Predictable Bone Fill; A Five Year Follow Up Of Periradicular Surgery: Case Report

Fauzia Quadir1                                BDS, FCPS

Yawar Ali Abidi2                             BDS, FCPS

Shahbaz Ahmed3                            BDS, MSc, FCPS

Sofia Ali Syed4                                 BDS M Phil


The goal of periradicular surgery is to eliminate the periradicular inflammatory tissues and seal the apical foramen to create optimum conditions for healing through the regeneration of tissues, including the formation of a new attachment apparatus which is achieved by thorough curettage of the lesion. It includes removal of the pathological periradicular tissues for visibility and accessibility to facilitate the treatment of the apical root canal system, or sometimes for the removal of harmful foreign materials present in the periradicular area.

This case report describes the non-surgical and surgical endodontic treatment of a large cyst-like periradicular lesion in a 22-year-old male patient in the left maxillary anterior region. Conservative root canal treatment was carried out for the non-vital teeth, followed by peri-radicular surgery. The clinical and radiographic examinations after a five- year follow up period revealed complete periradicular healing. The appropriate diagnosis of periradicular lesions and the treatment of infected root canal systems allowed complete healing of these large lesions with endodontic surgery.

KEY WORDS: Periradicular surgery, Root canal treatment, Healing. Cyst, Curettage.

HOW TO CITE: Quadir F, Abidi YA, Ahmed A. Predictable Bone Fill; A Five Year Follow Up Of Periradicular Surgery: Case Report. J Pak Dent Assoc 2014; 23(1):36-40


Jaw cysts are broadly divided into odontogenic and non odontogenic cysts. Odontogenic cysts are classified into inflammatory and developmental cysts1. Radicular cyst is the most common inflammatory odontogenic cyst. Approximately 60 % of all jaw cysts are radicular cysts1. These cysts can occur in periapical area of any tooth (radicular cyst) or lateral aspect of roots with respect to accessory lateral canals (lateral radicular cyst) or at previous tooth extraction site (residual cyst) at any age but are rarely seen in deciduous teeth2,3. They develop as a subsequence of dental caries and tooth trauma following pulp necrosis and periapical infection5. They derive their epithelial lining from proliferation of epithelial cell rests of Malessez within periodontal ligament. The pathogenesis of cysts has been described in three phases6. Initially, the rests of Malassez begin to proliferate due to inflammatory products, bacterial antigens and the epidermal growth factors, followed by formation of a lumen due to necrosis of central epithelium and enlargement of cyst by increased osmotic pressure7,8.

Radiographically, the radicular cyst resembles periapical granuloma and appears as a single, small or large round to oval or pear-shaped radiolucencies around the apex of affected tooth or lateral aspect of root or within the alveolar ridge at the site of extracted tooth. Loss of lamina dura and root resorption is frequently seen in radicular and lateral radicular cysts9.

The histopathologic features of all three cysts are same. The cyst is lined by non-keratinized stratified squamous epithelium of variable thickness. Transmigration of inflammatory infiltrate with large number of neutrophils and few lymphocytes through epithelium is common. Amongst plasma cells, spherical intracellular accumulations of gamma globulin known as Russel bodies are often present. Dystrophic calcification, cholesterol clefts, areas of hemosiderin pigmentation, foreign body type-multinucleated giant cells may be present in lumen, wall or both. The lumen contains proteinaceous fluid and cellular debris10,11,12,13.

The treatment modalities for radicular cysts are surgical endodontic treatment, extraction of tooth, enucleation with primary closure, and marsupialization followed by enucleation14.

Investigations15,16,17have shown that large periradicular lesions may not respond positively to nonsurgical endodontic treatment, which is the first line of action, and periradicular surgery is usually the treatment of choice. However, the general consensus is that bacterial elimination from the root canal system by effective biomechanical preparation will lead to more successful outcomes18.

The following case report describes a large cyst-like periradicular lesion which was treated with the combination of non-surgical and surgical endodontic treatment, resulting in a predictable periradicular healing.


A 22 year old male patient presented to the Operative Department of Fatima Jinnah Dental Hospital, Karachi, in November 2005, complaining of dull throbbing pain in his maxillary anterior teeth for the last four days. The medical history was not significant although he did give a history of childhood trauma to his maxillary front teeth. On clinical examination, extraoral diffused swelling was seen on his right molar region. Intraorally, there was a complicated fracture of left central incisor. There was a large swelling palatally, extending from the right central incisor to the first molar region. It was also discoloured and tender to percussion (Fig 1).  The vitality test was

Fig 01

done using an electric pulp tester (Dentsply USA) and negative results were obtained for upper left central incisor, upper left lateral incisor and upper left canine. On periapical radiographic evaluation, there was periapical radiolucency involving the roots of upper left central and lateral incisors and upper left canine (Fig 2).

Fig 02

The radiograph could show the entire extent of the lesion very well, therefore no other intra-oral view was ordered. However, an OPG was taken to have a broder picture of the lesion with respect to other structures. A treatment plan was formulated and endodontic treatment of the non-vital tooth was done. In the first visit root canal treatment was initiated. Profound anaesthesia was given. Rubber dam was applied. The pulp chambers were opened with 0.04 round burs(Mani). Cleaning and shaping was done using a crown-down technique using 5.25% sodium hypochlorite as an irrigant. Pulpectomy was completed in all the three teeth simultaneously. The teeth were dried with sterile paper points and then filled with an intracanal dressing of calcium hydroxide (Calcipulp, Septodent) up to their apices. The access cavities were sealed temporarily with Light-Cure Glass-ionomer (Vitremer, 3M) and the patient was recalled after one week. The patient did not appear on the second visit. However in 2007, the patient reappeared with a huge bluish fluctuant palatal swelling measuring 3x3cm in his anterior segment (Fig 3). There was a discharging

Fig 03

sinus in the labial sulcus related to the apex of upper left central incisor. An OPG and periapical radiograph was taken. On radiographic evaluation, a much larger radiolucency was seen as compared to the previous radiograph, involving the roots of upper left central incisor, upper left lateral incisor and upper left canine The pathology appeared as a radicular cyst causing slight resorption of the root of the upper left maxillary central incisor. After discussion with the patient, it was planned that the root canal treatment of these teeth will be completed followed by periradicular surgery. Root canal treatment was completed (Fig 4) after a 3weeks phase

Fig 04

of intracanal dressing of calcium hydroxide (Calcipulp, Septodent). Obturation was done using cold lateral condensation method and corebuildup was done with composite, which was followed by the periradicular surgery. The surgery was carried out under effective local anaesthesia. A four cornered envelope flap extending from right upper central incisor to left upper first premolar

Fig 05

with releasing incisions was given to visualize the field. The lesion was found to have caused significant resorption of the buccal cortical plate and the root of upper right central incisor. Complete curettage of the lesion was ensured. The cavity was dried and apicectomy of the roots of the involved teeth was done followed by retrograde filling with Kalzinol (De Trey, Dentsply) (Fig 5). The flap was repositioned and sutured. Part of the excised tissue was sent to the lab for histopathological examination, the report of which confirmed it to be a radicular cyst.

The patient was given post-operative instructions and was re-called after one week for the removal of the sutures and an initial follow up. After three months, the teeth were given individual porcelain fused to metal (PFM) crowns to restore the aesthetics (Fig 6). The

Fig 06

patient was kept on a regular periodic follow up. Last radiograph was taken five years after the treatment (Fig 7).  The periapical radiograph and OPG revealed

Fig 07

constant regression of the periapical radiolucency which almost completely disappeared. There was appreciable bone fill in the area during this five year period.


The prognosis of periradicular surgery improves with decreasing periradicular lesion size and lesser apical resection19.  Studies on the outcome of periradicular surgery have reported variable results, ranging from a 30-80% success rate20.  However, these studies differed in sample size, type of teeth, surgical technique, type of root end filling materials and radiographic evaluation criteria. Recently, some longitudinal studies reported a higher success rate in periradicular surgery of teeth not responding to orthograde endodontic treatment21. Similarly modern surgical endodontic procedures are associated with a success rate of 92.5%22.

The ‘apical seal’ has long been considered paramount to the success of periradicular surgery23. Many materials have been used for apical sealing including reinforced zinc oxide-eugenol cement (Kalzinol) which has been used in this case. The material has a favorable tissue response when compared to amalgam23. There are other factors apart from the sealing ability of the material that influence the outcome or healing of the periradicular surgery which include differences between individuals in term of their ability to fight infection, age, medical status24. The patient in this case report was young and had no medical history and showed a promising periradicular healing. Jansson reported a poorer prognosis for larger  periapical lesions25.

However, Grung  found no relationship between lesion size and prognosis, which is very evident in the presented case report26.

There are a few criteria set to assess the healing or success of the periradicular surgery which take into account important aspects of healing like bone regeneration, periodontal ligament formation and clinical scale like pain and swelling. According to the criteria reported by VonArx and Kurt27, the presented case attains the criteria of success and complete healing respectively. A five year radiographic comparison (Fig 7) of this case report shows complete bone healing and periodontal ligament attachment formation.


It proved from this case report that periradicular surgery is treatment of choice in cases unresponsive to orthograde endodontic treatment and with large cyst like lesions of endodontic origin.


  1. Barnes L, Eveson JW, Reichart P. editors: World Health Organization classification of tumours: pathology and genetics of head and neck tumours, Lyon, France, 2005, IARC Press. pp 306-307.
  2. Jones A, Craig G, Franklin C. Range anddemographics of odontogenic cysts diagnosed in a UK population over a 30-year period. J Oral Pathol Med. 2006;35:500-507.
  3. Grewal HK, Batra R. Non syndromic bilateral dentigerous cysts – a case report. Int J Dent Clin. 2010;2:49-51.
  4.  Bhaskar SN: Periapical lesions-types, incidence, and clinical features, Oral Surg Oral Med Oral Pathol 1966; 21:657-71.
  5. Joshi UK, Patil SK, Siddiqua A. Nasopalatine cyst a rare entity. Int J Dent Clin.2010;2:34-36.
  6. Shear M. Cysts of the oral regions. 3rd edn. Oxford: Wright; 1992
  7. Jansson L, Ehnevid H, Lindskog S, Blomlöf L. Development of periapical lesions. Swed Dent J.1993;17:85-93.
  8. Nair PNR. Non-microbial etiology: foreign body reaction maintaining post-treatment apical periodontitis. Endod Topics 2003;6:114-34
  9. Sapp JP, Eversole LR, Wysocki GP. Contemporary Oral Pathology. 2nd edn. Mosby;2004.
  10. Regezi JA, Sciubba JJ, Jordan RCK. Oral Pathology: Clinical Pathologic Correlations. 6th edn. Elsvier Saunders; 2012.
  11. Damm D.D, Bouquot JE, Neville BW, Damm DD, Carl Allen C. Oral and Maxillofacial Pathology. 3rd edn. Elsvier Saunders; 2008.
  12. Browne RM. Cysts-Investigative pathology of odontogenic cysts CRC press. Boca Raton. 1991.
  13. Schulz M, von Arx T, Altermatt HJ, Bosshardt D. Histology of periapical lesions obtained during apical surgery. J Endod. 2009;35:634-42.
  14. Joshi.N, Sujan.S, Rachappa.M . An unusual case report of bilateral mandibular radicular cysts. Contemp Clin Dent.2011;2:59-62.
  15. Ozan U, Er K. Endodontic treatment of a large cyst- like periradicular lesion using a combination of antibiotic drugs: a case report. J Endod 2005; 31: 898-900.
  16. Oztan MD. Endodontic treatment of teeth associated with a large periapical lesion. Int Endod J 2002; 35: 73- 78.
  17. Cali’skan MK. Prognosis of large cyst-like periapical lesions following nonsurgical root canal treatment: a clinical review. Int Endod J 2004; 37:408-16.
  18. Broon NJ, Bortoluzzi EA, Bramante CM. Repair of large periapical radiolucent lesions of endodontic origin
    without surgical treatment. Aust Endod J 2007; 33: 36- 41.
  19. Pearrocha M, Mart E, Garca B, Gay C. Relationship of periapical lesion radiologic size, apical resection, and retrograde filling with the prognosis of periapical surgery. J Oral Maxillofac Surg. 2007;65: 1526-1529.
  20. Friedman S, Lustmann J, Shaharabany V. Treatment results of apical surgery in premolar and molar teeth. J Endod 1991; 17: 30-33.
  21. Zuolo ML, Ferreira MO, Gutmann JL. Prognosis in periradicular surgery: a clinical prospective study. Int Endod J 2000; 33: 91-98.
  22. Maddalone M, Gagliani M. Periapical endodontic surgery: a 3-year follow-up study. Int Endod J. 2003; 36: 193-198.
  23. Chong BS, Pitt Ford TR, Kariyawasam SP. Shortterm tissue response to potential root-end filling materials in infected root canals. Int Endod J. 1997; 30:240-249.
  24. Chong BS, Pitt Ford AR. Root-end filling materials: rationale and tissue response Endodontic Topics 2005;11:114–130.
  25. Jansson L, Sandstedt P, LÃ¥ftman A-C. Relationship between apical and marginal healing in periradicular surgery. Oral Surg Oral Med Oral Pathol 1997; 83: 596.
  26. Grung B, Molven O, Halse A: Periapical surgery in a Norwegian County Hospital: Follow-up findings of 447 teeth. J Endod 1990;16: 391.
  27. Von Arx T, Kurt B. Root-end cavity preparation after apicoectomy using a new type of sonic and diamond- surfaced retrotip: a 1 year follow-up study. J Oral Maxillofac Surg 1999; 57: 656-661.

  1. Professor and Head Department of Operative Dentistry Dr. Ishrat ul Ebad Khan Institute of Oral Health Sciences, Karachi.
  2. Assistant Professor Department of Operative Dentistry Dr. Ishrat ul Ebad Khan Institute of Oral Health Sciences, Karachi.
  3. Assistant Professor Department of Oral Pathology Dow Dental College, Karachi

Corresponding author: “Dr.Fauzia Quadir” < >

Epidemiology of Head and Neck Neoplasm’s in Balochistan

Nabiha Farasat Khan1 BDS, MPhil (Oral Pathology), M. Med Edu

Muhammad Saeed2 BDS
Hafiz Khush Naseeb Leghari3 MBBS, MS
Arshad Kamal Butt4 MBBS, FCPS
Ayyaz Ali Khan5 BDS, MSc, PhD


Objective: To identifies the type and demographic details of Head & Neck neoplasm (H&NN’s) in Balochistan, Pakistan.

Methodology: A retrospective analysis (hospital based) was carried out on 498 consecutive cases fulfilling the requirements of inclusion criteria (subjects having carcinoma of Head & Neck) in Center for Nuclear Medicine and Radiotherapy (CENAR), Quetta, Balochistan from October 10.2012 to October 26.2013. Study variables included demographic factors, enquiries regarding residence, site affected and diagnosis. Data entry and statistical analysis was done by using SPSS version 20. Data was presented in the form of percentages. Subjects having H&NN’s were included for study through simple convenient non-probability sampling from CENAR data.

Results: Almost half of the H&NN’s subjects belong to Afghanistan (n=216/498), the area critically affected next to Afghanistan having 37.15% of H&NN’s was Quetta division (n=185/498), whereas Kalat division with 7.63% carcinomatouss lesion stands third number in this category (n=38/498). Commonest (n=128/498) age range of subjects having H&NN’s is between 60-70 years (25.7%). Fifty four percent neoplasm’s’ (54.02%) were squamous cell carcinoma (n=269/498), Lymphomas with the percentage of 14.26 stands on second frequently existing carcinoma in this class.

Conclusion: The consequences of current research suggests that individuals from Afghanistan comprised highest incidence rate of Squamous cell carcinoma which was commonest in Balochistan whereas second common H&NN’s seen in the province was cervical lymph node cancers (lymphomas) in this grouping.

KEYWORDS: Neoplasm, Head and Neck, Balochistan.

HOW TO CITE: Khan NF, Saeed M, Leghari HKN, Butt AK, Khan AA. Epidemiology of Head and Neck Neoplasm’s in Balochistan. J Pak Dent Assoc 2017; 26(3): 118-122.

Received: 5 June 2017,  Accepted: 13 September 2017


Assistant Professor & Head of Oral Pathology Department, BDS, M.Phil (Oral Pathology), M. Med Edu, Bolan Medical College, Quetta, Pakistaneoplasm of head and neck (H&NN’s) is becoming an alarming situations globally.1 It includes larynx, pharynx, Naso-Pharynx and oral cavity. 1Worldwide incidence of H&NN’s ranks sixth whereas 25% of all H&NN’s are reported in South Asian countries (Pakistan, Bangladesh, Sri-lanka, India, Nepal and Bhutan) thus these regions are characterized as high risk areas.2 In Pakistan it is the second commonest malignancy in males.1, 3 Bhurgari (2006) 4 reported that top ten sites of H&NN’s were lip, oral cavity, pharynx and larynx. 2 She demonstrate that in India the incidence of H&NN’s is higher in males (12.8%) as compared to females, (7.8%). whereas the level of pharynx carcinoma is many folds higher in males (9.6%) as compared in females (1.8%), however carcinoma of oro-pharynx contribute the highest incidence (28.6%) in India, 4 on contrary, the incidence of H&NN’s is double in males (21%) and 11% in females in Karachi, Pakistan. 4 Although in Pakistan data related with oral carcinoma is available at national level 3, 5, 6. 7 but it does not encompass the demographic details and its types in Quetta, Balochistan. Therefore, the aim of current study was to record the demographic details and types of H&NN’s in Balochistan.

  • Senior Demonstrator Prosthodontics, Dental Section, Bolan Medical College, Quetta, Pakistan
  • (Nuclear Medicine), Director/ PMO, Nuclear Medicine and Radiotherapy, Quetta, Pakistan
  • (Gastroenterology and Hepatology) Shaikh Zayed Federal Postgraduate Institute, Lahore, Pakistan
  • Director Institute of Advance Health Sciences and Research, Lahore, Pakistan

Corresponding author: “Dr. Nabiha Farasat Khan”


This was a hospital based study carried out in Center for Nuclear Medicine and Radiotherapy CENAR, Balochistan; to find demographic data of patients suffering from H&NN’s and its incidence in Balochistan, and most frequent types of H&NN’s. The data was recorded from 10th October 2012 to 26th October 2013. Permission to carry out this study was taken from Head of Dental section Letter No 707/HDS, Dated 24 January 2014 which is accepted by the Director of CENAR.

CENAR is the only center for cancer diagnosis and treatment in Quetta, which not only cover the patients of the province but also provides treatment and management to patients of the neighbor country Afghanistan. Data related with H&NN’s was gathered; demographic details were also collected and included in the current study. By investigating chart reviews of H&NN’s patient’s from 10. 10.12 To 26.10.13, data related with age, gender, residence, diagnosis and types of H&NN’s respondents of H&NN’s was separated and recorded manually by investigator within 2 months (January-February 2015).

Sampling Technique & Sample Size: Through simple convenient non-probability sampling technique 498 samples of H&NN’s were recorded from October 2012-13. Inclusion criteria for study population consisted of all registered patients of CENAR suffering from H&NN’s during the period of 1 year. Patients having cancer of other sites newly admit patients and patients other than October 2012-13 were excluded from the study to check the level, site of carcinoma and residence of patients suffering from H&NN’s.

Statistics: Data was entered in SPSS version 20 and statistical analysis was carried out and was presented in the form of percentages.


The study evaluates residence area and types of H&NN’s in Balochistan. It also demonstrates the demographic details of selected patients. Data gathered from CENAR demonstrates that 57% (n=213/498) more than half of these patients were males. Current study shows that 25.7% patients (n=128/498) were above the age of 60 years. Second common age range was above 70 years of age (n= 97/498).

Table 1 demonstrates age, gender, number of patients and their percentages.

Table 1.     Age and Gender of Head & Neck Neoplasm’s patients.

The data showed that 43.37% (n=216/498) belonged to Afghanistan; some of them (21.6%) were residing in Quetta while others came to Quetta for treatment. Map of Balochistan demonstrates patient’s residence area and its percentage, whereas Afghanistani affected population can be detected near Western border of Balochistan while Sindhi patients belong to South Eastern border of Balochistan. See Fig. (1).

The results pointed out that squamous cell carcinoma was the commonest reported carcinoma followed by Lymphomas and carcinoma of oral cavity becomes 3rd. The type and its percentage of H&NN’s in patients are presented in Bar chart. See Fig. (2).


Majority (57%) of the patients suffering from H&NN’s were males, 25.7% of them were above the age of 60 years. Out of these 498 H&NN’s patients 43.37% (216) were Afghani citizens. Squamous cell carcinoma was the commonest carcinoma observed in current study (54.02%)

Though Balochistan is the biggest province of Pakistan but unfortunately the population is scattered, poor and illiterate. 8, 9 All these elements affect health of the population. The tendency to register the cases of H&NN’s for its management is very low peculiarly in the case of female and child population, and especially in case of periphery due to the lack of facilities. (transport and health facilities) 9, 10 In Afghanistan (neighbor country of Pakistan) the condition is even worse than Balochistan, although the predispose factors remain same as in Balochistan.

Fig. (1). Map demonstrating Head & Neck Neoplasms Patients & their Residence Area.


Fig. (2). Types of Head and Neck Neoplasm’s in Bar Chart.

However, due to the result of US invasion in 2001 people are malnutrished to a greater extent. 11

Incidence of H&NN’s is prominent globally. Majority of studies conducted by Caucasians and Asiatic researchers analyzed that males are more commonly affected by H&NN’s as compared to females with M: F ratio of 1.37:1. 12 Previous studies completely matched with the analysis of current study as 57.2% (n= 285/498) H&NN’s patients were males in present study. The eminent degree of H&NN’s in Balochistani males may be due to the enhanced consumption of hot beverage particularly black tea, life style changes, naswar consumption, increased use of beef and smoking. 2, 3, 13

Current study shows that 25% patients having HNN’s were above the age of 60 years. This observation is correlated with the study result of Filho MR deM and his co-workers (2013), 13 in their study population (n=29) they observed that 41.4% patients (n=12) were above the age of 60 year. 13

Forty three percent patients (n=216/498) suffering from H&NN’s of current study belong to Afghanistan; however the condition was completely revert in the results of study carried out by Rooh-Ullah et al in 2012 7 where majority of the cases were from Quetta. He mentioned that during the period of 1998 to 2009, out of 10861 (90.34%) cancer patients only 1157 (10.65%) patients have had H&NC’s, 698 (12.42%) of them were males and 438 (9.43%) were females whereas there were 21 children. Calculations of his study carried out in CENAR 7 demonstrate that 3211 (29.56%) patients suffering from cancer of different sites were from Afghanistan. Whereas 90 Afghani males patients, 156 females and 8 children were suffering from H&NN’s. 7 The results of current study indicated highest level of H&NN’s from migrants of Afghanistan, the difference between our study results and results of Roohullah may be due to the increase in migration of H&NN’s patients from Afghanistan for the treatment due to lack of treatment facilities in Afghanistan. The possible cause of high incidence level of H&NN’s in Afghanistan is mal-nutritution, 14, 15 increased consumption of hot food fluid/solid (hot tea/soup), 16 altered immunity. 17 It may also be the side-effect of heavy bombing during the 2001 US war. 18

The incidence of H&NN’s in Baloch belt including Makran, Naseerabad and Sibi comprises very low rate, where as Kalat also demonstrates bottom line extent of H&NN’s (7.63%, 38/498 patients). This low level of H&NN’s in this belt is due to the fact that majority of the population belong to low socio-economic status are; illiterate and are unable to recognize the complications of their oral disorders thus unable to register and get treatment. 6, 8 In addition population of periphery is scattered and far away from center of province (Quetta) thus, unable to travel, 10 or it may be due to their movement towards Karachi for treatment purposes. 19 A positive factor of this low level of H&NN’s in Baloch population is its clear atmosphere. 20 However; there exists a general misconception in Pakistan

that one should visit to the hospital only when he/she becomes ill and people feel that regular health checkup is unnecessary. Many cancers can be detected on routine checkups but due to lack of understanding most of the cancers are diagnosed at late stages when the disease becomes incurable. On the other hand level of H&NN’s in Mastung is 3.01% and 1.81% in Khuzdar. The reason behind this high incidence rate in these two areas is that people of these areas have high consumption of smokeless tobacco in the form of naswar and huqqa, 20 in addition to that they also take hot black tea 16 which is another possible cause of H&NN’s.

As compared to these rural areas, urban population is literate thus able to distinguish all predisposing elements (Viruses, Chemicals, Genetic defects (hereditary), Tobacco, Alcohol, Food, and Sun exposure) as risk factors of cancer, moreover access to treatment facilities and awareness resources are easy as compared to rural areas. 9, 21

The higher incidence of H&NN’s was observed in Quetta division (n=185/498). The reason behind it is its cup shape appearance which causes air pollution; 20 in addition subjects are malnutrient due to low socio-economic and unable to take fruits, fresh food, vegetables 14 they are using naswar, 20 cigarette 18 and hot tea 16 all these variables enhances development of H&NN’s.

In current study, squamous cell carcinoma comprises the most common type of oral carcinoma (269/498). The reason behind it is bulk of the population is consuming smokeless tobacco in the form of naswar, tobacco in cigarette and huqqa etc.22Another etiological factor is low socio-economic status which heightens the risk of SCC.3 Sobin L demonstrated that in 1969 cancer of oral cavity in Afghanistan was very low 23 however; the situation is reversed now and most of the patients suffering from oral cavity neoplasm were from Afghanistan (n=216/498) and majority of them were suffering from squamous cell carcinoma.

Lymphomas were the second commonest cancer in 2012-2013. Most of the patients of cervical lymph carcinoma were from Afghanistan. The reason behind lymphoma (Hodgkin’s or Non-Hodgkin) may be poverty, depressed immunity or malnutrition. 23 Results of Sobin L study also identified Lymphomas as second most common carcinoma of Afghani, the rate of occurrence of Lymphomas was 4.7 (n=59/550). This may be the result of low/lack of medical facilities, use of smokeless tobacco, hot black tea etc. 22

Oral cancer is the third common carcinoma seen in Balochistan. The results of our study correlate with the results of Bhurgai 2006. 4 She observed that Karachi and Balochistan are highest risk zones for oral cancer, where as New Guinea and Solomon Islands also shows prominent incidence rate. 5

Strength & Weaknesses of Study

Current study provides information about types and sites of H&NN”s in CENAR (Balochistan). Demographic view of patients was also considered which were not available before. All data of H&NN’s available in CENAR was not recorded. Current study comprises H&NN’s data of only one year.

Need for Additional Research

There is a need to examine high risk populations for educational and investigation programmes. These programmes help in decreasing the burden and unfavorable outcomes of H&NN’s.


It was concluded that during the period of October 2012-3 most of the patients suffering from H&NN’s belong to Afghanistan and were affected with squamous cell carcinoma.


Authors of current study acknowledge I.T department Bolan Medical College, Quetta for their contribution in graphical views.


The abstract of the current study is not presented or published in a conference, or published in an abstract book or any other relevant information.

Conflict of Interest

Authors of the study declare no conflicts of interest to disclose. Moreover there is no funding sources related with this search.


  • Warnakulasuriya S. Global epidemiology of oral and oropharyngeal cancer. Oral Oncol 2009; 45: 309–16.
  • Mao L, Hong WK, Papadimitrakopoulou VA. Focus on head and neck cancer. Cancer Cell 2004; 5: 311–16.
  • Joshi P, Dutta S, Chaturvedi P, Nair S. Head and neck cancers in developing countries. Rambam Maimonides Med J 2014 ;5 : e0009.
  • Bhurgri Y, Bhurgri A, Usman A, Pervez S, Kayani N, Bashir I, et al. Epidemiological review of head and neck cancers in Karachi. Asian Pacific J Cancer Prev. 2006; 7: 195–200.
  • Chaudhry S, Khan AA, Mirza KM, Iqbal AH, Masood Y, Khan NR, et al. Estimating the Burden of Head and Neck Cancers in the Public Health Sector of Pakistan. Asian Pacific J Cancer Prev. 2008; 9: 529–32.
  • Rooh-Ullah, Khursheed MA, Shah MA, Khan Z, Haider Sw, Burdy GM et al. An alarming occurence of Esophageal cancer in Balochistan. Pak J Med Res 2005; 44: 101–04.
  • Rooh-Ullah, Ahmed HKN, Ahmed I, Khjawa A, Shuja J, Ahmed J et al. Prevalence of Cancer in CENAR Quetta. Annals of Punjab Med College 2012; 6: 37-41.
  • Malik AB, Amin N, Ahmad K, Mukhtar EM, Saleem M, Kakli MB. Pakistan Education for all 2015 National Review. Pak EFA Review Report 2015; Ministry of Education, Islamabad.
  • BALOCHISTAN Problems and Solutions. Vision 21–problems–solutions.pdf.
  • Nawaz-ul-huda S, Burke F, Azam M. Socio-economic disparities in Balochistan , Pakistan – A multivariate analysis. Malaysia J of Soci Space 2011; 4: 38–50.
  • Malnutrition in Afghanistan.
  • Global Cancer Facts & Figures 2007. American Cancer Society . 2007;…/globalfactsandfigures…
  • Chuang SC, Jenab M, Heck JE, Bosetti C, Talamini R, Matsuo K et al. Diet and risk of head and neck cancer: A pooled analysis in the INHANCE consortium. Cancer Causes Control 2012; 23: 69-88.
  • ADA Reports. Position of the American Dietetic Association : Oral health and nutrition. J Am Diet Assoc 2003; 3: 615–25.
  • Craw-ford NC. War-related Death, Injury, and Displacement in Afghanistan and Pakistan 2001-2014. Watson Institute for International Studies Brown University 2015.
  • Wu C-H, Bair M-J, Lin I-T, Lee Y-K, Chen H-L. Early endoscopic finding of esophageal thermal injury after having spicy hot pot. Adv Digest Med 2015; 2: 111–13.
  • Chang MC, Chiang CP, Lin CL, Lee JJ, Hahn LJ, Jeng JH. Cell-mediated immunity and head and neck cancer : With special emphasis on betel quid chewing habit. Oral Oncol 2005; 41: 757–75.
  • Azad M-D, Pervaiz G, Pervaiz MK. Most Significant Risk Factors for Head and Neck Cancer. Journal Stat 2007; 14: 1–12.
  • Bhurgri Y, Pervez S, Usman A, Khan JA, Bhurgri A, Kasi Q et al. Cancer Patterns in Quetta 1998-1999. J Pak Med Assoc 2002; 52: 560-65.
  • Ilyas SZ. Air Pollution Studies and Determination of Smoke Particles Size on Siryab Road , Quetta , Pakistan. World Appl Sci J. 2006; 1:122–26.
  • Agrawal M, Pandey S, Jain S, Maitin S. Oral Cancer Awareness of the General Public in Gorakhpur city India. Asian Pac J Cancer Prev 2012; 13: 5195-99.
  • Basharat S, Kassim S, Croucher RE. Availability and use of Naswar : an exploratory study. J Public Health 2012; 34: 60–64.
  • Sobin L. Cancer in Afghanistan. Am Cancer Soc 2016; 23: 678–88.

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.


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


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.