Computed tomography of the upper cheek teeth in horses with infundibular changes and apical infection

Reasons for performing study: Infundibular changes are frequently encountered computed tomographic studies of the equine maxillary cheek teeth but the possible importance of this finding is not known. Infundibular caries is a possible cause for pulpitis and apical infection in some horses. Objectives: To study the relationship between the 2 pathologies and the frequency of changes. Methods: The maxillary cheek teeth 108‐ 208 , 109–209 and 110–210 of 25 horses were evaluated using computed tomography and both the prevalence of infundibular and apical infection changes as the possible link with apical infection evaluated statistically. Results: The prevalence of infundibular changes was high in both normal and diseased teeth. Both apical infection and the occurrence of infundibular changes were more prevalent in 109–209 and 110–210. In spite of this, the 2 processes could not be linked to one another. No differences were noted between the left and right sides. Conclusions: A direct relationship between the 2 processes was not established statistically and other underlying causes for the high occurrence of both apical infection and infundibular changes in diseased and normal 108‐ 208 , 109–209 and 110210 are considered.     

Extraction of 22 equine cheek teeth with displaced sagittal fractures using polymethylmethacrylate stabilisation (2011–2016)

Displaced sagittal cheek tooth fractures are a cause of oral pain, quidding and apical infection. Intraoral extraction is the preferred technique to remove affected teeth, but can be difficult due to displaced and friable fracture fragments. Stabilising fracture fragments via filling of the fracture space with polymethymethacrylate (PMMA) prior to removal may be a useful method to facilitate intraoral extraction. Case details were examined retrospectively. A total of 22 cheek teeth required extraction in 20 horses because of displaced sagittal fractures. Clinical diagnoses were made using oral examination, oral endoscopy, skull radiography and computed tomography. All procedures were performed in standing, sedated horses in stocks. Fracture spaces were cleaned and packed with PMMA and teeth removed using a routine intraoral extraction technique. Digital photographs of extracted teeth were taken and tooth measurements calibrated using digital image software. Intraoperative difficulties, as well as post-operative complications were recorded. A total of 21 maxillary and one mandibular cheek teeth were extracted. All maxillary teeth had advanced infundibular caries. Intraoral extraction was successful in 16 cases; six were unsuccessful and required repulsion due to tooth fragmentation or abnormal dental anatomy. In 11 cases, maxillary or conchofrontal sinus trephination was performed to either treat sinusitis, repulse the tooth, or both. Two horses developed short-term complications following local anaesthesia of the maxillary nerve. The mean ratio of fracture depth to tooth length was 0.59 and mean ratio of fracture width to tooth width 0.53. The limitations of the study are its small sample size, retrospective nature and lack of control group to compare extraction success in PMMA and non-PMMA groups. It was concluded that using PMMA to stabilise displaced sagittal fractures in equine cheek teeth is a simple, effective method of facilitating intraoral extraction and may reduce the need for more invasive procedures.     

Equine idiopathic cheek teeth fractures: part 3: a hospital-based survey of 68 referred horses (1999-2005)

REASONS FOR PERFORMING STUDY: There is limited information available on the more serious sequellae of idiopathic cheek teeth (CT) fractures. OBJECTIVES: To obtain information on clinical and ancillary diagnostic findings in referred horses with idiopathic CT fractures. METHODS: Details of all horses suffering from idiopathic CT fractures referred to the Equine Hospital at the University of Edinburgh 1999-2005 were examined, and information concerning fracture patterns, clinical and ancillary diagnostic findings, treatments and long-term response to treatments were obtained and analysed. RESULTS: A total of 60 maxillary and 17 mandibular idiopathic CT fractures were diagnosed in 68 horses. Fracture patterns included maxillary CT lateral slab fractures (45%), maxillary CT midline sagittal fractures (16%) and various other patterns of maxillary CT fractures (17%). In the mandibular CT, lateral slab fractures were found (12%) and various other CT fracture patterns were present in 10%. The more centrally positioned CT (maxillary and mandibular Triadan 08s and 09) were preferentially fractured. Clinical signs included quidding in 47% of cases; bitting and behavioural problems (28%); signs of apical infection, including bony swellings and nasal discharge (21%); anorexia/weight loss (15%); halitosis (13%); and buccal food impaction (12%). The treatment of all cases was conservative whenever possible and included corrective rasping of the remaining tooth (46% of cases); oral extraction of the smaller and loose dental fragment (32%) and extraction of the entire fractured tooth by oral extraction (28%) or by repulsion (13%). Prophylactic treatment of adjacent, nonfractured CT with carious infundibula was possibly of value in preventing further midline sagittal maxillary CT fractures. CONCLUSIONS: Horses referred with idiopathic CT fractures frequently have clinical signs of apical infection of the fractured CT and these teeth require extraction, orally if possible. More conservative treatment of idiopathic CT fractures without signs of gross apical infection can resolve clinical signs in most cases. POTENTIAL RELEVANCE: In the absence of apical infection, extraction of only the loose dental fragments of CT with idiopathic fractures is usually successful.     

Dental diastemata and periodontal disease secondary to axially rotated maxillary cheek teeth in three horses

Malerupted axially rotated maxillary cheek teeth (CT) were identified as the primary cause of diastemata and severe periodontitis in 3 horses. Diastema widening and periodontal debridement was performed initially in one case but did not resolve clinical signs. Subsequently, all 3 cases underwent extraction of the axially rotated teeth per os without complication. Follow‐up indicated remission of periodontitis and signs of oral pain. In these cases, maxillary CT had erupted in a manner that resulted in axial rotation of CT with undulating buccal and palatal surfaces aligned with the interproximal surfaces of adjacent normally orientated teeth. This resulted in poor interproximal compression and diastemata causing severe periodontitis. Axially rotated maxillary CT and the severe periodontitis that they precipitate, have not been previously described as a discrete dental disease entity.     

A long-term study of apicoectomy and endodontic treatment of apically infected cheek teeth in 12 horses

The aim of this study was to evaluate the long-term results of apicoectomy and retrograde endodontic treatment in 12 horses with apical cheek teeth infections. The affected apices were removed using a diamond bur mounted on a dental drill, and after pulp removal the root canals were filed with Hedstrøm files and then alternately flushed with sodium hypochlorite, hydrogen peroxide and alcohol. The pulp canals were dried and filled with endodontic cement and gutta-percha points. An undercut was made in the apical aspect of the root canals that were then sealed with self-curing glass ionomer cement.Follow up information was obtained 38–67 months following treatment and indicated that the treatment had been successful in 7/12 horses (58%), partially successful in 2 horses (17%) and unsuccessful in 3 (25%). With good case selection, apicoectomy can preserve a proportion of apically infected cheek teeth. The use of advanced imaging techniques and improved surgical techniques could increase the success rate.     

A post-mortem study on the prevalence of peripheral dental caries in Scottish horses

Peripheral caries (PC) is an increasingly recognised equine dental disorder with unknown predisposing factors that differs from the well described maxillary cheek teeth infundibular caries. Advanced PC can lead to premature wear and fracture of cheek teeth and thus is of welfare importance. Recent studies have shown large variation in the prevalence of PC in different European countries, with a trend towards a greatly increasing prevalence. One hundred and one equine heads sourced from a Scottish rendering plant were examined for the presence and grade of PC using the modified Honma equine dental caries grading system. The presence of cheek teeth calculus, diastemata and fractures was also recorded. Peripheral caries was present in 91% of horses; only affected the cheek teeth and was predominantly (72.6%) Grade 1 Class 1 (localised pitting lesions only affecting cementum). The caudal three cheek teeth were more commonly affected (74.7% prevalence) as compared to the rostral three cheek teeth (32.1% prevalence). The palatal aspect of maxillary and the buccal aspect of mandibular cheek teeth were significantly (245% and 170%, respectively) more commonly affected by PC than the opposite sides. Female horses were more commonly affected than males. Because post-mortem examination allows the most detailed oral examination to be performed, this may partly explain the higher PC prevalence found in the current, as compared to previous studies, in addition to the particular population examined in this study.     

Maxillary odontogenic myxoma in young horses: Six cases (2003–2011)

Six young horses presented with a rapidly expanding maxillary mass with concurrent nasal discharge. All horses had a nonpainful firm unilateral facial swelling centred over the maxillary sinuses, accompanied by mucopurulent nasal discharge. Diagnostic imaging revealed an infiltrative nasomaxillary mass with cheek tooth involvement, diagnosed as odontogenic myxoma. The tooth involvement included missing, malformed and/or displaced dental precursors or unerupted teeth. Due to the rapid expansion and extent of the masses, and the poor prognosis reported for surgical excision, euthanasia was recommended and performed in all cases. Macroscopically, a soft oedematous tissue with a grey to green colour was seen in the regions of missing, malformed or displaced dental precursors or unerupted teeth. Histologically, this tissue consisted of spindle shaped cells surrounded by an abundant homogenous pale stroma, rich in acid mucopolysaccharides. Immunohistochemistry was positive for actin and the mesenchymal marker vimentin. The cheek tooth involvement identified in the described cases resembled what is previously reported in odontogenic myxoma in children and young adults. Even in man, maxillary odontogenic myxoma represents a therapeutic challenge due to the invasiveness of the lesions and radical surgical excision is recommended. Treatment is further complicated by sinonasal involvement. Surgery was not attempted in the cases presented here due to the extent of the lesions and the risk of recurrence. Clinicians should be aware of this rare condition when presented with young horses with sinonasal neoplasia.     

Repulsion of maxillary and mandibular cheek teeth in standing horses

Objective: To report the technique and results of cheek teeth repulsion in standing, sedated horses. Study Design: Case series. Animals: Horses (n=12), ponies (6). Methods: Medical records (2006–2009) of horses that had cheek tooth repulsion while standing were reviewed. Inclusion criteria included: maxillary or mandibular cheek tooth disease diagnosed by clinical and radiographic examination where attempted oral extraction failed necessitating repulsion. Horses were sedated and a local nerve block performed. Intraoperative radiographs facilitated instrument positioning and ensured repulsion of all dental remnants. Alveolar cavities were packed postoperatively and secondary dental sinusitis treated with lavage. Results: Median horse age was 7 years (range, 1–30 years). Maxillary (n=15) and mandibular (5) cheek teeth were removed successfully. One horse was euthanatized 1 week after tooth removal because of concurrent liver disease and 10 horses (59%) had resolution of discharge after the 1st treatment; 41% of extractions required follow‐up medical or surgical treatment to resolve signs [6/12 maxillary sinusitis and 1/5 persistent mandibular drainage]. Conclusions: Standing repulsion of diseased and fractured cheek teeth is an effective means of resolving clinical signs of dental disease when oral extraction fails. Chronic sinus involvement increased the risk of postextraction surgical treatment for sinusitis.     

Equine idiopathic cheek teeth fractures: part 2: a practice-based survey of 147 affected horses in Britain and Ireland

REASONS FOR PERFORMING STUDY: There is limited information on the prevalence of idiopathic cheek teeth (CT) fractures in the general equine population and on which CT are most commonly affected. OBJECTIVES: To obtain information on the prevalence of fracture patterns and clinical details of idiopathic CT fractures. METHODS: Details of cases with idiopathic CT fractures encountered were obtained via a questionnaire sent to suitably experienced veterinary practitioners and equine dental technicians (EDTs). RESULTS: Details of 147 horses that suffered a total of 182 idiopathic CT fractures; and median 0.4% (range 0.07-5.9%) of horses examined were diagnosed with such fractures; 133 maxillary CT and 49 mandibular CT fractures were found; maxillary Triadan 09s and 10s were preferentially fractured (46% of all fractured CT); fracture patterns included maxillary CT slab fractures (through 1st and 2nd pulp chambers) in 87 teeth (48% of all fractured CT), maxillary CT midline sagittal fractures (through the infundibula) in 31 CT; and various other types of maxillary CT fractures in 15 CT. In the mandibular CT, lateral slab fractures (through the 4th and 5th pulp chambers) were found in 28 CT and a variety of other fracture patterns in the other 21 mandibular CT. Clinical signs included quidding in 33% of cases, bitting and behavioural problems (29%) and halitosis (12%), however 39% of horses with idiopathic CT fractures were asymptomatic. Treatments included oral extraction of the smaller dental fragment in 37% of cases, extraction of the entire fractured tooth (9%); removal of sharp edges on the remaining part of fractured tooth (14%); reduction of height of the opposite tooth (4%); other surgical or endodontic treatments, or referral of case for further investigation and treatment (10%); or no specific treatment (39%). Following treatment, 81% of cases were reported to be asymptomatic, 6% had ongoing clinical problems and the outcome was unclear in 13% of cases. CONCLUSIONS: Idiopathic CT fractures are present in approximately 0.4% of horses and may variably cause none to severe clinical signs. Most idiopathic CT fractures respond well to treatment. POTENTIAL RELEVANCE: Understanding of the prevalence, clinical findings and treatment of idiopathic CT fractures will improve management of these disorders.     

Equine dental disease part 4: a long-term study of 400 cases: apical infections of cheek teeth

Of 400 horses referred because of equine dental disease, 162 suffered from primary apical infections of their cheek teeth (CT), including 92 with maxillary CT infections and 70 with mandibular CT infections. Maxillary swellings and sinus tracts were more common (82 and 26% incidence, respectively) with infections of the rostral 3 maxillary CT, than with infections of the caudal 3 maxillary CT (39 and 5% incidence, respectively). Nasal discharge was more commonly present with caudal (95%) than rostral (23%) maxillary CT infections. Mandibular CT apical infections commonly had mandibular swellings (91%) and mandibular sinus tracts (59%) and these infections were closely related to eruption of the affected CT. A variety of treatments, including medical treatment, apical curettage, repulsion and oral extraction of affected teeth were utilised in these cases, with oral extraction appearing to be most satisfactory. Infections of caudal maxillary CT with a secondary paranasal sinusitis were most refractory to treatment, with a complete response to the initial treatment achieved in just 33% of these cases. Most other cases responded fully to their initial treatment. The long-term response to treatment was good in most cases.     

Equine idiopathic cheek teeth fractures. Part 1: Pathological studies on 35 fractured cheek teeth

REASONS FOR PERFORMING STUDY: There is little published information on the pathology of idiopathic fractures of cheek teeth (CT). OBJECTIVES: To perform pathological examinations on equine CT with idiopathic fractures in order to establish fracture patterns and to gain information on their aetiopathogenesis. HYPOTHESIS: Gross and histological examination of CT with idiopathic fractures, including measurements of dentinal thickness, will provide information on fracture patterns, and on the duration and aetiopathogenesis of these fractures. METHODS: Of 35 CT with idiopathic fractures that were examined to determine their fracture patterns, 20 underwent gross, histological and ultrastructural examinations, including dentinal thickness measurements, with the latter compared to dentinal measurements of dental age and Triadan position matched control CT, to help determine the duration of any pre-existing endodontic disease. RESULTS: The fracture planes involved the pulp chambers in 30 out of 35 CT examined, and ran through coalesced, carious infundibula in the other 5 (maxillary) CT. The maxillary CT, particularly the Triadan 09 position were preferentially affected. The most common fracture plane, which was termed a maxillary buccal slab fracture, occurred through the 2 lateral (1st and 2nd) pulp chambers of maxillary CT and usually involved only the clinical crown. Buccal slab fractures of mandibular CT (through 4th and 5th pulp chambers) and midline sagittal fractures through the infundibula (of maxillary CT) were the next most common fracture patterns. Reduced dentinal thickness (probably indicating prior pathological changes in the fractured CT) was present in 25% of fractured CT. CONCLUSIONS: Most idiopathic equine CT fractures involve the pulp chambers, especially those on the buccal aspect of both upper and lower CT. No predisposition to fracture was found in the majority of affected CT that appeared to have a normal endodontic appearance prior to development of fractures through their pulp chambers. The remaining idiopathic CT fractures were caused by advanced infundibular caries. POTENTIAL RELEVANCE: All CT with idiopathic fractures are all at risk of pulpar or even apical infection.     

Post mortem survey of peripheral dental caries in 510 Swedish horses

Reasons for performing study: Peripheral caries (PC) of equine teeth is a poorly described disorder that can cause serious clinical problems if it progresses. Objectives: To assess the prevalence, sites and severity of PC in a population of Swedish horses. Methods: A post mortem study of 510 equine skulls was performed in 2 Swedish equine abattoirs. Results: PC only affected the cheek teeth (CT) and was present in 6.1% (31/510) of skulls. It affected mainly the peripheral cementum, and 87% of PC in the 29 affected mature horses occurred in the 3 caudal CT (Triadan 09‐11). Concurrent infundibular caries involving most maxillary CT (mean 9.7/skull) was present in 32% of skulls affected with PC. Trotting horses (mean age 8.1 years) believed to be on a high concentrate and silage diet were preferentially affected with PC in this population. Food was usually tightly adherent to the PC lesions and this feature may have promoted the progression of the disease. Significantly increased levels of diastemata were present in PC‐affected horses, and periodontal disease was present in areas adjacent to some PC lesions. Conclusions: PC is a relatively common disorder of horses under certain management conditions that can progress to cause serious dental disorders, especially if concurrent, widespread infundibular caries is present. Potential relevance: Equine clinicians should be aware of this significant dental disorder and research into its aetiopathogenesis, possible prevention and treatment are required.     

The prevalence of secondary dentinal lesions in cheek teeth from horses with clinical signs of pulpitis compared to controls

Reasons for performing study: With the advent of detailed oral examination in horses using dental mirrors and rigid endoscopy, secondary dentinal lesions are observed more frequently. More information regarding the association of secondary dentinal defects with apical dental disease would improve the sensitivity of oral examination as a diagnostic aid for pulpitis. Objectives: To assess prevalence and severity of secondary dentinal defects observed on examination of occlusal surfaces of cheek teeth (CT) from horses showing clinical signs of pulpitis compared to asymptomatic controls. Methods: Records from all cases of equine CT exodontia at the University of Bristol over a 4 year period were examined. Case selection criteria included the presence of clinical signs of pulpitis, an intact extracted tooth and availability of a complete history and follow up. Cases where coronal fracture or periodontal pocketing featured were excluded. CT from cadavers with no history of dental disease served as normal controls. Triadan positions and eruption ages of control teeth were matched with those of teeth extracted from cases. CT from selected cases and control teeth were examined occlusally. Secondary dentinal defects were identified and graded. Prevalence of occlusal lesions in CT with pulpitis and controls was compared. Results: From the records of 120 horses where exodontia was performed, 40 cases matched selection criteria. Twenty‐three mandibular and 21 maxillary CT were extracted from cases. The controls consisted of 60 mandibular and 60 maxillary CT from 7 cadaver skulls. Secondary dentinal defects were significantly over‐represented in CT extracted from cases of pulpitis (P<0.001). Of diseased mandibular CT, 56.5% had defects compared to none of the controls. Of diseased maxillary CT, 57% had defects compared with 1.6% of controls. Multiple defective secondary dentinal areas and severe lesions were more prevalent in diseased mandibular CT compared with diseased maxillary CT. Conclusions and practical significance: Careful examination of occlusal secondary dentine is an essential component in investigation of suspected pulpitis in equine CT.     

Equine dental disease part 2: a long-term study of 400 cases: disorders of development and eruption and variations in position of the cheek teeth

Of 400 referred horses with dental disorders, 349 cases suffered from primary disorders of their cheek teeth, ninety of these from disorders of development or eruption, or displacements. These included 20 cases with rostral maxillary and caudal mandibular cheek teeth overgrowths, 16 with diastemata, 15 with grossly enlarged mandibular 'eruption cysts', 4 with grossly enlarged maxillary cheek teeth 'eruption cysts', 10 cases with supernumerary cheek teeth and 23 cases with displaced cheek teeth. These displacements were believed to be developmental in 16 cases and acquired in the remaining 7 cases. Long-term response to treatments, that included removal of overgrowths and extraction of teeth with deep secondary periodontal disease was excellent for most disorders except diastemata.     

Periapical curettage: an alternative surgical approach to infected mandibular cheek teeth in horses

OBJECTIVE: To evaluate an alternative surgical method for treating periapical infection of the mandibular cheek teeth of horses. DESIGN: Retrospective study. ANIMALS: Eleven horses (3-13 years) with periapical mandibular tooth infection. METHODS: Hospital records (1992-2002) of horses that had periapical curettage for the treatment of mandibular cheek tooth root infection were retrieved. Clinical signs, radiographic, and surgical reports were reviewed. Outcome was obtained by telephone questionnaire for 7 horses and by physical examination in 2. RESULTS: Eleven horses (14 infected mandibular molariform teeth) had periapical curettage. Two horses were lost to follow-up. Mean follow-up was 41 months; 2 horses had subsequent tooth repulsion, 7 (78%) horses healed completely although 2 horses still had some local mandibular swelling. CONCLUSION: Periapical curettage, which allows alveolar drainage, appears to be a viable treatment option for periapical infections of equine mandibular cheek teeth. CLINICAL RELEVANCE: Periapical curettage can be performed simply, without expensive imaging or surgical equipment, and thus is useful for both referral and first opinion practice.     

The use of oral endoscopy for detection of cheek teeth abnormalities in 300 horses

The main objective of this study was to evaluate an endoscopic examination protocol for routine dental examination in horses. The oral cavities of 300 standing, sedated horses were examined under field and hospital conditions with a rigid endoscope using a standardised technique that included examination of the occlusal, lingual (palatal) and buccal surfaces of all cheek teeth rows. The most common cheek teeth abnormalities detected were sharp enamel edges (present in 96.3% of horses), focal overgrowths (64.3%), fissure fractures (54.3%), diastemata (24.3%) and infundibular hypoplasia/caries (48.3%). Rigid endoscopy of the equine oral cavity was found to be a safe non-invasive diagnostic technique that appeared to be superior to clinical oral examination for detecting subtle cheek teeth changes.     

Donkey dental anatomy. Part 1: Gross and computed axial tomography examinations

Post-mortem examination of 19 donkey skulls showed that donkeys have a greater degree of anisognathia (27% width difference between upper and lower jaws) compared to horses (23%). Teeth (n=108) were collected from 14 skulls and examined grossly and by computed axial tomography (CAT). A greater degree of peripheral enamel infolding was found in mandibular cheek teeth (CT) compared to maxillary CT (P<0.001). A significant increase in peripheral cementum from the apical region to the clinical crown was demonstrated in all CT (P<0.0001). All donkey CT had at least five pulp cavities with six pulp cavities present in the 06s and 11s. A new endodontic numbering system for equid CT has been proposed. A greater occlusal depth of secondary dentine (mm) was present in older donkeys (>16 years) than in the younger (<15 years) donkeys studied. Based on gross and CAT examinations, donkey dental anatomy was shown to be largely similar to that described in horses.     

CT FEATURES OF ALVEOLITIS AND SINUSITIS IN HORSES

Sinusitis is a common disorder in horses and may result from trauma, dental diseases, or space-occupying lesions. Radiography can only provide a limited amount of information. Computed tomography (CT) has been documented as an alternative imaging method. Eighteen horses (mostly Warmblood) with signs of chronic sinusitis were examined preoperatively with CT to assist in diagnosis of the underlying cause. There was a group of common CT features in horses with dental disease and sinusitis. The first molar was the most frequently affected maxillary cheek tooth. Hypoattenuation of the cementum, destruction of the enamel, and filling of the infundibular cavity with gas were the most frequent CT findings associated with caries. Gas bubbles within the bulging root area or fragmentation of the root in combination with swelling of the adjacent sinus lining were the most important CT features of dental decay. CT findings associated with sinusitis included excessive thickening of the respiratory epithelium in the rostral maxillary sinus; the caudal maxillary sinus was less often involved. The infraorbital canal, the nasomaxillary duct, and the frontomaxillary aperture were usually involved. The maxillary bone, however, especially the facial crest, was involved in nearly every horse, being characterized by endosteal sclerosis, thickening, periosteal reaction, and deformation leading to facial swelling in chronic infections. CT images allowed identification of involvement of individual teeth more clearly to reveal the diseased one for treatment. Three-dimensional imaging allowed improved understanding of the extent and severity of the pathologic change.     

Removal of 11 Incompletely Erupted,Impacted Cheek Teeth in 10 Horses using a Dental Alveolar Transcortical Osteotomy and Buccotomy Approach

Objective: To describe surgical technique and outcome in 10 horses with impacted cheek teeth that were removed by a transcortical osteotomy and buccotomy technique. Study Design: Case series. Animals: Horses (n=10) with impacted cheek teeth. Methods: Medical records (2002–2008) of horses with impacted cheek teeth requiring removal were reviewed; surgical technique and outcome were determined. Results: Exodontia of 11 cheek teeth was performed surgically in 10 horses; 3 horses had complications (residual swelling of the mandible) that resolved and all horses returned to their previous use. Conclusions: Transcortical buccotomy technique is effective for removal of incompletely erupted impacted cheek teeth in horses and has a good long‐term prognosis for remission of clinical signs. Clinical Relevance: Transcortical buccotomy approach is an effective technique for removal of unerupted impacted equine cheek teeth.