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
breakdown. Within this staging system, Stage IV periodontitis can include Tonetti et al1 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,
Department of Restorative Dentistry, Kornberg School of Dentistry, Temple University,
1
resulting in further tooth loss (TL),
Exton, Pennsylvania, USA.
2Private Practice, Philadelphia, Pennsylvania, USA.
increasing fremitus/mobility, second-
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: idcexton@gmail.com 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

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62
Fig 1 Normal/ideal, periodontally healthy
occlusion without TL.
common include the presence of
periodontitis, AF, and loss of OVD.
Since its first publication, mul-
tiple articles have obfuscated rath-
er than clarified the meaning and
clinical course of PBC. The goal of
this article is to reexamine its origi-
nal definition, elucidate its multiple
clinical manifestations, and propose
a grading system for PBC.
Methodology
A search of the term “posterior bite
collapse” using the database of the
Temple University Kornberg School
of Dentistry was performed, and a
finite series of articles published
from 1970 to 2018 was found. These
articles were secondary reviews and
provide cursory analyses of Amster-
dam and Abrams’ publications and
theses.
Historical Background
Since PBC’s first publication, multiple
articles have been published attempt-
ing to elucidate PBC but have only
brought greater confusion. Brayer
and Stern4,5 maintained that “the
flaring of the anterior teeth, whether
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due to excessive occlusal load and/
or a pathological neuromuscular pat-
tern, represents, together with the
loss of posterior occlusal support,
the most prominent clinical sign of
the total posterior bite collapse.” The
most common cause of PBC is the
loss of molars and their nonreplace-
ment. Conditions such as excessive
occlusal wear due to parafunction,
faulty dental restorations, malocclu-
sions, inadequate orthodontic treat-
ment, or dental caries might also be
considered predisposing or initiat-
ing factors that potentially result in:
drifting of the mandibular premolars
and molars into the now-edentulous
area; extrusion and rotation of the
maxillary molar into the edentulous
area; and temporomandibular dys-
function (TMD). Furthermore, oc-
clusal discrepancies could result in
infrabony defects, causing areas for
food impaction and plaque accumu-
lation,6 leading to the progression of
periodontitis with increasing tooth
mobility and, ultimately, AF and sub-
sequent loss of OVD. Similar findings
were published by Rosenberg7 and
Rosenberg and Lever,8 adding that
PBC may be found in the absence of
tooth loss and periodontitis. Dersot
and Giovannoli9 stated that PBC is a
sequelae of advanced breakdown,
influenced by periodontal inflamma-
tion and attachment loss (AL), which
can lead to tooth migration as a re-
sult of occlusal forces. Mesial drifting
of teeth with AF may be aggravated
by the nonreplacement of missing
teeth, malocclusion, or neuromuscu-
lar disorders.9 Shifman et al10 stated
“although there are different defini-
tions of PBC, only the definition by
Amsterdam provides a definite di-
agnosis and treatment plan.” They
also state that when reviewing the
literature, there are incongruities in
Amsterdam’s definition of PBC given
to disparaging clinical situations that
present with loss of OVD.
According to Tonetti et al,1 the
difference between Stage III and
Stage IV periodontitis is case com-
plexity. Primary factors such as tooth
mobility and PBC with drifting and
flaring of teeth can add complexity
to a case. The purpose of this article
is to elucidate the original definition
of PBC and its multiple clinical mani-
festations, as well as to propose a
grading framework for PBC.
PBC, Defined
PBC is a means to describe a clini-
cal syndrome with multiple, often
pathognomonic factors that deviate
from a normal or “ideal” occlusion
(Fig 1) in which the posterior occlu-
sion is compromised and may ulti-
mately result in the destruction of
the functional protective capacity of
the entire dentition. Secondary clini-
cal sequelae may include, singularly
or in combination: the accelerated
progression of periodontitis, TMD,
increasing mobility/fremitus, addi-
tional TL, AF, and loss of OVD. Etio-
logic factors may include (but are
not limited to), singularly or in com-
bination: TL without replacement
(Fig 2), orthodontic malocclusions
and dental-skeletal disharmonies
(Fig 3), periodontitis (Fig 4), acceler-
ated retrograde occlusal/interproxi-
mal wear (Figs 5 and 6), severe car-
ies, or iatrogenic and conformitive
dentistry3–5,7,8,11 (Fig 7).
 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.

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64
a b
Fig 5 CLI malocclusion in PBC with
primary OT and accelerated retrograde
wear. The dentition is periodontally stable,
with TL, loss of OVD, and no AF. Due to
the unstable IC position, the mandible is
postured anteriorly to a pseudo-dental
CLIII malocclusion with an increased IC/CR
relationship.
Fig 7 Periodontally stable dentition that
has been restored in PBC with missing
posterior teeth and loss of OVD. AF is not
evident due to the fixed partial denture
masking the flaring. Because of the AF,
occlusion is established such that the man-
dible is positioned anteriorly to a pseudo-
dental CLIII malocclusion with an increased
IC/CR relationship.
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a
c
Bite Collapse, AF, and OVD
AF and loss of OVD have always
been a point of contention in the di-
agnosis of PBC. The literature is re-
plete with the assumption that OVD
loss and AF are requisites for PBC.
The most common progression of
PBC is due to the premature loss of
the 6-year molar, resulting in the ac-
celerated mesiodistal drift of teeth
and loss of the stabilizing support
of the posterior teeth. The loss of
the natural protective capacity that
the posterior teeth provide results
in an extension of excessive occlu-
sal loads to the anterior teeth as the
mandible is positioned anteriorly.
This positioning is to avoid prema-
ture posterior interferences and to
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
IC/CR relationship.
b
Fig 6 (a) Buccal and (b and c) lateral oc-
clusal views of a CLIId1 malocclusion in
PBC with periodontitis and no TL. Broad
interproximal contact was seen in the
posterior dentition, indicative of acceler-
ated interproximal wear and drifting.
Increasing mobility/fremitus, extrusion of
the mandibular anterior teeth, AF, loss of
OVD, and an increased IC/CR relationship
were noted. Photos courtesy of Dr Morton
Amsterdam.
obtain a stable intercuspal (IC) po-
sition, resulting in AF and the even-
tual loss of OVD.3,11 Marks12 states
that the nonreplacement of miss-
ing posterior teeth can cause the
adjacent teeth to tip into the open
space, thereby shifting those por-
tions of the teeth that support the
posterior occlusion, resulting in the
loss of OVD. Based on these state-
ments, it is easy to conclude that
PBC is synonymous with TL, AF, and
loss of OVD.
However, Chasens13 states that
the remaining dentition may be
stable enough to maintain a physi-
ologic OVD (Fig 8). Furthermore, is
it possible to have PBC without loss
of OVD, TL, or AF? PBC can occur
in the periodontally stable patient
 65

a b

Fig 8 (a) Clinical and (b) radiographic view of a periodontally stable CLI malocclusion presenting with PBC, a missing mandibular right first
molar without AF, and no significant loss of OVD.

a b
Fig 9 (a) Buccal and (b) mandibular occlusal views of a periodontally stable CLIId2 malocclusion presenting with PBC. Maxillary AF is not
noted. However there is an increase in the anterior overbite relationship as OVD is lost due to accelerated retrograde wear of the denti-
tion.

a b c
Fig 10 (a) Buccal and (b and c) lateral views of a CLIId1 malocclusion presenting with PBC. The dentition presents with periodontitis, TL,
displacement of teeth, maxillary AF, and loss of OVD, contributing to an unstable IC position. The mandible is postured anteriorly to a
pseudo-dental CLIII malocclusion with an increased IC/CR relationship.

with primary OT, in which the den-
tition becomes mutilated when the
rate of retrograde wear exceeds
the rate of compensatory eruption,
resulting in a net loss of OVD with-
out AF14 (Figs 5 and 9). Ultimately,
indicators of probable loss in OVD
include increasing mobility/fremitus,
displacement of teeth, increased
AF, accelerated retrograde occlusal
wear, and an increase in IC/centric
relation (CR) relationship (Fig 10).
Bite Collapse in the Presence
of Dental/Skeletal Malocclusion
In 1900, Edward Angle published
the first classification of orthodon-
tic malocclusions, known today as

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66
normal occlusion and malocclusion
Class I (CLI), Class II (divisions 1 and
2; CLIId1 and CLIId2, respectively),
and Class III (CLIII). Although re-
ferred to as a “malocclusion,” these
occlusal patterns, which deviate
from the ideal, may be physiologic,
and are more susceptible to peri-
odontal breakdown, are classified as
PBC (Fig 3). Although most maloc-
clusions will follow the clinical pat-
tern of PBC originally published by
Amsterdam and others, they vary
depending upon Angle’s malocclu-
sion. Classification of malocclusion
at the time of clinical presentation
may prove to be difficult in cases of
restored dentition where PBC had
been present at the time of prior
treatment but was unaddressed
(“restored in PBC”; Fig 7).
Angle’s CLI Collapse
In the presence of periodontitis with
AL, this malocclusion may present
with increasing mobility/fremitus
and AF resulting in a loss of OVD3–
8,11,15,16
(Figs 2, 4, 5, and 8). If mandib-
ular molars are missing, the premo-
lars would tip distolingually into the
edentulous space; if present, the
second molar tips mesiolingually,
and excursion of the opposing mo-
lar may be seen.3–8,11,13,17–20 The loss
of OVD with AF and malpositioned
posterior teeth could cause the pos-
terior cusps to function effectively
steeper, creating frequent interfer-
ences between the opposing cusps,
which may be exacerbated by shal-
lower articular eminence inclina-
tions. In the presence of periodontal
attachment loss (PAL), secondary
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OT may be seen.21,22 These patients
may present with a dental pseudo-
CLIII malocclusion, as opposed to
a true orthodontic pseudo-CLIII, as
the IC and CR discrepancy increases
and the mandible is positioned an-
teriorly in order to obtain occlusal
stability.14
Angle’s CLIId1 Collapse
Similar to the CLI malocclusion, in-
creasing mobility/fremitus may be
noted with greater AF with the pro-
gressive loss of OVD (Figs 3a, 3b,
6, and 10). Loss of OVD in the pres-
ence of AF, extrusion, and drifting
of unopposed posterior teeth could
likewise cause posterior cusps to
function effectively steeper, which
may be exacerbated by shallower
articular eminence inclinations. Sec-
ondary OT may also be noted in the
presence of PAL. Mandibular pre-
molars tend to either maintain their
position or tip mesially. This could
be attributed to their relative posi-
tion against the maxillary arch and
the way in which forces are transmit-
ted along their long axis.
In cases where there is an in-
creased anterior overjet relation, sig-
nificant AF may not be seen in PBC.
As OVD is lost, the overbite would
increase with a decrease in overjet
due to the mandible’s anterior po-
sitioning to obtain a stable anterior
contact (Fig 3). These patients may
present with a dental pseudo-CLIII
malocclusion with an increased IC/
CR relationship.
Angle’s CLIId2 Collapse
In the CLIId2 malocclusion, the an-
terior teeth receive greater occlusal
forces and there typically is little AF
(Figs 3c, 3d, and 9). This is not only
due to the skeletal relationship, but
also due to occlusal forces directed
closer to the transverse axis of rota-
tion, thus negating the potential for
off-axis forces and flaring.14 These
patients tend to be “locked in” and
are unable to easily perform excur-
sive movements. As OVD is lost, in-
creased wear and/or chipping in the
teeth, increased fremitus/mobility,
or TMD may be seen.
Angle’s CLIII Collapse
The clinical appearance of the CLIII
malocclusion in PBC tends to be an
extension of its appearance without
PBC (Figs 3e and 3f). As this maloc-
clusion collapses, the edge-to-edge
or reverse anterior overbite relation
becomes exacerbated. As OVD is
lost, mandibular prognathism in-
creases with no AF. It should be de-
termined whether the malocclusion
is a true orthodontic CLIII or a den-
tal pseudo-CLIII due to loss of OVD
and anterior positioning of the man-
dible at an increased IC/CR relation-
ship (Fig 5).
Framework for Grading
Bite Collapse
Since PBC encompasses a wide
range of clinical manifestations and
can be diagnosed with or without
periodontitis, TL, AF, or loss of OVD,

Table 1 PBC Grading with Associated Clinical Sequelae
Malocclusion
TL without replacement
Periodontitis
Mobility/fremitus
AF
Loss of OVD
TL = tooth loss; OVD = occlusal vertical dimension; + = present; – = not present; ± = may or may not be
present.
a grading system was devised. This
system is based upon the two most
common etiologic factors that can
contribute to PBC: the presence
or absence of TL and the health of
the periodontium with potential
sequelae of AF and/or loss of OVD
(Table 1).
Grade 1
Grade 1 (G1) PBC malocclusions are
periodontally stable without TL (Figs
3 and 9). There is typically a lack of
AF but may show signs of increasing
mobility/fremitus, which may indicate
a loss in OVD. The presence of ac-
celerated retrograde wear may also
indicate loss in OVD. Dentition that
present with a healthy but reduced
periodontium23 are included, as well
as physiologic therapeutic dentition
that have been restored in PBC.
Grade 2
Grade 2 (G2) PBC malocclusions are
periodontally stable with unrestored
missing teeth (Figs 2, 5, 7, and 8).
These may present with or without
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Grade 1 Grade 2
+ +
– +
– –
± ±
± ±
± ±
AF or loss of OVD, and dentition
in which the remaining teeth are
able to maintain a physiologic OVD
fall in this group.13 However, in the
presence occlusal wear, a net loss in
OVD may be seen.14 G2 PBC also in-
cludes dentition that present with a
healthy but reduced periodontium.
Additionally, physiologic therapeu-
tic dentition that have been restored
in PBC are included.
Grade 3
Grade 3 (G3) PBC malocclusion
presents without TL in the presence
of active periodontitis (Fig 6). This
malocclusion may or may not pres-
ent with AF or concomitant loss of
OVD. However, OVD loss should be
suspected in the presence of ret-
rograde wear, increasing mobility/
fremitus, and AF. Physiologic thera-
peutic dentition that have been re-
stored in PBC are also included.
Grade 4
Grade 4 (G4) PBC malocclusions
present with both TL and periodon-
67
Grade 3 Grade 4
+ +
– +
+ +
± ±
± ±
± ±
titis with or without AF or concomi-
tant loss of OVD (Figs 4 and 10). This
grade may best coincide with Stage
IV periodontitis. In the majority of
cases, this dentition presents with
compromised periodontal support,
which may lead to additional TL,
thereby translating to progressive
loss of masticatory function, increas-
ing mobility/fremitus, and AF. In the
presence of AF in conjunction with
increasing mobility, there is invari-
ably loss in OVD.
Conclusions
PBC is a clinical syndrome consist-
ing of various alterations in the
dentition that deviate from an ideal
occlusion.3,7,8,11,14 The dental-occlu-
sal alterations, as well as dental-
skeletal discrepancies in the poste-
rior dentition in PBC, establish an
environment that is potentially more
susceptible to periodontal disease
and caries.6 In the presence of peri-
odontitis, the attachment apparatus
becomes severely compromised
and results in the instability of the
remaining dentition, which could
subsequently become easily affect-
Volume 41, Number 1, 2021
68
ed by occlusal forces.21,22,24 Forces
generated on the periodontally and
functionally compromised dentition
could cause susceptible teeth to
become displaced and, in the pres-
ence of AF, could exacerbate OVD
loss. Alternatively, the intact denti-
tion, in the absence of periodontitis,
may also present with PBC and loss
in OVD. Severe retrograde wear,
where the rate of wear exceeds the
compensatory rate of eruption, re-
sults in a net loss in OVD, increasing
AF and/or fremitus of the maxillary
anterior teeth.14
Because PBC encompasses
a wide range of clinical presenta-
tions that do not necessarily involve
the presence of periodontitis, TL,
AF, or OVD loss, a grading system
was established to delineate these
cases. When diagnosing a maloc-
clusion based upon the proposed
grades of PBC, additional notation
as to whether there are unrestored
missing teeth, AF, and/or OVD
loss should be made. Additionally,
AF that may be due to a tongue-
thrust habit or a Bolton discrepancy
should be evaluated. The clinician
should also be cautioned that it is
possible to encounter fully restored
dentition (physiologic therapeutic
dentition) that have been restored
in PBC, masking some of the hall-
mark signs of collapse. It should also
be noted that not all PBC cases re-
quire treatment. Early intervention
and careful maintenance of these
patients preventing the onset and
progression of periodontitis may al-
low for the preservation of a stable
physiologic malocclusion. However,
of those requiring treatment, estab-
lishing and maintaining periodontal
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health should come first, followed
by restoring the occlusion and re-
establishing the dentition’s protec-
tive capacity of form and function.
Additionally, in deciding to restore
PBC cases, careful consideration
and evaluation should be placed
on determining whether increasing
or restoring the OVD is required, as
well as understanding the concomi-
tant change in mandibular position
with each malocclusion in the pres-
ence or absence of AF. Any altera-
tion in OVD would also require eval-
uating the presence of an increased
IC/CR relation.
The periodontium requires a
specific form in order to maintain its
function in health. Violation of this
form would compromise its function
and serve as a contributing factor
for the progression of disease. The
decision to intervene with treat-
ment should be dependent upon
periodontal health, caries, func-
tion, occlusion, TMD, esthetics, and
phonetics.7 As Granger25 states, the
health of the mouth is related to the
function of the mouth. The better
the function, the longer natural me-
tabolism can maintain it.
Acknowledgments
The authors wish to acknowledge Dr Morton
Amsterdam for his dedication to the educa-
tion of countless dental professionals and
advancements in the practice of periodon-
tics and restorative dentistry, which were the
base inspiration for this article. The authors
declare no conflicts of interest.
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Volume 41, Number 1, 2021
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