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Dental and oral diagnostic imaging and interpretation

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Abstract

This chapter covers the principles, equipment and techniques required to carry out a range of diagnostic imaging techniques on the head. Interpretation and common presentations are covered in depth using clinical photographs, radiographs, computed tomography images, magnetic resonance images and ultrasonograms. : Full-mouth dental radiographs in the dog; Full-mouth dental radiographs in the cat

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Figures

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4.1 (a) Ceiling-mounted and (b) wall-mounted dental X-ray machines. (a, © Dr Alexander M. Reiter)
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4.2 Handheld dental X-ray device. (© Dr Alexander M. Reiter)
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4.3 Sizes 0, 2 and 4 dental film; the convex surface of the dimple (circled) must face the X-ray beam during exposure. (© Dr Alexander M. Reiter)
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4.4 Content of a film pack: A = outer plastic wrap; B= lead sheet; C = dark paper around the film ; D = film.
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4.5 Chairside processor with solutions for developing and fixing. Note also the packages of dental film and a stand for drying processed film.
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4.6 Single film clips (top right) and various sizes of film hangers. (© Dr Alexander M. Reiter)
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4.7 Size 2 sensor pad for use in direct digital radiography. (a) Front view. Note the cord which attaches the sensor pad to a computer. (b) Side view. Note the thickness of the sensor pad. (© Dr Alexander M. Reiter)
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4.8 (a) Phosphor plates within disposable plastic sleeves. (b) Scanning (laser reader) machine used to transfer latent images on to a computer.
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4.9 Parallel technique. The plane of the radiographic film and the long axis of the teeth of interest are parallel to each other, and the X-ray beam is aimed perpendicular to them. (© Dr Alexander M. Reiter)
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4.10 Bisecting angle technique. The radiographic film is placed at an angle to the long axis of the teeth of interest, and the X-ray beam is aimed perpendicular to an imaginary line bisecting that angle. (© Dr Alexander M. Reiter)
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4.11 Labial mounting of processed dental X-ray films of the dentition of (a) a dog and (b) a cat.
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4.12 In digital radiography, the software allows images to be organized in labial mounting, either automatically or manually.
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4.13 (a) Positioning of a dog for a dorsoventral head radiograph. The head should be symmetrically anchored on the supporting surface and the central beam aligned between the eyes. Side markers should always be used. (b) Resulting radiographic image. The superimposition of the jaw bones limits dental and periodontal assessment. (a) Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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4.14 (a) Positioning of a dog for a dorsoventral intraoral view of the upper jaw and nose. Maximal cassette coverage can be achieved by inserting it diagonally into the mouth. The beam should be aligned halfway between the nostrils and the eyes. Side markers should always be used. (b) Resulting radiographic image. (a) Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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4.15 (a) Positioning of a dog for a ventrodorsal head radiograph. The head should be symmetrically positioned and the central beam aligned half way between the mandibular symphysis and angular processes of the mandibles. Side markers should always be used. (b) Resulting radiographic image of the head in a cat. (a) Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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4.16 (a) Positioning of a dog for a ventrodorsal intraoral view of the lower jaw. Maximal cassette coverage can be achieved by inserting it diagonally into the mouth. The beam should be aligned halfway between the chin and the eyes. Side markers should always be used. (b) Resulting radiographic image; the mandibular second and third molar teeth could not be included with this technique. (a) Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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4.17 (a) Positioning of a dog for a lateral head radiograph. The head should be supported with radiolucent foam wedges to be perfectly parallel with the supporting surface in both dimensions. The central beam should be aligned on the zygomatic arch at the level of the eyes (or caudal hard palate). (b) Resulting radiographic image. (a) Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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4.18 (a) Positioning of a dog for an open-mouth oblique view of the right upper jaw. The head should be rotated from right lateral recumbency approximately 30 degrees towards dorsal recumbency. The mouth must be maximally opened with a radiolucent mouth gag. The central beam should be centred on tooth 107. Side markers should be put at the level of each maxilla. (b) Resulting radiographic image. (a) Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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4.19 (a) Positioning of a dog for an open-mouth oblique view of the right lower jaw. The head should be rotated from ventral recumbency approximately 30 degrees towards right lateral recumbency. The mouth must be maximally opened with a radiolucent mouth gag. The central beam should be centred on tooth 407. Side markers should be put at the level of each mandible. To view the right mandibular teeth without foreshortening, ensure that the head is rotated far enough. (b) Resulting radiographic image; teeth 410 and 411 are obscured by maxillary teeth. (a) Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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4.20 (a) Positioning of a mesaticephalic dog for an oblique view of the left temporomandibular joint (TMJ). The head is positioned in left lateral recumbency with the tip of the nose elevated by 15 degrees. In addition, the head can be rotated from left lateral recumbency by 5 degrees towards dorsal recumbency. The central beam should be centred slightly rostral to the palpable right TMJ. Side markers should always be used. (b) Resulting radiographic image, (*) indicates the mandibular condyle. (c) In skeletally immature dogs the mandibular condyle (*) is wider in shape and less sharply marginated which is a normal feature. (a) Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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4.21 (a) Positioning of a cat for an oblique view of the right temporomandibular joint (TMJ). The head is rotated from right lateral recumbency by 20 degrees towards dorsal recumbency. In addition the nose tip can be elevated by 5–10 degrees. The central beam should be centred slightly rostral to the palpable left TMJ. Side markers should always be used. (b) Resulting radiographic image, (*) indicates the condyle. (a) Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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4.22 Ultrasound machine; a transducer is applied to the skin in the neck area to image the medial retropharyngeal lymph nodes.
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4.23 Multi-slice helical computed tomography scanner, with the patient couch in the foreground and gantry at the back.
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4.24 Small animal dedicated cone-beam computed tomography (CT) units. The X-ray tube and image receptors are housed in a C-shaped arm that rotates around the patient. (a) The unit requires neither an external cooling system nor three-phase power supply, unlike a conventional CT unit. (b) In this model, the tunnel part can also be rotated horizontally. (c) Sagittal image of a canine mouth and nose generated from 0.46 mm slice width revealing high anatomical dental and periodontal detail. (a, c, Courtesy of Animage, LLC Pleasanton, CA, USA; www.animage.com)
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4.25 A 1.5 tesla magnetic resonance imaging (MRI) machine. The patient is in the gantry of the magnet that contains the high magnetic field. All anaesthesia equipment used must be MRI compatible.
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4.26 Dental radiographs taken in a dog showing (a) the left maxillary cheek teeth (arrows depict the line of conjunction between the vertical body of the maxilla and its palatine process) and (b) the right mandibular cheek teeth, (*) indicates the mandibular canal.
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4.27 Radiograph of the right maxillary fourth premolar tooth in a dog. The X-ray beam is coming from a lateral direction (arrowed), resulting in superimposition of the mesiobuccal (M) and mesiopalatal (P) roots. The distal root (D) is clearly visible. (© Dr Alexander M. Reiter)
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4.28 Radiograph of the right maxillary fourth premolar tooth in a dog. The X-ray beam is coming from a rostral direction (arrowed), resulting in the mesiopalatal root (P) being positioned more rostral than the mesiobuccal root (M) and the distal root (D) starting to overlap with the maxillary first molar tooth. (© Dr Alexander M. Reiter)
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4.29 Radiograph of the right maxillary fourth premolar tooth in a dog. The X-ray beam is coming from a caudal direction (arrowed), resulting in the mesiopalatal root (P) being positioned more caudal than the mesiobuccal root (M) which is overlapping with the distal root (D) of the maxillary third premolar tooth. (© Dr Alexander M. Reiter)
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4.30 Radiographic anatomy of the rostral left lower jaw in a dog. A = apex; AB = alveolar bone; AM = alveolar margin; CEJ = cementoenamel junction; D = dentine; E = enamel; LD = lamina dura; PC = pulp chamber; PDL = periodontal ligament space; RC = root canal.
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4.31 Radiographs of the right mandibular first molar tooth in two dogs. (a) There is osteosclerosis near the mesial and distal roots (*) and structural deficits of the cusps of the crown (arrowed). (b) There is condensing osteitis (*) near the distal root, apical root resorption and periapical lucencies (arrowed) and thickening of the ventral mandibular cortex (double-ended arrow). (© Dr Alexander M. Reiter)
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4.32 Radiograph of a left mandibular first molar tooth in a dog, showing a pulp stone (*) in the mesial aspect of the tooth’s pulp chamber. (© Dr Alexander M. Reiter)
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4.33 Radiographs of (a) the left upper jaw in a dog, showing an extra root (*) at the left maxillary third premolar tooth (207), and (b) the right lower jaw in a dog, showing the presence of two right mandibular first premolar teeth (405 and SN405), one of which is supernumerary (SN).
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4.34 Computed tomographic images of a dog with periodontal disease. (a, b) The curvilinear reconstruction images of both jaws allow for assessment of all teeth and roots, both simultaneously and individually. Obvious loss of alveolar bone (arrowed) is present at the right maxillary second premolar and second molar teeth and the left maxillary second incisor and second molar teeth (106, 110, 202 and 210). (c–g) Transverse slice images provide more detail for individual teeth. Loss of alveolar bone is arrowed.
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4.35 Radiographs of the left mandibular first molar tooth in two different dogs. Note the loss of alveolar bone (arrowed) in (a) the horizontal and (b) the vertical direction.
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4.36 (a) Clinical photograph and (b, c) radiographs in a cat, showing abnormal extrusion of the right maxillary canine tooth (double-ended arrow indicating root surface exposure) and associated vertical bone loss (arrowed) and alveolar bone expansion (*).
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4.37 (a) Clinical photograph and (b) radiograph of a left maxillary fourth premolar tooth in a dog with a complicated crown-root fracture; note the pointed appearance of the tooth’s main cusp (dotted lines) and periapical radiolucencies. (© Dr Alexander M. Reiter)
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4.38 Radiograph of the right maxillary second premolar tooth in a dog with fracture of the distal (arrowhead) and mesial (arrowed) roots. Alveolar bone loss adjacent to the affected tooth can also be noted.
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4.39 Occlusal radiograph of the upper jaw in a cat, showing multiple root remnants (arrowed). (© Dr Alexander M. Reiter)
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4.40 Radiographs of two cats. (a) Inflammatory resorption (type 1 resorption) affecting the left mandibular third premolar and first molar teeth (*). The periodontal ligament space is visible along the roots. Note alveolar bone loss adjacent to the affected teeth (arrowed). (b) Non-inflammatory resorption (type 2 resorption) of the left mandibular canine (304) and third premolar teeth (*). Note the lack of periodontal ligament space and bone proliferation, rather than resorption, adjacent to affected teeth.
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4.41 Radiograph of the rostral lower jaw in a dog, whose mandibular canine teeth had been treated with crown reduction and vital pulp therapy. Internal resorption (*) resulted in an oval-shaped lucency in the root canal of the left mandibular canine tooth.
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4.42 Radiograph of the caudal left lower jaw in a dog, showing a crater-shaped crown defect (*) and periapical disease around the root apices (arrowed) of the left mandibular second molar tooth affected by caries.
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4.43 Radiograph of the rostral upper jaw in a cat. Note the difference in width of the root canal between the vital right maxillary canine (104) and the non-vital left maxillary canine tooth (204).
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4.44 Chevron artefacts (*) surrounding the root apices of vital maxillary incisor teeth of a dog. (© Dr Alexander M. Reiter)
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4.45 Right maxillary canine tooth in a dog with periapical lesion compatible with a granuloma or an abscess (arrowed), characterized by a radiolucent halo and loss of lamina dura around the root apex.
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4.46 The rostral upper jaw in a dog, showing a periapical cyst (arrowed) associated with a left maxillary third incisor tooth. (© Dr Alexander M. Reiter)
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4.47 Acute exacerbation (i.e. abscess formation) of a periapical granuloma of the right maxillary fourth premolar tooth in a dog. Note (a) the cutaneous draining tract below the medial canthus of the eye, (b) the complicated crown fracture, and (c) radiolucencies (arrowed) around the root apices of the tooth.
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4.48 Combined endodontic and periodontal lesions of the right mandibular first molar tooth in two different dogs (the curved arrows show the direction of disease progression). (a) In the type 1 endo-perio lesion, note the structural deficits (*) of the cusps of the crown, resulting in a primary endodontic lesion with secondary periodontal involvement. (b) In the type 2 perio-endo lesion, there is a primary periodontal lesion with secondary endodontic involvement. Note the development of periapical disease at the mesial root (short arrows), which is less affected by bone loss compared with the distal root. (© Dr Alexander M. Reiter)
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4.49 Lateral luxation of a right maxillary canine tooth in a dog. Note (a) the mucosal laceration and (b) the widened periodontal ligament space (arrowed). (© Dr Alexander M. Reiter)
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4.50 Radiographs of a left maxillary canine tooth (a) prior to and (b) several months after root canal therapy. Note that the previously widened periodontal ligament space and the periapical lucency have decreased.
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4.51 Radiographs of the rostral lower jaw in a dog (a) prior to and (b) 5 years after successful vital pulp therapy of both mandibular canine teeth. Note the continued root development with continued apposition of dentine and apical closure.
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4.52 The left mandibular canine tooth in a dog with uncomplicated crown fracture (arrowed) and stricture of the root canal (*) due to diffuse pulpal mineralization.
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4.53 (a) Lateral head radiograph and (b) computed tomographic image of two young dogs with osteomyelitis of the calvarium. There is marked irregular periosteal reaction and osteolysis of the calvarium (arrowed), but the facial bones are relatively spared.
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4.54 (a) Ventrodorsal intraoral radiograph of the lower jaw of a 6-year-old Keeshond dog with fibrous osteodystrophy, showing marked osteopenia and a ‘floating teeth’ appearance due to secondary renal hyperparathyroidism. (b) Computed tomographic image of a dog with fibrous osteodystrophy due to primary hyperparathyroidism, showing marked mandibular and maxillary osteopenia and fibrous tissue proliferation.
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4.55 Lateral head radiograph of a 5-month-old West Highland White Terrier with craniomandibular osteopathy. There is marked enlargement of the mandibles (1), tympanic bullae (2) and calvarium (3) with palisading new bone formation.
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4.56 Lateral head radiograph of a 7-month-old Bullmastiff with calvarial hyperostosis. There is marked enlargement of the calvarium (arrowheads) and tympanic bullae (arrowed). The mandibles are usually not affected.
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4.57 Computed tomographic image of a dog with right facial trauma after being kicked by a horse. Note the right periorbital swelling (*), comminuted zygomatic arch fracture containing gas (arrowed), and an apical fracture of the distobuccal root of the right maxillary first molar tooth (arrowhead).
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4.58 (a) Transverse T1-weighted post-contrast and (b) para-sagittal T1-weighted magnetic resonance images in two normal dogs showing the anatomy of the temporomandibular joints. The relationship between the mandibular condyle (*) and mandibular fossa can readily be assessed with magnetic resonance imaging due to the ability to image in any plane. In (a), normal palatine tonsils are visible (arrowed). In (b), a normal mandibular salivary gland (SG) and one mandibular lymph node (LN) are also visible.
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4.59 Computed tomographic image of a dog with bilateral temporomandibular joint osteoarthritis. There is marked subchondral bone erosion.
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4.60 Computed tomographic image of a Bulldog with two subchondral bone cyst-like lesions in the right mandibular condyle (*). Note also the baroque shape of the bones forming the temporomandibular joints, consistent with dysplasia.
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4.61 Close-up image of a dorsoventral radiograph of a dog with a sagittal mandibular condyle fracture. The fracture line is barely visible (arrowed).
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4.62 Computed tomographic image of bilateral temporomandibular joint ankylosis in a cat.
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4.63 (a) Dorsoventral radiograph and (b) computed tomographic image of a Boxer with temporomandibular joint luxation. The right mandibular condyle (MC) is luxated rostrally (arrowed). The space where the mandibular condyle should be situated in the mandibular fossa is empty (*).
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4.64 Computed tomographic image of a 1-year-old German Shorthaired Pointer with a history of open-mouth jaw locking. The tip of the coronoid process of the right mandible is fractured (arrowed) due to impingement on the right zygomatic arch, which has a closed zygomaticotemporal suture and adjacent sclerosis consistent with premature zygomaticotemporal synostosis (*) and is situated more medial than the left zygomatic arch. For comparison, the left zygomatic arch has an open zygomaticotemporal suture (arrowhead), which is normal for a dog of this age.
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4.65 (a) Clinical photograph and (b) radiograph of a peripheral odontogenic fibroma (fibromatous type) in the rostral upper jaw in a dog. Note the soft tissue swelling (*) between the right maxillary second and third incisor teeth, resulting in increased interproximal spacing between the two teeth, and subtle radiolucency with a well defined, mildly sclerotic margin (arrowed).
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4.66 (a) Clinical photograph and (b) radiograph of an acanthomatous ameloblastoma in the rostral lower jaw in a dog. Note the cauliflower-like, reddened mass and marked bone invasion in the area of the right mandibular incisor teeth and the canine tooth. (© Dr Alexander M. Reiter)
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4.67 (a) Intraoral lateral oblique radiograph of a left maxillary compound odontoma in a dog. (b) Numerous tooth-like structures were removed from this lesion. (Courtesy of Frank J. M. Verstraete, University of California-Davis)
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4.68 Ventrodorsal radiograph of the head of a 14-year-old cat with a benign mandibular osteoma (*). The mass is smoothly marginated and shows no sign of osteolysis.
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4.69 (a) Dorsoventral radiograph of the head of a dog with a caudal maxillary osteosarcoma. There is a very irregular periosteal reaction and osteolysis (arrowed). (b) Computed tomographic image of a rostral mandibular osteosarcoma in a dog. The image shows the aggressive osteolytic nature (*) of this primary bone tumour. Note that there is no invasion of the opposite mandible.
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4.70 Oblique lateral radiograph of the head of a dog with a multilobular tumour of the calvarium (arrowed). This tumour arises from flat bones of the skull and has both expansile and infiltrative behaviour.
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4.71 (a) Transverse computed tomographic (CT) image in a bone algorithm and (b) transverse T1-weighted post-contrast magnetic resonance imaging (MRI) of a dog with a squamous cell carcinoma of the right maxilla. While the bone destruction is readily appreciated on CT (*), it can also be identified on MRI, where the normal dark signal from the cortical bone (arrowed) has disappeared in the region of the mass (black arrow). Tooth roots are visibly embedded in the neoplastic mass (arrowhead).
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4.72 (a, c) T2-weighted and (b, d) T1-weighted post-contrast magnetic resonance images of a cat with a focal and poorly marginated left-sided facial swelling that was diagnosed as mast cell tumour. (a, b) These images have been obtained at the level of the palpated mass and show diffuse swelling along the left side of the face (arrowed) that is (a) heterogeneously T2-hyperintense and (b) enhances strongly after gadolinium injection. These images show that the neoplastic tissue extends far more caudally than clinically perceived. (c) The T2-weighted image at the level of C1 (first vertebra) still shows abnormal thickened tissue along the left ventrolateral aspect of the neck (arrowed), which was (d) enhanced and represented extensive neoplastic infiltration.
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4.73 Transverse T2-weighted magnetic resonance image at the level of the mandibular lymph nodes in a dog with a squamous cell carcinoma along the right maxilla (same dog as in Figure 4.71). The right mandibular lymph nodes (*) are enlarged compared to the left lymph nodes (); they were aspirated and found to contain metastases.
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4.74 (a) Long-axis ultrasound image of a mildly enlarged medial retropharyngeal lymph node (between callipers) in a dog with sialadenitis. The node has mildly irregular margins, heterogeneous echostructure, and the perinodal fat is hyperechoic (reactive lymphadenitis on cytology). (b) Ultrasound-guided aspiration of a medial retropharyngeal lymph node in a dog. The needle is visible (arrowheads), as it is guided to the node (arrowed) for aspiration.
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4.75 Transverse T2-weighted magnetic resonance image of a dog with tonsillitis. Both palatine tonsils (*) are swollen, protruding and hyperintense, consistent with oedema or inflammation.
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4.76 (a) Ultrasound image of a tongue mass in a Chow Chow, acquired using a ventral intermandibular approach. The hypoechoic mass (between callipers) stands out from the surrounding lingual muscles. (b) Sagittal T2-weighted magnetic resonance image of a haemangiosarcoma (*) in the tongue of a dog. The excellent soft tissue contrast of magnetic resonance imaging provides clear delineation of the tumour margin within the tongue, even before the use of contrast material.
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4.77 (a) Transverse T2-weighted and (b) T1-weighted post-contrast magnetic resonance images of a dog with masticatory muscle myositis. Note the areas of hyperintensity on the T2-weighted image in the left temporal (T) and masseter (M) muscles consistent with oedema, and the intense patchy contrast enhancement after gadolinium injection.
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4.78 (a) Dorsoventral radiograph obtained following right zygomatic and parotid sialogram of a Border Collie with right facial swelling. The zygomatic duct (arrowed) is distended and irregularly shaped, and there is incomplete filling of the parotid gland (*). The diagnosis was zygomatic and parotid sialadenitis. (b) Sublingual and mandibular computed tomography sialography in a Labrador Retriever with a left-sided sublingual sialocele (ranula). The left mandibular gland (arrowed) shows normal contrast filling, whereas the left sublingual duct injection filled a sublingual sialocele (arrowhead).
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4.79 Transverse T1-weighted images in two dogs showing the normal magnetic resonance imaging appearance of the salivary glands. 1 = right parotid salivary gland; 2 = right mandibular salivary gland; 3 = right zygomatic salivary gland; EEC = left external ear canal; FS = right frontal sinus; M = medial pterygoid muscle.
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4.80 Long-axis ultrasonograms of the normal and inflamed mandibular salivary glands in a dog with mandibular sialadenitis. At histopathology, there was chronic active severe pyogranulomatous and fibrosing sialadenitis and cellulitis. (a) The normal gland (arrowed) is oval-shaped, has a well defined margin, a hypoechoic homogeneous parenchyma and a normal hyperechoic hilus. (b) The inflamed gland (between callipers) is enlarged, with a hyperechoic capsule and a hypoechoic core consistent with abscessation or necrosis. There is severe hyperechogenicity of the periglandular fat and soft tissues, with a striated pattern suggesting oedema/cellulitis.
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4.81 Transverse (a) T2-weighted, (b) T1-weighted pre-contrast and (c) T1-weighted post-contrast magnetic resonance images in a dog with left-sided zygomatic sialadenitis. Compared with the normal right gland, the affected gland (*) is enlarged, (a) T2-hyperintense, (b) contains patchy areas of T1-hypointensities on the T1-weighted pre-contrast series, and (c) after contrast administration contains patchy areas of enhancement, while some areas are not enhanced in comparison with similar regions of the normal contralateral gland, indicating areas of necrosis or infarction.
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4.82 (a) T2-weighted and (b) T1-weighted post-contrast transverse magnetic resonance images in a dog with left-sided mandibular sialadenitis. The left salivary gland (*) is severely enlarged, T2-hyperintense and after gadolinium injection there are patchy areas of enhancement and hypointense non-enhancing areas (compared with the normal gland), consistent with areas of necrosis or infarction. At histopathology, there was severe diffuse necrotizing and pyogranulomatous sialadenitis with multifocal fibrinoid vasculitis (infarcts). Culture of biopsy samples grew and .
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4.83 Intravenous contrast-enhanced computed tomographic image of a dog with a retropharyngeal stick injury. Two pieces of wood (within dotted circle), adjacent fluid and gas within an abscess capsule can be seen in the left retropharyngeal space.
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