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The International Journal of Periodontics & Restorative Dentistry The International Journal of Periodontics & Restorative Dentistry © 2021 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. 61 Posterior Bite Collapse and Diagnostic Grading for Periodontitis Scott S. Nakamura, DMD1 The major outcome from the 2017 David Donatelli, DMD, FACP2 World Workshop on the Classifica- Edwin S. Rosenberg, DDS3 tion of Periodontal and Peri-implant Diseases and Conditions was to pro- vide a staging system for periodon- titis. The framework and proposed The syndrome known as posterior bite collapse (PBC) has taken on multiple four stages of periodontitis, defined definitions over the years since its first introduction in 1964 by Morton Amsterdam by severity and extent of periodon- and Leonard Abrams. In 2017, the World Workshop in the Classification of tal breakdown and complexity of Periodontal and Peri-implant Diseases and Conditions proposed a staging management, was published by system for periodontitis, defined by severity and extent of periodontal 1 breakdown. Within this staging system, Stage IV periodontitis can include Tonetti et al in the Journal of Clinical PBC. However, without a clear delineation regarding the clinical presentation Periodontology and subsequently or pathogenesis of PBC, this further obfuscates its definition. It is therefore the adopted by the American Academy goal of this article to reexamine the original definition of PBC as defined by of Periodontology. According to this Amsterdam and Abrams, present an updated definition, and propose a clinical classification, Stage IV periodontitis grading system of PBC to coincide with the 2017 staging of periodontitis. Int can include posterior bite collapse J Periodontics Restorative Dent 2021;41:61–69. doi: 10.11607/prd.4930 (PBC) and references a Journal of Clinical Periodontology article by Nyman and Linde.2 The clinical syndrome known as posterior bite collapse first appeared in the 1964 textbook Periodontal Therapy. Morton Amsterdam and Leonard Abrams described a syn- drome with multiple etiologic fac- tors, where the loss of posterior oc- clusal support potentially led to the breakdown of the functional protec- tive capacity of the entire dentition, 1Department of Restorative Dentistry, Kornberg School of Dentistry, Temple University, resulting in further tooth loss (TL), Exton, Pennsylvania, USA. increasing fremitus/mobility, second- 2Private Practice, Philadelphia, Pennsylvania, USA. 3Department of Periodontics, University of Pennsylvania School of Dental Medicine, ary occlusal trauma (OT), anterior Philadelphia, Pennsylvania, USA. flaring (AF), and ultimately loss of occlusal vertical dimension (OVD).3 Correspondence to: Dr Scott S. Nakamura, Department of Periodontics and Restorative Unfortunately, since this is a broadly Dentistry, Kornberg School of Dentistry, Temple University, 80 W Welsh Pool Rd #207, Exton, PA 19341, USA. Email: [email protected] encompassing diagnosis, PBC has taken on different, often erroneous, Submitted March 8, 2020; accepted April 30, 2020. ©2021 by Quintessence Publishing Co Inc. interpretations over the years; most Volume 41, Number 1, 2021 © 2021 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. 62 due to excessive occlusal load and/ agnosis and treatment plan.” They or a pathological neuromuscular pat- also state that when reviewing the tern, represents, together with the literature, there are incongruities in loss of posterior occlusal support, Amsterdam’s definition of PBC given the most prominent clinical sign of to disparaging clinical situations that the total posterior bite collapse.” The present with loss of OVD. most common cause of PBC is the According to Tonetti et al,1 the Fig 1 Normal/ideal, periodontally healthy loss of molars and their nonreplace- difference between Stage III and occlusion without TL. ment. Conditions such as excessive Stage IV periodontitis is case com- occlusal wear due to parafunction, plexity. Primary factors such as tooth faulty dental restorations, malocclu- mobility and PBC with drifting and common include the presence of sions, inadequate orthodontic treat- flaring of teeth can add complexity periodontitis, AF, and loss of OVD. ment, or dental caries might also be to a case. The purpose of this article Since its first publication, mul- considered predisposing or initiat- is to elucidate the original definition tiple articles have obfuscated rath- ing factors that potentially result in: of PBC and its multiple clinical mani- er than clarified the meaning and drifting of the mandibular premolars festations, as well as to propose a clinical course of PBC. The goal of and molars into the now-edentulous grading framework for PBC. this article is to reexamine its origi- area; extrusion and rotation of the nal definition, elucidate its multiple maxillary molar into the edentulous clinical manifestations, and propose area; and temporomandibular dys- PBC, Defined a grading system for PBC. function (TMD). Furthermore, oc- clusal discrepancies could result in PBC is a means to describe a clini- infrabony defects, causing areas for cal syndrome with multiple, often Methodology food impaction and plaque accumu- pathognomonic factors that deviate lation,6 leading to the progression of from a normal or “ideal” occlusion A search of the term “posterior bite periodontitis with increasing tooth (Fig 1) in which the posterior occlu- collapse” using the database of the mobility and, ultimately, AF and sub- sion is compromised and may ulti- Temple University Kornberg School sequent loss of OVD. Similar findings mately result in the destruction of of Dentistry was performed, and a were published by Rosenberg7 and the functional protective capacity of finite series of articles published Rosenberg and Lever,8 adding that the entire dentition. Secondary clini- from 1970 to 2018 was found. These PBC may be found in the absence of cal sequelae may include, singularly articles were secondary reviews and tooth loss and periodontitis. Dersot or in combination: the accelerated provide cursory analyses of Amster- and Giovannoli9 stated that PBC is a progression of periodontitis, TMD, dam and Abrams’ publications and sequelae of advanced breakdown, increasing mobility/fremitus, addi- theses. influenced by periodontal inflamma- tional TL, AF, and loss of OVD. Etio- tion and attachment loss (AL), which logic factors may include (but are can lead to tooth migration as a re- not limited to), singularly or in com- Historical Background sult of occlusal forces. Mesial drifting bination: TL without replacement of teeth with AF may be aggravated (Fig 2), orthodontic malocclusions Since PBC’s first publication, multiple by the nonreplacement of missing and dental-skeletal disharmonies articles have been published attempt- teeth, malocclusion, or neuromuscu- (Fig 3), periodontitis (Fig 4), acceler- ing to elucidate PBC but have only lar disorders.9 Shifman et al10 stated ated retrograde occlusal/interproxi- brought greater confusion. Brayer “although there are different defini- mal wear (Figs 5 and 6), severe car- and Stern4,5 maintained that “the tions of PBC, only the definition by ies, or iatrogenic and conformitive flaring of the anterior teeth, whether Amsterdam provides a definite di- dentistry3 – 5,7,8,11 (Fig 7). The International Journal of Periodontics & Restorative Dentistry © 2021 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. 63 a b c Fig 2 (a) Buccal and (b and c) lateral views of orthodontic malocclusion Class I (CLI) presenting with bite collapse, bilaterally missing man- dibular first molars, and a reduced yet healthy periodontium. Tipping and extrusion of posterior teeth were noted, along with increasing anterior diastema, an increased intercuspal/centric relation (IC/CR) relationship, and mild loss of OVD. a b c d e f Fig 3 Periodontally stable malocclusions presenting with PBC without TL. OVD loss may be seen if the rate of occlusal wear exceeds the rate of compensatory eruption. (a and b) Class II division 1 (CLIId1) and (c and d) division 2 (CLIId2) malocclusions. (e and f) Class III (CLIII) malocclusion. Volume 41, Number 1, 2021 © 2021 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. 64 Fig 4 (a) Clinical and (b) radiographic views of a CLI malocclusion in PBC with peri- odontitis and TL. The denti- tion presented with secondary OT, increasing mobility/fremi- tus, displacement of teeth out of trauma, loss of OVD, and anterior displacement of the mandible with an increased a b IC/CR relationship. b Fig 6 (a) Buccal and (b and c) lateral oc- Fig 5 CLI malocclusion in PBC with clusal views of a CLIId1 malocclusion in a primary OT and accelerated retrograde PBC with periodontitis and no TL. Broad wear. The dentition is periodontally stable, interproximal contact was seen in the with TL, loss of OVD, and no AF. Due to posterior dentition, indicative of acceler- the unstable IC position, the mandible is ated interproximal wear and drifting. postured anteriorly to a pseudo-dental Increasing
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