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Posterior bite collapse (PBC), a condition in which the posterior occlusion is compromised, leading to failure of the protective capacity of the dentition, does not always require treatment; however, any treatment rendered is dependent upon the stability of the periodontium. This review article presents treatment guidelines based on the form and function of the masticatory system for restoring PBC when treatment is necessary.
Adequate diagnosis and analysis of each patient with PBC are required, and the decision to restore the occlusal vertical dimension should be tested using reversible treatment modalities. It is requisite that patients understand that a functional, physiological, therapeutic occlusion may not be achieved without comprehensive multidisciplinary integration of treatment and extensive fixed prosthodontics.
The clinical syndrome known as posterior bite collapse (PBC) consists of multiple, often pathognomonic factors that deviate from normal, or an occlusion wherein the posterior occlusion is compromised and may ultimately destroy the functional protective capacity of the entire dentition. Secondary clinical sequelae may include accelerated periodontitis progression, temporomandibular disorders (TMD), increasing mobility/fremitus, additional tooth loss, anterior flaring, and loss of occlusal vertical dimension. Etiologic factors may include tooth loss without replacement, orthodontic malocclusions and dentoskeletal disharmonies, periodontitis, accelerated retrograde occlusal/interproximal wear, severe caries, or iatrogenic and conformative dentistry. Not all PBC cases require treatment, but treatment is dependent upon the periodontium's stability and its ability to maintain its form and function. Treatment decisions can also be dependent upon periodontal health, caries, function, occlusion, TMD, esthetics, and phonetics. The purpose of this article is to provide general treatment guidelines based on form and function of the masticatory system for restoring a PBC case when treatment is necessary. This article does not discuss specific mechanics for restoring PBC cases.
This clinical guideline reviews the diagnosis, dental clinical findings, and general considerations in the management of posterior bite collapse (PBC). The clinical syndrome defining PBC was first published in 1964 by Amsterdam and Abrams; it consisted of multiple clinical findings and risk factors, presenting varying degrees and resulting in the compromised function of the entire dentition. The authors state that, although not all PBC cases require intervention, treatment decisions are dependent on the stability of the periodontium and its ability to maintain proper form and function. They go on to underscore the definition as described by Amsterdam and Abrams that “any malocclusion that deviates from the normal or ideal is diagnosed as PBC.”
The authors argued that the underlying problem in managing PBC is that there are no clinical practice guidelines on occlusion as there are many philosophies with varied approaches, and yet there can only be one correct diagnosis; hence, the authors previously published a grading system for the condition and offered multiple clinical considerations to guide the clinician in resolving PBC. A series of cases were presented to illustrate the varied manifestations and degrees in which PBC can present to the clinician.
It has been almost 6 decades since this “syndrome” was defined, and the state of art and science in dentistry with the age of information has radically changed the knowledge base. It would be reasonable to challenge if PBC truly is what it originally was defined or if perhaps the “syndrome” findings are a subset of an underlying medical diagnosis with multiple dental comorbidities.1 The current body of evidence regarding tooth wear and attachment loss continues to evolve, whereby medical conditions such as sleep-disordered breathing in its various forms contribute as significant medical risk factors stressing the stomatognathic system. Sleep bruxism, diurnal clenching, gastroesophageal reflux, and many other related stressors may likely present as previously unknown factors resulting in a general breakdown of the dentition and attachment loss with and without an inflammatory response. Perhaps taking a more global view to addressing the patient attached to the teeth rather than focusing on the teeth attached to the patient may result in better outcomes from a more accurate diagnosis focused on true etiology rather than on traditional dental findings.2,3 The time has arrived when dentistry must work in an interdisciplinary manner with our medical colleagues rather than as a multi-disciplinary, siloed process.4 Moreover, in critically appraising the definition of PBC (any malocclusion that deviates from the normal or ideal is diagnosed with PBC), the term “normal” and “ideal” must be evaluated. Does “normal” mean common or typical? Does “ideal” mean optimal? In either case, what is the evidence to support such dogmatic definitions? Perhaps it is time to critically reevaluate traditional thinking and dogma with a new set of eyes leveraging our current evidence base to minimize the risk of over-treating the wrong problem.