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Equine practice

A modern approach to equine dentistry

3. Imaging

Henry Tremaine

This article, the third in a series of four to review recent developments in

equine dentistry, describes the use of imaging to aid the diagnosis of dental
and oral lesions in horses, and provides a pictorial guide to features that
Henry Tremaine graduated from might be seen radiographically. Part 1, published in the January issue of
the Royal Veterinary College in In Practice (volume 34, pages 2-10), described the procedure for a routine
1989. He worked in mixed and dental examination in horses, while Part 2, published in the February issue
equine practice before undertaking (volume 34, pages 78-89), highlighted the common dental and oral lesions
an MPhil to study equine upper that may be seen in this species. Part 4 will consider the techniques available
respiratory tract diseases, and for the prevention and treatment of equine dental disease.
surgical training at Edinburgh
and Ohio State University. He
is currently a senior lecturer at
Bristol. He is a diplomate of the Ancillary diagnostic aids head, can cause complex radiographical superimposi-
European College of Veterinary tions that can be challenging to interpret.
Surgeons and an RCVS specialist The diagnosis of diseases afflicting equine dentition
in equine surgery. requires careful examination of the horse’s mouth
(see Part 1), but any features detected should be inter- Indications for radiography
preted in the light of historical information obtained
during the clinical workup. Imaging techniques can A radiographic examination should be performed
provide additional useful information to aid this whenever lesions involving endodontic or apical areas
diagnosis. For example, the clinical crown of hyp- of a tooth are suspected, including fractured teeth,
sodont teeth represents only a small proportion of the apical pulpitis, sinus disease, mandibular fractures or
tooth, with the larger component of each tooth being deep periodontal disease.
located subgingivally, so ancillary diagnostic aids
such as radi­ography are often necessary to appraise
any pathology affecting the apex of the tooth or Radiographic technique
endodontium.
Radiography is universally available in equine vet- The diagnostic sensitivity of radiographs relies on
erinary practice and the widespread use of digital and obtaining good quality, well-positioned images. Inter­
computed radiography has greatly improved the ease pretation of subtle pathology is impossible if radio­graphs
with which the general practitioner can obtain and are of inadequate quality. Diagnostic quality films can be
interpret dental radiographs. It is important to remem- obtained easily with modern intensifying screens and rel-
ber that the complex anatomy of hypsodont teeth, as atively basic x-ray generators, provided attention is paid
well as the many adjacent anatomical structures of the to appropriate restraint and precise positioning of the
horse and a good radiographic technique is employed.

Box 1: Radiation safety Restraint

Standard radiation safety protocols should be observed Horses are sensitive to objects and noise in close prox-
at all times when obtaining radiographs. This includes: imity to the head. Where possible, they should there-
■■ The use of adequate barrier protection for all staff fore be sedated to achieve good quality radiographs
in the x-ray room; and to make sure that radiation safety protocols are
■■ The provision of monitoring badges for regular adhered to (Box 1). A horse’s tolerance to imaging
users; can be improved further by ensuring the procedure is
■■ Limiting access to the room during radiographic
carried out in a tranquil environment where noise and
examinations;
■■ Correct collimation of equipment to ensure staff movement is kept to a minimum with low-level light-
are not exposed to the primary beam; ing, a non-slip floor, and the use of blinkers and ear
■■ A good technique to avoid the need to repeat plugs (eg, cotton wool). The number of people present
views unnecessarily. during radiographical examination should also be
Careful adherence to high standards at all times restricted to only those absolutely necessary to carry
doi:10.1136/inp.e1344 will enhance the value of the service provided to clients
Provenance: Commissioned out the procedure safely, and the area should be kept
and will help to achieve consistent results.
and peer-reviewed free of other animals (eg, noisy small dogs).

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Equine practice

Exposure
Examples of exposure factors for traditional wet films
are listed in Table 1. However, these are only a guide
and the technique should be perfected for each individ-
ual generator/screen combination to enable standard
techniques to be used thereafter. This is particularly
important for computed or digital radiography sys-
tems for which post-processing algorithms should
be adjusted in collaboration with the technicians, as
advised by the manufacturer to obtain good quality
images consistently. Such digital systems enable con-
siderably more post-processing than traditional films,
a feature that makes them tolerant of a degree of vari-
ability in technique. Computed radiography systems
have a greater range of post-processing capability than
most digital systems, although the latter may offer
slightly increased latitude.

Standard radiographic projections

Standard projections useful for the radiography of equine

dentition are illustrated on page 117. Descriptions of
Fig 1: When undertaking projections vary somewhat between texts, but standard
radiography, movement
artefacts can be reduced Movement radiographic nomenclature is used here.
by using a stand to support Film quality is commonly adversely affected by move-
the horse’s head during the ment artefacts, which can occur if the cassette is not Projections for imaging incisor lesions
procedure
supported on an immobile stand or if the horse sways Lateral, intraoral and ventrodorsal projections should
during the radiographic procedure. The cassette be used to image the mandibular incisors, while dorso­
should therefore be held in a rigid or semi-immobile ventral views are more suitable for examining premax-
stand (additional support can be provided by an assist- illary incisors. These views are achieved by advancing
ant as necessary), and the head of the horse should the corner of a cassette into the horse’s mouth, with its
be supported using a custom-made head stand, den- head supported and the beam aimed perpendicularly.
tal head stand or stool, which will reduce movement A sedated horse will usually grip the cassette between
considerably (Fig 1). the incisors, but others may require the use of a radio­
lucent speculum, although these often cause more
Positioning masticatory movement.
Despite the latitude and tolerance of digital radi­
ography systems, precise positioning contributes Projections for imaging premolars,
greatly to achieving diagnostic quality films every time. molars and paranasal sinuses
Placement of the screen, collimation and a standard- Latero-lateral (often abbreviated to lateral) projec-
ised tube–screen distance should be used consistently tions are required to image the premolars, molars and
in order for the radiographic techniques calculated paranasal sinuses (Fig 2). This is achieved by aiming
for each system to produce good results. Tube–screen the beam horizontally, with the cassette perpendicu-
distances of 70 to 100 cm are common and the use lar and collimation adjusted to include all the cheek
of a measuring stick for the distance chosen is helpful teeth and the paranasal sinuses. Optimal exposure
to ensure accuracy. Alternatively, the distance can be may vary to radiographically display the radiodense
checked using the generator’s intrinsic tape measure. dentition and radiolucent structures of the paranasal
Laser distance monitors are somewhat confusing and sinuses. Rostrocaudal angulation should be minimised
for consistency should only be used to set the distance for consistent results. This projection is the best for
to the cassette and not to the surface of the target revealing fluid menisci in the paranasal sinuses and, as
tissue, which can vary considerably in thickness. parallax artefact is minimised, correlating the position
of markers to the adjacent tooth. The beam should be
centred on the rostral aspect of the facial crest.
Table 1: Wet-film exposure factors for
radiography of equine dentition
Latero-45° ventral-lateral oblique
Region Projection kV mAS
projections
Incisors and Intraoral 50-55 5-6 The latero-45° ventral-lateral oblique projection (Fig
canines
3) will skyline the mandibular apices on the side adja-
Maxillary apices Lateral/lateral 55-66 6-8 cent to the screen. The precise angle may vary slightly
oblique
between breeds and in young horses with long reserve
Mandibular Lateral/lateral 65-70 6-8 crowns. The mandibular teeth have two roots and ros-
apices oblique
trocaudal angulation is best avoided. To achieve this,
Other projections Dorsoventral 68-75 8-10 the x-ray tube should be rotated to be parallel to the
kV Kilovolts, mAS milliampseconds long axis of the head and the collimator adjusted to

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Equine practice

achieve a 45° angle. The cassette should remain paral- adjacent to the cassette. While it is easier to achieve
lel to the masseter muscle (ie, vertical) and the beam consistent results with the beam at 90° to the long axis
must be centred ventrally to project onto the cassette of the head, the convex curved array of the maxillary
after collimation. The use of a speculum to open the arcade means that some rostrocaudal angulation can
mouth and separate the upper and lower arcades be introduced to optimise imaging different teeth and
can reduce superimposition and improve diagnostic to reduce superimposition of the three roots. Some
ability. authors angle the beam parallel with the interproximal
space between the individual teeth of interest. This can
Latero-30° dorsal-lateral oblique be estimated by draping a tape over the horse’s maxilla
projections on the target side at the level of the tooth of interest
The latero-30° dorsal-lateral oblique projection (Fig 4) and adjusting the rostrocaudal angle of this so that the
enables imaging of the apices of the maxillary arcade incident beam is parallel with the tape.

Fig 3: Latero-45° ventral

open-mouthed oblique
Fig 2: Latero-lateral (lateral) projection projection Fig 4: Latero-30° dorsal projection

Fig 6: Dorsoventral displaced projection

Fig 5: Dorsoventral projection (with the mandible displaced laterally)

Fig 7: Latero-15° ventral open-mouthed Fig 8: Latero-10° dorsal open-mouthed

oblique projection oblique projection

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Equine practice

Fig 10: Non-screen film suitable for intraoral imaging

ately cut non-screen film (Fig 10) placed in the horse’s

mouth. They are most useful for imaging the apex of
individual maxillary teeth. The beam is positioned
using the bisecting angle technique (Fig 11). However,
the availability of computed tomography and its
greater ease of use may supercede this technique.

Fig 9: Sedated horse with its mouth held open using a

Butler’s speculum to facilitate open-mouthed imaging
Normal radiological features

Dorsoventral projections In order to detect pathological radiographic changes

Dorsoventral views (Fig 5) were previously considered on images with a degree of confidence, it is important
supplementary but they are now part of the standard to have a detailed understanding of normal equine
series of projections that should be taken as routine. dental anatomy. Radiological interpretation of images
The mandibles of a well-sedated horse should be rested of the head can be challenging due to the complex
on the cassette (supported on a stool, head stand or superimposition of many different structures of vari-
bucky system) to direct the beam vertically and there- able radiographic density. This is further compounded
fore symmetrically. The beam is centred on the sagit- by the fact that extremely dynamic physiological proc-
tal plane at the level of the medial ocular canthi, and esses continue to take place as a result of developmen-
angled to incident perpendicularly to the cassette. This tal change.
projection can be modified by displacing the mandi-
ble away from the side of interest using some tape or
bandage, which removes some of the superimposition Physiological trends
of the mandibular and maxillary dentition of the side
of interest (Fig 6). Eruption of dentition and replacement
The dorsoventral projection is particularly useful of deciduous dentition
for revealing radio-opacities in the ventral conchal Horses are born with incompletely erupted dentition
sinus, imaging fracture planes on fractured teeth and and during the first few months of life the deciduous
highlighting extensive periodontal changes. incisors and premolars erupt and come into wear. The
ages at which these teeth erupt are shown in Table 2,
Open-mouthed oblique projections but it should be noted that there is considerable vari-
Open-mouthed oblique (occlusal) views (Figs 7, 8) are ation between horse and pony breeds, and also indi-
used for imaging the clinical crowns and revealing viduals within a breed. Permanent dentition begins
the radiological consequences of diastemata in cases as embryonic dental sacs, which become mineralised
of periodontal disease. The mouth of a sedated horse as they mature, first by the deposition of enamel by
should be held open with a Butler’s speculum (Fig 9) ameloblasts on the inside of the enamel epithelium
and the beam angled at 10 to 15° dorsal or ventral to and cementum on the outside, and subsequently by the
the horizontal to skyline the arcade being examined. deposition of dentine by odontoblasts on the external
Computed and digital radiography have greatly periphery of the pulp. This is an ongoing process and
Fig 11: Diagram showing the enhanced radiographic sensitivity, and correct tech- the embryonic tooth continues to grow at the api-
bisecting angle technique. niques combined with precise accurate position- cal end, resulting in a gradual increase in length that
Blue = screen/film,
Red = incident x-ray beam, ing should yield diagnostic films in both the field or continues for approximately two years after dental
Green thick line = axis of hospital setting. eruption.
the tooth to be projected, Exfoliation of the superficial deciduous remnants
Green oblique line =
Intraoral films or caps is stimulated by eruption of the underlying,
bisecting angle.
The beam is perpendicular Intraoral films can be obtained in heavily sedated maturing permanent dentition. At a given time, the
to the bisecting angle horses using a specially made cassette and appropri- arcade will contain teeth of differing maturity, result-

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Equine practice

Table 2: Approximate ages of eruption Pathological response to dental

of the equine dentition disease
Tooth Deciduous Permanent
1st incisor <1 week 2·5 years
Dental tissues have limited regenerative potential and
therefore the response of these tissues to insult is also
2nd incisor 4 to 6 weeks 3·5 years
limited. In the case of enamel, which has no reparative
3rd incisor 6 to 9 months 4·5 years potential, demineralisation in the face of inflamma-
Canine 4 to 5 years tory mediators (eg, with caries) results in radiographic
Wolf tooth 5 to 6 months lysis, a change that lags behind the changes affecting
1st cheek tooth Birth to 2 weeks 2·5 years less dense tissues.
Cementum will also undergo lysis in the face of
2nd cheek tooth Birth to 2 weeks 3 years
enzymes produced by cariotic bacteria. In addition,
3rd cheek tooth Birth to 2 weeks 4 years
under certain stimuli such as chronic infection, up-
4th cheek tooth 9 to 12 months regulation of cementoblasts occurs resulting in hyper-
5th cheek tooth 2 years cementosis or cementoma formation. The converse is
6th cheek tooth 3·5 to 4 years true in cases with equine osteoclastic tooth resorp-
tion and hypercementosis (EOTRH) syndrome, an
incompletely understood and only recently described
ing in variable appearance radiographically. Hence, disease that results in osteoclastic demineralisation of
knowledge of the age of the horse, particularly up to the dentition commencing apically and at the gingival
five years of age, is essential when interpreting dental sulcus.
radiographs. It should be noted that these physiologi- Dentine is produced throughout a horse’s life, not
cal processes normally occur symmetrically on the left only for the reparation of defects (as is the case with
and right arcades simultaneously. brachydonts) but also to maintain the secondary den-
tine bridge that separates sensitive dental pulp from
Immature and growing teeth a contaminated oral cavity. Dentine is able to react
During the development of a tooth, common pulp quicker than other mineralised tissues and will under-
eventually divides into multiple pulp horns apically go lysis and demineralisation as a result of caries, pulp
and the apex divides into separate ‘roots’, numbering necrosis and along fracture lines. These changes can
a single one in incisors and canines, two in mandibu- be detected on radiographs.
lar teeth and three or, occasionally, four in maxillary
cheek teeth. In developing teeth, the roots have a wide Response of surrounding tissues
apical foramen, allowing access of the afferent neuro­ Alveolar bone is metabolically dynamic and so tends to
vascular bundle, and the roots are incompletely min- respond to pathological challenge more quickly than
eralised with an apparent lucent halo surrounding the the teeth. Demineralisation (seen radiographically as
recently deposited enamel and dentine. The lamina lysis) occurs adjacent to nidi of infection or fractures,
dura denta in these teeth is well demarcated and the or as a result of a loss of vascularity or exposure to lytic
radiolucent zone of the alveolar bone that surrounds inflammatory mediators in the oral cavity (eg, in cases
the roots should not be misdiagnosed as pathologi- of alveolar bone plate lysis in horses with periodontal
cal lysis. As a tooth approaches its mature length, the disease). In contrast, increased mineralisation (seen
demand for vascularity is reduced according to the radiographically as sclerosis) occurs more peripherally
reduced metabolic demand for dentine production. In to infected or necrotic nidi (eg, sequestra) and around
addition, as odontoblasts of the root secrete dentine fracture calluses.
circumferentially around themselves, a narrow apical
foramen forms and remains just patent enough for the Neoplastic changes
residual pulpar vasculature. At this stage, the roots Tumours affecting dentition are rare, but proliferative
become more pointed in appearance and are easily ameloblastomas, odontomas and compound odonto-
distinguished on radiographs. mas have been reported (see Part 2). These may develop
rapidly, exceeding the rate at which hydroxyapatite can
Hypsodonty be laid down, resulting in a demineralised appearance
Hypsodont teeth have enamel that extends deep to on radiography. Tumours of the periodontal bone, such
the gum line and, in the case of horses (in contrast to as ossifying fibromas, can have disorganised prolifera-
rodents and lagomorphs), the teeth cease to grow one tion of the bone and fibrous tissue, which is sometimes
to two years after eruption. Thereafter, they continue incompletely mineralised. Structures referred to as
to erupt to replace tissue lost from the occlusal surface ‘cementomas’ are usually non-neoplastic and hyper-
by masticatory attrition. This mechanism is driven by cementosis is a more accurate term. Periodontal soft-
contraction and reforming of Sharpey’s fibres of the tissue tumours, such as squamous carcinomas, are
periodontal ligament, a collagenous structure originat- aggressive and produce mediators that accelerate rapid
ing in the hard lamina dura denta of the alveolar bone demineralisation of surrounding bone.
and inserting into the peripheral cementum. Although
the control mechanisms are incompletely understood,
this mechanism appears to be independent of pulp via- Examples of dental radiographs showing
bility and, consequently, non-vital teeth can continue these and other physiological features and
pathological changes are illustrated in Box 2
to erupt. Hypsodonty results in a gradual decrease in
on pages 120 to 127.
the length of the reserve crown as a tooth ages.

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Box 2: Examples of dental radiographs illustrating physiological features and pathological changes

Fig 12: Latero-lateral radiograph showing the long Fig 13: Latero-30° dorsal-lateral oblique inverted radiograph of the hemimandible of a
curved reserve crowns of the canine teeth with four-year-old horse showing indiscrete roots with wide apical foramina (arrow), which
calculus on the crown of one tooth (arrows) is typical of animals of this age

Fig 14: (left) Dorsoventral

radiograph of a clinically normal
horse showing the symmetrical
nasal septum, and normal
symmetry and superimposition of
upper and lower dental arcades.
Fig 15: (right) Radiograph taken
from a three-year-old horse
showing normal dental apices
of developing teeth with a
non-mineralised apical area
delineated by the lamina dura
denta of the maxillary bone and
wide apical foramina (arrows)
to allow vascularisation of pulp
to supply the highly active
odontoblasts.
(Picture, Miriam Casey)

Fig 16: Radiograph of the hemimandible of a 13-year-old horse

showing the well-defined narrow roots (arrows) at the apex of the Fig 17: Radiograph showing the narrowed apical foramen of the
teeth which are no longer growing, resulting in an apical foramen multiple roots (arrows), increased mineralisation of alveolar bone
of reduced diameter. (Picture, Miriam Casey) and short clinical crowns of a geriatric horse

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Box 2 continued

Fig 19: Intraoral radiograph

Fig 18: Lateral radiograph of the incisors and rostral of the mandibular incisors
dentition of a three-month-old foal. In addition to showing displacement of
the obvious Class II malocclusion (‘parrot mouth’, the left corner incisor 303 at
see Part 2), there is malocclusion of the rostral the corner of the mandibular
premolars –06s, indicating a congenital deformity bone as a result of an
originating caudal to the interdental space. This avulsion fracture (arrows).
had consequences for subsequent orthodontic This has also resulted in
treatment deviation of the canine 404

Fig 20: Intraoral radiograph showing remodelling

and hypercementosis around the apices of the
incisors in an aged horse. Such changes can be Fig 21: Intraoral radiograph showing the incisors of a
due to equine osteoclastic tooth resorption and horse with maleruption of 303 (arrows), possibly due
hypercementosis (EOTRH) or chronic periodontitis to trauma pre-eruption. Such abnormalities may have
that has extended to the dental apex a cosmetic effect but are often clinically asymptomatic

Fig 22: Latero-45° ventral-lateral oblique radiograph taken from a

five-year-old horse with a unilateral mandibular swelling. The image Fig 23: Latero-30° dorsal-lateral oblique radiograph taken from
shows a lucent halo (arrows) around the rostral and caudal roots of a nine-year-old horse that presented with a mildly painful left
307, with some thickening and irregularity of the lamina dura denta. maxillary swelling. The image shows a focal area of maxillary bone
The caudal root shows dentinal lysis. These changes are indicative of lysis (arrows) around the caudal root of 207, which is indicative of
apical pulpitis maxillary apical pulpitis

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Equine practice

Box 2 continued

Fig 25: Magnified image of

a radiograph taken from a
horse with pulpitis of 307,
A B
showing alveolar bone
Fig 24: (a) Latero-30° dorsal-lateral oblique radiograph showing a radio-opaque marker placed over a left lysis (arrows) around the
maxillary swelling. The image reveals lysis around the caudal root of 207, indicating pulpitis. (b) Magnified image caudal root in the ventral
showing the changes to the caudal apex (arrows) and surrounding alveolar bone of the tooth from the same horse mandible

Fig 26: (a) Normal left latero-45° ventral-lateral

oblique radiograph taken from a four-year-
old horse showing the apical areas of the left
mandibular arcade. The ventral mandible is thinned
due to expansion of the dental apex. The third and
fourth premolars have wide apical foramina. There
is a region of radiolucent bone around the dental
roots corresponding to the periodontium.
(b) Radiograph from the same horse showing the
corresponding projection of the right arcade. Note
the areas of increased lucency around 107 and
108 (arrows), which represents sclerosis of the
alveolar bone plate between these teeth. These
features are indicative of altered metabolism of the
interproximal bone in response to an insult. There
is also undulation of the peripheral enamel on the
rostral root of 108, which is strongly suggestive of
impaction due to a physically obstructed eruption
pathway.
(c) Dorsoventral radiograph from the same horse
showing increased radio-opacity on the axial aspect
of the mandible (arrows) indicating a medially
displaced 108 causing modelling of the mandibular
cortex, which is further suggestive of eruption
C obstruction

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Box 2 continued

Fig 27: (left) Radiograph of the

right ventral mandible of a horse,
showing premolar 307, which
is erupting at an inappropriate
angle. The coronal aspect of
the tooth is abutting against
the adjacent tooth resulting
in impaction and eruption
impedance. There is sclerosis at
the apex resulting in sclerosis of
the periradicular alveolar bone
and a concertina appearance of
the peripheral enamel (arrows).
Fig 28: (right) Latero-20° dorsal
lateral open-mouthed oblique
(occlusal) radiograph taken from
a horse wearing an aluminium
speculum. A valve diastema of
significant width is clearly visible
between teeth 409 and 410
(arrows)

Fig 30: Open-mouthed

Fig 29: Open-mouthed oblique radiograph taken oblique radiograph of
from an eight-year-old horse showing a narrow the mandibular dentition
valve-type diastema between 409 and 410 and coronally of a six-year-old
an open diastema between 410 and 411 (arrows). horse showing lysis of the
Although these radiographic changes are not alveolar bone plate (arrows),
marked, such lesions have the potential to trap food which is associated with
leading to severe periodontal food pocketing and chronic periodontitis in a
gingivitis, resulting in dysmastication due to pain valve-type diastema

Fig 31: (a) Latero-lateral

radiograph of the maxillary
dentition and paranasal sinuses
of a horse, showing increased
soft-tissue radio-opacity in the
rostral and caudal maxillary
sinuses, and a fluid meniscus in
the dorsal conchal sinus (arrows),
which is indicative of fluid
exudates within the sinuses.
(b) Displaced dorsoventral
radiograph from the same horse
showing a parasagittal fracture
of maxillary tooth 209 (arrows),
which is permitting oroantral
communication that may allow
inoculation of the sinuses with
A oral bacteria B

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Box 2 continued

209

A B

Fig 32: (a) Latero-30° dorsal-lateral oblique radiograph showing the maxillary dentition of a five-year-old horse with open apical foramina
typical of animals of this age when growth of the apex is ongoing. There is incomplete mineralisation of the dentine of the dental roots, thus
indicating dental immaturity. There is increased sclerosis around the apex of the 1st molar (4th cheek tooth) 109. This tooth also has a wider
area of lysis around the caudal roots (arrows). These findings are strongly suggestive of apical pulpitis (abscessation) resulting in secondary
dental sinusitis. (b) Radiograph of the left maxillary arcade of the same horse. Similar pathological changes are visible afflicting tooth 209,
indicating an atypical bilateral dental apical pulpitis, although the left side was clinically asymptomatic of sinus involvement

109

Fig 33: (a) Latero-30° dorsal-lateral oblique radiograph of the maxillary dentition
of a horse in its teens. The image shows advanced caries of 109, with destruction
of the dental architecture and marked sclerosis of the alveolar bone. (b) Displaced
dorsoventral radiograph taken from the same horse showing a parasagittal fracture
of 109, which is possibly a pathological fracture associated with the caries B

Fig 34: (a) Right latero-

30° dorsal-lateral oblique
radiograph showing dentinal
lysis of 109, shortening of the
roots and marked sclerosis of
the alveolar bone around this
tooth. There is also uneven
occlusal wear resulting in mild
‘wave mouth’ (see Part 2).
These signs are all suggestive
of caries of the tooth.
(b) Displaced dorsoventral
radiograph from the same
horse showing a distracted
mandible to the left with
marked lysis of 109 (arrow) due
to caries, which is secondary to
a sagittal fracture with some
buccal displacement of the
lateral fragment. This intra-oral
projection of the incisors shows
maleruption of 303, possibly
due to trauma pre-eruption.
Such abnormalities may have
a cosmetic effect but are often
A B
clinically asymptomatic

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Box 2 continued

A B

Fig 35: (a) Latero-15° dorsal lateral oblique (occlusal) radiograph

clearly showing a wide valve-shaped diastemata between 408
and 409 (arrow) associated with profound periodontitis after
treatment by diastema widening.
(b) The same projection of the left mandibular arcade reveals more
advanced periodontal pathology secondary to food impaction in
the diastema. There is some resorption of the alveolar bone plate
coronally with a zone of sclerosis (arrow) surrounding the lamina
dura denta.
(c) Latero-45°ventral lateral oblique radiograph showing a discharging
tract (highlighted by a radiopaque marker) communicating with
the peridontium of a diseased tooth. This advanced degree of
periodontitis is usually non-reversible, with clinical signs only
improving after extraction of the afflicted tooth

Fig 37: Inverted, open-mouthed

radiograph taken from a horse that
presented with signs of oral dysphagia
(quidding) and halitosis. Oral
A B
examination revealed the presence of
Fig 36: (a) Latero-30° dorsal lateral oblique radiograph of an aged pony showing a a maxillary supernumerary molar. This
circumscribed radio-opaque oval lesion (arrows) overlying the maxillary cheek teeth. feature is often overlooked on an oral
The radiological differential diagnoses would be a very chronic sinus empyema examination, but is clearly visible on
associated with maxillary dental disease, a sinus cyst or a tumour. this latero-30° dorsal lateral oblique
(b) Inverted oblique view from the same horse to skyline (lesion orientated oblique radiograph. Such pathology is often
projection) a loculated expansile lesion typical of a cyst or a tumour seen bilaterally

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Equine practice

Box 2 continued

Fig 38: Radiograph from a horse that experienced

unilateral swelling of the mandible after routine
periodontal treatment. The image shows diffuse
heterogenous radio-opacity of the mandibular
ramus (arrows) with a sclerotic heterogenous B
appearance. Biopsy and subsequent histopathology
confirmed it to be an ameloblastoma, which may Fig 39: (a) Transverse computed tomogram from
have caused oral pain not distinguishable from an aged Shetland pony with marked facial swelling,
periodontal pain. (Picture, K. O’Brien) showing distinct expansion of the maxillary bone
with a homogenous radio-opacity below the bone
within the rostral maxillary sinus and ventral conchal
sinuses plus lysis of the dental alveolus over 108.
Computed tomography revealed greater three-
dimensional detail of the structures deep within the
skull by avoiding the anatomical superimposition
that is a feature on radiographs. Such techniques
are invaluable when planning treatment.
(b) Frontal plane section of the same bone showing
an extensive destructive expansile lesion with
displacement of the nasal septum.
(c) Three-dimensional-reconstruction of the raw
computed tomography data from the previous
radiograph of the bone showing the destructive
bone lesion, which was confirmed to be a tumour.
(d) Lateral radiograph from the same pony. A well-
circumscribed heterogenous radio-opacity is visible
overlying the apices of the maxillary cheek teeth on
the left side

Further reading
BUTLER, J. A., COLLES, C.,
DYSON, S., KOLD, S. E. &
POULOS, P. W. (2000) The head.
In Clinical Radiology of the
Horse, 2nd edn. Blackwell.
pp 327-403
GIBBS, C. (1999) Dental
imaging. In Equine Dentistry,
2nd edn. Eds G. J. Baker and
J. Easley. pp 171- 202
STASZYK, C., BIENERT, A.,
KREUTZER, R., WOLSHEIN, P.
& SIMHOFER, H. (2008) Equine
odontoclastic tooth resorption
and hypercementosis. Veterinary
Journal 178, 372-379
WEAVER, M. & BARAKZAI,
S. Z. (2010) Handbook of Equine
Radiography and Radiology.
C D Saunders
WELLER, R., LIVESEY,
L., MAIRL, J., KNUSS, K.,
Summary and digital systems, while good anatomical knowledge BOWEN, E., CAUVIN, E.,
WEAVER, M., SCHUMACHER,
and a study of the radiological consequences of pathol-
J. & MAY, S. (2001) Comparison
Dental imaging is an essential ancillary aid to oral ogy will ensure accurate interpretation. Additional
of radiography and scintigraphy
examination for the diagnosis of equine dental disease. techniques, such as nuclear scintigraphy and com- in the diagnosis of dental
A sound technique and patience can produce high- puted tomography, can provide further information in disorders in the horse. Equine
quality images in the field using traditional, computed treatment planning. Veterinary Journal 33, 49-58

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A modern approach to equine dentistry 3.

Imaging

Henry Tremaine

In Practice 2012 34: 114-127

doi: 10.1136/inp.e1344

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