Journal of Oral Rehabilitation 1998 25; 376385
Posterior bite collapse revisited
A. SHIFMAN, B-Z. LAUFER & H. CHWEIDAN
Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel
SUMMARY Although there are different definitions of
posterior bite collapse, only the classical definition
of Amsterdam provides a definite diagnosis and
treatment plan. This situation entails a subtle loss
of the occlusal vertical dimension with resultant
flaring of the maxillary incisors. Other causes for
flaring, such as derangements of form and functions
Introduction
Characteristic tooth movements have been described as
an undesirable sequela of loss of the mandibular first
molar, especially if it occurs at a young age (Salzman,
1938; Erlich & Yaffe, 1983). Changes in tooth positions
were observed not only in the affected segment and in
the opposing dental arch, but also in the anterior region.
The term posterior bite collapse (PBC) has been coined
for this phenomenon inasmuch as it is attributed to loss
of occlusal vertical dimension (OVD), (Amsterdam &
Abrams, 1968; Amsterdam, 1974). Other terms used in
the literature are: collapse of the bite (Ramfjord & Ash,
1966), collapse of the occlusion (Stern & Brayer, 1975),
posterior overclosure (Academy of Prosthodontics,
1994).
The classic description of Amsterdam (1974) is that:
we also see gradual loss of the protective function of
the posterior teeth resulting in excessive stress in loading
of maxillary anterior teeth and their fanning (resulting
from migration of the maxillary anterior teeth). This is
usually accompanied by fanning of the mandibular
anterior teeth, which are seeking containment, with
resultant loss of occlusal vertical dimension. He further
states that: it frequently takes place in much more
subtle fashion in any instance of accelerated mesial
376
Department of Oral Rehabilitation, The Maurice and
of lips and tongue, bruxism, habits, as well as the
presence of advanced periodontal disease or
malocclusions, should be ruled out before the
diagnosis of posterior bite collapse can be made. The
complexity of differential diagnosis is illustrated
with three case reports.
drift, resulting from space loss, because of the lesion of
caries, tooth loss, or an imbalance of the anterior
component of force. (Amsterdam, 1974). Obviously,
this sequence can take place only in Angle Class I
normocclusions. The slight loss of OVD sufficient to
overload the maxillary anterior teeth, may not
necessarily be detected clinically by increased
interocclusal rest space (free way space). Similar
consequences of PBC were denoted: the mandibular
anterior teeth that initially were in light or no contact
with the palatal surfaces of the maxillary anterior teeth
now contact heavily, resulting in flaring of the maxillary
anterior teeth. (Amsterdam & Abrams, 1973). They
further explain that: the open contacts frequently
initiate an adult or secondary tongue-thrusting habit,
and the mandibular anterior teeth can also flare.
(Amsterdam & Abrams, 1973). As anterior tooth
movements can be initiated by tongue-thrusting habits
per se, the authors do not present a clue for differential
diagnosis of these two aetiologies.
A different mechanism for the flaring of the maxillary
anterior teeth in cases of loss of the mandibular first
molar is proposed by Ramfjord & Ash (1966). They
ascribed it to: an increased slide in centric hitting the
front teeth, and by abnormal occlusal relations that
1998 Blackwell Science Ltd
 POSTERIOR BITE COLLAPSE REVISITED 377

have induced a change of masticatory habits and muscle

tonicity rather than a loss of vertical dimension.
Amsterdam & Abrams (1968) also allude that PBC
may emanate from the concurrence of loss of OVD and
anterior displacement of the mandible. Stern & Brayer
(1975) concede that in loss of posterior occlusal support:
a forward drift of the mandible will take place. This
search for new support in the region of the front teeth
thus leads to an increased load on upper incisors.
According to these authors, many aetiologic factors may
lead to reduction or loss of posterior occlusal support:
loss of arch integrity as in early loss of a tooth, congenital Fig. 1. Front view of occluded dentition of patient 1.
spaces between teeth, dental caries and faulty
restorations, iatrogenic causes in previous occlusal
restorations, tooth attrition and malocclusion. Perio-
dontal involvement in these cases is considered
secondary and as a result of tooth migrations or mal-
alignments. Their suggested treatment is a combined
periodontal, orthodontic and prosthodontic effort.
Rosenberg (1988a,b) proposes that the primary causes
of PBC are periodontal disease and dental caries. These
diseases can lead to occlusal trauma, tooth mobility and
migration and eventually to PBC, manifested both in
loss of posterior occlusal support and anterior
Fig. 2. Maxillary dental arch of patient 1.
repositioning of the mandible. These occlusal changes
may disrupt the neuromuscular balance of the
Patient reports
masticatory system and may even cause muscle spasm
and MPD syndrome. Rosenberg (1987) also suggests that Patient 1
accelerated occlusal wear may be one of the aetiologic
factors present in PBC. He illustrates this by a case A 52-year-old woman complained of spacing of the
report of a patient missing posterior teeth with extreme maxillary and mandibular teeth that had gradually
wear of her anterior teeth and a pseudo Class III developed during the previous 5 years. The patient was
situation. The inclusion of such a patient in the realm unaware of the cause of this situation and denied any
oral habits. She however, recalled that about 20 years
of PBC is a far remote clinical picture from that described
ago she lost the left first molars and right second
by Amsterdam (1974). It is claimed that anterior tooth
premolars in both dental arches. The maxillary left
migration is, however, a requisite sign for PBC (Brayer
posterior segment was restored at that time and 2 years
& Stern, 1970). It seems that a subtle loss of OVD can
ago the mandibular right posterior segment was also
cause the anterior teeth to migrate, although other
restored.
mechanisms for this phenomenon can take place.
Extra-oral examination did not reveal any
Reviewing the literature reveals incongruity in the abnormalities; lips were competent and in normal shape
various definitions of PBC from a well defined clinical and tone. Intra-orally, anterior flaring in both arches
situation described by Amsterdam (1974) to divergent was evident (Fig. 1). Both arches were extensively
clinical situations that encompass every case displaying restored posteriorly (Figs 2 & 3). The occlusion in the
loss of OVD. The aim of this article is therefore to posterior segments was maintained bilaterally, although
redefine the concept of PBC through apparently similar the mandibular left molar was tipped mesially and
patient reports, that, however, differ in pathogenesis, lingually (Figs 4 & 5). There was a nearly complete
prognosis and treatment plan. space closure of the maxillary second premolar (Figs 2

1998 Blackwell Science Ltd, Journal of Oral Rehabilitation 25; 376385

378 A . S H I F M A N et al.
Fig. 3. Mandibular dental arch of patient 1.
Fig. 4. Right-side view of occluded dentition of patient 1.
Fig. 5. Left-side view of occluded dentition of patient 1.
& 4). None of the teeth were mobile or sensitive to
percussion. Fremitus was not detected. Overall pocket
depths varied between 2 mm to 5 mm with few sites
bleeding on probing. Interocclusal rest space was within
the range of 2 mm to 3 mm. Maximal intercuspal
position was about 1 mm anterior to the retruded
contact position. Overbite was 3 mm and the overjet
3 mm. Radiographically, the maxillary anterior teeth
displayed an approximate loss of one-third of the
1998 Blackwell Science Ltd, Journal of Oral Rehabilitation 25; 376385
alveolar bone whereas the mandibular anterior teeth
displayed loss of about half of this bone. No bone loss
was evident in the posterior segments (Fig. 6).
Diagnosis. Anterior migration of the teeth induced by
posterior overclosure and secondary tongue thrust.
Chronic periodontitis adult type (moderate).
Patient 2
A 31-year-old married woman complained of flaring of
her upper anterior teeth which occurred 6 years ago.
Although not complaining of pain or severe discomfort,
the patient was very anxious about losing her dentition,
in particular the upper incisors. Several consultations
in the past recommended periodontal surgical treatment
which she refused because of the fear of postoperative
unaesthetic root exposure. Nevertheless, the patient
had remained under regular periodontal maintenance
therapy and was highly motivated for good oral hygiene.
A year before the present examination, occlusal
adjustments were performed to allow free mandibular
excursions. Her general medical condition was
noncontributory, although she had been smoking for
the last 10 years (1020 cigarettes per day). She gave
birth 5 months ago. In addition, she reported that her
husband made her aware of night-time tooth grinding
that appeared a few months ago. She was then also
aware of occasional daytime tooth clenching.
Extra-oral examination did not reveal any
abnormalities, except for slight deviation in openclose
cycle. The temporomandibular joints and the
mandibular elevator muscles were not tender on
palpation. Intra-oral examination showed spacing of
maxillary incisors in an almost completely preserved
dentition with few restorations in the molar teeth
(Figs 79). Carious lesions or wear facets were not
detected. Although the mandibular left second molar
was missing, and despite the crossbite on the right and
the fractured buccal cusp of the maxillary left first
premolar, molar support was deemed to be adequate
(Figs 10 & 11). Gingival tissues were red, oedematous
and receded. Small amounts of supragingival and
subgingival calculus were present. Overall pocket depths
varied from 3 mm to 7 mm, the latter mainly in
maxillary incisors. Most of the teeth were mobile (grade
1). Interocclusal rest space was within the range of
2 mm to 3 mm. Maximal intercuspal position coincided
with the retruded contact position. Overbite was 3 mm
 POSTERIOR BITE COLLAPSE REVISITED
Fig. 7. Front view of occluded dentition of patient 2.
Fig. 8. Maxillary dental arch of patient 2.
and overjet 2 mm. Radiographically, generalized loss of
the alveolar bone was evident in both dental arches. A
loss of two-thirds of the bone anteriorly and one-half
of the bone posteriorly, was estimated (Fig. 12).
Diagnosis. Early onset of generalized periodontitis with
recent onsent bruxism. Periodontally induced anterior
migration of maxillary incisors.
1998 Blackwell Science Ltd, Journal of Oral Rehabilitation 25; 376385
379
Fig. 6. Periapical dental radiographs
of patient 1.
Fig. 9. Mandibular dental arch of patient 2.
Fig. 10. Right-side view of occluded dentition of patient 2.
Patient 3
A 36-year-old woman complained of mobility of her
lower anterior teeth and of unaesthetic appearance of
the upper anterior teeth that were spaced and labially
inclined. She reported that at the age of 17 she suffered
from gum swelling and, a year later, spacing and flaring
of the front teeth developed. At the age of 22 the flaring
was rectified with a removable orthodontic appliance,
but relapsed after a year following bilateral loss of the
upper first molars.
380 A . S H I F M A N et al.
Fig. 11. Left-side view of occluded dentition of patient 2.
Fig. 12. Periapical dental radiographs
of patient 2.
Fig. 13. Front view of occluded dentition of patient 3.
Extra-oral examination did not reveal any
abnormalities. Intraorally, spacing between the
maxillary central and lateral incisors was observed
(Fig. 13). Both the maxillary second premolar and first
molar teeth were missing bilaterally with partial closure
of the edentulous spaces (Fig. 14). The mandibular
dental arch was complete (Fig. 15). With the exception
of a few sites of deep periodontal pockets notably the
mandibular anterior teeth, general pocket depths were
moderate (3 mm to 5 mm) including the maxillary
anterior teeth which displayed grade 1 mobility and
fremitus. The mandibular central incisors displayed
1998 Blackwell Science Ltd, Journal of Oral Rehabilitation 25; 376385
Fig. 14. Maxillary dental arch of patient 3.
Fig. 15. Mandibular dental arch of patient 3.
grade 3 mobility with firey red gingival tissues and
purulent exudate. Overbite was 2 mm and overjet
3 mm. Posterior occlusal contacts were diminished
(Figs 16 & 17). A difference of 2 mm existed between
maximal intercuspation and the retruded contact
position. Interocclusal rest space was 1 mm to 2 mm. No
such habits as tongue thrusting could be demonstrated.
Radiographically, complete alveolar bone loss was
evident around the mandibular central incisors. The
maxillary anterior teeth displayed loss of about half of
the bone. In the posterior segments, there was less
 POSTERIOR BITE COLLAPSE REVISITED
extensive bone loss but angular osseous defects and
furcation involvements were detected (Fig. 18).
Diagnosis. Early onset localized periodontitis. Perio-
dontally induced anterior tooth migration perpetuated
by posterior overclosure.
Discussion
Labial migration of the anterior teeth, described as
fanning, splaying, or flaring is a discerning sign that
regularly induces patients to seek treatment. This sign
Fig. 16. Right-side view of occluded dentition of patient 3.
Fig. 17. Left-side view of occluded dentition of patient 3.
1998 Blackwell Science Ltd, Journal of Oral Rehabilitation 25; 376385
381
denotes loss of arch form and occlusal stability. The
occlusal stability is maintained by three factors: arch
integrity, occlusal relations and the periodontal health.
Arch integrity
It has been assumed that when teeth are stable in their
position, there is an equilibrium of forces acting on
them. This equilibrium includes all the forces that may
affect tooth position, namely forces from contiguous
muscles such as the tongue and lips, opposing and
adjacent teeth, external objects such as food, fingers,
etc., and the surrounding bone and periodontal tissues.
The equilibrium position theory presented by
Weinstein et al. (1963) is defined as that position of a
tooth from which it will not be moved by the natural
enviromental forces acting thereon. Changing this
balance of forces, can result in the tooth moving to a
position relieving this effect. Weinstein et al. (1963) lists
several pathological conditions associated with mal-
alignment of teeth such as: aglossia, muscular dystrophy,
facial paralysis and cerebral palsy as an indirect proof
for this theory. In addition, he showed by mathematical
plotting of the angulation of the anterior teeth and the
combined angulation of the lips (correlated with the
force they exert on the teeth), that there are several
positions of stability, e.g. in normocclusion, or with
trapped lower lip. When he added 2 mm thick labial
or lingual extensions to teeth, he could demonstrate
movement of the teeth to the opposite direction
reaching plateau within a few weeks.
Kydd (1957) measured tongue and lip muscle forces
and found statistically significant differences between
them, the latter being considerably less. However, he
did not measure habitual, but maximal forces which
rarely exist during normal function. Lear & Moorrees
(1969) measured force magnitude of the musculature
during rest, speech, mastication, and swallowing,
summed up according to their relative duration in 24 h.
Fig. 18. Periapical dental radiographs
of patient 3.
382 A . S H I F M A N et al.
Although the study was conducted on a small sample
(seven subjects), a considerable imbalance was found,
with the lingual forces being greater. Proffit, McGlone
& Barret (1975) examined tongue and lip pressures in
Australian aborigines. They found an inverse
relationship between tongue pressure and arch size, so
aborigines large dental arches can not be explained by
tongue pressure. A different approach to this problem
was used by Brader (1972) who developed a complex
mathematical solution, showing that the dental arch
fits a trifocal ellipse and the difference in forces between
the tongue and perioral musculature fits his equation.
It appears that the resultant equilibrium is not a simple
action of labio-lingual muscular forces within the dental
arch (Proffit, 1978). Other determinants of tooth
positions and arch form such as the occlusion have
therefore to be considered.
Occlusal relations
Currently, the mutual protection concept is the
favourable scheme for physiologic occlusion. This
scheme infers that the anterior teeth protect the
posterior teeth in mandibular excursions by disocclusion
and that the posterior protect the anterior teeth at the
intercuspal position (Shillingburg, Hobo & Whitsett,
1978; Mohl et al., 1988). At maximal intercuspation,
maxillary incisors slightly contact or do not contact
(Andersson & Myers, 1971). However, these teeth may
contact when pressure is applied during maximal closure
(Riise & Ericsson, 1983) or with the change of head
posture (Mohl, 1984). Even a slight loss of OVD can
overload the maxillary incisors, resulting in their flaring.
Flaring can occasionally be treated only at the level of
the anterior segments, namely by orthodontic
movements of the inclined incisors, combined with
tooth alterations for occlusal clearance and permanent
splinting of these teeth. However, a different treatment
approach should be adopted. A slight increase in OVD
can be achieved by orthodontic or by spontaneous
eruption of the posterior teeth (Yaffe & Ehrlich, 1985)
or by prosthetic means as indicated for patient 1. This
procedure permits unhindered orthodontic movements
of the anterior teeth, improves overbite/overjet relations
and thus reduces the load on these teeth. It is
hypothesized that once secondary tongue habits are
controlled, no permanent splint of the anterior teeth
is required and these teeth may even spontaneously
reposition into a new stable equilibrium. As loss of OVD
in these patients is occult, this is a specific situation
which rightfully deserves a separate diagnosis of PBC.
With respect to the anterior guided occlusion, it is
hard to conceive how uni-rooted maxillary incisors are
capable of protecting the multi-rooted posterior teeth
when forces are applied lingually on inclined planes.
Two mechanisms were proposed to explain how the
load acting upon maxillary incisors is reduced during
excursive movements: (1) in the class III lever system
of the mandible, incisors function on a longer lever arm
than molars (Dawson, 1989); (2) disclusion evokes a
neuromuscular inhibition (Williamson & Lundquist,
1983).
Indeed, greater forces can be exerted when the
anterior teeth are splinted (Waltimo & Kononen, 1994).
Some authors contend that in PBC, flaring of the
maxillary incisors results from these teeth being hit by
the opposing mandibular incisors during protrusive
movements (Stern & Brayer, 1975; Ramfjord & Ash,
1966). Furthermore, Yaffe, Hochman & Erlich (1992)
showed that a group of patients exhibited a protrusive
pattern in sirognathographic sagital tracings of
deliberate mastication. All these patients shared severe
attrition of the anterior teeth or moderate attrition with
fremitus or flaring. They suggest that this protrusive
pattern may be regarded as an additional aetiologic
factor for anterior flaring. It seems that this type of
flaring can only take place when the neuromuscular
protective mechanism has failed, such as may occur in
bruxism.
Periodontal involvement
The foregoing discussion is based on the premise that
in PBC maxillary incisors are subjected to excessive load
but have adequate alveolar bone support with the
presence of mild periodontal disease, at the most. This
is referred to as primary occlusal traumatism (Academy
of Prosthodontics, 1994). Flaring of maxillary incisors
can be induced even by physiologic forces acting upon
these teeth when there is a substantial loss of alveolar
bone. This is regarded as secondary occlusal traumatism
(Academy of Prosthodontics, 1994). Maxillary incisors
can thus be affected by secondary occlusal traumatism
even in situations where no loss of OVD is present.
Recently, migration of maxillary anterior teeth has
been correlated to alveolar bone loss and to the presence
of acute inflamation around these teeth, as well as to
the loss of more than three posterior teeth in the same
1998 Blackwell Science Ltd, Journal of Oral Rehabilitation 25; 376385

Table 1. Comparison of findings, pathogenesis, diagnoses and treatment approaches in described patient reports
Patient Flaring Region of Region of Occlusal
primary secondary diagnosis
impairment impairment
1 1 Posterior Anterior PBC
2 1 Anterior AOI
3 1 Anterior Posterior APOI
PBC, posterior bite collapse; AOI, anterior occlusal impairment; EOP, early onset periodontitis; APOI, anterior and posterior occlusal
impairment.
dentition (Martinez-Canut et al., 1997). Also it has been
reported that anterior spacing can spontaneously be
closed after surgical peridontal treatment (Brunsvold,
Zammit & Dongari, 1997). This phenomenon is
attributed to disruption and reintegration of the trans-
septal peridontal fibres.
Differential diagnosis
Although flaring is a sign common to all the patients
presented in this article, they differ in pathogenesis,
prognosis and treatment plan (Table 1).
Patient 1 presented with anterior flaring occurring
after loss of posterior teeth. In this patient, no more
than a one-third loss of the alveolar bone surrounding
the maxillary incisors was evident. This situation
corroborates the classical description of PBC
(Amsterdam & Abrams, 1973; Amsterdam, 1974).
Patient 2 presented with severe periodontal disease
and bone loss. Despite the flaring, there was no sign of
loss of OVD and therefore the situation should not be
diagnosed as PBC. This patient should be treated with
intensive periodontal protocol. Also, to control bruxism,
an interocclusal device (night guard) is indicated. The
suggested rehabilitative treatment for this patient is
limited to the anterior segment; namely, orthodontic
correction of the flaring followed by permanent splinting
of the maxillary incisors. Prognosis is guarded.
Patient 3 presented with a localized type of early
onset periodontitis and is considered to have a better
prognosis than patient 2, with the generalized type of
this disease (American Academy of Periodontology,
1996). When the disease is controlled, a combined
orthodontic and prosthodontic treatment can be
instituted; restoration of the OVD and permanent
splinting of the rectified maxillary incisors is indicated.
1998 Blackwell Science Ltd, Journal of Oral Rehabilitation 25; 376385
POSTERIOR BITE COLLAPSE REVISITED 383
Peridontal Region of Region of Need for Need for
diagnosis primary secondary increasing anterior
restorative restorative OVD splint
treatment treatment
Adult peridontitis Posterior (Anterior?) 1
General EOP Anterior 1
Local EOP Posterior Anterior 1 1
Hopeless mandibular incisors can be replaced by a
fixed or removable prosthesis. In this patient, flaring
appeared because of periodontal disease precending the
loss of the maxillary teeth and subsequent loss of OVD.
This sequence of events do not conform to that described
by Amsterdam for PBC (Amsterdam & Abrams, 1968;
Amsterdam, 1974). Other authors, however, broaden
the definition of PBC to a variety of conditions associated
with loss of OVD (Stern & Brayer, 1975; Rosenberg,
1987, 1988a,b). According to this definition, patient 3
may also be regarded as a PBC-situation.
To define a separate disease entity one has to describe
a clinical situation featuring common pathogenesis,
prognosis and treatment plan. For instance, all the
patients described in this article were afflicted with
periodontitis. As they greatly differed in the
aforementioned parameters of disease, their diagnosis
is subdivided into adult periodontitis (patient 1),
generalized early onset periodontitis (patient 2), and
localized early onset periodontitis (patient 3). The same
holds true for the diagnosis of loss of OVD. The classic
description of PBC (Amsterdam, 1974; Amsterdam &
Abrams, 1968, 1973), is that the anterior flaring is
caused by failure of the posterior occlusion to protect the
anterior segment from overloading. The rehabilitative
treatment should therefore start in the posterior
segment, by increasing the OVD. Need for a
rehabilitative treatment in the anterior segment, is to
be evaluated thereafter. It is thus advantageous to
preserve the term PBC for this clinical situation. It
should not be confused with other situations involving
loss of OVD or flaring that is caused by other factors,
with or without involvement of the posterior segments.
The latter may be termed as anterior or anteroposterior
occlusal impairment, respectively (Table 1).
384 A . S H I F M A N et al.
Prevalence of PBC
To date, there are no known clinical studies that assess
the prevalence of PBC in a patient population. Some
studies, however, deal with changes in the dental arches
following the loss of first molars, which is considered
the main aetiologic factor for PBC. Salzman (1938)
found mesial drift of the second molar in more than
90% of the subjects, and distal drift of premolars in
about 80% of the subjects. The amount of drift was up
to 8 mm for maxillary second molars, 8 years after
extraction, and up to 43 mm for mandibular second
premolars. Drifting occurred mainly in the first year
after extraction (23 mm), and thereafter about an
additional 05 mm annually. Conversely, Erlich & Yaffe
(1983), in a sample of 84 patients missing permanent
maxillary or mandibular first molar, found that in 61%
of these patients the space closure of the teeth adjacent
to the extraction site was less than 25 mm. The fact
that some subjects lost the tooth as much as 20 years
previously, demonstrate that space closure is frequently
self-limiting (Erlich & Yaffe, 1983). Possible explanations
for this phenomenon are: (1) achieving a definite
intercuspation will avoid further movements; (2) trans-
septal fibres may be remodelled and their activity
reduced.
Conclusions
(i) The classic description of PBC (Amsterdam, 1974;
Amsterdam & Abrams, 1968, 1973) is valid. This
diagnosis is a guide to a specific treatment plan.
(ii) PBC is a specific case of loss of OVD. It features a
subtle loss of OVD that induces flaring. A change in the
interocclusal rest space is an unreliable sign for PBC.
(iii) Flaring of maxillary incisors is a requisite sign for
PBC but not a pathognomonic one. To diagnose PBC,
other contributing factors for flaring must be excluded,
namely: incompetent lips, primary tongue thrusting,
various habits, atypical swallowing, advanced
periodontal disease, occlusal parafunctions, and habitual
holding of foreign objects or fingers in the mouth.
(iv) The role of excursive mandibular movements as a
contributing factor for flaring is unclear. It may be a
different disease entity that warrants further research.
(v) Expanding the definition of PBC to a variety of
conditions with loss of OVD, does not contribute to a
better prescription of a treatment plan for the
individual case.
(vi) PBC is probably an infrequent clinical situation and
is encountered only in Angle Class I occlusal relations.
Acknowledgments
The authors wish to thank the following graduate
students for providing the illustrations and patient
reports for this article: Dr Yoseph Nissan (patient 1), Dr
Ido Alt (patient 2), Dr Harry Chweidan (patient 3).
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Correspondence: Dr Arie Shifman, PO Box 1031, Petach Tikva
49110, Israel.