultrasonographic examination allows evaluation of
the bony surfaces of the joint, the fibrocartilagenous disc,
Ultrasonography and the joint capsule, and quantification of the amount of
Ultrasonographic examination of the TMJs is easily per- synovial fluid within the joint. The surface of the bones
formed with the horse standing and is usually well tolerated should appear as smooth, hyperechogenic lines. The disc
by the horse.7,34 To obtain optimal quality of the image, hair appears as a homogenous wedge, the base of which is located
over the TMJ to be examined should be clipped, but the laterally and the apex of which points medially, between the
procedure can sometimes be performed adequately without surface of the zygomatic process of the temporal bone and
clipping the hair. The area is cleansed and covered with a the surface of the mandibular condyle and is similar in
coupling gel. Both TMJs should be examined for compari- echogenicity to the menisci in the stifle. The caudal recess of
son. A 7.5 MHz (or higher) linear array transducer provides the discotemporal compartment of the TMJ is filled with
sufficient depth to image the TMJ, while still providing excel- synovial villi and is difficult to distinguish ultrasonographi-
lent resolution of the images. cally from the disc. The joint capsule is visible as an interface
The transducer should be positioned perpendicular to the between the disc and the parotid salivary gland, which over-
joint space to acquire transverse images of the joint, and so, lies it on the caudal part of the joint, or subcutaneous tissue,
to keep the transducer perpendicular to the curved outline which overlies it on the rostral part of the joint. No synovial
of the lateral aspect of the joint, the transducer must be fluid, or only a very minimal amount, is visible if the TMJ is

381
 23 Treatment

X-ray tube

70°

Path of the
X-ray beam

Dorsal Medial

Dorsal
Collimation Area

15°
Temporal bone

Ventral

Ventral
Path of
Lateral Mandibular condyle
X-ray beam
B = Centering Point

Fig. 23.6  Tangential projection of the equine TMJ described by Townsend (2009).33 (A) This schematic drawing illustrates the X-ray beam angle at 70° to
the dorsal plane and cassette; (B) Dorsal view of the radiographic projection showing the beam angle at 15° to the centering point and the collimation area.
The radiographic image on the right is the result of this projection.

normal. Changes in the TMJ seen ultrasonographically that

are pathognomonic for disease of the joint include irregular
Computed tomography
outline of the bony surfaces, increased amount of synovial Computed tomography (CT) is the method of imaging of
fluid, hyperechogenicity of the synovial fluid, disruption of choice for diagnosing disorders of the TMJ of human beings
the homogenous appearance of the disc, or thickening of the and small animals.35 It allows the medial components of the
joint capsule (Fig. 23.3). joint to be evaluated without superimposition of other

382
 The temporomandibular joint

structures. Computed tomographic anatomy of the normal non-septic osteoarthritis of the TMJ.16 We have observed
TMJ of horses has been described,36 and CT has been used good, long-term outcome after administering methylpred-
to diagnose septic arthritis of the TMJ of a horse.17 Until nisolone acetate into the TMJ of horses affected with osteo­
recently, to image the head of a horse using CT, the horse arthritis of that joint. Those horses that did not respond to
had to be anesthetized, which increased the costs and risks treatment had evidence of advanced osteoarthritis seen
of the procedure. Now, some equine referral centers can during post-mortem examination (Fig. 23.4). We have had
perform CT scans of the head with the horse sedated, which limited success in resolving clinical signs of osteoarthritis
has led to a wider use of this modality for diagnosing disor- of the TMJ after administering a glycosaminoglycan and
ders of the equine head. hyaluronic acid into the TMJ.
Dental malocclusion accompanies disease of the TMJ of
human beings and likely also accompanies disease of the
Treatment TMJ of horses. Determining whether disease of the TMJ is a
result or a cause of abnormal malocclusion may be difficult.
Horses with a disorder of the TMJ can be treated conserva-
Horses affected with disease of a TMJ should be carefully
tively or surgically, according to the type of disorder.
examined for dental malocclusion, and any occlusal abnor-
malities, such as shear mouth and slant mouth, should be
Conservative treatment corrected.
Conservative treatments available for horses with a disorder
of the TMJ are similar to those available for a horse with a Surgical treatment
disorder of any other similarly affected joint with similar
There are few reports of surgical management of horses with
likelihood of success. Intra-articular injection of a cortico­
disease of the TMJ. Rostral luxation of a TMJ of one horse
steroid has been used successfully to treat horses with
was successfully corrected, with the horse anesthetized, by
placing a metal mouth gag between the cheek teeth on the
affected side and placing pressure on the rostral aspect of the
mandible and on the rostral aspect of the maxillae to close
the mouth.19 After recovering from anesthesia, the horse was
able to masticate food, though the horse was permanently
blind in the ipsilateral eye, probably from damage to the eye
inflicted by the coronoid process of the mandible when it
displaced rostrally.
Arthroscopic evaluation of osteoarthritic TMJs and arthro-
scopic lavage of septic TMJs have been described.8,14,16 Due
to the bipartite nature of the TMJ, the discotemporal and
discomandibular compartments of the TMJ must be evalu-
ated through individual arthroscopic portals, but only the
lateral aspect of the discotemporal joint can be evaluated
fully because the curvature of the mandibular condyle
Ventral renders the rest of the joint inaccessible.6,8 Authors of one
Rostral
report declared the discomandibular joint to be inaccessible
Rostral
because of the position of the transverse facial artery and
Fig. 23.7  Lateral (left image) and dorsal (right image) scintigrams of the vein;8 other authors reported it to be accessible, though dif-
TMJs of a horse, 3 hours after the horse was injected with TC99m- ficult to evaluate due to obstruction of vision by synovial
methylendiphosphonate. Regions of interest are drawn around the TMJs, villi and poor maneuverability.6
and reference regions of interest (ROIs) are defined over the ramus of the To examine the TMJ joint arthroscopically, the horse is
mandible. The ratio between the ROI over the TMJ and the reference ROI is
anesthetized and positioned in lateral recumbency with the
calculated and compared between sides.

Fig. 23.8  Left lateral scintigrams of the TMJs

5 years 12 years 18 years of three horses of different ages, 3 hours after
Caudal Caudal Caudal injection of TC99m-methylendiphosphonate.  
The uptake of the radiopharmaceutical drug
decreases remarkably as horses age.

Ventral Ventral Ventral

383
 23 Treatment

affected TMJ uppermost. The horse can be positioned in sterile, isotonic saline solution. A 5-mm long, longitudinal
dorsal recumbency if both TMJs are to be arthroscopically incision is made in the skin at this site with a no. 15 blade.
examined. After preparing the region of the TMJ for aseptic A 10-cm long, blunt, teat cannula with obturator is placed
surgery, the TMJ is distended with sterile, isotonic saline solu- through this incision and directed rostromedially into the
tion after inserting a needle into the compartment of the joint joint (Fig. 23.2). Egress of fluid confirms that the cannula
using a technique described above, with or without ultra- has been placed into the joint. A 16-gauge, 2.54-cm (1-inch)
sonographic guidance. The needle is left in place, and a lon- needle is placed in the most dependent part of the distended
gitudinal, 5 mm long, skin incision is made adjacent to it. An TMJ, and a 5-mm long, longitudinal skin incision made
arthroscopic sleeve and blunt obturator are introduced into adjacent to it. A second teat cannula is placed through this
the joint, through the incision, in a rostromedial direction. incision into the compartment to allow egress of fluid intro-
The obturator is replaced with a 4-mm diameter, 30°, forward duced into the joint through the other teat cannula. After the
arthroscope, and the joint is distended, through the arthro- joint has been lavaged, a Penrose drain can be placed into
scope, with sterile, isotonic saline solution. A needle can be the TMJ through the ventral skin incision (Fig. 23.2) and
placed into the joint further rostrally to allow egress of fluid, maintained, with a suture, for several days before it is
which is important for improving visualization if the original removed.
penetration by the obturator caused intra-articular hemor- Unilateral, mandibular condylectomy and meniscectomy
rhage, and for providing continuous lavage of the joint. has been reported to be a successful treatment for horses
A septic discotemporal compartment can be lavaged with with severe septic or non-septic osteoarthritis of the
the horse standing and sedated if financial constraints TMJ.22,24,37 When mandibular condylectomy was performed
imposed by the owner make performing the procedure with bilaterally, more severe and longer-lasting abnormalities of
the horse anesthetized unfeasible. The region of the affected mastication were observed.37 Deviation of the mandible
TMJ is prepared for aseptic surgery, and local anesthetic solu- toward the non-treated side was reported to occur after uni-
tion is infiltrated subcutaneously at the site for arthrocentesis lateral condylectomy and meniscectomy.37 Deviation was
of the caudal recess of the discotemporal compartment thought to be caused by a temporary lack of stability of the
described above. This is a palpable depression just dorsal joint and atrophy of the masseter muscle on the treated side.
and caudal to the mandibular condyle, which lies halfway A horse in a more recent report, however, did not experience
between the lateral canthus of the eye and the base of the deviation of the mandible after unilateral condylectomy and
ipsilateral ear. A needle is placed into the discotemporal meniscectomy and had immediate improvement in its
compartment, and the joint is distended with 10–25 ml of ability to open its mouth and to masticate.22

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dissection, vascular injection and section. 13. Simhofer H, Anen C, Niederl M, et al. 19. Hurtig MB, Barber SM, Farrow CS.
Equine Vet J 2006; 38(2): 143–147 Comparison of the Masticatory Cycles of Temporomandibular joint luxation in a
6. Weller R, Maierl J, Bowen IM, et al. Horses Before and after Dental Treatment horse. J Am Vet Med Assoc 1984; 185(1):
The arthroscopic approach and intra- Using Kinematic Analysis. In: 6th 78–80
articular anatomy of the equine international Conference on Equine 20. Grosse G. Die Veränderungen am
temporomandibular joint. Equine Vet J Locomotion. Cabourg, France, 2008 Kiefergelenk des Pferdes in Verbindung
2002; 34(4): 421–424 p. 19 mit Zahn- und Gebißanomalien,
7. Weller R, Taylor S, Maierl J, et al. 14. Carmalt JL, Wilson DG. Arthroscopic Veterinärmedizinische Dissertation. Justus
Ultrasonographic anatomy of the equine treatment of temporomandibular joint Liebig Universität, Leipzig, 1938
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1999; 31(6): 529–532 55–58 luxation, and chronic septic arthritis
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Arthroscopic anatomy of the equine Kiefergelenkes. In: Silbersiepe E, Berge E, juvenile horse. Journal of Veterinary
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22. Nagy AD, Simhofer H. Mandibular scintigraphy in the diagnosis of dental 33. Townsend NB, Cotton JC, Barakzai SZ.
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35(7): 663–668 examination of the facial, nasal and 38(5): 601–606
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Comparison of radiography, scintigraphy Radiological findings. Equine Vet J 1987; Ultrasonographic anatomy of the
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144(14): 377–379 Equine Pract 1993; 9(1): 49–74 35. Schwarz T, Weller R, Dickie AM, et al.
24. Patterson LJ, Shappell KK, Hurtig MB. 30. Wyn-Jones G. Interpreting radiographs 6: Imaging of the canine and feline
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101–102 31. Pommer A. Die röntgenologische 36. Rodriguez MJ, Latorre R, Lopez-Albors O,
25. Payne M, Nakielny RA. Darstellung des Kiefergelenkes des et al. Computed tomographic anatomy of
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Radiol 1996; 51(1): 1–10 Wochenschrift 1994; 36: 230 young horse. Equine Vet J 2008; 40(6):
26. May KJ. Incisor problems that may result 32. Ramzan PH, Marr CM, Meehan J, 566–571
in inflammation of the Thompson A. Novel oblique radiographic 37. Barber SM, Doige CE, Humphreys SG.
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27. Weller R, Livesey L, Maierl J, et al. 162(22): 714–716 Surgery 1985; 14(2): 79–86
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 Appendix

Equine dental equipment and instrument suppliers

Alberts David A. Jann Equine Dental Instruments

PO Box 220 West Coast Medical Equipment Services, 200 Main St
Old Chatham Inc. Elmwood
New York, 12136 10700 Jersey Blvd., Suite 270 WI 54740, USA
Tel: 877-DENTAL-8 Rancho Cucamonga, CA 91730 Tel: +1 877 921 7122
www.albertsequine.com USA Fax: +1 775 677 9330
[email protected] Direct Office Line: +1 909 466 4646 www.equinedentalinstruments.com
Fax: +1 909 466 4647 [email protected]
Arista Surgical Cell Phone: +1 909 921 7811
(A division of AliMed, Inc.) [email protected] Equine Innovations, Inc.
297 High Street www.westcoastmedicalequipment.com PO Box 570
Dedham 428 Industrial Way
MA 02026, USA Discus Dental New Plymouth, ID 83655
Tel: 800 225 2610 (Formerly Lightspeed) USA
Fax: 800 437 2966 8550 Higuera Street [email protected]
Tel: +1 781 329 2900 Culver City www.hoofjack.com
Fax: +1 781 329 8392 CA 90232, USA Tel: +1 208 278 5283
Sales & Customer Service: 800 422 9448 Toll free: 877 455 5100
Brasseler USA Endodontics: 800 817 3636
One Brasseler Blvd www.discusdental.com Equine Veterinary Dental Services
Savannah www.discusdental.com/endo/ Dr Oliver Liyou BVSc (Hons) MACVSc
GA 31419, USA (Equine Dentistry)
Tel: 800 535 6638 Duluth Trading Co. 42-45 Mulgi Drive
Fax: +1 921 921 7578 170 Countryside Drive South Grafton NSW 2460
www.brasselerusa.com Belleville, WI, 53508 Australia
[email protected] Tel: +1 800 5058888 Tel: +61 02 66424 700
Fax: +1 888 950 3199 Fax: +61 02 66428 564
Capps Manufacturing www.duluthtrading.com [email protected]
4804 West Birch Rd www.evds.net.au
Clatonia DW Tooling
NE 68328, USA 126 Castle Drive EVDS Dental Instruments
Tel: +1 888 881 4686 Leechburg PO Box 860
Fax: +1 402 989 4545 PA, 15656 Grafton, NSW 2460
www.cappsmanufacturing.com Tel: 866 4-DWTOOL Australia
[email protected] Tel: +61 0407 411 415
Carbide Products Co., Ltd Fax: +61 02 6649 3272
22711 Western Ave Eisenhut-Vet AG [email protected]
Torrence Sandweg 52 www.evdsdentalinstruments.com
CA 90501-4944, USA CH-4123 Allschwil
Tel: +1 800 64-BLADE Switzerland EV Veterinary Products, Ltd
www.horsedental.com or Tel: +41 61 307 9000 The Barn, Wrestlers Farm
www.carbprod.com or Fax: +41 61 307 9009 Brockhurst Rd, Brockhurst
www.carbideproducts.com www.swissfloat.com Shropshire, TF11 8NE
[email protected] UK
Equine Blades Direct, Ltd Tel: +44 (0)1952 691 272
Ashgrove Farm Fax: +44 (0)1952 691 900
Sand, Wedmore www.ev-veterinaryproducts.co.uk
Somerset BS28 4XF [email protected]
UK
Tel: +44 (0) 1934 710780
Fax: +44 (0) 1934 710777
www.equinebladesdirect.com
[email protected]

387
 Appendix

1800 Endoscope LLC HMB Endoscopy Products Milburn Equine

6220 Manatee Ave. West, Unit 301 3746 SW 30th Ave. 23048 N. 15th Ave
Bradenton, FL 34209, USA Hollywood, FL 33312 Phoenix, AZ 85027
1-800-Endoscope USA USA
Tel: +1 941 792 7138 Tel: +1 954 792 6522 Tel: +1 800 279 6452
Fax: +1 941 761 4613 Fax: +1 954 792 6535 Fax: +1 800 492 0957
www.1800Endoscope.com [email protected] www.milburnequine.com
[email protected]
Instrumentation Concept Inc. Olsen E-Z Cuts, Inc
Flury Tools AG 2936 Reward Ln 1420 Kennebec Rd
Römerstrasse West 32 Dallas Hampden
CH-3296 Arch TX 75220, USA ME 04444, USA
Switzerland Tel: +1 214 850 9142 Tel: +1 207 862 6698
Tel: +41 32 679 55 48   +1 214 850 9143 www.olsenezcuts.com
Fax: +41 32 679 55 10 Fax: +1 214 570 9291
[email protected] www.instconcept.com PowerFloat Inc.
http://www.flurytools.ch [email protected] Suite 416 – 440 – 10816 Macleod Trail
South
Dr. Fritz GMBH Jorgensen Laboratories Calgary, Alberta
Feldbergstrasse 3A 1450 N. Van Buren T2J 5N8 Canada
Tuttlingen Loveland Toll Free: +1 877 969 2233
Germany, 78532 CO 80538, USA Office: +1 403 995 1209
Tel: +1 502 896 6076 Tel: +1 800 525 5614 Fax: +1 403 995 4434
Veterinary Dental Forum & www.jorvet.com [email protected]
American Veterinary Dental Society www.powerfloat.net
PO Box 803 Jupiter Veterinary Products
Fayetteville, TN 37334 6351 SW 95th Avenue Precision Technologies
USA Cedar Key, FL 32625 T/A Herbst Manufacturing
Tel: +1 800 332-AVDS or +1 931 438 0238 USA Kilpool Hill, Wicklow
Fax: +1 931 4336289 Tel: +1 352 543 5167 Ireland
[email protected] Fax: +1 352 543 9694 Tel: +353 404 67164
www.veterinarydentalforum.com [email protected] Fax: +353 404 67363
www.avds-online.org www.jupitervetproducts.com www.precisionvet.com
[email protected]
Harlton’s Equine Specialties Jørgen Kruuse A/S
792 Olenhurst Court Havretoften 4 Shanks Veterinary Equipment, Inc
Columbus DK-5550 Langeskov 505 East Old Mill St
OH 43235, USA Denmark Milledgeville
Tel: +1 800 247 3901 Tel: +45 72 14 15 16 IL, 61051, USA
Fax: +1 614 847 0774 Fax: +45 72 14 15 00 Tel: +1 815 225 7700
www.harltons.com [email protected] Fax: +1 815 225 5130
[email protected] www.kruuse.com www.shanksvet.com
[email protected]
Haynes Lubricants Lang Dental Manufacturing Co., Inc
Haynes Manufacturing Company PO Box 969 Shipp’s Dental and Specialty Products
24142 Detroit Rd 175 Messner Dr 8361 W. Tangerine Road
Westlake, Ohio Wheeling Marana
44145, USA IL 60090, USA AZ 85658, USA
Tel: +1 440 871 2188 Tel: +1 800 222 5264 Tel: 800 442 0107
Toll Free: 800 992 2166 Fax: +1 847 215 6678   +1 520 682 9972
Fax: +1 440871 0855 www.langdental.com Fax: +1 520 844 1811
www.HAYNESMFG.com www.drshipp.com
[email protected] MedRx
1200 Starkey Rd, #150 Skulls Unlimited International
Henry Schein, Inc Largo, 10313 S. Sunnylane Rd
135 Duryea Rd FL 33771, USA Oklahoma City
Melville Tel: +1 888 392 1234 OK 73160, USA
NY 11747, USA Fax: +1 727 584 9602 Toll Free: 800 659-SKULL
Tel: +1 800 872 4346 www.medrx-usa.com Tel: +1 405 794 9300
www.henryschein.com [email protected] Fax: 800 676 5459
www.skullsunlimited.com
Horse dental equipment Megassist Solutions, LLC
ZI de Bellevue PO Box 607
8 rue Blaise Pascal Energy
35221 Chateaubourg IL 62948, USA
France Tel: +1 877 634 2838
Tel: +33 2 99 00 71 29 www.milesequinegizmo.com
www.horse-dental-equipment.com [email protected]

388
 Appendix

Sontec Instruments Swissvet Veterinary Products Western Instrument Co.

7248 S. Tucson Way 3839 Dellwood Drive ‘Proudly Made in the USA’
Centennial Knoxville, TN 37919 PO Box 16428
CO, 80112, USA USA Denver
Tel: +1 800 821 7496 Tel: +1 877 794 7735 (877-swissfloat) CO 80216, USA
Fax: +1 303 792 2606   +1 865 540 8899 Tel: +1 800 525 2065
www.sontecinstruments.com Fax: +1 865 540 8850 Fax: +1 303 295 1923
www.swissvet.com www.westerninstrument.com
Stubbs Equine Innovations, Inc.
2928 Flat Creek Rd, Veterinary Dental Products World Wide Equine, Inc.
Johnson City, TX 78636 400 North Main Street PO Box 1040,
USA Elmwood, WI 54740 Glenns Ferry, ID 83623
Tel: +1 830 868 7544 Tel: +1 866 3299990 Tel: +1 208 366 2500
Fax: +1 830 868 9368 International Tel: +1 715 639 2415 Fax: +1 208 366 2870
www.stubbsequine.com International Fax: +1 715 639 9205 www.horsedentistry.com
www.VeterinaryDentalProducts.com [email protected]

389
 Glossary

Equine dental terminology

Ablation – Taking away, wearing down, Alveolar – Of or pertaining to the sockets Anachoresis – Exposure to bacteria
erosion of an area. of the teeth. through a hematogenous or lymphatic
Abrasion – Mechanical wearing away of Alveolar bone – Bone forming the sockets route.
teeth by abnormal stresses. of the teeth. Anaplastic sarcoma – Undifferentiated
Abrasive points – Burrs, rotary instruments Alveolar crest – Highest part of the tumor of mesenchymal origin.
that have an abrasive coating on the alveolar bone closest to the occlusal Anatomical crown – That part of the tooth
operative head. surface of the tooth. where enamel constitutes a portion of
Abscess – Collection of pus, generally as a Alveolar mucosa – Mucous membrane its external or internal structure.
result of an infection. covering the bone that contains the Anatomical root – That part of the tooth
Absorbent points – Cones of porous paper teeth. where enamel does not constitute a
used to dry the root canal after Alveolar nerve – Branches of the portion of its external or internal
instrumentation. mandibular nerve entering the structure and is covered with
Acellular cementum – Cementum that has mandibular foramen and innervating cementum.
no cells within it. all mandibular teeth. Anelodont teeth – Teeth with a limited
Achondroplasia – Developmental Alveolar process – The part of the maxilla period of growth; the root canals
abnormality of cartilage. Failure of or mandible that contains the alveoli progressively narrow and the apical
cartilage formation. of erupted teeth or the crypts of foramina become constricted with age.
developing unerupted teeth. Subdivided into hypsodont and
Acid etching – The microscopic
Alveolus – The socket within the jaws in brachydont.
roughening of enamel, dentinal or
cemental surface with a dilute acid to which the reserve crown and roots of a Angle of the mandible – Junction of the
increase its mechanically retentive tooth lie. horizontal and vertical ramus of the
property to restorative materials. Amalgam – An alloy or combination of mandible.
Usually the procedure preferentially finely powdered metals that are mixed, Angular process – Portion of the vertical
removes the enamel prism cores and or triturated, with mercury to form a ramus of the mandible.
leaves the prism peripheries intact. condensable mass. Anisognathism – Condition of having
Acquired – Pertaining to something Amalgamation – The process of unequal jaw widths in which the
obtained by itself, not inherited. combining an alloy with mercury (e.g., distance between the mandibular cheek
Acrodont – Tooth that is attached to the silver or copper alloy triturated with teeth rows is smaller than the distance
crest of the jaw through ankylosis and mercury makes up an amalgam). between the maxillary cheek teeth rows.
lacks root formation. Amalgamator – A mechanical device or a It is seen in the equine, feline, canine,
ground glass mortar and a glass pestle bovine, and other species.
Acrylic – Basically methyl methacrylate
resin, mixed from a powder (polymer) used to triturate an alloy. Ankylosis – Fusion of a tooth with
and liquid (monomer). Referring to Amelo-(prefix) – Indicating enamel or alveolar bone. Joining together of bone
synthetic compounds that contain tissues of the epithelial odontogenic and bone, by direct union of the parts,
acrylic acid, which is formed by the origin. resulting in rigidity.
oxidization of acrolein. Ameloblast – Germ cell originating from Anodontia – Condition in which most or
Adamantinoma – Obsolete term for epithelium from which the enamel is all the teeth are congenitally absent,
ameloblastoma. formed. usually indicating a failure of tooth
development
Aerobic bacteria – Bacteria that thrive in Ameloblastic odontoma – Dental tumor
the presence of oxygen. originating from the dental laminar Anomaly – A difference or deviation from
epithelium. that which is ordinary or normal.
Ala (pl. Alae) – Latin for wing, referring to
the sides of the nostrils of the nose. Ameloblastoma – The most common Anorexia – Loss of appetite.
Alginate – Irreversible hydrocolloid tumor (enamel cell origin) of the dental Anterior (Rostral) – Situated in or toward
impression material used in small laminar epithelium. It is slow-growing the front. This term is commonly used
animal dentistry, especially when partial – but often demonstrates a multiple cystic to denote the incisor and canine teeth
or full – mouth models are needed structure and can extend into bone. or the area toward the front of the
that require good, yet not excellent Amelodentinal junction – Junction mouth.
detail. between enamel and dentin. Anterior teeth – Collective term for the
Alignment – Arrangement (e.g., of teeth) Amelogenesis – The process of enamel incisors and canines.
in a row. formation. Antral – Relating to an antrum.
Allele – An alternative form of a gene. Amylase – Enzyme in saliva and pancreatic Antrum – An air-filled natural cavity,
juice. Converts starch into simple usually in bone. Also called a sinus (e.g.,
sugars. maxillary antrum=maxillary sinus).

391
 Glossary

Apexification – Maturation of root ends. Bisecting angle – Technique of taking Bud stage – First stage of development of
Apical – Relating to the apex of a tooth, radiographs to minimize linear the enamel organ that develops from
i.e., the root area of a mature tooth (or distortion by aiming the beam the dental lamina.
similar area of an immature tooth perpendicular to the line that bisects Bullous pemphigoid – Autoimmune
before root formation). the angle formed by the long axis of the disease frequently causing lesions at the
Apical foramen, foramina (pl) – tooth and the film. oral mucocutaneous junction.
Entrance(s) to the pulp cavities of a Bishoping – Tampering with the dental Bundle bone – Extra thickness of bone
tooth (where the blood vessels, nerves, appearance of an animal, normally a added to the cribriform plate of alveolar
and lymphatics enter pulp). horse, to make it look younger for bone.
Apicoectomy – Endodontic treatment that fraudulent reasons by burning or Burrs (Burs) – Rotary instruments with
involves amputation of the root tip. drilling and staining an artificial cutting blades or abrasive surfaces as an
concavity in the dentin of the incisors active part of the operative head.
Approximal, see Proximal –
in an attempt to mimic the
Interproximal. Collective term that refers Cachexia – Condition of weakness of the
infundibulum of a younger animal.
to surfaces of teeth that face adjoining body and weight loss that results from a
teeth of the same dental arch or row. Bit – Mechanical device held in the mouth debilitating chronic disease.
and attached to the reins.
Aradicular hypsodont – Dentition without Calcification – Process by which organic
true roots (sometimes referred to as Biting force – The occlusal pressure (N/ tissue becomes hardened by a deposit
open-rooted or elodont) that produces cm2) exerted by teeth when engaged by of calcium salts within its substance.
additional crown throughout life. As the the muscles of mastication. Literally, the term denotes the
tooth is worn down, new crown Blast histology – Embryonic cell or deposition of any mineral salts that
emerges from the continually growing formative layer. contribute toward hardening and
tooth, as in lagomorphs and the Blind wolf tooth – Colloquial term. maturation of tissue.
incisors of rodents. Unerupted wolf tooth. Calculus – Mineralized dental plaque that
Arcades – Refers to the arches of teeth in Body of the mandible – Horizontal adheres to tooth surfaces and prosthetic
some brachydont species. In horses the portion of the mandible, excluding the dental materials.
straight rows of cheek teeth are alveolar processes. Campylorrhinus lateralis (wry nose) –
separated from the incisors by the Bolus of food – A ball of food that has Twisted premaxilla, nasal bones and
physiological diastema (‘bars of been chewed and mixed with saliva and and nasal septum. Developmental
mouth’) so all of the teeth do not form is ready to be swallowed. abnormality.
an arch. Bone – Hard connective tissue that forms Canal – Long tubular opening, e.g.,
Articular disc – Fibrous disc, e.g., between the skeleton of the body. through a bone or tooth root.
the mandibular condyle and the Brachy- (prefix) – Indicating something Cancellous bone – Less dense bone
zygomatic process of the temporal short. situated between surrounding denser
bone. cortical bone plates.
Brachycephaly – Condition in which
Articular process – Portion of the vertical individuals have short, (usually broad) Canine teeth – The teeth found between
ramus of the mandible that is part of facial profiles. the incisors and cheek teeth usually in
the temporomandibular joint. male horses; the fighting teeth of a
Brachygnathic – Having an abnormally
Attrition – Process of normal wear on short mandible. horse (Triadan 104, 204, 304, 404).
the crown due to prehension and Cap – Colloquial term for the remnant of
Brachydont – Teeth with a short crown:
mastication. a deciduous cheek tooth that covers an
root ratio (e.g., primates, dogs, cats, and
Auto-immune disease – Immune-mediated carnivores in general). erupting permanent cheek tooth
inflammatory reaction to the host’s own (premolars only) and is later shed.
Brachygnathism, see Brachygnathic – A
tissues. Cap stage – Second stage of enamel organ
congenital deformity in which the
Avulsion – Tearing away of a part, such as upper incisors overlap the lower development.
a tooth. incisors due to shortness of the Capsule (joint) – Fibrous band of tissue
Axial – Pertaining to the longitudinal mandible – however equine overjet and surrounding a joint and limiting its
(long) axis of a structure. overbite may actually be due to motion.
Bacterial plaque – Dental plaque. Soft elongation of the maxilla. Carbide – Hard compound of carbon and
mass of microorganisms, cellular Branchial arches I and II – Developmental another element such as tungsten used
material and food debris that adheres to sections of the facial region. for making blades that can be used for
the surfaces of teeth and/or gingiva. Bruxism – Abnormal grinding of the teeth. grinding and floating equine teeth.
Basal cell carcinoma – Tumor originating Bucca – Latin for ‘cheek.’ Caries – Demineralization of calcified
from basal cell layer of epidermis. dental tissues and destruction of their
Buccal – Pertaining to or directed toward
Beak – Colloquial term for a dental the cheek (outside/lateral aspect of organic parts through the acid produced
overgrowth resembling the beak of a mouth). by microorganisms.
bird. Cariogenic acid – Acid produced by
Bucco- (prefix) – Signifying buccal, cheek.
Bell stage – Third embryonic stage cariogenic bacteria.
Buccostomy – The formation of a surgical
of enamel organ formation in which Caudal – Relating to the posterior aspect
opening (fistula) through the side of
the crown form is established. of a structure.
the face that is later kept patent.
Benign – Non-malignant. Such lesions do Caudal infraorbital block – Intraoral
Buccotomy – Surgical incision made
not destroy the tissue from which they regional anesthetic nerve block achieved
through the side of the face, usually
originate or spread to other parts of the by injecting the infraorbital nerve at the
performed in herbivores, to accomplish
body (metastasize). caudal aspect of the infraorbital canal.
an intra-oral procedure that is
Bifurcation – Division into two parts or inaccessible through an oral approach. Cellular cementum – Cementum that has
branches, e.g., two roots of a tooth. cells (cementocytes) trapped in it.

392
 Glossary

Cellulitis – Diffuse inflammation, often Colic – Pain related to abdominal, Crown – 1) The part of the tooth which
purulent, of the soft tissues. primarily alimentary disease. contains enamel (both clinical crown
Cement – Dental cement is a material used Commissure – Junction of the upper and and reserve crown), i.e., all of the tooth
to apply orthodontic brackets, lower lip at the angle of the mouth. except the roots, which by definition
appliances, crowns, or other Band of tissue joining two parts or contain no enamel. 2) A restoration
prosthodontic devices. A plastic organs together. that covers part or the entire clinical
material that is used to affix dental Complex or compound odontoma – crown.
restorations. A type of filling material. Mixed odontogenic tumor composed of Crypt – Term used to describe the early
Cementoblasts – Cells that form both epithelial and mesenchymal cells tooth socket.
cementum. in a disorganized mass that contains no Cryosurgery – Surgical destruction by
Cementoclasts – Cells that resorb tooth-like structures. Can have a cystic freeze/thaw cycles. Using liquid
cementum. component. nitrogen.
Cementocytes – Cementoblasts that have Composite – Type of dental restorative Cup – Hollow structure with open top.
become entrapped within cementum. material typically composed of an Curvature of Spee – Rising slope of
Cementodentinal junction (CDJ) – organic polymer matrix of high caudal aspects of the mandible, and
Junction where the cementum and molecular weight, usually bisphenol thus of the occlusal surface of the
dentin contact. A-glycidyl methacrylate (bis-GMA) caudal mandibular cheek teeth.
resin, with or without fillers. Cusp – 1) A pronounced elevation on the
Cementoenamel junction (CEJ) –
Junction of enamel and cementum. Concha – Any body structure that occlusal surface of a tooth terminating
resembles a shell in shape (e.g., the in a conical, rounded, or flat surface.
Cementogenesis – Process of cement
nasal turbinate bone). 2) Any crown elevation that begins
formation.
Condylectomy – Excision of condylar calcification as an independent center.
Cementoid – Term meaning
process of the mandible. Cyanoacrylate – Adhesive material, usually
cementum-like.
Condyloid process – That portion of the self-curing in the presence of moisture
Cementoma – Benign proliferation of the
vertical ramus of the mandible that is in an anaerobic environment.
connective tissue that produces
part of the temporomandibular joint. Cyst – Sac of fluid lined by epithelial cells;
cementum or cementum-like tissue.
Congenital – Denoting a condition usually it may grow to varying sizes.
Cement, cementum – A bone-like, calcified
abnormal, present at or before birth, Debridement, dentistry – The removal of
component of teeth, includes peripheral
but one that is not necessarily debris from a dental cavity in an
cementum which composes a significant
hereditary. alveolus or root canal. The surgical
portion of the equine clinical crown
and infundibular cementum. Contrast – Radiography relates to the removal of cellular debris from the
variation in the black and white density surface of a wound.
Cemental hypoplasia – A developmental
on areas of radiographic images. Decay – The decomposition of organic
disorder commonly seen in maxillary
cheek teeth infundibula due to Coprophagy – The act of eating feces. matter.
incomplete cementogenesis. Coral formation – Colloquial term. Deciduous teeth – The first dentition; milk
Centric occlusion (central occlusion) – Metaplastic calcification of the conchal teeth. See Primary teeth.
Relationship of the occlusal surfaces of cartilage caused by chronic sinus Deglutition – Action of swallowing.
one dental arch to those of the other infection. Dehiscence – The spontaneous breakdown
when the jaws are closed and the teeth Corona – Tooth crown. of a surgical wound.
are in maximum intercuspation. Coronal – Direction toward the crown. Dens – Tooth.
Cephalic – Relating to the skull or head. Relating to or towards the crown part of Dens in dente (tooth within a tooth) –
Cephalometrics – Anatomical a tooth. Developmental disorder that is formed
measurements of skull structures. Coronoid process – Bony projection at the when the top of the tooth bud folds
Cheeks – Lateral boundaries of the oral dorso-rostral portion of the vertical into itself, producing additional layers
cavity. ramus. It is the attachment location for of enamel, cementum, dentin, or pulp
Cheek teeth – An equine term to describe the temporal muscle. tissue inside the tooth as it develops.
premolars 2-4 and the three molar Cortex – The external layer of an organ or Dens invaginatus – A developmental
teeth. bone; hence, cortical. anomaly involving an invagination on
Cheilitis – Inflammation of the lips. Cranial nerves – Nerves of the head. the lingual or palatal surface of an
Craniofacial deformity – Skull and face incisor.
Choke – Esophageal obstruction.
deformities. May be developmental or Dental arch – All teeth forming an arch in
Chondrosarcoma – Malignant tumor of
acquired. either the maxillary or mandibular jaw
cartilage.
Crest – As pertains to radiation, the height in species with true dental arches –
Chronic – A process continuing over a long correctly should only refer to the equine
period of time (e.g., many months). of the wave.
Crib-biting (cribbing) – Destructive incisors that do form a true arch.
The opposite of acute.
behavior when horses bite their food Dental attrition – The wear or loss of
Cingulum – A convexity on the surface of a tooth substance due to normal
tooth – used loosely to describe the containers or surroundings resulting in
an abnormal wear pattern to their masticatory and prehension forces.
vertical ridges on the buccal aspects of
incisors and possibly may also be Dental cap, colloquial – The remains of a
maxillary cheek teeth.
associated with the ingestion of air. horse’s deciduous premolars once the
Cleft palate – Lack of joining together of roots have been resorbed.
hard or soft palate. Cribriform plate – Dense bone that forms
the wall of the alveolus. Cribriform Dental lamina – Embryonic downgrowth
Clinical crown (erupted crown) – The part of oral epithelium that is the forerunner
plate also refers to the horizontal
of the crown that lies outside of the of the enamel bud.
lamina of the ethmoid bone.
alveolus and gingiva (i.e., the part that
is visible in the oral cavity).

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Dental papilla – Mesodermal structure Digestive tract – gastrointestinal tract Enamel pearls (enamelomas) – Small
partially surrounded by the inner Diphyodont – The feature of having two enamel growths on the root of the
enamel epithelial cells that later form sets of teeth, one designated deciduous teeth; considered abnormal structures.
the dentin and pulp. or primary and the other permanent. Enamel prisms – Basic enamel unit
Dental sac – Layers of flat mesodermal The teeth of most domesticated animals running from the dentinoenamel
cells partially surrounding the dental and humans are diphyodont. junction to the surface of enamel.
papilla and enamel organ. It forms the Disarming, veterinary – Procedure where Enamel rod – Individual pillars of enamel
cementum, periodontal ligament, and one or more teeth are either extracted formed by ameloblasts.
some alveolar bone. or shortened in order to prevent Endo- (prefix) – Within.
Dental star, colloquial term – Occlusal animals from inflicting injuries. Endoderm – Inner germ layer of an
appearance of secondary dentin in Distal – Farthest away from a median line embryo that forms the epithelial lining
equine incisors. of the face – useful term for brachydont of organs such as the digestive tract,
Dentes canini – Canine, cuspid, eye, or teeth. liver, lungs, and pancreas.
fang teeth. Dolichocephaly – Condition marked by a Endodontics – Branch of dentistry
Dentes decidui – Deciduous teeth. long, narrow facial profile. involved with treating the pulp and
Dentes incisivi – Incisor teeth. Domestication – Adjustment of animals to root canals.
Dentes molares – Molar teeth. living with humans; taming. Endoscope – Instrument used for
Dentes permanentes – Permanent teeth. Dominant – An allele that produces an examining inside hollow organs and the
Dentes premolares – Premolar teeth. effect on the phenotype even when abdominal cavity.
present in a single dose. Endoliths – Calcifications within the
Denticles – Small, tooth-like structures.
Dorsal – Toward or situated on the top. endodontic system; more commonly
Dentigerous – Containing teeth or
Dorsum of the tongue – Top surface of the referred to as pulp stones.
tooth-like structures.
tongue. Epistaxis – Hemorrhage from the nose.
Dentigerous cyst – Developmental dental
follicle remnant with ectopic, cystic Duplicidentata – Double-row dentition. Epithelial attachment – Interface at the
tooth-like structure usually lying on the Dysmastication – Difficulty chewing. base of the gingival sulcus or
temporal bone. Dysphagia – Difficulty swallowing. periodontal pocket that unites the
Dysphrehension – Difficulty grasping food gingiva to the tooth.
Dentin (dentine) – A soft (ivory like)
component of the mineralized tooth with lips and teeth. Epithelium – Cellular layer that covers the
that increasingly fills the pulp chamber Dysplasia – Abnormal development of a external and internal surfaces of the
with age (e.g., with secondary dentin). part or organ. body or organs.
Dentinal tubules – Linear, tube-like spaces Dyspnea – Difficulty in breathing. Epulis – Any type of benign growth
in the dentin that are occupied by the situated on the gingiva.
Ectoderm – Outer embryonic germ layer
odontoblastic processes. Erosion – External loss of calcified dental
that forms skin, salivary glands, hair,
Dentinocemental junction (DCJ) – See tissue due to a chemical process
sweat glands, sebaceous glands, nerves,
CDJ. without active bacterial involvement.
etc.
Dentinoenamel junction (DEJ) – Junction Eruption of teeth – The process of
-ectomy (suffix), medicine – Excision of a
where the dentin and enamel tissues movement of tooth from the alveolus
part.
meet. into the oral cavity.
Edentate – Lacking teeth – due to absence
Dentinogenesis imperfecta – A hereditary Eruption cysts (pseudocysts) (“3 or 4 year
of their development or their later loss
condition in which dentin is old bumps”) – Enlarged areas of soft
in the horse. Some other species are
abnormally formed, leading to tissue at the developing apices of
normally edentulous (toothless).
generalized dental dysplasia. immature permanent cheek teeth. These
Elevator – Instrument used to elevate the cysts can cause bony swellings on the
Dentition – General character and tooth or root section out of the alveolus ventral surface of the mandible, less
arrangement of the teeth, taken as a during extraction. commonly on the maxillary bones, in
whole, as in carnivorous, herbivorous, Empyema – The accumulation of pus in a 2–4 year old horses.
and omnivorous dentitions. Mixed hollow organ or body cavity.
dentition refers to a combination of Eruption times – Times for anticipated
Emphysema – The abnormal presence of eruption of teeth.
permanent and deciduous teeth in the
gas in a part of the body. Eruptive stage – Period of eruption from
same dentition.
Enamel – A calcified dental tissue which is the completion of crown formation
Dermatitis – Inflammation of the skin and
the hardest substance in the body, and until the teeth come into occlusion. The
subcutis.
provides great wear resistance for teeth. prefunctional eruptive stage occurs at
Developer – Radiography solution to
Enamel cuticle (Nesmith’s membrane) – A the beginning, before the teeth move
make the latent image on an exposed
thin membrane that covers the crown into occlusion.
X-ray film visible.
of a tooth at eruption. Exfoliation – Shedding or loss, e.g., of a
Diarthrodial joint – Movable joints.
Enamel hypoplasia – Condition in which primary tooth.
Diastema (plural, diastemata) – A space the enamel layer is thin or reduced. Exodontia – Extraction of teeth.
between teeth. In the horse refers both
Enamel lamellae – A hypomineralized Exostosis (pleural exostoses) – Local
to the physiological space between the
structure in teeth that extend from the deposition of new bone that projects
incisors and premolars (the interdental
dentinoenamel junction to the surface beyond the normal limits of the
space) more commonly to the
of the enamel. skeleton.
pathological presence of an abnormal
space between adjacent teeth. Enamel organ – Ectodermal (epithelial) Exothermic – A chemical reaction that
structure that leads to the formation of generates heat.
Digastricus muscle – Paired muscles from
tooth enamel. External fixation – Methods by which
jugular process of occipital bones to
mandible. Opens the mouth. fractured bones are supported by
devices outside the body.

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 Glossary

External fixator – Device with which Floating (see also Rasping). Veterinary – Genetic – Term describing the condition
fractured bones are immobilized using The process of smoothing down the of being hereditary.
percutaneous pins that are joined sharp buccal or lingual enamel Genotype – The genetic makeup of an
outside the body. overgrowths (“points”) on the cheek animal.
Extirpate – To completely remove or teeth of horses. The act of using rasps to Gingiv- or gingivo- (prefix) – Denoting the
destroy a part or organ. remove sharp edges from teeth. gingiva.
Extirpation – Complete surgical removal Fluorosis – Disruption in the Gingiva – Keratinized oral membrane that
or destruction of a tissue, such as a mineralization of developing teeth due immediately surrounds the teeth and
pulp. to excess ingestion of fluoride, often alveolar bone.
Extra-oral – Outside the mouth. seen as chalky white spots or Gingival – Of or pertaining to the gums.
discoloration of the enamel.
Extract – To pull out or remove. Gingival crest – Most occlusal extent of
Focal film distance (FFD) – Distance from gingiva.
Extrinsic – Originating outside a structure.
the focal spot on the tube’s target to the
Extrusion – Movement of a tooth further Gingival crevice (sulcus) – Subgingival
film.
out of the alveolus, typically in the space that under normal conditions lies
Follicle – Fibrous sac which surrounds the between the gingival crest and the
same direction as normal eruption.
developing tooth germ and by which it epithelial attachment to the adjacent
Eye teeth – See cuspid.
is attached to the oral mucosa. peripheral cementum.
Facial nerve – Cranial nerve VII,
Follicular cyst – Dentigerous cyst or Gingival fibers – Periodontal fibers in the
innervating the facial muscles of
dilation of the follicular space around gingiva.
expression and caudal belly of the
the crown of a tooth that is unerupted
digastric muscle. Gingivitis – Inflammation of the gums.
or impacted.
Facultative anaerobes – Bacteria that can Glass ionomers – Dental restorative
Foramen – A small circular opening or
live in either aerobic or anaerobic compounds that chemically bind to
passage, e.g., where the mental nerve
conditions. enamel and dentin by ions forming
leaves the mandible.
Familial – Used to describe conditions that salts that bond to the calcium in the
Frenulum – Fold of tissue that limits the tooth, even if slight moisture is present.
affect a family to an extent
movement of an organ (e.g., frenulum
that is considered greater than expected Glossectomy – Surgical removal of part or
under the tongue or between lips and
by random chance or circumstance. all of the tongue
gums).
FDI system – System for tooth Glossitis – Inflammation of the tongue.
Fulcrum – Dentistry. A device used to
identification promulgated by Glossoplegia – Paralysis of the tongue,
increase leverage of dental equipment
the Federation Dentaire Internationale either unilateral or bilateral.
during extractions
(International Dental Federation). Gnathic – Relating to the jaw, meaning the
Functional occlusion – Active tooth
Fetid – Having a smell of decaying matter. mandible in modern usage.
contact during mastication and
Fibroma – Benign tumor of mesodermal swallowing; also called dynamic Granuloma – Localized mass of reactive
origin. occlusion. tissue containing macrophages
Fibrosarcoma – Malignant tumor of Furcation – Point at which roots diverge. associated with an area of chronic
fibrous connective tissue. Teeth with multiple roots have bi- or suppuration and/or healing.
Fibrous dysplasia – Incomplete trifurcation. Gutta percha – An ionomer of rubber
differentiation of fibrous tissues. Gag – Speculum – An instrument to extracted from the sap of certain
Replacement of bone as a result of prevent the closure of the mouth during tropical trees. Endodontic filling agent
parathyroid dysfunction. oral examination or surgery. that is about 60% crystalline and
Filiform papillae – Small pointed slightly viscoelastic.
Galvayne’s groove – A groove in the labial
projections pointing caudally that surface of 103/203 (upper permanent Halitosis – Malodorous or foul breath.
heavily cover most of the dorsum of the corner incisor of the horse) which was Hard palate – Bony vault of the oral cavity
anterior two-thirds of the tongue. believed begin to appear at proper covered with soft tissue.
Filing Dentistry – Grinding or rasping of approximately 10 years, is half way Hard tissue – Calcified or mineralized
dental tissues. down at 15, fully down at 20, half worn dental tissues or bone.
Fissure – A small crack, e.g., an enamel away at 25 and absent at 30 years of Hausmann gag – A metal-framed,
fracture in a cheek tooth. age. This feature has been shown to give ratchet-operated device used to keep the
Fistula – A tract (duct) leading from an an inaccurate indication of age. mouth of horses open for examination
internal cavity in the body to the Gamma radiation – Radiation of the same or treatment.
surface or from one body cavity to approximate wavelength as X-radiation Haversian system – System of blood
another, e.g., from a paranasal sinus to that is naturally occurring rather than vessels located within bones.
the mouth (oromaxillary fistula) or man-made. Hemimandibulectomy – Excision of half
from the oral to the nasal cavity Germination – Dental disorder in which of the mandible.
(oronasal fistula). A tract connecting the developing bud attempts to split Hemisection – To cut in half.
two epithelialised surfaces. but fails to do so completely, resulting Hemostasis – To arrest hemorrhage.
Fixer solutions – Radiography chemicals in duplication of part of the tooth but
Hereditary – Genetically determined;
used to preserve and enhance the latent not total twinning.
passing or capable of passing from
image on a radiographic film. Gene – A unit of information in DNA that parents to offspring.
Flap – Portion of mucous membrane or codes for a particular disease or trait.
Hertwig’s epithelial root sheath –
skin separated from the surrounding General anesthesia – Controlled, drug- A downgrowth of the inner and outer
tissues except for at least one edge. induced unconsciousness, whereby enamel epithelium that initiates dentin
pain, voluntary muscle movement and formation.
an effective swallowing reflex are
eliminated.

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Heterodont – The feature of having more Impacted teeth – Teeth which have been Interceptive orthodontics – Generally
than one type (size, shape) of tooth prevented from erupting by mechanical considered to be the extraction or
represented in the dentition, such as obstruction, usually compression from recontouring (crown reduction) of
incisors, canines, premolars, and the two adjacent teeth. Impactions may primary or permanent teeth that are
molars. cause large eruption cysts to develop at contributing to alignment problems of
Homodont – The feature of having all the apex of the impacted tooth and the permanent dentition.
teeth that are of the same general shape focal hard swellings (‘3- and 4-year-old Interdental – Located between teeth.
or type, although size may vary. bumps’) on the mandible or maxilla. Interdental (interproximal) space – The
Hook – Colloquial term for a sharp narrow Implant dentistry – Intra-osseous, space between two adjacent teeth. Also
overgrowth developed on a tooth biocompatible structure placed in the used to describe the space between
through abnormal wear, e.g., on 06s or alveolar bone, which is used as a equine incisors and cheek teeth (e.g.,
11s. Also note 7- or 9-year incisor support in prosthodontics. ‘bars of the mouth’).
“hooks”, now shown to be inaccurate Impression – Mold taken of the teeth and/ Internal fixation – Surgical stabilization of
for age determination. or intra-oral contours of the jaw for the fracture with pins, plates, screws, etc.
Horizontal ramus – That portion of the preparation of a replica model. attached within the affected bones.
jaw composed of the body and Impression material – A substance used in Interproximal – See interdental.
symphyseal area of the mandible. the making of a mold of the teeth and/ Interproximal space – See interdental
Hydroxyapatite (hydroxylapatite) – or the contours of the jaw. space.
Calcium- and phosphate-containing Impression tray – Receptacle, usually Interradicular septa – Obsolete term for
crystals found in hard substances of the custom-made in veterinary use, to fit interalveolar septa, i.e., Bony partitions
body, such as bone, cementum, dentin, the jaw being treated for carrying the between adjacent teeth.
and enamel. impression material.
Intradental oral cavity (IDOC) – Space
Hyoid apparatus – Bony structure Incisal – Occlusal direction in incisors. whose boundaries are the lingual and
originating from 2nd and 3rd branchial Incisal bone – See Incisive bone. palatal margins of the teeth.
arches. Attached to petrous part of Incisivomaxillary suture – Articulation of Intrinsic – Lying entirely inside a structure.
temporal bones and supports the root the incisive bone and the maxillae. Intrinsic muscles of the tongue – Muscles
of the tongue, pharynx, and larynx. Incisors – Teeth found at the front of the that produces the complicated
Hyper- (prefix) – Exaggerated, excessive. horse’s mouth (e.g., all teeth embedded protrusion and prehensile movement of
Hypercementosis – Increased thickness of in the premaxilla are incisors by the tongue. They are innervated by the
cementum, usually seen at the apex of definition, as are those situated in the hypoglossal nerve.
the tooth. rostral mandible). Incisors are used for Isognathism – Condition of having equal
Hyperemia – Congestion of blood, as may grasping (prehension) of food. In jaw widths, in which the premolars and
be seen in pulp. horses there are normally 12 deciduous molars of opposing jaws align with the
Hyperplasia – Enlargement or and 12 permanent incisors (Triadan occlusal surfaces facing each other.
overdevelopment of organ or tissue 101–3; 201–3; 301–3; 401–3).
Jaw – The upper jaw is formed by the
through increased production of cells. Incisive bone (premaxilla incisal bone) – premaxilla (incisive) and maxillary
Hyperplastic – Affected by The bone attached to the rostral aspect bones and the lower jaw is formed by
hyperplasia. of the maxilla which bears the upper the mandibular bone; both jaws
Hyperptyalism – Excess salivation. incisors. contain the teeth.
Hypodontia – Condition in which some Incline planes – Orthodontic appliances Juvenile ossifying fibroma – Benign,
teeth are missing although the term designed to make contact with the locally invasive, gingival tumor.
anodontia is often loosely used in this cusps or incisal edges of the teeth of the Keratin – Substance contained by the
regards. opposing occlusion to stimulate tooth surface cells of skin, hair and hooves.
Hypoplasia – Reduced or inadequate tissue movement directed by the inclination.
Labium (pl. labia) – Latin for ‘lip’.
formation. Inferior – Indicating the relative position
Labial – Of or pertaining to the lips. Also,
Hypoplastic enamel – Thin enamel, of a structure that is lower than others.
as a direction, towards the lips or the
commonly seen in conjunction with Inflammation – Reaction of living tissue to rostral aspect of mouth.
enamel hypocalcification. See enamel infection or injury.
Lamina dura – Radiographic term
hypoplasia. Infra- (prefix) – In anatomy, indicating a denoting the cribriform plate, bundle
Hypsodont – Teeth which have a limited position beneath the structure being bone, and the dense alveolar bone
growth period but prolonged eruption qualified. In dentistry, indicating a surrounding the reserve crown and
(in contrast, elodont teeth, as in rabbits, position apical to the structure being roots.
have permanent growth and eruption qualified.
Lampas – Physiologically normal swelling
throughout life; brachydont teeth, such Infundibulum – Enamel infoldings found of the mucosa of the hard palate, often
as humans have a limited growth and in centers of incisor and the upper greatest just behind the upper incisors
limited eruption time). cheek teeth that are filled (or partially especially in young horses.
Iatrogenic – Induced injury that is caused filled) with cementum. The single
Lateral – Away from the median plane (is
by or created by treatment, e.g., incisor infundibulum is colloquially
the opposite of medial); refers to the
fractures of 311 or 411 using a termed the ‘cup.’ There are two
buccal aspect (outside) of teeth. A
guillotine or fractures of cheek tooth infundibula in each upper and none in
position farther from the midline of the
caused by dental shears. the lower cheek teeth.
body or median plane. Opposite of
Idiopathic – Disease of unknown origin. Insidious – Slow or gradual onset. Refers medial.
to a disease and indicates that it does
Lateral excursion – Lateral movement of
not exhibit early symptoms of its onset
the mandible relative the maxilla.
or progress.

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 Glossary

Lateral excursion to separation – A Mandibular arch – First branchial arch that Mental foramen – Foramen on the lateral
measure of cheek teeth occlusion and forms the mandible and maxillae. side of the mandible, below the
occlusal angulation. This term refers to Mandibular condyle – Rounded top of the premolars.
the point during lateral excursion of the mandible that articulates with the Mental regional block – Regional
mandible with the jaws closed when mandibular fossa. anesthetic nerve block achieved by
the angled occlusal surface of the cheek Mandibular foramen – Opening on the injection at the mental foramen. It
teeth causes separation of the incisors. medial surface of the vertical ramus of provides analgesia to the incisors,
Ligament – Regularly arranged group of the mandible for entrance of nerves and canines, and possibly the lower 06.
collagen fibers. blood vessels to the lower teeth. Mesaticephaly – Condition marked by a
Lingual – Referring to the tongue; also, as Mandibular fossa – Depression on the head shape of medium proportions.
a direction, towards the tongue, used to inferior surface of the skull in the Mesenchymal cells – Embryonic
refer to medial aspect of the mandibular temporal bone that articulates with the connective tissue that begins the
cheek teeth (palatal refers to identical condyle of the mandible. development stage of the dental papilla
aspect of maxillary cheek teeth). Mandibular symphysis – Point at which and the dental sac.
Lingual arteries – Primary blood supply to the two hemimandibles merge, forming Mesenchyme – Connective tissue derived
the tongue. the mandible. from mesoderm.
Lingual frenum – Fold of tissue that Masseter muscle – Muscle of mastication Mesial – Toward or situated in the middle
attaches the undersurface of the tongue arising from the zygomatic arch and (e.g., toward the midline of the dental
to the floor of the mouth. inserting on the lateral ramus of the arch).
Lingual mucosa – Thick, rough, keratinised mandible. It acts to close the mandible. Mesial drive – Phenomenon in
mucous membrane covering the Mast cell – Mesodermal cell containing brachydont dentition in which the
dorsum of the tongue. granules that release histamine in permanent molars continue to move
Lips – Most rostral extent of the oral inflammatory reactions. mesially after eruption. In equine teeth,
cavity. The upper and lower lips Mastication – The grinding of food by the the caudally facing 06s cause a caudal
converge at the angles of the mouth to teeth. movement of the rostral cheek teeth.
form its commissures. Masticatory mucosa – Mucosa Mesocephaly – Condition marked by a
Lophodont – The feature of having teeth (parakeratinized or keratinized) of the balanced facial profile, somewhere
that have a lamellar structure of hard palate and gingiva. between dolichocephalic and
longitudinal layers of enamel and Masticatory surface – Occlusal surface of brachycephalic.
dentin that become fused with teeth. Mesoderm – Middle germ layer of the
cementum, with cusps that connect to Maxilla – One of the paired bones of the embryo that forms connective tissue,
form ridges, as in the cheek upper jaw which contain the two rows muscle, bone, cartilage, blood, etc.
teeth of the rhinoceros and elephant. of upper cheek teeth and also contain Metaplasia – The transformation of one
Luxation – Partial or complete dislocation the maxillary sinuses and contributes to type of tissue into another.
from a joint, as in the the hard palate. Metaplastic calcification – Pathological
temporomandibular joint or of a tooth Maxillary – Of or pertaining to the deposition of calcium in soft tissues.
from its alveolus. Metastasis – Dissemination of tumor cells
maxilla.
Lysis – Dissolution or breaking down. to other parts of the body.
Maxillary cheek teeth row – Upper cheek
Macrodontia – Teeth that are teeth. Methyl methacrylate – Liquid monomer
developmentally disproportionally used in the manufacture of acrylic
Maxillary sinuses – Paired paranasal
large. resins by mixing it with a powder
sinuses located in the maxillae.
Macroglossia – Oversized or large tongue. polymer.
Maxillofacial – Structures including and
Malar – Relating to the zygoma, cheek covering maxillary and facial bones. Microdontia – Teeth that are
bone. disproportionally small.
Meatus – A naturally occurring canal or
Malignant – Term to describe tumors that channel. Microglossa – A small tongue.
show an uncontrollable growth and Midline – Imaginary line that
Medial – Opposite of lateral.
destructive growth pattern of the tissue divides the body into right and
of origin and that may exhibit Medial pterygoid muscles – Muscles of
mastication arising from the sphenoid left halves.
metastasis. Midsagittal plane – Imaginary plane that
bone and inserting on the condyle and
Malocclusion – Faulty occlusion; abnormal divides the body vertically into right
articular processes of the mandible.
contact of opposing upper and lower and left halves.
They serve to close the mandible.
teeth. Mixed dentition – The feature of having
Median line – Vertical line that divides the
Maleruption – Improper eruption of primary and permanent teeth in the
body into right and left (e.g., the
tooth/teeth. dental arches or rows at the same time.
median line of the face).
Malformation – Failure to develop Molarization – Changes in the appearance
Median plane – A plane running vertically
properly. of premolar teeth to resemble molar
(dorsoventrally) down the midline of a
Mandible – The lower jaw bone formed by horse from nose to tail. teeth.
the fusion of the two hemimandibles at Molars – Grinding cheek teeth that have
Median raphe – Midline of the palate
the symphysis. no deciduous predecessors in the dental
dividing the right and left sides.
Mandibular – Pertaining to the mandible. arcades (e.g., the last three cheek teeth).
Melanoma – Mesodermal origin tumor
Mandibular alveolar block – Regional containing pigment bearing (Triadan 109–11; 209–11; 309–11;
anesthetic nerve block achieved by melanocytes. 409–11.) The term molars is also
blocking the mandibular nerve as it wrongly used to refer to all 6 cheek
Mental – Relation to the chin.
enters the mandibular canal on the teeth.
medial aspect of the mandible.

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Monkey mouth – Colloquial term for sow” Odontoblast – Dentin-forming cell that Orthognathic surgery – Surgery of
mouth. Prognathism, Protruding originates from the dental papilla. mandibles to correct tooth alignment.
mandible. Odontoblastic cell layer – Layer in the Osteoconductive – Characteristic of a
Monophyodont – The feature of having pulp that is closest to dentin. product that aids in regenerating new
only one set of teeth that erupt and Odontoblastic process – Cellular bone in an osseous site. Almost all
remain functional throughout life, i.e., extension of the odontoblast, extending guided tissue regeneration products are
there are no deciduous teeth. along the length of the dentinal osseoconductive.
Morphology – Study of the form and tubules. Osteoinductive – Characteristic of a
structure of an organism or part of it. Odontogenic cyst or tumor – Lesions product that aids in the generation of
Mottled enamel – Enamel that is opaque arising from cellular components of the new bone in any site, even muscle
or chalky and may be discolored due to developing tooth structure. tissue. Autogenous bone grafts and
its porous nature. Odontoma – Mixed odontogenic tissue bone morphogenic protein can do this;
Mouth – Entrance to the oral cavity. tumor containing both epithelial and however, freeze-dried bone and
mesenchymal cells. It may be either irradiated bone are not osseoinductive
Mouth speculum – Mechanical device used
compound (disorganized mass) or because the necessary cells have been
to hold the mouth open.
complex (with denticles). killed by treatment of this product.
Mucobuccal fold – Point at which the oral
Oligodontia – The absence of one or more Osteointegration – Process in which a
mucosa and the top or bottom of the
teeth. material’s surface becomes attached or
vestibule turn toward the alveolar ridge.
-oma (suffix) – Indicating a tumor. bonded to bone; also known as
Mucocele – See sialocele. functional ankylosis. In the process,
Nares – Nostrils. Opaque – Not easily able to transmit light.
metal oxides on the surface of an
Nasal septum – Cartilagenous wall Open fracture – A fracture where there is a implant bond to bone.
between the left and right sides of the breach in the overlying skin or mucous
Osseous wiring – Placement of wires in
nasal cavity, made up of the ethmoid membranes.
direct contact with bone to provide
and vomer bones. Operculum – Persistence of a thick, fibrous reduction and support to segments of a
Nasmyth’s membrane – Membrane gingiva over a partially or even fully bony fracture.
covering the surface of the tooth crown erupted tooth.
Ostectomy – Removal of osseous defects
at the time of eruption. Oral cavity (cavum oris) – Area extending and infrabony pockets by the removal
Necrosis – The death of organic tissue; from the lips to the oral pharynx at the of bony pocket walls.
hence, necrotic. level of the palatine tonsil.
Osteo- (prefix) – Indicating bone.
Neoplasia – A new growth or tumor. Oral cavity proper – Area extending from Osteoblasts – Cells that form bone.
Neoplasm – Benign or malignant tumor; the alveolar ridge and teeth to the oral
Osteoclasts – Multinucleated cells
morbid mass of tissue growing at an pharynx. It does not include the
responsible for destroying bone.
abnormal rate. vestibule.
Osteocytes – Osteoblasts that have
Newborn gingival cyst – Cyst arising from Oral mucosa – Stratified squamous
surrounded themselves with bone.
the remnants of dental lamina in epithelium running from the margins of
the lips to the area of the tonsils and Osteogenic – Bone producing.
newborn animals.
lining the oral cavity; also known as Osteoid – Bone-like.
Non-successional (non-succedaneous)
oral mucous membrane. Osteoma – Benign bone tumor.
teeth – Permanent teeth (classically
molars) that do not succeed a Oral mucous membrane – See oral Osteomyelitis – Infection of bone marrow.
deciduous counterpart. mucosa. Osteoplasty – Shaping of bone to restore
Object film distance (OFD) – Distance Organic matrix – Non-calcified framework its physiologic contour.
between the film and the object during in which crystals grow. Osteosarcoma – Osseous tumor that can
radiography. Minimizing OFD can Oro- (prefix) – Combining form indicating develop on the mandible or maxilla
reduce distortion. oral, mouth. that is locally invasive but has less
Obturation – The process of filling, Oronasal fistula – An opening between the metastatic potential than its counterpart
packing, as in endodontic filling of pulp oral and nasal cavities – usually is a in the appendicular skeleton.
cavities. complication of extraction or periapical Osteotome – Bone cutting chisel.
Occluding – Contacting opposing teeth. abscess of one of the 1st three upper Osteotomy – Surgical operation of cutting
Occlusal – Articulating or biting surface. cheek teeth. through a bone.
Occlusal plane – Side view of the occlusal Oropharynx – Area between the soft palate Overbite – Relationship of the teeth in
surfaces. and the base of the tongue. which the incisal edges of the maxillary
Ortho- (prefix) – Straight. anterior teeth extend below the incisal
Occlusal relationship – Way in which the
Orthodontic acrylics – Materials used to edges of the mandibular anterior teeth
maxillary and mandibular teeth touch
form a framework or base structure when the teeth are placed in a centric
each other.
from which various inclines, springs, occlusal relationship.
Occlusal surface – Surface of a tooth
arch wires, or expansion devices can be Overjet – See overlap, horizontal.
within the marginal ridges that contacts
the corresponding surfaces of attached. Overlap, horizontal (overjet, overjut) –
antagonists during closure of the Orthodontics – That area of dentistry Rostral projection of the upper anterior
mouth. concerned with the supervision and and/or posterior teeth beyond their
guidance of the growing dentition and antagonists in a horizontal direction.
Occlusion – Surface-to-surface contact
between opposing teeth. correction of the mature dentofacial Overshot – See Retrognathism.
structures. It involves those conditions Palatal – Pertaining to the palate or roof
-odontics (suffix) – Indicating a dental
that require movement of teeth and/or of the mouth.
subject or discipline.
correction of malrelationships of the
Odonto- or odont- (prefix) – Relation to Palatal surface – Lingual (medial) surface
jaws and teeth and malformations of
teeth; indicating toothed. of the maxillary teeth.
their related structures.

398
 Glossary

Palate – Roof of the mouth is formed by Periodontal – Literally means ‘around or Plaque – A soft coating, essentially bacteria
the hard palate to level of 111, 211 near the teeth;’ surrounding a tooth; together with some mucins and
where it then joins the soft palate. usually used to refer to gums or the proteins (see Pellicle) that invariably
Palatine artery – Large artery that lies just other soft tissues (periodontal forms on teeth; remains thin if they
medial to the upper arcades of cheek membrane/ligaments). Also refers to the receive natural cleaning, as most parts
teeth at the edge of the hard palate. alveolus. do in the horse; builds to great
Palatine rugae, See rugae. Periodontal disease – Inflammation of the thickness in areas that are not naturally
gingiva or periodontium. cleaned and is the cause of calculus
Palliative – Treatment that alleviates the
Periodontal ligaments – Tough fibers buildup in these areas. Precursor to
severity of pain or disease without
which secure the cement on the buildup of dental calculus and tartar;
curing it.
periphery of the tooth to the bony bacterial/organic/inorganic matrix
Papilla – Small nipple-like process. involved in mineral leaching process.
alveolus; act as shock absorbers to
Paranasal – Around the nose, as in Pleurodont – Tooth that has no root but is
dampen occlusal pressures.
paranasal sinuses. attached to the lingual or palatal surface
Periodontal membrane – See Periodontal
Parotid duct – Duct formed by two to of the jaws.
ligament.
three tributaries from the parotid Plexus – A complex network of nerves,
salivary gland. It opens into the mouth Periodontal pocket – Space created by
periodontal erosion of gingival sulcus. blood vessels or lymphatics.
at the parotid papilla at the level of the
Periodontal probes – Flat or round-tipped Pocket –An abnormally deep defect
caudolateral root of the maxillary fourth
instruments that have various lengths in between the gingiva and the crown or
premolar.
millimeters marked on them. root surface of the tooth.
Parotid salivary gland – ‘V’-shaped salivary
Periodontitis – An active disease state of Posterior – Behind or toward the back/
gland located beneath the ear and
the periodontium. caudal part. Situated toward the back,
behind the caudal border of the
Periodontium – Supporting tissues such as premolars and molars.
mandible and the temporomandibular
joint. It has superficial and deep surrounding the teeth. Polydontia – Condition of having
portions. See parotid duct. Periodontology or Periodontics – Area of supernumerary teeth.
Partial anodontia – Hypodontia, i.e., dentistry concerned with the study and Posterior teeth – Teeth of either jaw
Condition in which some but not all of treatment of the diseases involving the to the rear of the incisors and canines.
the teeth are missing. gingivae and the supporting tissues of Prefunctional eruptive stage – See
Parrot mouth – Overbite, overjet, the teeth. Eruptive stage.
mandibular brachygnathism. Periosteum – Tough elastic membrane Prehensile – Adapted for grasping.
Passive eruption – Condition in which the covering the surface of bones; fibrous Premaxilla – Bony area of the upper jaw
tooth does not move but the gingival and cellular layer covering bones and that includes the alveolar ridge for the
attachment moves apically. containing cells that can become incisors and the area immediately
Pathologic movement – Orthodontic osteoblasts. behind it in primates. Also called the
tooth movement that occurs when a Periradicular osteomyelitis – Radiographic incisive bone.
heavy force is exerted, resulting in osteopenia and expansion effects of the Premolars – Permanent teeth that replace
necrosis of periodontal tissues on the alveolus seen in some cases of chronic the primary molars. Cheek teeth that
pressure side and poor to no deposition pulpal inflammation. have deciduous predecessors (Triadan
of bone on the traction side. Peritubular dentin – Dentin immediately 106–8, 206–8, 306–8, 406–8). Have
Peg tooth – A small tooth with a cone- surrounding the tubule. It is slightly evolved to be similar to molars of
shaped crown. See also microdontia. more calcified than the rest of the horses. Premolar 1 ‘wolf tooth’ has no
dentin. predecessor.
Pellicle – A thin film of salivary proteins
found on the clinical crown of teeth. Permanent teeth (dentes permanentes) – Primary dentin – Dentin formed from the
Final or lasting set of teeth that are beginning of calcification until tooth
Percutaneous – Through the skin.
typically of a very durable and lasting eruption.
Percutaneous skeletal fixation – Use of
nature (opposite of deciduous). Primary dentition – Deciduous teeth; also
pins or wires extending from fracture
Phenotype – External appearance or known as first set of teeth (baby teeth,
fragments and secured externally with
performance of an animal. milk teeth). Primary teeth, see
an additional device (e.g., rod or acrylic
Phy- (prefix) – To generate. Deciduous teeth.
tubing).
Physiologic mobility – Degree of tooth Primordial cyst – Cyst resulting from the
Peri- (prefix) – Around.
movement that can be considered degeneration of the stellate reticulum of
Periapical – Around the apex of a tooth or the enamel organ, found in place of a
the root in a mature tooth. normal, limited to
the width of the periodontal ligament. tooth.
Periapical abscess – Active infection Prognathism (underjet) – Protrusive jaw
around the apex, with suppuration. Physiologic movement – Movement in
orthodontic treatment that occurs when (‘sow mouth,’ ‘Monkey mouth’); the
Periapical cyst – Cystic reaction around mandibular incisors are more rostral
the root tip in mature tooth, often a light-to–mild force is applied and acts
as a stimulus to initiate cellular than the upper incisors. The opposite of
developing from epithelial cells from brachygnathism.
the rests of Malassez. resorption on the pressure side and
deposition of bone in the tension side. Prophylaxis, prophylactic – Preventive
Periapical granuloma – Granulomatous care; in equine dentistry means regular
reaction around the apex without Pica – An intense desire to ingest non-food
items. dental maintenance. Also may refer to
demonstrable bacteria. tetanus antitoxin and antibiotic
Pericoronitis – Inflammation of the administration when required.
gingiva. Prosthesis – Artificial device to replace
missing natural parts. Dentistry. Crown
denture or bridge.

399
 Glossary

Proximal – See approximal. Anatomy. Radio-opaque – Offering resistance to the Root – The enamel-free area at the apex of
Situated close to the center of the body, passage of X-rays. a tooth.That portion of the tooth
the median plane or the point of origin Ramp – Coloquial term, e.g., pathological normally embedded in the alveolar
of an organ or limb. exaggeration of distal upward slope of process and covered with or fully
Ptyalism – Excessive production of saliva. mandibular cheek teeth. composed of cementum.
Pulp (dental) – Highly vascular and Ramus – The vertical ramus is the portion Root bifurcation – That point at which a
innervated connective tissue contained of the mandible that is covered by the root trunk divides into two separate
within the pulp cavity of the tooth. It is masseter muscles and forms the angle branches.
composed of arteries, veins, nerves, of the jaw and temporomandibular Root canal – The apical opening(s) of the
connective tissues and cells, lymph joint. The horizontal ramus houses the pulp chamber(s) of the tooth. These
tissue and odontoblasts. cheek teeth. openings are wide in young teeth (open
Pulp canal – Canal in the root of a tooth Ranula – Salivary retention cyst (sialocele) roots) but constrict due to secondary
that leads from the apex to the pulp located under the tongue caused by dentin deposition in older teeth.
chamber. Under normal conditions, it blockage of the sublingual duct or Root sliver – Portion of root left in place
contains dental pulp tissue. gland. after exodontia.
Pulp cavity – Entire cavity within the Rarefaction – Loss of bone substance that Root resection – Cutting off of a root but
tooth, including the root canal, pulp creates an area of radio-opacity on not its associated portion of crown.
chamber and horns. See Pulp chamber. radiographic examination. Root trifurcation – That point at which a
Pulp chamber or pulp cavity – Canals in Rasping – Floating of teeth. root trunk divides into three separate
the central portion of tooth that houses Recession – Migration of the gingival crest branches.
connective tissue, nerves and blood in an apical direction. Rostral (anterior) – Toward the front of
vessels and gives vitality to the tooth. Recessive – An allele that produces an the body (e.g., toward the muzzle).
Pulp exposure – Unnatural opening of the effect on the phenotype only when Rostral hook – Colloquial term for a focal
common pulp chamber or pulp horns present in a double form. overgrowth of the rostral aspect of the
by pathological or mechanical means. Removal appliances – Orthodontic devices 06s (usually uppers in horse with
Pulp stones – Small dentin-like designed to be easily and routinely overjet, but occasionally on lower 06s
calcifications found in the pulp. removed and then reinserted. in horses with underjet.
Pulpal necrosis – Partial or total pulpal Reparative dentin (tertiary dentin) – Rugae – Small ridges of tissue extending
death. Localized formation of dentin in laterally across the hard palate.
Pulpectomy – Extirpation of the entire response to local trauma such as Rule of dental succession – No
pulp. occlusal trauma or caries. successional and deciduous precursor
Pulpitis – Inflammation of the pulp that Repulsion – Exodontia by means of forces should be erupted simultaneously or in
may be reversible or irreversible. applied to the dental apices. competition for the same dental arcade
Pulpotomy – Surgical removal of Reserve crown – The portion of the crown space at the same time.
a portion of the pulp in a vital tooth. which is yet to erupt into the oral Sagittal – Anatomical plane running
Purulent – Condition involving the cavity. parallel to the median (midline) plane
presence of pus. Resorption – Physiologic removal of (e.g., sagittal fracture of a cheek tooth
tissues or body products as of the root through the infundibula).
Pus – Yellow, white or green fluid that is
the product of inflammation composed of deciduous teeth or of some alveolar Salivary glands – Glandular system
mainly of dead leukocytes, plasma and process after the loss of the permanent secreting saliva, a serous and mucus-like
liquefied tissue cells. teeth. fluid that assists in the lubrication and
Restorative dentistry – Area of dentistry digestion of food.
Pyorrhea – A lay term denoting
periodontal disease. that is concerned with treatment, repair Salivary mucocele – Localized collection
and conservation of teeth broken down of saliva in tissues other than a salivary
Quadrants – One-fourth of the dentition.
through trauma or caries. gland or duct.
The four quadrants are divided into
right and left, maxillary and Retro- (prefix) – From behind, backwards. Secondary dentin – Normal physiologic
mandibular. Retrognathism – Anatomical relationship dentin (both regular and irregular)
where the mandible lies in an formed throughout the pulp cavity
Quidding – The term used to describe the
excessively caudal/retrusive position in following eruption.
dropping of partially masticated boluses
of food from the mouth. relation to the upper jaw. Veterinary, Secondary dentition – Permanent
Overshot. dentition.
Radicular ankylosis – Obsolete term for
dental ankylosis. Loss of part or all of Retarded eruption – Delayed eruption of Section – The process of cutting; a division
the periodontal ligament, resulting in teeth from a variety of influences. or segment of a part.
fusion of root cementum and alveolar Retrograde – Reverse approach. In Sedation – Drug-induced calmed state,
bone. endodontics indicates root filling from diminished physical activity and a
Radicular hypsodont – Subdivision of an apical approach. reduced response to stimuli, where pain
hypsodont dentition, sometimes called Reversible pulpitis – Inflammation of the is not fully eliminated and an effective
closed root, in which true roots erupt pulp that can be resolved, returning the swallow reflex is maintained.
additional crown through most of life. pulp to a healthy state. Selenodont dentition – The feature of
These teeth eventually close their root Rhinitis – Inflammation of the mucous having cheek teeth with cusps that
apices and cease growth. As teeth are membrane lining of the nasal passage. connect to form a crescentic outline,
worn down, new crown emerges from quarter-moon or concavoconvex ridge
Ridge – A linear elevation. May be
the reserve or submerged crown of the pattern as in the even-toed hoofed
marginal, triangular, cusp, incisal,
teeth. animals (order Artiodactyla) except
oblique or transverse.
Radiolucent – Offering little or no swine.
resistance to the passage of X-rays.

400
 Glossary

Sequestrum – A detached piece of necrotic Static occlusion – Relationship of the teeth Symphysis – The central rostral point of
bone that is devoid of its blood supply. when the jaws are closed in centric the mandible where the two parts of
Seven year hook – Colloquial term for occlusion. the hemimandibles join. This may
overgrowth of lateral corners of 103 Steinmann pin – Cylindrically shaped remain a fibrous joint throughout life
and 203 erroneously believed to always metal rod with threaded or trochar or it may ossify at birth.
occur at 7 years of age. points used as an intramedullary splint Synarthrosis – Any immobile or fused
Seroma – Localized accumulation of in fracture repairs. joint that lacks a synovial capsule; it is
serous exudate associated with surgical Stellate reticulum – Ectodermal derived usually formed by fibrous tissue,
dead space. middle layer of the enamel organ. It cartilage or a mixture of both.
Sharpey’s fibers – The part of the serves as a cushion for the developing Tartar – Calcified salivary deposits on
periodontal ligament embedded in enamel. clinical crowns. Calcium hydroxyapatite.
cementum or alveolar bone. Step mouth – A cheek teeth row with one Temporalis muscle – Muscle of
Shed – Term used for exfoliation of or more rectangular ‘step-like’ occlusal mastication arising from the temporal
deciduous teeth. abnormalities. Usually due to loss of a fossa and inserting on the coronoid
Shear mouth – A wear disorder of cheek tooth with overgrowth of its occlusal process of the mandible to close the
teeth where the angulations of the counterpart. mandible.
occlusal surfaces are increased (e.g., Stomatitis – Inflammation of the soft Temporary teeth – The first set of
>45° to the horizontal plane). tissues of the oral cavity or mouth. temporary teeth that are shed at some
Shell teeth – A hereditary and/or Stomodeum – Depression in the facial point and replaced by permanent teeth.
congenital disorder of teeth in which region of the embryo that is the Temporomandibular joint (TMJ or jaw
there is crown but little to no root beginning of the oral cavity; the joint) – The articulation of the
development. primitive mouth. mandible and temporal bones of the
Sialocele – Retention cyst of salivary Sublingual caruncle – Small elevation of skull.
fluids. soft tissue at the base of the lingual Temporomandibular ligament –
Sialolith – Salivary stone; calcifications frenum that is the opening for the Thickened part of the
found in salivary glands or ducts. mandibular salivary duct. temporomandibular joint capsule on
Sublingual fold – Fold of tissue extending the lateral aspect.
Sinus – Air cavity connected with the nasal
cavity also means an epithelial lined backward on either side of the floor of Teratoma – Tumor or group of tumors
tract between an area of suppuration the mandible above the mylohyoid line composed of tissues that would not
and an epithelial surface. in the canine region. normally occur at that site. Derived
Sublingual salivary gland – Smaller of the from germ cells and often containing
Sinusitis – Inflammation of a paranasal
major salivary glands. teeth or hair.
sinus or sinuses that can be due to
apical infections of caudal 4 maxillary Subluxation – Incomplete dislocation of a Tertiary dentin – See reparative dentin.
cheek teeth as well as to non-dental joint such as the temporomandibular Tetracycline stain – Intrinsic grey, green,
causes such as primary infections, cysts joint or a tooth from its alveolus. yellow or brown discoloration of the
or tumors. Submandibular – Referring to the region dentin and enamel caused by systemic
Slant mouth, slope mouth, diagonal bite – below the mandible; e.g., to a group treatment with a tetracycline-based
A disorder of wear where the incisor of lymph nodes around the antibiotic at the time of development of
occlusion surface angle deviates from submandibular salivary gland. the tooth.
horizontal (e.g., due to eating with only Submerged teeth – Teeth covered by Thecodont – The feature of having teeth
one side of the mouth), due to a cheek bone. that are firmly set in sockets.
teeth disorder or wry nose. Successional lamina – An elongation of Theory of periodontal ligament force –
Smooth mouth – Age-related dental the primary tooth germ from which a Eruption theory that the periodontal
attrition with loss of occlusal enamel of permanent tooth will eventually take ligaments, forces necessary for occlusal
the clinical crowns. shape. maintenance also contributes to
Soft palate – Unsupported soft tissue that Successional (succedaneous) teeth eruption.
extends back from the hard palate free – Permanent teeth that replace or -tomy (suffix) – Surgical cutting of a part.
of the support of the palatine bone. succeed a deciduous counterpart, Tomes process (Tomes fibers) –
Soft tissue – Non-calcified tissues such as typically certain diphyodont incisors, Ameloblast processes.
muscle, nerves, arteries, veins and cuspids or premolars. Tongue – A mobile prehensile structure of
connective tissue. Sulcus – Elongated valley in the surface of the oral cavity used for grooming and
Sow mouth, Monkey mouth, colloquial a tooth formed by the inclines of intake of food and fluids.
term – Prognathism protruding adjacent cusps or ridges that meet at an Tooth – A calcified structure containing
mandible. angle. dentin attached to the jaws of
Speculum – Mechanical device used to Superior – Indicating the relative position vertebrates occurring in or at the
hold the mouth open. of a structure that is higher than others. mouth; or in the alimentary canal of
Spreader – Forceps used to separate cheek Supernumerary roots – Those roots some invertebrates.
teeth for extraction. beyond the normal complement of a Tooth bud – The formative structure of a
Squamous cell carcinoma (SCC) – tooth. tooth in the dental follicle.
Malignant tumor of the squamous Supernumerary teeth – Those beyond the Tooth eruption – Emergence and
epithelium. normal complement (extra). movement of the crown of the tooth
Star, dental star – The exposed secondary Suppurate – To discharge pus. into the oral cavity.
dentin-filled portion of the pulp Supra- (prefix) – Above. Tooth germ – Soft tissue that develops
chamber on the occlusal surface of the Supraeruption – Eruption of a tooth into a tooth.
incisors is used in the estimation of age. beyond the occlusal plane.

401
 Glossary

Tooth migration – Movement of a tooth True temporomandibular joint ankylosis Vice – A bad habit.
through the bone and gingival tissue. – Inhibited jaw movement due Vincent’s infection (Acute necrotizing
Tooth resection – Cutting off of a portion to a bony union across the gingivitis, Trench mouth) – Fusiform
of the crown with or without its temporomandibular joint surface. and spirochete (Borrelia vincentii) gum
associated root structure. Tushes, tusks, colloquial term (see infection in man.
Trabeculae – Interlacing meshwork that canines). Vital tooth – Tooth or pulp tissue with
makes up the cancellous bony Twinning disorder – Dentistry. Condition intact innervation and vascular supply.
framework. in which there has been a complete Vomer – Bone that forms the lower part of
Transverse – Across a longitudinal cleavage of the splitting germination the nasal septum.
anatomical plane or direction from bud with the extra tooth being a mirror Wave mouth – An acquired disorder of
medial to lateral (i.e., lingual to image of the original, not a separate wear of the cheek teeth where their
buccal). tooth bud. occlusal surfaces have a wavelike
Trephination – Process of making an Twitch – A loop of cord attached to a stick appearance in a rostrocaudal direction.
opening into a bone with a trephine used to control horses during veterinary Wry nose – Campylorrhinus lateralis.
(e.g., for surgical exposure of the examination or treatment through Wolf teeth (Triadan 105, 205, 305, 405) –
sinuses or repulsion of a tooth). pinching the upper lip by tightening the Vestigial teeth in the horse; the first
Trephine – To perforate with a trephine cord with the twisting action of the premolar; small teeth rostral to the
(see trephination). A cylindrical saw for stick. second premolar.
cutting a circular piece of bone out of a Ulcer – Break in the skin or mucous Wry mouth – Condition in which one of
skull. membrane resulting in the exposure of the four jaw quadrants is grossly out of
Triadan nomenclature – System for the deeper structures. proportion to the other three causing a
precise numbering of teeth and their Underbite, Underjet, Undershot, Sow facial deviation from the midline.
position. Modified and applied to many mouth – Protruding mandible. Zygomatic arch – Arch of bone on the side
species. Ventral – Anatomically, that which is of the face or skull formed by the
Trifurcation – Division of three tooth below (e.g., opposite of dorsal). zygomatic bone and temporal bone.
roots at their point of junction with the Vestibule – Space between the lips or Zygomatic bone – Bone that forms the
root trunk. cheeks and the teeth. cheek area.
Trigeminal nerve – Cranial nerve V that Vestige, vestigial – The remnant of a
innervates many of the muscles of structure that functioned in a precursor
mastication and is sensory for much of of that species (e.g., the wolf teeth of
the head region. horses, canine teeth in mares).

402
 Index

A occurrence  157 bit seating  115, 264, 265f

pathology  157–159 bitless bridles  39–40, 40f
abnormalities of eruption  213–214, 215f prognosis  159 bits  27–42
abscess  292–293 treatment  159 accessories  40–42
cheek teeth apical  129 amelogenesis imperfecta  105–106 fitting  39, 39f
Academy of Veterinary Dentistry  23 AMELX gene mutations  105–106 head carriage  28, 28f
acid-etch technique  350b American Association of Equine Practitioners mouthpieces  28–30
acrylic splints  125, 126f (AAEP)  24 proper use  27
Actinobacillus spp.  161–162 American Association of Equine signs of problems  27–28
acupuncture  189–190 Practitioners  45 see also curb bits; overcheck bits; snaffle
adaptations American Veterinary Dental College  23–24 bits
cranial  8–9 American Veterinary Dental Society  23 blood supply of teeth  71
dental  3–5 American Veterinary Medical Association Bodamer oral speculum  333
addition silicones (AS)  363 (AVMA)  299–300 body condition score system, numerical  188,
adenocarcinoma, salivary  176 anachoresis  137–138 188t
advertising  44, 44f analgesia of the temporomandibular (TM) bonding, types of  346b
Age of Enlightenment  14–15 joint  244, 244f bonding agents  350–351, 352b
age, dental  11–12, 16–17, 18f–19f, 23–24, anatomical crown  51 basic technique for composite
66–67, 141 anatomy  78–80 restoration  352b, 353f–354f
aging  85–96 Anchitherium  3 classification  351b
Arabian horses  94t anelodont teeth  51–52 primer  350
Belgian draft horses  94t aneurysmal bone cyst  149, 176–177, 177f substrate preparation  350
changes in shape of marks  93, 93f anisognathia  70, 129–130 bone cyst
changes in shape of occlusal surfaces  93 anodontia  101, 101f–102f aneurysmal  149, 176–177, 177f
cups, disappearance of  91–93, 92f apical area  51 non-aneurysmal  178
deciduous incisor eruption  91 apical infections  137–139, 137f–138f, 205, bone gouge  335, 335f
dental star appearance  91, 92f 214–217 bone grafting materials  360–363
different horse breeds  90–95 Arabian horses, aging in  94t bone morphogenic proteins (BMP)  360
Galvayne’s groove  95 Archaeohippus blackbergi  9f bone rongeur and mallet  335, 335f
hook on upper corner  95 arthrocentesis in temporomandibular joint bone tumors see osteogenic tumors
incisors, upper and lower, direction (TMJ)  380 bone wax  337
of  93–95 Ashleigh Elbow bit  35f, 36, 37f, 38–39 bosal  40
marks, disappearance of  93, 93f atipamezole  241 brachygnathism see parrot mouth
mini-Shetland ponies  94t attrition  51–52, 64–65, 90–91, 129 brachytherapy, tumors  156
permanent incisor eruption  91, 91f auto-cured resins  349 bradoon (bridoon)  32
standardbred horses  94t autogenous bone grafts  360–361 bridles  27–42
air abrasion unit  259, 259f, 273, 274f autogenous vaccines  155 bitless  39–40
alginate hydrocolloid impression materials proper use  27
(AHIM)  364f, 365–366 British Equine Veterinary Association
allografts  361 B (BEVA)  24
alloplastic bone graft  362, 362f buccal area  51
Bacillus Calmette-Guérin (BCG)  166
alpha-2-agonist  241 buccal ulcer  116f, 129–130, 130f
‘barbs’  13
Alumispec speculum  250–251, 251f buck tooth see parrot mouth
‘beaks’  99–100
alveolar bone  71 buildup (core) composites  349–350
Belgian draft horses, aging in  94t
alveolar crest  71 bupivacaine  308–309, 320f
bridoon (bradoon)  32
alveolar crown  51 burrs  255, 255f, 273, 370
billing statement  45–46
alveolar disease  133–134 diamond  371f, 372–374, 374f
biopsy, tumor  151–152
alveolar periosteitis  133–134 Burch overcheck bit  36–38, 36f–37f
excisional biopsy  152–153
amalgam  347–348 Burgess-type extractor  322
fine needle aspiration  152–153, 153f
ameloblastoma  157–159, 158f, 217–218, business  43–47
hollow needle (Trucut) biopsy  152–153
217f, 305 absentee clients  45–46
wedge or sectional biopsy  152–153
clinical features  157 advertising  44, 44f
‘bishoping’  12
definition  157 client awareness  45
bisphenol A epoxy and glycidylmethacrylate
diagnostic confirmation  157 client communication  45–46
(Bis-GMA)  349
differential diagnosis  157 convenience  45

403
 Index

corporate image  44, 44f definition  51 computed tomography  23–24, 199,

cost of service  45 developmental displacement  107f–108f, 221–228, 334f
equipment  44–45 111–112 dental-associated structures  227–228
grouping with scheduled procedures  46 displacements  129 normal appearance of dental and
health management  44 enamel overgrowths  129–130 periodontal tissues  223–224
processes  45–46 idiopathic  142–144, 143f pathological findings in dental
referral of complex cases  44 maleruption  106–108 disease  224–228
structures  43–45 normal radiographic anatomy  210–212, technical principles  222–223
systems  47 211f–212f temporomandibular joint (TMJ)  382–383
total practice commitment  44 permanent, per os, extractions  323–331 tumors  151–153
veterinarian/client relationship  43–44 dental fragments  327–328, 329f–330f, conchofrontal sinus  301–302, 301f
Butler speculum  250 331 condensation silicones  363
Butler’s gag  206–207, 206f radiography  327–328, 329f connate tooth  101
butorphanol  200, 241, 280–281 restraining  324, 324f Conrad speculum  250–251, 269
Buxton bit  35f, 36, 37f, 38–39 selecting horse  324–325 conventional (traditional, macrofilled)
technique  325–329 composites  349–350
radiographic projections  203–208 Cope’s Law  77
C contrast studies  208, 208f–209f copper mouthpieces  30
calcium hydroxide  357, 358f, 370 dorsoventral projection  205, 206f core (buildup) composites  349–350
liner  347 dorsoventral projection with offset Cormohipparion plicate  6f
sealers  357–358 mandible  206 corporate image  44, 44f
calcium sulfate  362–363, 362f intra-oral oblique projections  correction bit (swivel ported)  30f, 31
calculus accumulation  282, 283f 207–208, 208f corrective dental procedures see dental
calculus  268, 269f lateral projection  203–204, 203f–204f equilibration
campylorrhinus lateralis see wry nose laterodorsal-lateroventral oblique cost of service  45
Canadian Veterinary Medical Association  24 projection 30°  204, 204f–205f coupling (stub) line  38, 38f
canines  51 lateroventral-laterodorsal oblique coupling agents  346b
anatomy  67–68 projection 35–45°  205, 205f Crabb overcheck bit  36–38, 36f–37f
extractions  321–322, 322f open-mouthed oblique projections  206– cranial adaptations  8–9
instruments  257 207, 206f–207f craniofacial abnormalities  99–100
normal radiographic anatomy  210, 210f retention of  108, 110f documentation  293
radiographic projections  201–203, 202f row  51 crib-biting  67, 281–282
intra-oral radiographs  201 disparity in  106 ‘crickets’  30
lateral oblique projections  201–203 supernumerary  103–105, 104f Crit Davis overcheck bit  36–38, 36f–37f
lateral projections  201 surgical extraction  331–343 cross under bitless bridle  40, 40f
supernumerary  103 by repulsion  332–341, 332f–333f crush  246f
cannons  28 complications  339–341 cryosurgery  155
Capps full mouth speculum  250, 250f using horizontal or vertical buccotomy culture of exudate  231–232
carbide chip blade, interchangeable  23 approach  341–343, 341f–343f cup, disappearance of  86, 86f
carbide chip rotary drum  273f complications  343 ‘cupped out tooth’  279–280, 280f, 285–286
carcinoma  305, 305f vertical impaction  110, 110f curb bits  29f–30f, 31–32, 32f
squamous cell  163–166, 164f–166f, 218, care after extraction  329 grazer curb bit  27, 30f, 31–32
219f, 233f complications  329–331 curb strap  31, 31f
caries  15, 139–142, 140f–141f cheeker nose band  41, 41f Curve of Spee 6  70, 100, 189, 193f
grading of infundibular  196 cheeks, trauma of  115–116, 117f Cushing’s disease, equine see pituitary pars
grading system  141t chemically activated resins (self-cured, intermedia dysfunction
infundibular cemental  138 auto-cured)  349 cysts  17, 300
peripheral cemental  141–142, 142f chemotherapy  155–156 aneurysmal bone  149, 176–177, 177f
cast materials  363–366 chew rates  82 eruption  191
cavesson noseband  40 chewing cycle  80–82, 81f, 129–130 cytological examination  231–232
cavity bases  347 chisels  258
cavity liners  347 chlorhexidine  248, 284–285, 295, 355,
cavity varnishes  347 359 D
cement hypoplasia  63–64 chloroform dip technique  357 D-ring snaffle  27, 30–31
cementoma  159, 159f, 217–218 chondrosarcoma  218 danglers (‘keys’)  30
clinical features  159 cingula  68 deciduous dentition
definition  159 cisplatin  167–170 normal radiographic anatomy  208–210,
pathology  159 cleft palate (palatoschisis)  298–299, 308 209f–210f
prognosis  159 client premolars, extractions  323, 323f
treatment  159 absentee  45–46 deciduous tooth instruments  257
cements  345 awareness  45 dental adaptations  3–5
cementum  61–64 communication  45–46 dental arcade balancing  270
in fossil records  6 clinical (erupted) crown  51 dental charts  195–196, 261
central infundibular cemental hypoplasia  55, composites  348 dental development, disorders of  101–105
63–64 classification  349–350 dental-enamel adhesives see bonding agents
cheek teeth coupling agents  346b dental equilibration  261–277
anatomy  68–70, 68f fillers  346b cheek teeth and incisor
apical abscesses  129 matrix  348 overgrowths  269–273

404
 Index

complications  274–275 double bridle (full bridle)  32–33, 33f–34f evolution  11

in miniature horse, ponies and draft doxycycline gel  285, 359–360 excisional biopsy  152–153
breeds  268–269 Dr Bristol snaffle  28 excursion to molar contact (EMC)  191, 281,
timetable for routine dental Dremel motors  255 282f
examinations  275 driving bits  35–36, 35f exodontia (dental extraction)  319–344
dental evolution  3–10, 51–52 drop noseband  40–41, 41f canine teeth  321–322, 322f
cranial adaptations  8–9 dual-cure resins  349 cheek tooth by surgical approach 
dental adaptations  3–5 dysmasesis (dysmastication)  149–150, 156, 331–343
dental ontogeny and wear  7, 7f–8f 173 by repulsion  332–341, 332f–333f
equid interrelationships and phylogeny  3 dysplasia, dental  101, 105–106, 108f, 139, using horizontal or vertical buccotomy
histology  6 213, 215f approach  341–343, 341f–343f
number of teeth  5 apical infections secondary to  124 deciduous premolars  323, 323f
sexual dimorphism  7–8 incisors  320–321, 320f
dental examination  185–198 supernumerary, permanent incisors  320–
dental extraction see exodontia E 321, 320f–321f
dental forms  261 ectodermal dysplasia syndrome  101 after trauma  321
dental formula  66–67, 77 education indications  319
dental fragments  327–328, 329f–330f, 331, continuing  44 permanent cheek tooth per os  323–331
370 during war decades  21–24 care after extraction  329
dental fulcrum  326–327, 328f–329f formal  14–15 complications  329–331
dental halters  245–246, 263–264, 264f origins of organized dentistry  15–21 dental fragments  327–328, 329f–330f,
dental history  185–188 egg butt snaffle  30–31 331
dental nomenclature  51 elastomeric impression materials (EIM)  363– radiography  327–328, 329f
dental plaster (Plaster of Paris)  366 365, 364f restraining  324, 324f
dental prophylaxis (‘floating teeth’)  261 electrochemotherapy  155 selecting horse  324–325
dental punch  332, 336–337, 336f–337f embryology of teeth  52–55, 53f technique  325–329
off-set  337 empyema of paranasal sinuses  231–232 wolf teeth  322–323, 323f
dental record form  46f, 185, 186f enamel  55–57, 55f–57f external enamel epithelium  52–53
computerized  185, 187f enamel spot (enamel ring or mark)  66–67 extraction see exodontia
dental records  195–196 endodontic irrigants  353–355 extraction equipment  258
dental scalers  258f endodontic materials  258–259, 353–359 extraction forceps  16f, 267–268
dental signalment  185 endodontic therapy  369–375 extractors  320, 320f
‘dental star’  59, 66–67, 86, 91f–92f endoscopy, portable equipment  252f extraoral physical examination  189–191
cup, disappearance of  86, 86f epulis  149, 171–172, 172f
marks, disappearance of  86 clinical features  172
morphology  88–90, 88f diagnosis  172
F
dental tissue tumors see odontogenic tumors differential diagnosis  172 facial crest  73
dental tumors see odontogenic tumors pathology  172 facial trauma, management  115–122
dentinal tubules  88 prognosis  172 farriery  13f, 14
dentine  57–59, 57f treatment  172 fibroma
intratubular  59, 88–89 Equi-Chip  271 juvenile ossifying  305, 305f–306f
peritubular  88–90, 89f equid interrelationships  3 oral  172–173
detomidine  200, 280–281 equine Cushing’s disease see pituitary pars ossifying  173–174, 174f, 218
developmental displacement of intermedia dysfunction fibrosarcoma  218
teeth  111–112 equine dental instruments  14f, 22f fibrous dysplasia  149, 177f, 178–179, 218
cheek teeth  107f–108f, 111–112 Equine Dental System  258–259 pathology  178–179
incisors  111, 112f equine odontoclastic tooth resorption and treatment  179
diagnostic tests, ancillary  195 hypercementosis (EOTRH)  144– fibrous metaplasia  149
‘diagonal bite’  100, 269–270 145, 144f, 282–283, 283f–284f Figure 8 (grackle) noseband  40–41, 41f
diastemata  132, 273 equipment fillers  346b
apical infections secondary to  124 dental  44–45, 185, 245–260, 248b fine needle aspiration  152–153, 153f
closed/valve  132, 132f radiographic  199 fissure  70
developmental  110–111, 111f Equus cracoviensis mandible  71–72 fistula
formation  266–267 Equus mosbachensis mandible  71–72 oro-antral  331, 338
in geriatric equids  283–285, 284f Equus muniensis mandible  71–72 oromaxillary  232
open  132, 132f eruption  85 oromaxillary sinus  311–314, 312f–314f
primary  132 abnormalities of  106–108, 213–214, 215f oronasal  232, 331, 332f
secondary  132 crown  51 orosinus  235, 236f
senile  132 deciduous incisors  85, 86f sinocutaneous  315–316, 315f
valve  273 permanent incisors  85, 86f fixed ring snaffle  30–31
diathermy  155 eruption cysts  109, 191, 211 flap
Dick float blade  23 vertical impaction  110, 110f frontonasal osteoplastic  301–304, 301f
displacements Estrada’s flexible shaft rotary tooth maxillary osteoplastic  301, 304–305,
apical infections secondary to  124 grinder  23, 23f 335–336, 335f
developmental  111–112 etch-and rinse (ER) bonding agent  350–351, Flash noseband  40–41, 41f
distal area  51 352f–353f float blade
domestication of horses  11–12 ethics  299 Dick  23
dosing syringe  248–249, 249f ethylenediaminetetraacetic acid (EDTA)  355 solid carbide  23

405
 Index

floating equipment  252–254 guaifenesin  295 I

Makita rechargeable battery powered guarded carbide dental burr  270f
oscillating float  23f Guenther oral speculum  333 idiopathic parotitis (‘grass glands’)  73
manual floats  252–254, 254f guided bone regeneration (GBR)  360 illumination  251
S-float  253 guided tissue regeneration (GTR)  360 imiquimod  169
table float  253, 254f Gunther screw-type speculum  250, 250f immunotherapy, tumors  155
tungsten carbide float blades  252–253 gutta percha  337, 357–359, 359f, 373–374, impactions, dental  266–267
‘floating teeth’  261 373f impressions, dental  293
flowable composites  349–350 materials  363–366, 363b
5-fluorouracil  167–169 incisal cup  66–67
Fordon motor  255 H incisor cap retention  267
fossa  70 incisor nipper, fractures caused by  274, 274f
hackamore (traditional) bitless bridle  39–40,
fossil record  3–10 incisors  51
40f
fractures, dental  142–144 anatomy  65–67
half-cheek snaffle bit  30–31, 35f
caused by incisor nipper  274, 274f change in shape of  86–87
hamartoma  149
idiopathic cheek teeth  142–144, 143f occlusal surfaces  86, 87f
hand floats  252–254, 254f
interdental space (diastema)  124–126, direction of upper and lower incisors  87,
positioning  262–263, 263f
124f–125f 87f, 93–95
haplodont supernumerary teeth  101, 102f
mandibular  122–127 length vs width of upper corner
hard palate  120–121, 120f
maxillary  122–127 incisors  87, 87f
Haussmann speculum  250
slab  143 hook on upper corner incisor  87
head shaking, dental-related  187–188
traumatic  142 developmental displacement  111, 112f
head stands  245–246, 246b, 247f
French snaffle  28 eruption of
healing of oral injuries  115
Frick/Hauptner Universal Forceps  15–16, 16f deciduous  85, 86f
health management  44
frontonasal osteoplastic flap  301–304, 301f permanent  85, 86f
hemangiosarcoma, oral  175–176
‘frown’  99, 269–270, 281, 282f extractions  320–321, 320f
hematology, tumors  152
full bridle (double bridle)  32–33, 33f–34f supernumerary, permanent  320–321,
hematoma
full-cheek snaffle  30–31 320f–321f
ethnoid  232
functional jaw orthopedics  289 after trauma  321
progressive ethnoidal  300, 302f
functional morphology  77–78 normal radiographic anatomy  210, 210f
hemorrhage
fungal granuloma  300 radiographic projections  201, 202f
intrasinus  115
intra-oral  201
nasal  115
lateral projections  201
Hertwig’s epithelial root sheath  55
G Hipparion  78
retention of  108, 108f–109f
supernumerary  102–103, 102f–103f
gag  16f, 249–250, 249f Hipparion tehonense  8f
increased radiopharmaceutical uptake
gag bits  27, 32, 32f–33f histology  6
(IRU)  220
galt trephine  334, 334f history of equine dentisty  11–25
infraorbital nerve block  242–243, 242f
Galvayne’s groove  16–17, 67, 87–88, 87f, 95 Age of Enlightenment  14–15
infundibula  52, 54f, 55, 64f–65f, 65
gamma scintigraphy, tumors  151 ancient roots  11–12
infundibular caries
genetic defects  299–300 barbary  13–14
cemental  138
geriatric dentisty  279–287 education during war decades  21–24
grading of  196
anatomic overall tooth changes  279–286 formal education  14–15
instrumentation  245–260
canine disorders  283 origins of organized dentistry  15–21
interchangeable carbide chip blade  23
cheek teeth disorders  283–286 stablemasters  12–13
interdental area  51
incisor disorders  281–282 hog mouth see sow mouth
interdental space (diastema), fractures
intercurrent geriatric diseases  279 hollow needle (Trucut) biopsy  152–153
of  124–126, 124f–125f
periodontal disease  282–283 homeopathy, tumors  156
internal enamel epithelium  52–53
sedation and restraint  280–281 hook  99–100
interprismatic enamel plates  55f–56f, 57
gingival crown  51 formation  292–293
interproximal area  51
gingival hyperplasia  149 on upper corner  95
intertubular dentine  59
gingival sulcus  73 hooks, dental  269–271
intracanal medicaments  355–357
gingivitis  267–268, 282 horizontal buccotomy approach  341–343,
intradental oral cavity (IDOC)-  81–82
glass ionomer cement  345, 346b, 347, 341f–343f
intra-oral injuries, management  115–116
351–353, 355f–357f, 357–358, complications  343
intrasinus hemorrhage  115
374f Horsepower hand piece  255
intratubular dentine  59, 88–89
basic technique  354b Hutton overcheck bit  36f, 38
intrauterine molding  291
classification  352b hybrid composites  349–350
irrigants  359
‘gleet’  13 hydroxyapatite crystals  55
irrigation unit  274f
glossectomy  116–117, 118f hypercementosis syndrome  106
gloves  248 hyperdentition see supernumerary teeth
grackle noseband  40–41, 41f hypodontia (anodontia)  101, 101f–102f J
grading of infundibular caries  196 hypoglossal nerve paralysis  292f
granulation tissue  149 hypoplasia, apical infections secondary junctional cemental hypoplasia  63–64
granuloma to  124
apical  232, 233f, 235, 236f hyposont teeth  4–5
fungal  300 Hyracotherium (eohippus)  3–4, 5f, 7–8, 11,
K
‘grass glands’  73 77–78 keratinized mucosa  73
grazer bit  27, 30f, 31–32 Hyracotherium tapirinum  7–8, 8f ketamine  295

406
 Index

‘keys’  30 mandibular nerve block  243, 243f mucosal ulcer  270

Kimberwicke bit  33, 34f mandibular periositis  28 mullen mouthpiece  28–30
Kirschner wires  311, 311f mandibular prognathism see sow mouth muscles of mastication  72
mandibular ulcer  119–120, 120f mycotic sinositis  231–232, 235, 237f
mandibulectomy, partial  305–306 Myler bit  30f
L marginal leakage  349 myxomatous tumors of the jaw and
lamina dura (lamina dura denta)  71, 211 marks gingivae  174–175, 175f
laminae limitantes  59 changes in shape of  93, 93f clinical features  174
‘lampas’  13–14, 191 disappearance of  93, 93f definition  174
laser surgery  154, 155f martingale  40–42, 41f diagnostic confirmation  174
length of occlusal enamel edge (ERPD)  77 standing (tie-down)  41–42, 41f occurrence  174
leverage bits see curb bits running  41–42, 41f pathology  174–175
leverage overchecks  38 mastication  80–82, 81f prognosis  175
lidocaine  320 materials treatment  175
light-activated resins (light-cured)  348–349 cast  363–366 myxosarcoma, malignant  174–175, 175f
lingual area  51 dental  345–368
lingual power stroke  72 endodontic  258–259, 353–359
lip impression  363–366, 363b
N
tattoos  190t restorative  258–259 Nannohippus,  78
trauma  115–116, 117f matrix  348 nanofilled composites  349–350
Liverpool driving bit  35f, 36, 38–39 maxillary bones  73 nanohybrid composites  349–350
local antibiotic administration (LAA) maxillary fractures  122–127 nasal conchae, distortion of  232
(perioceutics)  359–360, 360b, maxillary nerve block  241–242, 242f nasal endoscopy, tumors  152
361f maxillary osteoplastic flap  301, 304–305, nasal hemorrhage  115
loose cheeks  30f 335–336 nerve blocks of the head  241–244
loose ring snaffle  30–31 McAllen speculum  250–251, 269 infraorbital  242–243, 242f
loph basins  81–82 McKerron overcheck bit  36–38, 36f–37f mandibular  243, 243f
lophodont  70 McPherson type speculum  192, 248f, 250, maxillary  241–242, 242f
lophs  70 269 mental  243–244, 244f
luting agents  345 mechanical hackamore bitless bridle  40, 40f temporomandibular (TM) joint  244,
lymphosarcoma  178f, 179 Meister speculum  250–251 244f
melanoma  169–171, 169f–170f nerve supply of teeth  70–71
clinical features  169 no rinse (NR) (self-etch, self-priming)  346
M diagnostic confirmation  170 No34 gouge dental elevator  267–268
macrodontia  106 differential diagnosis  170 non-aneurysmal cystic lesions of bone  178
magnetic resonance imaging (MRI)  151–153, pathology  170 non-bonded amalgams  346b
151f, 199 prognosis  171 non-steroidal anti-inflammatory
Makita rechargeable battery powered treatment  170 medication  274–275
oscillating dental float  23f mental nerve block  243–244, 244f nosebands  40–41, 41f
mallets  258 mepivacaine  320–321 cavesson  40
malocclusion  289, 291 Merychippus  5f, 78 cheeker  41, 41f
altered wear causing tooth mesial  51 drop  40–41, 41f
movement  291–293 Mesohippus,  5f, 7, 78 Figure 8 (grackle)  40–41, 41f
class 3 (MAL3) see sow mouth methadone  241 Flash  40–41, 41f
classification  291 microdontia  106, 106f shadow roll  41, 41f
congenital or genetic  290 microfilled composites  349–350 number of teeth  5
documentation  293 microhybrid composites  349–350 numerical body condition score system  188,
eruptive  290 Mineral Trioxide Aggregate (MTA)  359, 370 188t
sequelae  291 mini-Shetland ponies, aging in  94t
traumatic  290 mirrors  251–252, 252f, 290f
type 2 (MAL2) see parrot mouth
O
mobile dental workstations  245, 246f–247f
mandible  71–72 molar cutters  257–258, 270 O ring snaffle  30–31, 35f
mandibular aneurysmal bone cyst  176–177, molar extractor  325–326, 326f–327f obstetrical wire  306
177f molar forceps  267–268 obturation materials  357–359
clinical features  176 molar occlusal surface area (OSA)  77 occlusal area  51
diagnosis  176 molar separators  325, 325f–326f occlusal pulpar exposure  135–137, 136f
differential diagnosis  176 molars  51 occlusal surface  64–65
pathology  177 Moller’s shears  17f change in  86, 86f
prognosis  177 monkey mouth see sow mouth odontoblast processes  53
treatment  177 mouthpieces  28–30 odontoblasts  53, 58, 58f
mandibular bar  119–120, 119f–120f copper  30 odontoclastic tooth resorption  106
mandibular fractures  122–127 danglers (‘keys’)  30 odontogenic tumors  149, 156–161, 157t,
caudal  126–127, 126f diameter  30 217–218
interdental space (diastema)  124–126, jointed or broken  28 odontoma  159–160, 160f, 217–218, 218f
124f–125f materials  30 clinical features  160
rostral  122–124, 122f–123f mullen  28–30 definition  159–160
mandibular interdental space  119–120, rollers (‘crickets’)  30 diagnostic confirmation  160
119f–120f sweet iron  30 differential diagnosis  160

407
 Index

incidental tumor-like dental masses  160– occurrence  173 periodontal elevators  325, 325f
161, 161f pathology  173 periodontal forceps  258f
occurrence  160 prognosis  173–174 periodontal materials  258–259, 359–363
pathology  160–161 treatment  173 periodontal splinting  360, 362f
prognosis  160 osteitis  161–162 periodontitis  133–134
treatment  160 osteoarthritis  378–379, 378f–379f, 383 Periogard  248
odontoplasty  261 osteoblastoma  218 perissodactyls  3
oligodontia  213, 214f osteogenic tumors  149, 161–163 peritubular dentine  88–90, 89f
O’Mara leverage overcheck bit  36f–37f, 38 osteoma  161, 218, 300 permanent dentition
omeprazile  297 osteomyelitis  132, 161–162, 270 displacement  266–267
ontogeny and wear  7, 7f–8f osteosarcoma  161–163, 162f, 218 normal radiographic anatomy  210–212
open diastemata  111 clinical features  161 pharyngeal ulcer  119
open mouth radiography definition  161 Phenacodus  78
diastemata  132, 133f diagnostic confirmation  162 phenylbutazone  307–308, 311
oral charting  195–196 differential diagnosis  161–162 phylogeny  3, 4f
oral irrigants  359 occurrence  161 physiological diastema  119–120, 119f–120f
periodontal irrigants  359 pathology  162–163 physiology  77–84
Oral Cleansing Gel  257 prognosis  163 pick  192–193, 193f, 257, 258f, 370
oral endoscopy  152, 193–195, 194f–195f treatment  163 pituitary adenoma see pituitary pars
oral environment, trauma and  115 overbite see parrot mouth intermedia dysfunction
oral examination  185–198 overcheck bits  36–38, 36f–37f pituitary pars intermedia dysfunction
equipment  247–248 Burch  36–38, 36f–37f (PPIDD/equine Cushing’s
tumors  152 Crabb  36–38, 36f–37f disease)  179, 179f
oral fibroma  172–173 Crit Davis  36–38, 36f–37f plain overcheck bit  36–38, 36f–37f
clinical features  173 Hutton  36f, 38 plaster of Paris  337
definition  172 leverage  38 plug  328–329, 331f, 338, 339f
diagnostic confirmation  173 McKerron  36–38, 36f–37f polyacid modified resin composites 
occurrence  172–173 O’Mara leverage  36f–37f, 38 349–350
pathology  173 plain  36–38, 36f–37f polycarboylate cements  345, 346b
prognosis  173 Raymond leverage  38 polydontia see supernumerary teeth
treatment  173 Speedway  36f polyether (PE) impression materials  365
oral hemangiosarcoma  175–176 overfloating of occlusal surface  295 polymer sealers  357–358
clinical features  175 overjet see parrot mouth polymethylmethacrylate (PMMA)  337, 363
diagnosis  175 overshot jaw see parrot mouth polyp  149
differential diagnosis  175 polysiloxane putty  337
pathology  175–176 polysulfide (PS) impression materials  365
P
prognosis  176 polyvinyl siloxane (PVS)  364f
treatment  176 packable composites  349–350 power equipment disk burr  269, 269f
oral irrigation equipment  248–249, 249f pain, post-dental-procedures and  274–275 power grinder  295, 296f
oral mucosa  73 palatal area  51 power instruments  254–259, 254f
oral papilloma  171, 171f palatoschisis see cleft palate PowerFloat  255, 256f
clinical features  171 papilloma, oral  149, 171, 171f predentine  59–60
diagnosis  171 paradontal disease  133–134 premaxillary (incisive) bone  73
differential diagnosis  171 Parahippus  6, 7f, 78 premaxillectomy  307–308, 307f–308f
pathology  171 parakeratinized mucosa  73 premolars  51
prognosis  171 paranasal sinuses extractions  323, 323f
treatment  171 anatomy of  212, 212f first see wolf teeth
oro-antral fistula  331, 338 empyema of-  231–232 probes  257, 258f
orodental masses  150f percussion of  232 prognathism see sow mouth
Orohippus,  78 surgery of  300–305 progressive ethmoidal hematoma  300, 302f
oromaxillary sinus fistula  311–314, parotitis, idiopathic  73 Prophy Air Abrasion Unit  258–259
312f–314f parrot mouth  99, 100f, 213f, 269–270, 272, Pseudohipparion  78
oronasal fistula  121, 331, 332f 273f, 289–291, 290f, 293–298 Pseudohipparion simpsoni  7
oropharynx, trauma  119, 119f in adult horses  297–298 pulp  59–61, 61f
orthodontic spring device  290f in foals (incisor overjet)  293–297, pulp cavities  60
orthodontics, basic equine  289–300 294f–298f pulp disorders  134–137
biomechanical  289 mandibular brachygnathism  293 pulp exposure, acute  369, 370f
ethics  299 orthodontic management  294 apical approach (apicectomy)  372–374,
functional  289 placement of orthodontic wires  296, 296f 372f–374f
preventative or interceptive  289 pathology  129–147 diagnosis  369–371
orthokeratinized mucosa  73 patient observation  188–189 management  370–371
oscillating saw  306, 306f, 309 Pelham bit  33–35, 34f occlusal  135–137, 136f
osseous sequestra, bit-induced  28 Pepgen P-15  362 oral approach  371–372
osseous tubercles  72–73 performance dentistry  261, 264–268 pulp horn  58, 58f
ossifying fibroma  173–174, 174f, 218 by feel  262, 262f pulp stones  135–137, 135f
clinical features  173 peridontal elevators  320, 320f pulpitis  60–61, 134–135
definition  173 periodontal disease  133–134, 217, 221 anachoretic  267
diagnostic confirmation  173 Periodontal Disease Index, equine  196 pulpodentinal complex  59

408
 Index

Q root fragment punch  327–328, 330f smooth mouth  63, 63f, 131–132, 131f,
root hypercementosis  106 279–280, 280f
quidding  111–112, 132, 143–144, 188–189 rostral positioning snaffle bits  29f, 30–32
of maxillary cheek teeth row  106 Dr Bristol  28
of upper CT rows  99–100 D-ring  27, 30–31
R rubber snaffle  99–100 egg butt  30–31
rabies  190 fixed ring  30–31
radiation therapy, tumors  155–156 French  28
radiography  199–201, 201b
S full-cheek  30–31
accessory equipment  200–201 salivary adenocarcinoma  176 half-cheek  30–31, 35f
cassette holders  200–201, 201f clinical features  176 loose ring  30–31
digital  23–24 diagnosis  176 O ring  30–31, 35f
equipment  199 differential diagnosis  176 sodium hypochlorite  354–355, 357, 373f
exposures  200–201, 200t pathology  175–176 soft palates  120–121, 120f
grids  200 prognosis  176 soft tissue retractors  251
imaging systems  200 treatment  176 soft-tissue tumors  149, 163–176, 163t
interpretation  212–221 salivary glands  73–74, 74f solid carbide float blade  23
abnormalities of development salivary tissue  121, 121f ‘sow mouth’  99–100, 100f, 213, 272, 291,
eruption  213–219 sandwich technique  352–353 298
dental disorders  213 sanitation  248 speculum (specula)  15–16, 249–251, 250f
paranasal sinus disorders  213 sarcoid  167–169, 168f Alumispec  250–251, 251f
sensitivity and specificity of clinical features  167 Butler  250
radiography  212–213 diagnosis  167 Capps full mouth  250, 250f
normal anatomy  208–212 differential diagnosis  167 Conrad  250–251, 269
deciduous dentition  208–210, pathology  167 Gunther screw-type  250, 250f
209f–210f prognosis  169 Haussmann  250
permanent dentition  210–212 treatment  167–169 McAllen  250–251, 269
patient preparation  200 Schouppe coil or spool  249–250 McPherson-type  192, 248f, 250, 269
projections  201–208 scintigraphy  199, 219–221, 220f–221f Meister  250–251
canines and wolf teeth  201–203 normal anatomy  220 Series 2000  250
cheek teeth  203–208 other skull lesions  221 Stubbs screw-type  250, 251f
incisors and canines  201, 202f periapical infection  220 Speedway overcheck bit  36f
introduction  201 temporomandibular joint (TMJ)  380–381, squamous cell carcinoma  163–166,
radiation safety  199–200 383f 164f–166f, 218, 219f, 233f
rostral mandibular fracture  123 secondary dentine  58 clinical features  164–165
scintigraphy  219–221, 220f–221f irregular  58 definition  163
techniques  199 regular  58 diagnostic confirmation  166
temporomandibular joint (TMJ)  380, secondary occlusal surface  64–65 differential diagnosis  165
381f sectional biopsy  152–153 occurrence  163
tumors  151–153 sedation  241, 245 pathology  166
X-ray machines  199 self-cured resins  346b, 349 prognosis  166
‘ramps’  99–100 senile diastemata  284–285, 285f treatment  166
Raymond leverage overcheck  38 septic arthritis  377–378 stablemasters  12–13
referral of complex cases  44 Series 2000 speculum  250 standardbred horses, aging in  94t
repulsion  332–341, 332f–333f sexual dimorphism  7–8 Staphylococcus aureus  188f
complications  339–341 shadow roll noseband  41, 41f methicillin-resistant (MRSA)  188
resin composite cement  345, 346b Sharpey’s fibers  61–63, 62f Steinmann pin  311, 311f, 327–328, 330f
resin modified glass ionomers  351–352 shear mouth  130–131, 130f, 269–270, 272, stellate reticulum  52–53
restorative dentistry  345–353 379 Stent bandage-  313–314
bases and liners  347 osteoarthritis  378–379, 378f–379f, 383 step mouth  106–108, 131, 269–270,
cavity preparation  346–347 septic arthritis  377–378 285–286, 285f
direct placements  345 sialoliths  121 stocks  21, 22f, 245, 246f
direct placmenet restorative side pull bitless bridle  40, 40f stone casts  293, 365f
materials  347–350 sidechecks  36–38 straight shanked pleasure horse bit  30f
laboratory-assisted (prosthodontics)  345 signal  27 strangles  73–74, 231
restorative materials  258–259 Simons mouth speculum  15, 16f Streptococcus spp.  231
restraint  185, 245, 280–281 sinocutaneous fistula  315–316, 315f Streptococcus equi var. equi  231, 377–378
retention of deciduous teeth  108–110 Sinohippus  3 Streptococcus zooepidemicus  378
cheek teeth  108, 110f sinoscopy  195, 233–235, 234f–237f stub (coupling) line  38, 38f
incisors  108, 108f–109f sinus empyema  270 Stubbs equine dental light  251, 251f
retrognathism  298 sinusitis Stubbs pneumatic powered oscillating
reverse crown  51 paranasal  231–232 floats  257f
Reynolds cap extractor forceps  257f, 267–268 primary  221, 221f Stubbs screw-type speculum  250, 251f
rhinoscopy  232, 232f–233f sinusotomy  300–305 styles  68
ridges (cingula, styles)  68 slab fractures  143 (sub)luxation  378
rollers (‘crickets’)  30 ‘slant mouth’  100, 281 supernumerary teeth  101–102, 213,
romifidine  200, 280–281 ‘slope mouth’  100, 281 214f
root elevators  327–328, 330f ‘smile’  99, 269–270, 272–273, 281, 282f apical infections secondary to  124

409
 Index

canine and 1st premolar teeth (wolf interdental space (diastema)  124–126, ultrasonography
teeth)  103 124f–125f temporomandibular joint (TMJ)  381–382
cheek teeth  103–105, 104f intra-oral injuries, management  tumors  151–152
incisors  102–103, 102f–103f 115–116 underbite see sow mouth
supplemental teeth  101 lips  115–116, 117f underjet see ‘sow mouth
surgery, tumors  154–155 mandibular  122–127 undershot jaw see sow mouth
diathermy  155 mandibular interdental space  119–120, unerupted (reverse) crown  51
laser surgery  154, 155f 119f–120f
sharp surgery  154 maxillary  122–127
sutures  306–308, 306f–307f, 338 oral environment and healing of oral V
sweet iron mouthpiece  30 injuries  115 valve diastema  111
Swissfloat  255, 256f oropharynx  119, 119f vertical buccotomy approach  341–343
swivel ported (correction) bit  30f, 31 rostral mandibular  122–124, complications  343
122f–123f vertical power stroke  72
salivary tissue  121, 121f vesicular stomatitis  190
T soft palates  120–121, 120f veterinarian/client relationship  43–44
tall teeth  269–270 temporomandibular articulation  122, visual dentisty  262, 262f
tatto  190, 190t 122f ‘vives’  13
team driving  38–39 tongue  116–119, 118f
99m
Technetium  199 treatment planning  195–196
teletherapy, tumors  156, 166–167 trephines  334f W
temporal teratoma  214, 216f galt  334, 334f
wave mouth  106–108, 131, 131f, 269–271,
temporomandibular articulation  122, triple trephine technique  329
286, 286f
122f Triadan classification  66, 66f
wear, abnormalities of  129–132
temporomandibular joint (TMJ)  79–80, triethylene glycol dimethacrylate
wedge biopsy  152–153
377–385 (TEGDMA)  349
white spot  88, 89f
analgesia  244, 244f Trucut (hollow needle) biopsy  152–153
wind sucking  67, 281–282
anatomy  377, 378f tuberculate supernumerary teeth  101
‘wisdom tooth’  69
diseases of  377–379 tumors, oral and dental  149–181
wolf teeth  13, 103, 265–266, 265f–266f
(sub)luxation  378 biopsy  151
anatomy  68
clinical examination  379–380 brachytherapy  156
blind (unerupted)  191, 265
computed tomography  382–383 chemotherapy  155–156
extractions  27, 322–323, 323f
diagnosis  379–383 classification  149, 150f
instruments  257
intra-articular anesthesia and cryosurgery  155
normal radiographic anatomy  210, 210f
arthrocentesis  380 diagnostic procedures  151–153
overcheck and  38
osteoarthritis  378–379, 378f–379f, differential diagnosis  154
radiographic projections  201–203
383 disorders of the jaws and teeth resembling
shedding of  15
radiography  380, 381f neoplasms  176–179
work location  245
scintigraphy  380–381, 383f homeopathy  156
wry nose (campylorrhinis lateralis)  100,
septic arthritis  377–378 immunotherapy  155
101f, 213, 269, 272, 289–291,
treatment  383–384 management, general principles  154
298–299, 299f, 301f, 308f
conservative  383 odontogenic  149, 156–161, 157t,
surgery  308–311, 309f–311f
surgical  383–384 217–218
ultrasonography  381–382 osteogenic  149, 161–163
function  377 other ‘treatments’  156 X
muscles of mastication and  72 other tumors that affect mouth and
jaws  179 xenografts  361–362
tension band wires  295
presenting signs  150 X-ray machines  199
teratoma, temporal  214, 216f
radiation therapy  155–156 xylazine  200, 280–281
tetanus toxoide  192f
Tolazoline hydrochloride  281 soft-tissue tumors  163–176, 163t
surgery  154–155
Tome’s process  53
teletherapy  156
Y
tongue, trauma of  116–119, 118f
traditional (hackamore) bitless bridle  39–40, Turner tooth  105 yohimbine  241
40f
transverse ridges  130
abnormal  271
U Z
trauma  115–127, 142, 218–219, 219f ulcer zinc oxide-eugenol (ZOE) cement  345, 347,
caudal mandible  126–127, 126f buccal  116f, 129–130, 130f 348b, 348f, 357–358
cheeks  115–116, 117f mandibular  119–120, 120f zinc phosphate (ZP) cements  345, 347
facial, management  115–122 mucosal  270 zygomatic arch  73
hard palate  120–121, 120f pharyngeal  119 zylazine  295

410