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Equine Orthodontics
Jack Easley, DVM, MS, Diplomate ABVP (Equine)

Author’s address: PO Box 1075, Shelbyville, KY 40065; E-mail: [email protected].

Take Home Message

The principles of orthodontic tooth movement and manipulation of jaw growth and
development can be utilized in equine dental practice. A technique to improve or even
correct the serious malocclusion of parrot mouth (overjet and possibly overbite) in foals
utilizing maxillary retention wires combined with a fixed acrylic and aluminum bite
plane, has been used for over ten years by the author with good results. A description of
the corrective procedure and short- and long-term case follow-ups are presented.

Introduction

Orthodontics is the field of dentistry that deals with the prevention and treatment of
dental malocclusions. The objective of equine orthodontics is to correct or prevent dental
or dentofacial malocclusions or malalignments through surgery, dental crown
equilibration and/or the use of functional dental appliances.1 Through the use of
corrective orthodontics, the oral dental function and periodontal health of the horse are
improved. This article concentrates on the use of orthodontic treatment to improve or
correct parrot mouth in the young horse.

The term “parrot mouth” has been used to describe a horse with rostral malocclusion of
the upper incisor teeth in relation to the lower incisor teeth. The condition is seen in
horses that have a very long maxilla or a very short mandible. Often, the upper lip
overlaps the lower and on profile can resemble a bird’s beak. The condition should more
accurately be termed retrognathism if the mandible is of normal length but positioned
caudal to its normal position in relation to a long maxilla. The term brachygnathism is
used to describe a receding or short mandible. The degree of incisor overjet (measured as
the distance the upper incisor teeth protrude labial or rostral to the lower incisors) is quite
variable in horses with this condition. Foals born with incisor overjet may range from
having upper and lower incisor occlusal contact with a slight labial malalignment to
having no incisor occlusion with up to 4 cm of distance between the labial surface of the
upper and lower incisor arcades (Fig. 1). The premolar arcades of horses with incisor
overjet are usually malaligned but often to a lessor degree than are the incisors.2 Parrot
mouth has been described as a Class 2 malocclusion because the mandibular teeth
occlude distally (caudally) in relation to the maxillary teeth.3

The occlusal surfaces of the upper and lower incisors of a young horse with parrot mouth
are initially level, but as the foal grows, the incisive bones or premaxillae, drift ventrally
causing an overbite. The degree of incisor overbite is measured as the distance the
 Figure 1. 5 day-old Thoroughbred filly with a
1 cm overjet and no overbite. Only the central
incisors have erupted and they are not yet in
wear. The premaxilla (incisive bone) is level
with no ventral curvature.

occlusal surface of the upper incisors overhangs that of and the lower incisors when the
mouth is completely closed and the cheek teeth in full occlusal contact (Fig. 2). Full
occlusion of cheek teeth is not possible in horses that have proper incisor occlusal
contact. As the upper and lower incisors continue to erupt unopposed, the exposed
crowns of the incisors are not worn by normal attrition, causing the lower incisors to
become trapped behind the upper incisors. The upper incisors often contact the hard
palate and at this point, a distinct bend or downward curvature of the roof of the mouth
often develops. Entrapment of the lower incisors behind the upper incisors places caudal
pressure on the lower jaw, further retarding rostral mandibular growth and development.
The cheek teeth malocclusion leads to the formation of a rostral focal overgrowths
(hooks) on the upper 2nd premolars (506, 606) and at times, lower sloping (ramps) or
focal overgrowths (hooks) on the last lower premolars (708 and 808). In older foals and
yearlings, these overgrowths worsen the condition by limiting rostral mandibular growth.

Figure 2. Lateral skull radiographs of a 5-month-old foal with parrot mouth. Notice the ventral
curvature and downward drift of the premaxilla. The lower incisor teeth are trapped behind the
upper incisors. The rostral hooks on the upper 2nd premolars (506 and 606) and tall transverse ridges
on the cheek teeth further restrict rostral mandibular growth.
A technique developed to help correct the occlusal abnormality in young horses involves
placing a tension band wire on the upper jaw to retard rostral maxillary and premaxillary
growth. A fixed acrylic platform with a metal incline plane is also used to place dorsal
pressure on the upper incisors, thus preventing or correcting the overbite. Contact of the
lower incisors with the incline plane during normal mastication tends to pull the lower
jaw rostrally, promoting its rostral growth. Additionally, the thickness of the acrylic
platform and bite plate contacting the lower incisors, separates the premolars which
decreases the lock on the cheek teeth. This allows the lower jaw to move forward
independently of the upper jaw.

Surgical Technique

Preoperative Care

Foals with parrot mouth should be carefully examined for other congenital or
developmental abnormalities. The owner/trainer should be advised about breed registry
requirements, the possible genetic origin of the parrot mouth condition, the likely success
of surgery, the risks and benefits as well as costs of orthodontic treatment. Using parrot
mouth horses for breeding should be discouraged.

The earlier treatment is initiated, the greater is the correction that can be expected.
Young foals in the rapid stages of growth respond faster and more completely to
treatment, but to avoid interference with the eruption of the intermediate incisors (02s),
treatment should be postponed until these teeth are in wear (6-12 weeks). Foals that are
candidates for orthodontic correction should have a full set of skull radiographs and
occlusive measurements taken prior to proceeding with correction. The cheek teeth
should be gently floated to slightly round tall transverse ridges and to reduce rostral or
caudal hooks. The incisor plate brings the cheek teeth slightly out of full occlusal contact.
“Over-floating” of the cheek teeth occlusal surfaces is discouraged as this prohibits cheek
tooth contact during mastication. Foals need not be weaned prior to surgery but should be
on a diet consisting of pelleted feed and good pasture or chopped hay.

Surgical Procedure

An IV catheter is placed and the foal is premedicated with broad spectrum antibiotics and
a nonsteroidal anti-inflammatory drug. The mouth is thoroughly rinsed with a dilute
chlorhexidine solution. The foal is sedated with xylazine HCl, 1.1 mg/Kg, IV and general
anesthesia is induced with ketamine HCl 2.2 mg/Kg, IV. Anesthesia is maintained with a
solution consisting of xylazine HCl (500 mgs), ketamine HCl (1000 mgs) and guaifenesin
(1 liter, 5% solution) (i.e., triple drip), given slowly, intravenously, to effect.

The foal is positioned in lateral recumbency. During the procedure, oxygen is delivered
at 10 liters/minute through a nasotracheal tube. The exposed crowns of the incisor teeth
are reduced and leveled with a rasp or power grinder until only 2-4 mm of crown
protrudes above the gum line, taking care not to damage the gingiva or expose the incisor
pulp horn. A small area just ventral to the rostral aspect of the facial crest is clipped and
surgically prepped. With one hand in the mouth, the interdental space between PM3 and
PM4 on the uppermost arcade, is identified. A small, stab skin incision is made just
below the facial crest between PM3 and PM4 taking care to avoid branches of the dorsal
buccal nerve. A 3.2 mm diameter Steinmann pin is introduced through the skin incision
and directed between the reserve crowns of PM3 and PM4 in a slightly dorsal ventral
direction just above the buccal gum line, exiting in the mouth 2-3 mm above the palatal
gingiva. Care should be taken to avoid the palatine artery which lies about 3 mms medial
to the palatine surface of the teeth. Intra-operative radiographic and fluoroscopic
examinations are helpful and necessary at times to properly position the pin between the
teeth without damaging the cheek teeth roots. The pin is removed and a 14 gauge, 3.8 cm
long, hypodermic needle is placed in the created hole to act as a wire guide. A section of
18 gauge, 316 stainless steel, orthopedic wire is cut to a length at least three times the
distance from PM4 to the central incisor teeth (i.e., about 36 cm). One end of the wire is
placed through the hub of the needle to enter the oral cavity at the gingival margin. The
needle is removed over the free end of the wire. The free end of the wire is then doubled
back and passed through the skin incision and pushed through the buccal mucosa into the
buccal space on the lateral aspect of the cheek teeth. Care should be taken to avoid
catching soft tissue of the cheek or damaging a branch of the facial nerve during the
process. The ends of the wire are grasped with a forceps and pulled rostrally out of the
mouth to form a loop around the distal aspect of the reserve crown of PM3. Kinking the
wire should be avoided because this may cause the wires to break from fatigue. The small
skin incision is left open to heal by second intention. The foal is repositioned in lateral
recumbency on the opposite side and the procedure for wire placement is repeated on the
opposite arcade.

With both wire loops protruding from the oral cavity, the foal is positioned in dorsal
recumbency with a pad placed caudal to the poll to hyperextend the neck, leaving the roof
of the mouth parallel to the ground. The wire loop on each side is pulled tight and twisted
several times on itself in the interdental space. The loop should be twisted by directing
the buccal portion of the loop ventrally and the palatal portion of the loop dorsally. While
twisting, the loop should be positioned close to the hard palate to avoid any of the wire
contacting the occlusal surface of the cheek teeth. The twisted loops from each side are
pulled forward and brought around the labial edge of the incisor arcade and twisted
together. The wires should lie across the labial surface of the incisors at the gum level.
The end of the wires is cut and bent ventrally so it lies tucked in the groove between the
two incisors. A 3.2 mm thick plate of perforated aluminum is sized to fit over the occlusal
surface of the upper incisors and extend caudally over the hard palate, 1 cm caudal to the
contact point of the lower incisor arcade on the hard palate. Paraffin rope is placed at
gum level around the upper incisors, pulled under the wires on each side, and extended
several centimeters caudally on the roof of the mouth to form a dental “dam” for acrylic
administration. Hard-setting dental acrylica is mixed and placed within the boundary of
the paraffin rope. After the acrylic begins to set, the paraffin rope is removed and the
acrylic is molded by hand in the roof of the mouth and is then extended laterally and
rostrally to incorporate the wires and labial surface of the upper incisor arcade into the
acrylic mass. The acrylic is formed with the curved rostral edge of the metal plate resting
on the
 B.
A.
Figure 3a. Parrot mouth foal in dorsal recumbency with orthodontic wires in place. Paraffin rope
has been placed to act as a dam for acrylic. A 3.2 mm thick aluminum plate has been fitted on the
occlusal surface of the upper incisors and projects caudal enough to make contact with the lower
incisors when the mouth is closed. Figure 3b. Parrot mouth foal with orthodontic wires and acrylic
appliance with a metal incline plane in place

occlusal surface of the upper incisors and the caudal edge of the plate level with or
slightly more dorsal than the rostral aspect. This creates a flat or inclined surface for the
lower incisors to contact, freeing the mandible from caudal force and creating a slight
rostral pull as the incisor teeth slide over the plate during mastication. As the foal chews,
dorsal pressure is also applied to the upper incisors and premaxillae, eventually lifting
them into a more normal position.

The acrylic should cover the twisted ends of the wire, the wire loops and the gingivae to
prevent the wire from irritating the soft tissue. Splinting the upper incisor arcade with
acrylic is important to stabilize the teeth so the force of the orthodontic wires is prevented
from spreading or twisting the incisors. The band of acrylic around the upper incisor teeth
and orthodontic wires, holds the acrylic incline plate firmly in the roof of the mouth
(Figs. 3a and 3b).

After the acrylic sets, the foal is allowed to recover from anesthesia and is placed back
with the dam. Most foals quickly learn to nurse with the appliance in place. Foals that do
not nurse well are supplemented with a complete foal ration.

Postoperative Care

Postoperative care consists of keeping the skin wounds clean until they are healed. While
adjusting to the orthodontic appliance, most foals are kept on oral omeprazole for 4-5
days to help prevent gastric ulcers. Postoperatively, foals usually eat and nurse well after
1-2 days of adjustment. The plate and wires are checked daily to detect loose or broken
wires or loose acrylic. The patient also needs to be examined by a veterinarian on a
 Figure 4. Lateral radiograph of a 10-month-
old foal with retention wires, acrylic plate and
aluminum incline plane attached to upper
jaw. The foal had a 1.4 cm overjet and a 6 mm
overbite when first evaluated and treated at 4
months of age. The overbite has been
completely corrected with the upper and
lower incisor teeth in occlusal contact with
just a 3 mm overjet remaining.

monthly basis to ensure that the appliance is secure and not causing any problems
intraorally (Fig. 4). During these follow-up visits, the cheek teeth are also inspected and
any abnormal wear patterns are corrected with floating.

The bite plate wears thin over time from lower incisor contact and typically after 3-6
months, the appliance and/or wires must be removed. If correction is not complete at that
time, the surgical procedure is repeated until the desirable results are achieved. The
overbite of most foals correct approximately 5 mm every 3-6 months. The most rapid
correction is noticed between 2-8 months after which improvement continues slowly until
the horse is approximately 19 months old.

Results

Twenty-eight foals with incisor overjet greater than 4 mm, were examined and treated by
the author between January 2000 and December 2003. Medical records were reviewed
and follow-up telephone questionnaires carried out in 2006.

The group consisted of 16 Thoroughbreds, 6 American Quarter horses, 3 American

Saddlebreds, 1 Warmblood out of a Thoroughbred mare, 1 Arabian and 1 Morgan. The
sexes were nearly equally distributed (15 fillies and 13 colts). The dams of 2
thoroughbred foals were noted to have an incisor overjet. None of the sires of the affected
foals were known to have a parrot mouth condition but these sires were not examined by
the author. At the time of initial surgery, the foals ranged in age from 11 weeks to 9
months of age with a mean of 4.5 months of age. The incisor overjet at the time of initial
surgery, ranged from 4 mms to 3 cms. The incisor overbite ranged from 0 to 2.5 cms.
The foals underwent 1-4 surgeries over a 4-14 month period. The foals had a mean of 2.5
surgeries over an average period of 9.4 months.
Orthodontic appliances were removed or replaced when they showed signs of wear (e.g.,
broken wires, worn aluminum plates, or loose or broken acrylic). One or a combination
of these problems occurred between 2 weeks and 6 months after application of the
orthodontic device. Most foals developed some degree of transient gingivitis beneath the
acrylic appliance, most notably on the labial aspect above the upper incisors. Dark
staining of the deciduous upper incisor crown cementum was common. The wires
grooved the exposed dental crowns of the upper incisors of most foals. During the course
of treatment, a small valve diastema was observed between upper deciduous PM3 and
PM4 on all foals.

Complications at the time of surgery were minimal. One foal experienced transient
hemorrhage following puncture of the palatine artery. No anesthetic-associated problems
were encountered. Transient postoperative facial swelling which slowly resolved in 5-6
days was noted around the skin incisions in 6 foals. Transient, unilateral facial nerve
paralysis (neuropraxia) was observed in 1 foal but this spontaneously resolved in 2-3
weeks. Young nursing foals were supported nutritionally for 12-24 hours post surgery
until they were able to manage nursing with the orthodontic appliance in place. Feed
tended to pack around the wires and buccal pouches of most foals but this was easily
managed by daily oral lavage administered by caretakers.

A follow-up study in 28 horses, 1-5 years post treatment showed that all cases improved.
Correction of overjet ranged from .4 to 2.4 cms in overjet (corrected). Average
improvement with the first appliance and wire application was 4 mm in overbite and 5
mm in overjet. Average additional improvement with the second application of appliance
and wires was 6 mms in overjet and complete correction of overbite. Four horses
experienced crowding of permanent incisors or retention of deciduous incisor teeth. Two
horses at 2-3 years of age, had retained deciduous central upper incisors with the
permanents erupting rostral to the deciduous teeth. One yearling lost a 103 (central
deciduous incisor) when the acrylic loosened and a permanent replacement tooth did not
erupt in this horse. Cheek tooth malocclusions were not accurately measured and
documented. Abnormal wear patterns (06 upper hooks, caudal lower last cheek teeth
hooks, and exaggerated transverse ridges) recurred and had to be repeatedly corrected
during the time the appliance and wires were in place and also during the period between
removal of the acrylic appliance and long term follow-up.

Discussion

Several different approaches have been taken in the management and/or correction of
parrot mouth in the horse.1,4,5 The condition is not life threatening and many horses with
proper dental care and feeding management, have had productive performance careers
despite this malocclusion. Orthodontic correction during the first 6 to 18 months of life
when the equine skull is in a rapid phase of growth and development, does improve the
horse’s occlusion. Most owners of horses that have received orthodontic correction have
reported improvement in quality of life for the horse after treatment.
 Other orthodontic techniques including the use of retention wires on the upper jaw with
no incline plane, have been successfully used in foals with incisor overjet but no
overbite.3 Over a period of 18 months, a fixed acrylic incline plane without the use of
retention wires was used to correct a young horse suffering from parrot mouth.5 Surgical
distraction osteogenesis has been used to correct maxillary deviation in the foal and has
been used by this author (with limited results) to lengthen the lower jaw.6 It appears that
the combined approach with retention wires on the upper jaw combined with a fixed
acrylic and aluminum incline plane, has advantages over other techniques. Correction of
the malocclusion is more rapid with minimal complications when using the combined
approach.
Acknowledgment and special thanks to Rob Menzies, BVSc and Bridget Gallet, DVM for their research support.

References and Footnote

1. Easley J. Basic equine orthodontics. In: Baker GJ and Easley J ed. Equine
Dentistry, 2nd ed. London: Elsevier Saunders, 2005; 249-266.
2. DeBowes RM, Gaughn EM. Congenital dental diseases of horses. In: Gaughn
EM and DeBowes RM, ed. Vet Clin North Am Equine Pract, Vol 14, No 2,
Philadelphia: WB Saunders, 1998; 275-281.
3. Wiggs RB and Lobprise HB. Basics of orthodontics. In: Wiggs, RB and Lobprise
HB eds, Veterinary Dentistry, Principles and Practice, Philadelphia:Lippincott,
1997:438-441.
4. Gift L, DeBowes R, Clem M, et al: Brachygnathism in horses: 20 cases (1979-
1989). J Am Vet Med Assoc, 1992; 200-715.
5. Klugh DO. Acrylic bite plane for treatment of malocclusion in a young horse.
J Vet Dent, 2004, 21(2), 84-87.
6. Puchol JL, Herran R, Durral I, et al. Use of distraction osteogenesis for the
correction of deviated nasal septum and premaxilla in a horse. J Am Vet Med
Assoc, 2004; 224-226.

a. Lange’s Dental Acrylic.

_______________________________________________________________________________
American Association of Equine Practitioners - AAEP -
Focus Meeting, 2006 - Indianapolis, IN, USA
This manuscript is reproduced in the IVIS website with the permission of AAEP www.aaep.org