BACK TO BASICS: DENTISTRY FUNDAMENTALS


man pin for saline lavage. One month later the LeD30RtVO view (E) was obtained prior to extrac- tion of 109. There was an increase in the apical alveolar bone lysis and fluid within the right RMS (arrow), as well as fluid lines (small arrow) and a patchy fluid density within the CMS (arrow head). The 109 was orally extracted, and the right maxil- lary sinuses were lavaged via trephination of the right conchofrontal sinus. The patient continued previously prescribed systemic enrofloxacin treat- ment for 4 weeks, and the referring veterinarian followed this with ceftiofur for 1 month. The right nasal discharge persisted and radiographs were ob- tained by the referring veterinarian that demon- strated a larger area of right paranasal sinus involvement. In the DV view (F), there is fluid density of both the right and left RMS, the right CMS, as well as the right VCS. Oral examination revealed normal healing of the 109 and 209 extrac- tion sites. The horse was referred for a computed tomography (CT) study, which ruled out further dental pathology and identified bilateral rostral maxillary sinusitis with sinusitis also involving the right CMS and right dorsal and VCSs. The multi- planar reconstructions at the level of the distal as- pect of the 109 alveolus (G). Note the location of the dorsal and VCSs in the sagittal slice; in standard DV radiographs of the skull these structures are superimposed, especially with medial distention of the VCS toward the midline. A dental etiology for the bilateral sinusitis in this case could not be iden- tified with CT. The sinusitis was treated surgically with large frontal sinus flaps and endoscopic laser fenestration of the VCS to establish adequate drain- age into the nasal passages.


Case 5 (Fig. 5)


An 8-year-old Thoroughbred mare presented with a history of amucopurulent right nasal discharge with a fetid odor of 1 week’s duration. Oral examination was unremarkable. Rhinoscopy revealed only muco- purulent drainage from the right nasomaxillary ori- fice. In the lateral view (A), note the fluid opacity within the RMS, fluid line within the CMS (white arrowhead) and the multiple fluid lines within the dorsal nasal conchal bulla (arrows). The bulla of the maxillary septum is thickened and caudally displaced (black arrowhead). The bulla of the maxillary sep- tum, formerly referred to as the bulla of the VCS, is the thin bony and domed continuation of the maxillary septum over the shared sinus compartment of the ros- tral maxillary sinus and the VCS dorsal to the infraor- bital canal.2 In the DV view (B), the bulla of the maxillary septum appears as a cystic structure of rather uniform fluid density (black arrow) that has enlarged to fill most of the right CMS. In the initial LeD30RtVO view (C) there was overlapping of the right maxillary fourth premolar (108) and the first molar (109), with an area of possible apical alve- olar sclerosis. However, in a second view with a slight caudo-rostral angulation of the central


X-ray beam (D), this overlap was eliminated and the apical anatomy of 108 and 109 appeared nor- mal. Fluid lines are present within the right dor- sal nasal conchal bulla (DNB, white arrows), right CMS (white arrowheads), and caudal aspect of the bulla of the maxillary septum (black arrowheads). Comparison with the RtD30LeVO view (E) in which the left DNB is free of fluid; thickened caudal aspect of the bulla of the right maxillary septum (black arrowhead) has rotated to amore ventral position in this projection. The diagnosis was primary right maxillary sinusitis with right nasal bulla empyema. Treatment was surgical debridement via a frontona- sal flap. Elevation of the flap revealed a small vol- ume of fluid in the CMS and marked enlargement of the bulla of the maxillary septum bulging into the CMS as viewed through the frontomaxillary fora- men (F, white arrowheads); ethmoid turbinates (ETH). Removal of the dorsal aspect of the bulla of the maxillary septum revealed inspissated pus within the RMS and the VCS.


4. Discussion


With the evolution of portable digital radiography systems it is possible for general practitioners to obtain diagnostic quality dental radiographs in the field. The indications for obtaining dental radio- graphs and positioning of the X-ray generator and sensor for standard radiographic views has been previously described.1,3 While the signs of dental disease are generally not difficult to evaluate in incisors, canine teeth and mandibular cheek teeth, the maxillary cheek teeth have 3 roots which are not readily isolated and the paradental sinus anatomy is complex, variable and often difficult to evaluate with standard radiographic projections. The author rec- ommends doing a minimum of 6 standard views for maxillary cheek teeth, as this often provides a com- parison of right and left sides. A DV, lateral, and right and left D30V and V50D lateral obliques are recommended. For the V50D lateral oblique views, a speculum or bite block is used to hold the mouth wide open. This permits imaging of the apices of the maxillary cheek teeth (as well as the apices of the mandibular cheek teeth on the ipsilateral side). Consistency in positioning for the radiographs im- proves the clinician’s ability to recognize abnormal anatomy and identify radiographic signs of dental and sinus disease. Radiographic signs of apical infection of the max-


illary cheek teeth are blunting of the root apices, periapical alveolar bone lysis (apical halo), widening of the periodontal ligament space and sclerosis of the apical alveolar bone. The clinician must be aware that radiographic signs of apical infection may lag behind the occurrence of other clinical signs, such as facial swelling, and unilateral nasal discharge. Radiography complements, but does not replace a thorough oral examination and rhinoscopy. Addi- tionally, it has been well documented that CT is significantly more sensitive than digital radiogra-


AAEP PROCEEDINGS  Vol. 65  2019 433


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