EQUINE VETERINARY JOURNAL
Equine vet. J. (2005) 37 (6) 505-509
Supernumerary cheek teeth (n = 24): clinical features,
diagnosis, treatment and outcome in 15 horses
G. C. QUINN, W. H. TREMAINE and J. G. LANE*
Department of Veterinary Clinical Science, University of Bristol, Langford House, Langford, Bristol BS40 5DU, UK.
Keywords: horse; cheek teeth; supernumerary; secondary sinusitis
Summary
Reasons for performing study: There are few reports of case
series of horses with supernumerary cheek teeth (SCT) that
document clinical findings, treatment and long-term outcome.
Objectives: To review the clinical and ancillary diagnostic
findings and responses to different treatments in horses
with SCT.
Methods: The case records of 15 horses were reviewed and
long-term outcomes obtained by telephone interview.
Results: Fifteen horses with a total of 24 SCT were identified.
Two SCT were incidental findings and were not treated.
Clinical signs were improved or resolved in 11 of 13 of the
teeth treated conservatively and all 6 treated by extraction
had a favourable outcome. Four horses were subjected to
euthanasia within a short period of diagnosis, either due to a
poor prognosis at the outset or failure to respond to initial
conservative treatment.
Conclusions: Some SCT are chance findings and do not cause
clinical signs. In those instances where clinical signs of dental
disease are mild, conservative treatment including the
management of diastema and reduction of overgrowths is
often effective. Horses with severe clinical signs attributable to
an SCT are likely to require extraction of the offending tooth.
Potential relevance: An SCT is an uncommon dental anomaly
but should be considered in the differential diagnosis of cases
with signs of severe dental disease. The preferred management
for SCT is very variable and determined by the severity of the
associated changes, but ranges from conservative measures
through forceps extraction per os to major facial flap surgery.
Introduction
Teeth additional to the normal dental formula are referred to as
supernumerary (Kokten et al. 2003). The prevalence of
supernumerary teeth in human population groups has been found
to be 0.1–3.6% (Pindborg 1970). Among horses, supernumerary
teeth are also uncommon, although true prevalence is unknown
(Rooney and Robertson 1996). Isolated cadaver studies and one
retrospective study of 400 horses with dental disease confirm low
prevalence within the equine population (Miles and Grigson 1990;
Dixon et al. 1999a).
In man, the majority of supernumerary teeth are considered to
*Author to whom correspondence should be addressed.
[Paper received for publication 22.09.04; Accepted 03.03.05]
505
develop as a horizontal proliferation or hyperactivity of the
permanent or deciduous lamina (Kokten et al. 2003). Alternative
theories include the suggestion that they may be formed from
division of the primordial germinal tissues or alveolar buds
(Eisenmenger and Zetner 1985), supported by in vitro experiments
on tooth germs (Pindborg 1970). It has also been conjectured that
trauma may be a factor in initiating division of tooth germs in the
horse and, additionally, that deformed or conjoined teeth may
result from the incomplete division of these primordial germ
tissues (Baker 1999).
Supernumerary teeth that have normal morphology are also
referred to as supplementary teeth (Pindborg 1970; Dixon et al.
1999a; Kokten et al. 2003). They are more frequently seen
caudal to the normal arcade and, in this position, are also
termed distomolars (Pindborg 1970; Dixon et al. 1999a; Kokten
et al. 2003).
In man and domestic species, such as the brachycephalic
dog, supernumerary teeth are more commonly located in the
incisor region (Pindborg 1970; Lane 1982; Eisenmenger and
Zetner 1985; Kokten et al. 2003). In the horse, clinical signs
attributed to supernumerary incisor teeth are rarely noted and
therefore treatment is not sought (Baker 1991; Dixon et al.
1999b; Baker 1999). In man and also in the horse, SCT in the
maxillary arcade are more prevalent when compared to the
mandible (Pindborg 1970; Miles and Grigson 1990; Baker 1999;
Dixon et al. 1999a; Kokten et al. 2003). In the horse, it is
unusual for SCT to afflict both mandibular and maxillary arcades
in the same animal (Miles and Grigson 1990; Dixon et al.
1999a). However, the disease frequently appears bilaterally
(Baker 1999; Dixon et al. 1999a).
SCT are sometimes detected as an incidental finding on a
routine dental examination and oral inspection (Mueller 1991;
Lane 1994; Lowder 1998). SCT are often associated with
nonspecific signs of dental disease, including oral phase
dysphagia, bit evasion behaviour, facial swelling and a
mucopurulent nasal discharge (Lane 1994; Hawkins and Dallap
1997; Dixon et al. 1999a; Knottenbelt 1999; Walesby and Miles
2002). As well as detecting additional teeth, a detailed oral
inspection may identify dental overgrowths, axial displacements
or the presence of a diastema, which can appear as a consequence
to malocclusion (Lane 1994; Dixon et al. 1999a; Carmalt 2003).
Subsequent impaction of ingesta within the diastema leads to
gingivitis and progressive periodontal disease (Dixon and
506 Supernumerary cheek teeth

TABLE 1: Summary of subject details, clinical findings, treatment and outcome of 15 horses with 24 supernumerary cheek teeth

Age Clinical signs

Case (years) Breed Sex (duration, months) Oral inspection Radiography Management Outcome

1 6 ID M BE (1) 112, 212 present; Presence of 112, 212 Mechanical reduction Returned to work
overgrowth, malocclusion of 112, 212
2 9 ID G UND, Dys (5) 112, 212 present Presence of 112, 212; SFF exploration, Returned to work, free
ST doming dorsal conservative management from clinical signs after
to 110–112 of 112 and 212 6 months
3 11 Hunter G UND (10) 212 present; Presence of 212; diastema, Conservative management Returned to work,
malocclusion, overgrowth overgrowth, domed ST density of 212 intermittent nasal
dorsal to 210–212 discharge
4 9 Hunter G UND (18) 112, 212 present; diastema FFL, diastema Crown reduction of 112; filling Returned to work,
of diastema site with dental occasional nasal
compound between 211 and 212 discharge
5 10 Hunter G BE, Dys (1) Overgrowth, malocclusion Presence of 112, 212 Mechanical crown reduction Returned to work
of 112 and 212 of 112 and 212
6 11 TB M UND (6) 112 present; diastema, Granular ST density SFF and sinus lavage; Died of unrelated causes
overgrowth, malocclusion dorsal to 111,112; crown reduction of 112
diastema between 111 and 112
7 16 ID M Dys (3) 212 present; overgrowth, Presence of 212; Attempted oral extraction of Deterioration of clinical
malocclusion, periodontitis domed ST density 212 under anaesthesia; signs. Euthanasia
over 210–212 conservative management
8 6 WB M BE (2) Axially displaced and rotated SCT adjacent to 111; Conservative management Euthanasia
SCT adjacent to overgrown domed ST density of 111 unsuccessful; oral
and maloccluding 111 dorsal to 110 and 111 extraction impracticable
9 8 CB G UND, Dys, 112 present; diastema Granular ST density dorsal Sinus lavage; Full recovery
BE (12) to 111,112, FFL; diastema oral extraction of 112
between 111 and 112
10 13 TB M UND (4) 112, 212 present Presence of 112, 212; Oral extraction of 212; Full recovery
FFL in left CMS/CFS; crown reduction of 112
diastema between 211 and 212
11 11 Shire M UND (2) 112, 212 present; Presence of 112, 212; Oral extraction of 212 Full recovery, no clinical
diastema proximal to 212 FFL on left; ST density signs associated with 112
dorsal to 211 and 212
12 8 TB G Facial swelling Occlusal defect, Deformed, misshapen 110; Maxillary sinus flap and Full recovery
(1) periodontal 2 adjacent conjoined SCT repulsion of 110; removal
pocketing 110 and ectopic dental fragments of adjacent SCT and
dental fragments
13 10 Hunter G UND (8) 112, 212 present; Generalised ST density Repulsion of 212 Required 2 further general
diastema proximal to 212 of paranasal sinuses; via frontal flap anaesthetics to manage
diastema between 211 and 212 under anaesthesia oro-antral fistula;
protracted recovery but
returned to work
14 5 TB M UND, Dys (3) SCT adjacent to displaced Supernumerary 108, Euthanasia NA
108; diastema between 109 and deformed 109,
110; overgrowth of 110 overgrown 110, impacted 111

15 7 TBx M UND (7), 112, 212 present; overgrowth, Presence of 112, 212; Euthanasia NA
obstructive malocclusion, periodontitis; amorphous ST density
dyspnoea diastema between 111 and 112 filling paranasal sinuses

ID = Irish Draught; TB = Thoroughbred; WB = Warmblood; CB = Cleveland Bay; M = mare; G = gelding. BE = bit evasion; UND = unilateral nasal discharge; Dys = Oral
phase dysphagia; ST = soft tissue; FFL = free fluid lines; SFF = standing frontal flap surgery; CMS = caudal maxillary sinus; CFS = conchofrontal sinus; NA = not applicable.

Brammer 1997; Dixon 1997; Dixon et al. 1999a). Extension of
disease into the paranasal sinuses can arise with a large diastema
and severe periodontal disease of the maxillary distomolars
(Dixon 1997; Dixon et al. 1999a). Whenever oro-antral
communication along a periodontal tract develops, clinical
findings may also include a foul-smelling, mucopurulent nasal
discharge (Lane 1994).
Conservative management of SCT may be employed when
clinical signs are mild, but there are limited reports documenting
the use of extraction techniques (Dixon and Brammer 1997;
Hawkins and Dallap 1997; Dixon et al. 1999a; Walesby and Miles
2002; Tremaine 2004). This report reviews the clinical findings,
treatment and outcome of 15 horses with a total of 24 SCT.
Materials and methods
The hospital records of 15 horses encountered with disorders
relating to SCT over an 8 year period were retrieved and the clinical
findings, treatments and outcomes reviewed. Further follow-up
information was obtained from the referring veterinary surgeon
and/or the owner/trainer of the horses by telephone interview.
Results
A total of 24 SCT were identified in 15 horses. A summary of the
subject details, clinical findings, management and outcome is
shown in Table 1.
G. C. Quinn et al.
Subject details
Median age at the time of presentation in this series was 9 years,
range 5–16 years. There were 8 mares and 7 geldings of mixed
breed distribution, but no ponies were represented.
Clinical signs
An ipsilateral nasal discharge was the most common presenting
sign (n = 10) with oral phase dysphagia (n = 5), bit evasion
behaviour (n = 3) and facial swelling (n = 2) additional clinical
signs observed. Although 8 horses were afflicted bilaterally with
distomolars, none showed a bilateral nasal discharge. A total of
6 teeth did not give rise to clinical signs.
Oral inspection
A detailed examination per os permitted identification of the
supernumerary tooth/teeth in all but one of the cases. The
exception was a horse (Case 12) with ectopic teeth adjacent to
Triadon 110 which had an obvious occlusal defect of the erupted
crown, but the extra teeth were not identified until radiographs
were obtained. There was a failure to identify an SCT on an initial
examination in one horse with a nasal discharge, but the diagnosis
was later confirmed when radiographs were reviewed.
Pocketing of ingesta within a diastema was seen with 10 teeth
in 8 horses. This included 2 horses where marked buccal
periodontal pocketing and painful gingivitis were also observed at
initial presentation.
Twenty of the 24 teeth described were distomolars positioned
caudal to 111/211. One horse had an abnormal tooth positioned
adjacent to 108 and in 2 further horses the teeth were positioned
adjacent to 110; in one case there were 2 ectopic teeth. In all
instances in this series, the SCT were located in the maxillary arcade.
Radiography
Ten horses had either a profuse purulent or an intermittent mucoid
nasal discharge on the side(s) affected, and erect radiographs
showed fluid lines within the paranasal sinuses (4 horses) and/or an
increased soft tissue opacity (Fig 1) overlying the apices of the
caudal 2 or 3 cheek teeth within the caudal maxillary sinus (n = 7).
Treatment
Two SCT did not give rise to clinical signs (Cases 11 and 13) and
no treatment was applied. Thirteen teeth were managed
conservatively without extraction (Cases 1–11, 13). Six teeth were
extracted, 3 with forceps per os (Cases 9–11) and 3 by repulsion
(Cases 12 and 13). Two horses were subjected to euthanasia
without treatment (Cases 14 and 15), in each case due to chronic
oro-antral fistulation associated with a large diastema adjacent to
the SCT that allowed the passage of ingesta into the maxillary
sinuses. Two additional horses (Cases 7 and 8) were subjected to
euthanasia a short period after diagnosis, when conservative
treatment had been unsuccessful. These horses showed marked
oral phase dysphagia with extensive gingivitis too sensitive to
allow standing extractions to be performed. They were
anaesthetised for forceps extraction per os, but it was not possible
to obtain sufficient mechanical purchase on the erupted SCT of
either horse. Despite reduction of the remaining overgrown
507
109
Fig 1: Radiographic 30° dorsolateral oblique projection of the right
maxillary arcade. Note area of heterogeneous ‘domed’ soft tissue opacity
over apex of 111 and 112 (arrow), interproximal diastema between 111 and
112, and malocclusion overgrowth of 112. The projection did not include
the entire arcade, and although tooth 106 is missing from the projection,
112 can be identified by counting from 109 as this can consistently be
identified as having the shortest reserve crown.
crowns, both were later destroyed due to deterioration of the
clinical signs after 4 and 6 weeks, respectively.
The conservative techniques applied consisted primarily of
regular attention to reduce dental overgrowths of the unopposed
teeth. In one horse (Case 4), a diastema was widened before the
placement of dental compound filling material. Four of the 6 horses
managed conservatively (Cases 2–4 and 6) were presented initially
with a mild to moderate purulent unilateral nasal discharge. The
treatments included broad-spectrum antibiotic therapy for 5 days
and, in 3 horses (Cases 2, 6 and 9), lavage of the paranasal sinuses
through an indwelling catheter; all experienced a significant
reduction or complete cessation of the nasal discharge.
Outcome
Five of 8 horses managed by conservative methods alone, returned
to their previous athletic activities and remained free of significant
clinical signs over a 12–40 month follow-up period. One horse
died from unrelated causes a short period after returning home, but
signs relating to the SCT had resolved. Two horses failed to
respond to conservative measures over a short period (Cases 7 and
8) - see above. The 3 horses subjected to standing oral extraction
of a single SCT made uneventful recoveries. Repulsion of 110 and
the removal of adjacent conjoined SCT, together with ectopic
dental fragments (Case 12; Fig 2) was performed through a
maxillary facial flap and led to an uneventful recovery. In another
horse (Case 13) where repulsion of 212 was achieved through a
frontal facial flap, 2 further surgical procedures were required to
manage complications associated with chronic oro-antral
fistulation before the horse returned to work.
Discussion
This report of 24 SCT in 15 horses provides the opportunity to
draw some conclusions about the diagnosis and management of an
unusual condition of horses. The possibility of an SCT might be
considered in horses exhibiting a persistent putrid nasal discharge,
oral phase dysphagia (‘quidding’) or abnormal resentment of bit
contact when ridden. The overgrowth of an unopposed tooth into
508
110
111
109
Fig 2: Reconstruction to illustrate the position of the conjoined
supernumerary cheek teeth adjacent to tooth 110 in Case 12.
the sensitive soft tissue of the buccal mucosa or gingivae would be
sufficient to explain the painful responses during eating, and/or to
contact with the cheek region when ridden. A putrid nasal
discharge is a nonspecific finding in suppurative disorders
afflicting the nasal chambers or paranasal sinuses and in horses
with SCT arises when infection has tracked from the oral cavity
apically to cause a secondary sinusitis.
The tools required to confirm or refute a diagnosis of SCT are
not complex and require no more than methodical and detailed
oral inspection and a similarly methodical radiographic survey of
the maxilla. No cases of mandibular SCT were documented in this
study and it is concluded that this is a very rare developmental
anomaly, thereby agreeing with previous reports (Miles and
Grigson 1990; Hawkins and Dallap 1997; Dixon et al. 1999a;
Walesby and Miles 2002). Conjoined supernumerary teeth were
identified in one horse (Case 12) and these, together with doubled
or deformed teeth, are cited in an earlier report as a frequent
morphological feature of SCT (Dixon et al. 1999a).
Median age of the horses at the time of presentation was
9 years. No ponies featured in the series and there was a relative
over-representation of mares compared to geldings. This was not
reflective of the local referral population for the hospital, which
has a mixed breed distribution with the predominant gender being
geldings. However, the numbers are too low to draw statistical
conclusions on any gender predisposition. A horse is unlikely to
show overt clinical signs attributable to an SCT until the tooth is
fully erupted and sufficient time has elapsed from eruption for
significant pathological changes to develop from dental
overgrowths or diastema, or for other sequelae to arise.
It seemed that a failure to reach an early diagnosis often
resulted from the lack of a methodical oral examination and/or an
incomplete radiographic survey of the entire dental arcade. In
addition to identifying additional teeth, oral inspection and
palpation frequently reveals dental overgrowths, axial
displacements or the presence of diastemata with impaction of
ingesta, gingivitis and periodontal disease (Mueller 1991; Lane
1994; Dixon and Brammer 1997; Lowder 1998; Dixon et al.
1999a). In this series of horses, radiography was also used to
illustrate dental overgrowths, dental malalignment and diastema.
Although not pathognomonic, the presence of a rounded opacity in
the floor of the maxillary sinuses, to some extent obscuring the
Supernumerary cheek teeth
111
Fig 3: Supernumerary tooth (arrow) positioned axial to the erupted crown
of 111 in Case 8.
dental apices of the caudal 2 or 3 cheek teeth, was a relatively
consistent finding with this diagnosis (Fig 3). This radiographic
feature was present in 7 of the 12 horses with maxillary distomolars
and one further horse with conjoined teeth axial to 110 (Fig 2).
There was generally an association with an obvious diastema,
suggesting that the opacity comprised a diffuse granulomatous
reaction in the floor of the CMS. It is conjectured that this
represents the response to the apical migration of ingesta within the
diastema and an attempt to ‘wall off’ contamination as it reached
the floor of the maxillary sinus. Two horses (Cases 2 and 6),
underwent exploratory frontal flap surgery which confirmed the
presence of a rounded, very firm, proliferative reaction overlying
the apices of the caudal cheek teeth corresponding to the densities
identified previously on radiographs.
The presence of supernumerary teeth can escape recognition
on lateral radiographs (Gibbs 1999) and can also be overlooked on
oblique views unless the entire complement of cheek teeth from a
single arcade is included on one film without superimposition of
the contralateral arcade. The authors recommend the use of the 4th
maxillary cheek tooth (Triadan 109, 209) as a landmark for
orientation when the entire arcade is not included on an individual
film; 109 and 209 are the first permanent cheek teeth to erupt and
have the shortest reserve crowns. When this tooth is used as the
reference point, the remaining teeth can be counted rostrally or
caudally (Fig 3).
Nonsurgical or conservative measures provided long-term
control of signs relating to 11 of the 24 teeth in this series and a
further 2 teeth were asymptomatic. Therefore, when clinical signs
are mild or SCT detected as an incidental finding, conservative
methods including reduction in height of overgrowths, dietary
modification or treatments directed at managing diastema are
indicated (Mueller 1991; Dixon and Brammer 1997; Lowder
1998; Dixon et al. 1999a; Dixon 2000).
When conservative methods have failed or clinical signs of
nasal discharge, dysphagia or bit evasion are severe, exodontic
techniques are indicated (Mueller 1991; Dixon and Brammer
1997; Dixon et al. 1999a). Oral extraction with forceps was
successful for 3 of the 5 teeth where it was attempted. However, it
is generally accepted that oral extraction should be attempted for
all equine cheek teeth before resorting to surgical methods of
extraction. Familiarity with the forceps technique improves
success (Tremaine 1997, 2004; Easley 1999; Lowder 1999).
Loosening of the periodontal attachments of maxillary
G. C. Quinn et al.
distomolars was found to be straightforward, but delivery of the
tooth into the mouth may be inhibited by the restricted space for
manipulation of the forceps, lack of patient compliance and
limited opening of the temporomandibular joint.
Repulsion of cheek teeth, particularly those lying more
caudally, has a high incidence of post operative complications
(Prichard et al. 1992; Lane 1994, 1997; Dixon and Brammer
1997; Lowder 1999; Dixon et al. 1999a; Easley 1999). The
surgical approach for repulsion of a distomolar is additionally
difficult and carries a significant risk of oro-antral fistula
formation (Dixon and Brammer 1997; Dixon et al. 1999a).
Treatment of an SCT located axial to the normal dentition can be
managed only on a case-by-case basis.
The radiographic appearance of ingesta within the caudal
maxillary and conchofrontal sinuses consists of a generalised
heterogeneous density. Such evidence of gross contamination was
taken to be a poor prognostic finding and led to euthanasia without
treatment in 2 horses. Had treatment been attempted, it would
have necessitated aggressive surgical management of the
secondary sinus infection and efficient closure of the oro-antral
fistula as well as extraction of the SCT itself. In the one horse
where this approach was used (Case 13), recovery was protracted.
SCT are an unusual finding in horses and, although this study
represents the largest case series documented to date, it remains
too small to draw statistical conclusions relating to the prevalence
of the disorder, or to indicate a single optimal method of
treatment. However, it has demonstrated that a successful outcome
may be achieved by measures ranging from conservative, through
oral extraction with forceps, to major invasive surgery, after
matching the management to the detailed oral findings and
radiographic features.
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