Occlusion: Lost Art, Lost Discipline: Part I

And clowns that caper in sawdust rings And common folk like you and me Are builders for eternity?
Each is given a bag of tools, A shapeless mass,
A book of rules;
And each must shape– Ere life has flown–
A stumbling block Or a stepping stone.

R. L. Sharpe

ART and OCCLUSION–are these two ostensibly disparate disciplines really stumbling blocks for each other, or may they be possibly be conjoined so that each separately derives something of the other, such that when melded together they coalesce to form a higher entity far more comprehensive than each could achieve singly? I will endeavor to explain this condign alliance wherein both fields do become indelibly intertwined, wherein each become appreciably enhanced by the other, and how to-gether they shape the necessary ‘stepping stone’ required for ‘stepping up’ to a more comprehensive understanding of, and an appreciation for, “THE AESTHETICS OF OCCLUSION.”

At the very least, a general assumption would be that art and occlusion coincide only insofar as both ostensibly aim to improve the lives of humankind. The latter disci-pline normally concerns itself with human betterment, the former with creative pleasure. Viewed another way, art and occlusion–or by the same token, poetry and prose– are similar to one another like an excursion and a jour-ney. The purpose of an excursion (art/poetry) is the process. The purpose of the journey (occlusion/ prose) is its goal. But the relationship actually is much more significant, and goes much deeper; it’s a relationship which that has been virtually ignored by the profession for decades, and for which I hope to provide ample clarifica-tion.

“Occlusal problems are a constant component of the daily practice of dentistry. Whatever the field of practice: restorative dentistry, prosthetic dentistry, pe-riodontology, orthodontics, implantology or orthog-nathic surgery, occlusion is the common denominator and the practitioner must pay attention to the mani-festations of occlusal problems for each and every pa-tient. Occlusion is not an area reserved solely for the specialist.”

Professor Jean Romerowski, University of Paris VII

I’ve used the term “Aesthetics of Occlusion”, and why shouldn’t I? Is there not a real ‘aesthetic’ to the oc-clusion? Can one not recognize the artistic, baroque forms within dentate morphology? Are there not undulating forms of sculptural elevations and depressions, flowing lines and intricate, labyrinthine crevices on the occlusal surface? Does not contemplating the meandrous, cascad-ing, rococo cuspal occlusal morphology call forth the mental image of picturesque rolling hills and a lush, ver-dant, bucolic mountainous countryside? Are these arab-esque dentate forms, then, not to be viewed as art, or artistic, or aesthetic? The artist Georgia O’Keeffe once remarked that she found that she could say things with shape and form that she couldn’t say in any other way— things she had no words for. Are our dental morphologi-cal shapes and forms speaking to us in a silent language we have not yet deciphered? I pose the question once again: are these florid, ornate shapes and forms not in any way to be considered artful? Not to be thought of as art? And if they are to be considered artful, and I believe that they are, then why is the dentist—purportedly the dental ’artist’—why is he or she so incapable of faithfully repli-cating the human dentate forms they deal with every day?

The straight line is the line of Man, the curved line is the line of Nature; it’s a sad fact that most dentists do not understand the aesthetic shapes and curves of dental morphology and cannot properly draw the teeth they at-tempt to repair. There’s an art to our dental morphology, and it’s not being taught in our dental schools. What a shame, since all occlusion is predicated on morphology. Morphology exists for the benefit of occlusion, not oc-clusion for the benefit of morphology. You can’t have good occlusion without good morphology, and poor mor-phology will only beget poor occlusion. Simply stated, in reality morphology is the deus ex machina of occlusion. We are all apprentices in a profession where so few ever become masters of occlusion. However, the key to un-derstanding occlusion is the understanding of morphol-ogy and the various musculoskeletal biodynamic influ-ences which affect occlusal morphology during function. Generally speaking, during most of their professional lives, dentists have looked at morphology and occlusion as though they were seeing them for the first time! We can’t solve occlusal problems when we use the same kind of thinking that was used when we supposedly were ‘taught’ occlusion. Sadly, the road to “success” in occlu-sion is paved with good intentions but poor morphology!

“The greatest and noblest pleasures which men can have in this world is to discover new truths, and the next is to shake off old prejudices.”

Frederick The Great

Our brains have two separate ways of processing in-formation and perceiving reality, one verbal and analytic (left brain), the other visual and perceptual (right brain). The problem is that artistic, imaginative, and visual skills are not taught in dental schools, yet visual perception is obviously crucial to dentistry, and especially to the anatomy of occlusion. Drawing classes are certainly not required. Courses devoted to perceptual skills, inventive-ness, creativity, or how our visual learning actually oc-curs simply do not exist; thus, the eye will not see what the mind has not taught it to recognize since language dis-places imagery. By learning how to consciously develop a ‘cognitive shift’ into the artist’s mode of seeing, we’d be far better equipped to comprehend the spacial complexi-ties of our world of dentistry. We can learn to release the recondite artistic abilities within us all, and free ourselves from the overwhelming L-brained verbal, linear, sequen-tial, numerical world which constantly surrounds us, and enter the R-brained world of visual-spatial perception, metaphors, insights, and dreams. “Vision is the art of see-ing what is invisible to others” (Jonathan Swift). If you can visualize it, you can draw it; and if you can draw it, you can carve it. Thought is the sculptor.

No great artist ever sees things as they are, If he did he would cease to be an artist.

Oscar Wilde

It is difficult, if not impossible, for most dentists to think otherwise than in the fashion of their own contem-porary world set up by conventional ‘wisdom’. The most common (and oftentimes erroneous) facts are those we think we know best and therefore never scrutinize. There is something comfortable, obviously, about views that allow for no deviation and that spare you the painful ne-cessity of having to think. To work in the everyday world of dentistry and long to truly understand the seminal art/occlusion kinship seems to me the saddest form of misplaced yearning. After decades of assorted and con-tradictory pedagogical teaching techniques marinated in strictly mechanical approaches, we have a disconcerted group of practitioners whose potential for increased qual-ity has never been realized. There can hardly be a more disconsolate question than: “Is the practice of dentistry really the art and science of morphologic occlusion?” (which it is); yet in one way or another, dentists continue to ask this question often as if still searching for some re-semblance, some meaning in an obscure, indecipherable metaphor they cannot seem to fathom.

Self-exposure must be a part of dentistry in order to placate one’s aspirational angst regarding the quintessen-tial realities of art as it relates to occlusion. Knowledge is indispensable. Put another way; ‘To follow contemporary mores and just wink / Is certainly easier than to pause and think’. Many dentists yearn to occasionally trespass on Quality Street, but getting them sufficiently motivated to perhaps achieving permanent residency there means they must to be willing to pay the rent to dwell on Quality Street. Effort and result are not always simultaneous, thus the old adage is often brandished about (well-meaning but imprecise), ”Practice makes perfect”–a generally mis-perceived concept which I shall clarify presently.

We do not what we ought, What we ought we do not do, And lean upon the thought

That ‘chance’ will bring us through. Mathew Arnold

Commonly, we speak of to the Art and the Science of dentistry, either of which are totally feckless without ex-pertise. Neither is independent of the other, nor more im-portant than the other. The truth of our art keeps our science from becoming robotic and inhuman, and the truth of our science keeps our art from becoming base panderism. Art and science are similar in that they are ex-pressions of what it is to be human in this world. The artist must imitate that which is within the thing, that which is active through form and figure, and discourses to us by symbols. Science is efficient; it is the logical study of the physical and natural world phenomenon by using sys-tematic observation and experiment. Science is extrinsic, the effective way of doing things. Art is intrinsic and emo-tional, the beautiful way of doing things, an end in itself. Dental art and science have their meeting point in method. If you attempt to marry and equate art with science, then you fail. If you allow what is not similar about art and sci-ence, and their different methods and processes, to co-exist and thrive in a kind of prosthodontic pavane, then a real art/science collaboration and occlusal aesthetic will emerge. Both areas of knowledge are undeniably essential to the understanding of Occlusodontology; but just how does ‘Art’ actually relate to–of all things–‘Occlusion’, which generally is thought of as more ‘functional’ than ‘artistic’, two entirely different things, with no apparent plausible interconnection?

The two constituent elements are likeness and un-likeness, or sameness and difference, and in all gen-uine creations of art there must be a union of these disparates. The artist may take his point of view where he pleases, provided that the desired effect be percep-tibly produced that there be likeness in the difference, difference in the likeness, and a reconcilement of both in one. Samuel Taylor Coleridge

Art is the aesthetic ordering of experience to express meanings in symbolic terms, and the reordering of nature–the qualities of space and time–in new perceptual and material form. Being an end in itself, and intrinsic, in every work of art there is a reconcilement of the internal with the external; the unconscious is so impressed on the conscious as to appear in it. The sense of beauty is intu-itive, and it searches for its moment of self-exposition. Art is science made clear. A work of art truly is an ad-venture of the mind, the mind being able to paint what the eye cannot see. “The true sign of intelligence is not know-ledge but imagination” (Albert Einstein).

Imagination is the springboard of creativity, where freeplay can happen. For the artist, it is not a destination, a reason, a mission nor is it a simulacra of a production-orientated “business”–it is the unfettered freedom of thought, and thought alone. An artist may be driven to be-come scientific, but from the moment he or she converts their thinking they cease being artists. Without art, our restoration morphology would show crudeness, and thus any ‘occlusion’ fabricated would be calamitous.

I think a strong claim can be made that the process of scientific discovery may be regarded as a form of art…A well constructed theory is in some re-spects undoubtedly an artistic production. A fine ex-ample is the famous theory of relativity by Einstein. Quite apart from any question of its validity, it cannot but be regarded as a magnificent work of art
Sir Ernest Rutherford,

Royal Academy of the Arts, 1932

Science (occlusion?) is often considered complex and chilling. Understandably, the mathematical language of science is understood by very few. The vistas it pre-sents can be scary—an enormous universe ruled by chance and impersonal rules, empty and uncaring, un-graspable and vertiginous. But science (technology/oc-clusion?) is also the instrumental ordering of the world of human experiences within a logic of efficient means, and which alters the direction of nature to use its powers for physical and environmental betterment. Yet there can be no art without fact, and no science without fancy; art and science clearly are not separate realms walled off from each other. Indeed, they truly do compliment each other. The true artist is quite rational as well as imaginative, cre-ative, and reasons what he is doing; if he does not, his art suffers. The true scientist is also quite imaginative and creative, as well as rational, yet sometimes leaps to solu-tions where reason can follow only slowly; if he does not, his science suffers.

By choice, one can live exclusively in one’s art, or devote oneself completely to science. Both views have validity, but when conscientiously each is taken separately they exhibit less puissance and show a loss of effectual-ness due to the lack of full development caused by the one-sidedness. Rather than contradiction, art and science actually compliment each other, and do so in a teeter-tot-ter balance capable of being consciously directed; per-ceptual synthesis. But this must be an entropic process in order to be valid, not externally mandated. For example, Da Vinci was intuitively able to combined art and science as well as aesthetics and engineering. He started his sci-entific anatomic studies long after his artistic training, having learned to “see” as an artist first. The science then followed. All great scientists have, in a certain sense, been great artists; the man with no imagination may collect facts, but he neither can make great discoveries, nor make great art.

Can one think that because we are engineers, beauty does not preoccupy us or that we do not try to build beautiful, as well as solid and long lasting struc-tures? Gustave Eiffel

Contained within the art and science of dentistry is a profusion of odd juxtapositions, artifices, and camou-flages which conceal enchanting truths and enchanting beauty. Einstein famously stated, “The pursuit of truth and beauty is a sphere of activity in which we are per-mitted to remain children all our lives.” Beauty is an order, a structure, a relation of parts that form a whole that is greater than the sum of the parts. This can also be a def-inition of truth. Truth and beauty are, in this essential re-spect, the same. But of course they are not entirely the same. Truth speaks to the intellect, beauty to the emotions. Yet they are the same in the sense that they are both rev-elations on the order of things, where the principle of unity must always be present. Accordingly, I believe there are two kinds of truth: the truth that lights the way, and the truth that warms the heart. The first of these is Science, the second is Art. Neither is independent of the other nor more important than the other, as I’ve indicated. “Truth is incontrovertible. Malice may attack it and ignorance may deride it, but in the end, there it is.” (Winston Churchill). “Every truth passes through three stages before it is rec-ognized. In the first it is ridiculed, in the second it is op-posed, in the third it is regarded as self-evident.” (Arthur Schopenhauer). Similarly, we refer to the art AND sci-ence of dentistry as being self-evident, noting that either is totally ineffectual without the other, and that both re-quire expertise and finesse.

Attainment and science, retainment and art— the two couples keep to themselves, but when they do meet, nothing else in the world matters.

Vladimir Nabakov

There is no painless process for giving birth to clin-ical excellence. A smooth sea never made a skillful mariner. Excellence is NEVER an accident, nor is it EVER negotiable. Excellence must be wooed, pursued, construed, and imbued! The nostrum has not yet been in-vented that will replace knowledge, skill, care and judg-ment. What we think, or what we know, or what we believe is, in the end, of little consequence. The ONLY thing of consequence is what we actually DO! Truly, the deed is everything, the glory naught. Thinkers think and doers do. But until the thinkers do and the doers think, progress will be just another word in the already overbur-dened vocabulary of the talkers who talk. The individual has always had to struggle to keep from being over-whelmed by the ‘group’ or the ‘pack’ mentality, i.e., con-sumed by contemporary mores. If you try being apart, you will be lonely often, and sometimes frightened, even cas-tigated. But no price is too high to pay for the privilege of thinking for yourself.

The chief enemy of creativity is “good sense.” Creativity starts where language ends.

Pablo Picasso

Now let me address Art and Occlusion more specif-ically. There is a fascinating and important dental pas de deux between form and function to be considered. Since all restorative dentistry deals in the marriage of form (art-ful morphology) and function (integrative intercuspation), and since the end result of all dental form must be suc-cessful cranio-mandibular function, morphology is obvi-ously destined to always assume a powerfully significant role in correct occlusion…which is, after all, the founda-tion and common denominator of all dentistry. A properly functioning occlusion is the result of properly formatted morphology. Occlusion without morphology is refractory and lame; morphology without occlusion is graceful but static. Occlusion is a unique cognitive nexus, a place where art and science come together in the human mind and are then refined and improved through clinical ex-perience. Malocclusion, on the other hand, is the tax mor-phology pays to clinical indifference.

However, if “the two couples keep to themselves” (Nabakov), dentists can easily initiate stress into the gnat-hic organ, since common dental procedures which in-variably alter the occlusal and incisal surfaces of opposing teeth manipulate musculoskeletal proprioception in a manner entirely unique to dentistry. Any decision to alter occlusal relationships is always a serious one, since ill-conceived, amorphic, artificially contrived dentate pseu-doforms may promulgate stress-inducing avoidance patterns which hobble the chewing cycle with occlusal dysrhythmia (Fig. 1).

Unfortunate oversights in our dental schools have al-lowed the teaching of occlusion to become marinated in conjecture, supposition, and speculation for decades, cur-rently having been ignominiously relegated to the disen-franchised, stagnant backwaters of dental education.

Live in contact with dreams and you will get some-thing of their charm: live in contact with ‘facts’ and you will get something of their brutality.

Winston Churchill

The ability to create a harmonious, non-deflective interocclusal relationship taxes the ingenuity of even the most careful and experienced dentist. No dental subject has received

more attention, or has had a more contro-versial history—with more divergent opinions and con-flicting theories—than has the strictly mechanical (artless) teaching of dental occlusion. There classically has been a critical, universal lack of adequate undergraduate as well as graduate education in the field of occlusion (especially morphology), and currently there sadly appears to be a virtual ‘occlusion moratorium’ in dentistry. Dentists, fol-lowing current trendy societal patterns and mores, have apparently boxed themselves into being ‘estheticians’. Rather than trying to find a way to treat the actual signs of occlusal disease, they cosmetically repair the symp-toms instead. It’s akin to a dermatologist simply treating acne with makeup. So what, then, does the future hold for occlusion/morphology? Given the current path most likely mediocrity, anxiety, confusion, widespread dis-satisfaction, and little patient benefit. Not a very pretty picture.
The biggest argument for a better occlusal education, one thoroughly grounded in the complex nuances of mor-phology, is a five minute conversation on these disciplines with the average dentist. But even during the years when occlusion was being inchoately taught, it generally was ‘taught’ by well-meaning but essentially artless dentists tethered to mechanical devices, vector forces and cali-brated amplitudes, compounded by variations in dogmatic instrument philosophy. Teaching the art of morphology as an indisputable key to understanding occlusion was never even considered.

A student at a well- known dental school was re-cently quoted as saying, ”The older faculty need to change their mentality about how to teach us.” Students today have grown up in a video game environment, which may well be the future of our dental education. But while recent dental research has made impressive advances in 3D virtual reality simulation, haptic feedback devices, and robotic patients, dental schools are not yet ready or able to invest in this sophisticated simulation technology. Moreover, to date none of these advancements include in-tercuspation simulation or morphology design apps. Were there no art applied to dental creation, the resultant inel-egance and ineptness of our restorations would make oc-clusion indeed baneful. How can we fabricate (carve, sculpt, shape, etc.) restorations to form an occlusion if we don’t know what they should look like? Lingering con-temporary ‘wisdoms’ are the main landmarks of the past.

Imagination is the beginning of creation. You imagine what you desire, you then will what you imag-ine and at last you create what you have willed.

George Shaw, English naturalist and an anatomist (1751-1813)

The human stomatognathic system may be a com-plicated one, but the mechanics of restorative treatment need not also be unnecessarily involved and complicated, as they often become. “Sophisticated” instrumentation and digitalized computer-assisted diagnostics with their analogous accoutrements are still nonetheless simply ex-trapolative. Skill in the digital age is confused with the mastering of digital devices; this veils the importance of understanding materials and intuiting the artful elements of shape and form. Articulators, irrespective of the plethora of devices to ‘simulate’ (or not!) the precise paths of mandibular movements, are useful mechanistic holding devices, no more and no less. They are all subject to human error in manipulation, record transfer, and by the imputation of magical qualities. The thought by some that by the mere possession of an analogue articulator or a dig-ital device, it will design and faithfully reproduce an oc-clusion and/or proper dentate morphology is fatuous. (Man will occasionally stumble over the truth, but usu-ally manages to pick himself up, walk over or around it, and then mindlessly carry on with his ‘search’). If anes-thesiologists followed this same path, they would still be using ether.

I cannot teach anybody anything, I can only make them think.

Socrates

The occlusion landscape is littered with ailing, mori-bund, or just plain dead and extinct mechanical instrume-nts and occlusal theories. Theories are like toothbrushes. Everyone has one, but nobody wants to use someone else’s. Currently, there is (unfortunately!) little ‘scientific’ evidence specifying occlusal and superstructure design theories for reconstructive fixed prostheses or implants. Occlusal scheme design and ‘correct’ occlusal formats have obviously evolved through clinical experience over the years, but there is no apparent ‘evidence’ to indicate that one particular design is superior, since there has been a dearth of long time follow-up reportage. In the past, it seems to have been a matter of conjuring up sufficient conclusions from insufficient premises and supposed ‘ev-idence’. Fortuitously, innate complex neurophysiological mechanisms allow the jaw muscle system to reflexly ac-commodate to the imposition of mechanical intercuspal malrelationships fostered by the slavish adherence to the archaic “hinge axis theory” of mandibular manipulation, which purportedly achieved a true “centric registration”

(?). There has been a long-held dental paradigm which tended to either accept the existing jaw position or to reposition it distally; the mandible invariably ended up in a compromised position.

The early use of articulators of any kind, as well as other attempts to replicate in the laboratory that which oc-curs kinematically in the oral cavity during function, gavebirth to an overly simplistic and mechanistic way of veiwing occlusion. This rudimentary model compulsively tried to relate the mandible to the skull in a way that all-owed for replication. As long as it was ‘reproducible’, the particular mandibular position with which the patient presented was the accepted ‘treatment position’; either that, or it was determined that it should be placed (ma-nipulated) more distally. The main decisive factor which was taught and stressed, was that the position selected HAD to be reproducible. Ah, but the key to understand-ing OCCLUSION is the understanding of MOR-PHOLOGY and the various everyday musculoskeletal biodynamic influences which affect occlusal morphology, not servile homage to mechanical devices. We can’t solve presenting occlusal problems when we use the same kind of thinking that was used when we supposedly were ‘taught’ occlusion in the past.

The only current diagnostic criteria (gold standard) for occlusal disorders is a thorough history and global clinical examination performed by an expert examiner who is not blinded by conventional thought. None of the occlusal contact detection instruments currently in use by dentists can be said to be more than ancillary documenta-tion devices with no proven ability or diagnostic validity. The bottom line is the individual’s ability to “think out-side the box”, to be innovative, creative, knowledgeable, visionary, and to perform expert clinical dentistry. Doing so entails a comprehensive understanding of the artistic nuances and clinical applications of human dental mor-phology. Morphology is not just what it looks like. Mor-phology is how it works, it’s sculptural knowledge made functional. Morphology trumps mechanics. Morphology is the condign abetment of articulation, which is the thing that really happens on the way to occlusion. To have great occlusion, there must be great morphology. We cannot cling to the past with marbleized intellectual rigidity if we are looking to break free from the staid occlusal think-ing that has been set up by conventional ‘wisdom’; we must step outside of our customary experiential comfort zones and seek new, different, and creative ways to in-corporate the ‘aesthetics of occlusion’ into our daily prac-tice. Creativity is allowing yourself to make mistakes. Art is knowing which ones to keep. Sprezzatura! (the art of effortless mastery).

The learn’d is happy nature to explore… The fool is happy he knows no more.

Alexander Pope

Few, (if any) schools taught/teach Dental Morphol-ogy as an art form, as I’ve mentioned. Sadly, adults in the Western world do not generally progress in their artis-tic skills much past the level of competence they achieved in grade school: they have a one-sided perception of life, the result of societal discrimination against the creativity in-herent in the right side of the brain. No matter what level of education or success they may have achieved in other areas of life, most adults draw like children and possess few perceptual skills. Some of these adults may eventual-ly seek admission to our dental schools. The penalty for these unfortunate people is to be imprisoned by a current technodigital mindset artlessly taught by dentists who un-fortunately teach mechano-morphology, and who may have no feeling for the fluidity of shape and form required to embrace the aesthetically animating Art of Morphol-ogy.

Language is ‘the dress of thought’, similarly mor-phology may be thought of as ‘the dress of the occlusion’. Custom (conventional ’wisdom’ ) is a tyrant; it does not recognize that morphology is actually the “Holy Grail” of occlusion. Just as we have dyslexia in language, we can have dysgraphia in writing, dyspictoria in art, dysmor-phia in anatomy, and dysfunction in occlusion. It’s the same kind of disability. Unfortunately, dentistry cannot truly flourish in such an artistically malnourished envi-ronment. Truthfully, is not the average dentist just a little confused and discontented with his or her knowledge of morphology and occlusion, perhaps even suffering from a painful occlusophobia? However, enlightenment is gen-erally preceded by confusion and discontent, which are the first necessities of progress …assuming the individ-ual’s will to think other than in the basically mechanical fashion promulgated by that which was taught by con-ventional ‘experts’. Every accomplishment starts with the decision to try. Patience, persistence and perspiration make an unbeatable combination for success.

Our chief want in life is somebody who shall make us do what we can.

Ralph Waldo Emerson

Like painting, music, poetry, sculpture, photography—and for that matter any form of creative human en-deavor—dentistry (morphology/ occlusion) is an art if done by an artist. In the hands of the uninspired or talent less, it’s neither more nor less than a craft, a means to pro-vide a living, or perhaps a pastime. The artist’s gift for sublime creation exists, unexplainably, in certain human beings, and that gift manifests itself through whatever form of expression that human being chooses. If it hap-pens to be morphology and occlusion so much the better for dentistry. The patient who has just completed a suc-cessful, aesthetic, complete mouth rehabilitation may well be assured that art, as well as science, was at the founda-tion of his or her rehabilitative success. Structural beauty (artful morphology!) must have been a determining crite-rion if successful function was achieved. First comes the muse, then the morphology.

Art and science compliment rather than contradict each other, as has been explained, via an entropic process not externally mandated. For example, society and con-ventional customs or reigning aesthetic fashion may at-tempt to dictate whether “high” art (?) is a string quartet, an oil portrait, a photograph, a bonsai tree, an operatic aria, or (wonder of wonders!) an occlusal reconstruction. However, the intrinsic artistic spirit can inhibit each, in which case each will speak for itself. Put simply, dentistry (occlusion/morphology) if done by an artist can’t not be art, if art is what he or she (the dental artist) intended. Most dentistry isn’t “high art” of course, nor is much of it truly ‘scientific’, given that much of what appears in our patients’ mouths isn’t necessarily intended to be seen as art, “cosmetic” though it may be.

And the first rude sketch that the world had seen was joy to his mighty heart, ‘till the Devil whispered behind the leaves ”It’s pretty, but is it Art?”

Rudyard Kipling

Expressing oneself aesthetically in dentistry involves an almost seamless fusion of instinct, mind, and eye. Every act of seeing becomes an act of judgment; but every closed eye may not be sleeping, and every open eye may not be seeing. It is the eye of ignorance that assigns a fixed and unchangeable prejudice, value, or color to every object seen. It seems apparent to me that dental education needs to study and explore a variety of art media; it should bring to clinical application a knowledge of design, spa-tial relationships, negative space appreciation, visual-image construction, fine line discrimination, exploring ‘creative nonconformity’, etc. In addition, there must be a desire to comprehend the human experience through a reflection made clearer by a close contact with the arts, an understanding of—and the appreciation for—the creative vistas of mental imagery. I believe we are in the middle of an imagery crisis; we’re experiencing a reduction in the wonder of creativity itself, and we’re hearing paltry few answers to the questions of how mental imagery is propagated, controlled, and how it is brought to fruition. Somewhere between chance and result lies imagination, the only thing that protects our creativity. Creativity starts where language ends, and is a natural extension of our being. Creativity, and where it comes from, is one of the last great human frontiers, and one over which we seem to have little control. You cannot reduce creativity to a systematic formula in our function-obsessed input-out-put, process-driven, bottom- line -driven digital world where morphology, occlusion, and dental artistry become consequently stifled.

An inconvenient truth, as has been stated, is that most dentists cannot faithfully replicate human dentate form. For example they have difficulty in conceiving that the occlusal geometrical configuration of the maxillary teeth is rhomboidal, and that of the mandibular teeth is trapezoidal, whereas the reverse is true when viewed proximally (Fig. 2).

Simple truths previously stated (although a pure and simple truth is rarely pure and never simple): If you can’t visualize it, you can’t draw it, and if you can’t draw it, you can’t carve it. And, if you can’t carve it, you haven’t been able to perceptually process morphologic visual in-formation enough to properly replicate human dentate form. The mind can see what the eye cannot. Conversely, the eye does not see what the mind has not taught it to recognize. It’s the retina-brain default connection. You have to ‘see’ there to ‘be’ there; always begin with the end clearly visualized in the mind. Restorations are carved with the mind, not the hand; the hand is merely a facili-tating appendage. The hand can never execute anything higher than the mind can imagine, no matter the legerde-main.


Drawing is a struggle between nature and the artist, in which the better the artist understands the intentions of nature, the more easily he will triumph over it. For him, it is not a question of copying, but of interpreting a simpler and more luminous language.

Charles Baudelaire

You have to learn to mentally perceive morpho-anatomic form not merely as a subject of formalist exer-cise, but something indeed capable of being transformed into corporeal reality. You’ll then begin to translate know-ledge into three dimensions. You’ll make morphology, which is the common denominator of all Occlusodontol-ogy, its precursor, and indeed the handmaiden to all oc-clusion—come alive! Replicating human dentate form is the sine qua non of all dentistry; it is the knowledge and will of the dentist expressed through shape and form, ob-jectifying right-brained thought and thus creating corpo-real reality. Thought becomes the sculptor. Between thought and reality, creation lies waiting in the Art of Morphology, which truly is the “Rosetta Stone” of Oc

clusion. MORPHOLOGY—the best way to learn occlu-sion—GUARANTEED!

We must realize that morphology and occlusion are inverse sides of the same coin. I have referred to mor-phology as the ‘the dress of occlusion’. Morphology is also the foundation and the pedigree of occlusion. For want of an aesthetic form (morphology), synchronous oc-clusion (function) may be forfeited. Ignorance of mor-phology becomes occlusion’s misfortune. You must not miss the crucial point that the two are indivisible: the way you work and the way you see spring from the same source. How you see is as important as what you see. Practicing without such visual knowledge might right-fully be regarded as dysmorphic ‘occlusoshamanism’, since teeth only mimic correct structural form and they function poorly—thus clinical morphageddon ensues. Alas, we’ve gone from the impetuous, feisty, and knowl-edgeable OCCLUSION! sturm und drang of the 50’s, 60’s, and 70’s to the regrettable death of the discipline (occlusopurgatory!) via ‘cosmetic’ default. It’s easier to get morphology to maintain an occlusion, than it is for occlusion to maintain its morphology. Occlusion without morphology is dysfunctional and injurious, and morphol-ogy without occlusion, sculpturally artful though it may be, nonetheless becomes static and inutile.

Those who dream by day are cognizant of many things which escape those who dream only by night.

Alexander Pope

To protect, preserve, and promote occlusal health, as well as the prevention and treatment of occlusal dis-ease–primary areas of intense scientific study, clinical re-search, and chairside application in the distant past–has now been essentially ignored as clinicians are failing to peer beyond what they consider the esthetic challenges of just the anterior teeth. And if or when they do so, they’re sadly unable to effectively correct occlusal malfunction as they happen to delve perilously into the unknown; the dark and foreboding posterior cuspated terrains of cranio-mandibular intercusption. In other words, while a plethora of trendy ‘Esthetic/Cosmetic’ courses virtually abound, most regrettably our dental schools (and post-graduate courses) continue to suffer a critical lack of adequate “Im-agery, Form, and Function” education in morphology and occlusion. Conventional voguishness is a tyrant.

The inevitable clinical result, unfortunately, is that crude posterior restoration dysmorphism ensues since cli-nicians are unable to discern (or correct) cuspal wear pat-terns which might otherwise be managed quite nicely, and artfully, via creative morphologic SHAPESHIFTING to subserve existing maxillo-mandibular malrela -tionships while at the same time maintaining essential anatomic form (Fig 3, A-C).

To paraphrase Francis Bacon, “There is no excellent form that hath not some strangeness in the proportion.” You can’t control the wind, but you can adjust your sails. Similarly, you may not be able to control changing neu-romuscular patterns secondary to life’s stresses, but you can adjust the resultant occlusion accordingly. That is, of course, if you know exactly how to adjust the occlusion! Dentate physiognomy, i.e., the resident occlusal topogra-phy, will speak to you if you but can understand the hid-den language inscribed therein. Posterior wear patterns (facets) visibly inscribe their history of functional inter-ferences via a kind of pictographic script. However, we do have the opportunity to be transformative with the aes-thetics of shape and form; indeed, we can engage in art-ful and creative pleomorphic topography alterations (ie, “occlusal adjustments”) in response to the given mor-phologic challenges fostered by occlusal malfunction.

These occlusal hieroglyphics are certainly no random
and meaningless scribble. It happens to be a real or-
ganic language which we must succeed in deciphering
if we are to master the elements of occlusal adjust-
ment. Shaw, 1924

End Part 1

PART II WILL EXPLORE MORE SPECIFICALLY THE “OCCLUSAL BALLET”, “LINGUOVISION”, AND THE CRITICAL NEED TO UNDERSTAND MOR-PHOLOGY AND ITS QUINTESSENTIAL RELA-TIONSHIP TO THE ART AND SCIENCE OF OCCLUSION.

About The Author

Dr. Harold M. Shavell, the author of the paper, is a 1962 graduate of the University of Illinois School of Dentistry (USA), where he was the recipient of the senior student Odontographic Society Award for outstanding compre-hensive dentisty. From 1962-1966 he served overseas in The US Army Dental Corps as Chief, Dental Clinic #4, Bad Kissingen, Germany. He has been a guest lecturer to the postgraduate departments of continuing education at the University of Illinois, Loyola University, and many ther universities throughout the US and overseas. He has been a member of the attending staff at Michael Reese Medical Center and a Consultant in Operative Dentistry at Illinois Masonic Medical Center where, for more than fifteen years, he conducted a year-long course in Com-prehensive Dentistry for the postgraduate dental resident teaching programs in the Chicago area. More recently, he conducted a similar monthly GPR guest lecturing pro-gram at Evanston Hospital.

Dr. Shavell has presented before the European Acad-emy of Gnathology and numerous other European insti-tutions in Denmark, Austria, France, Germany, Italy, Switzerland and The Netherlands. He has lectured ex-tensively to national, state, and local dental socities throughout the United States and in many countries of the world. In addition to various closed-circuit practical demonstrations on provisionalization, morphology, oper-ative dentistry, crown and bridge, occlusion, and perio-prosthetics, Dr. Shavell has published numerous articles in the scientific literature, and has been a contributor to dental textbooks.

In 1990, Dr. Shavell was among certain select au-thors recognized by the Journal of Operative Dentistry (May-June; 15, 3) for having made a ‘highly significant contribution to the advancement of operative dentistry’ in the ninety year post-G.V. Black era (“Classic Articles in Operative Dentisty: A Collection of the Most Significant Articles in Operative Dentistry in the Twentieth Cen-tury”). On August 31, 1998. Upon his retirement from ac-tive practice, Mayor Daley and the Chicago City Council officially proclaimed it was “Dr. Harold M. Shavell Day” in the city of Chicago. On August 10th, 2012, at the 37th Annual Meeting of the American Academy of Esthetic Dentisry, Dr. Shavell was the recipient of the Academy’s highest honor, the prestigious Charles L. Pincus Award for outstanding contributions to the advancement of es-thetic dentistry. This award has been presented only eight other times since the Academy’s inception.

Dr. Shavell has been an honored recipient of the Thomas P. Hinman Medallion, and a recipient of the dis-tinguished John Muir Medical Film Festival Award in Dentistry for 1984. He has been a member of the Acad-emy of Operative Dentistry; the American Academy of Occlusodontia; the American Prosthodontic Society; the Pierre Fauchard Academy; an Assosciate Member of the American Academy of Periodontology; 50 year Life member of the American Dental Associa-tion; 50 year Life Member of the Chicago Dental Society; Fellow and Life Member of the American Academy of Esthetic Den-tistry; Fellow, Academy of Dentistry International; Fel-low, American College of Dentists; and Fellow, International College of Dentists. Above all, Dr. Shavell (after four year’s service in the U.S. Army dental Corps 1962-1966), maintained a full time Perio-Prosthetic Restorative Dental Practice in Chicago from 1966-1998.

Commentary by Dr. Fazal Ghani, Associate Editor JPDA.

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