+ Constricted Path of Closure: A Diagnostic Challenge

Case Report

J Dent App. 2015;2(5): 219-222.

Constricted Path of Closure: A Diagnostic Challenge

Rakesh Kontham1* and Ujwal Kontham2

1Associate Professor, Department of Orthodontics, Nair Hospital Dental College, Mumbai-400008, Maharashtra, India

2Professor, Department of Pediatric Dentistry, Dr D Y Patil Dental College and Hospital, Pimpri, Pune, Maharashtra, India

*Corresponding author: Rakesh Kontham, Associate Professor, Department of Orthodontics, Nair Hospital Dental College, Mumbai-400008, Maharashtra, India

Received: December 15, 2014; Accepted: March 11, 2015; Published: March 13, 2015


Centric relation; Attrition; Constricted path of closure; Deprogrammer


Malocclusion prevents uniform contact of teeth during mandibular movements. Occlusal interferences can lead to severe loss of tooth structure and can lead to TMJ disorders. Dental examination must include an evaluation of the occlusion for interferences and signs of wear or instability of the occlusion. The most common types of occlusal wear are [1,2].

True Bruxism (Parafunction)

Occlusal wear triggered by the brain and has no functional purpose.

Occlusal Dysfunction

Occlusal wear triggered by posterior interferences leading to excessive grinding.

Constricted Path of Closure (CPC)

Occlusal wear occurs during closure in maximal intercuspal position (MIP) due to anterior interferences pushing the condyles distal to centric relation (CR) [3].

A distinction between these three types of abnormal occlusal function becomes mandatory for correct treatment planning. It is especially important to diagnose patients with constricted path of closure (CPC) because the mandible needs to move forward into a stable jaw relationship, which in turn can influence the treatment plan dramatically [4-6].

CPC patients include those with deep overbite, steep interincisal angle, under torqued upper anteriors after orthodontic treatment and palatally over contoured anterior restorations. These patients are at a high risk of severely damaging the anterior teeth and restorations. Muscle and TM joint symptoms may develop as these are continually forced to adapt especially in presence of stress or trauma [7-10].

A deprogrammer is a valuable tool for diagnosing CPC cases without any need for elaborate procedures and high –end equipment [11,12].

The following case reports describe the importance of using a deprogrammer in diagnosis, treatment planning and alleviation of symptoms of patients with CPC.

Case 1: Constricted Path of Closure

A 37-year-old female patient reported with reduced mouth opening, a general feeling of tightness in both cheeks and pain on forced opening. The patient had to manipulate the mandible in a downward and forward direction to increase the mouth opening each time she chewed and this was accompanied by a clicking sound in both the joints. When the mandible was brought forward in an edge to edge position the mouth opening returned to normal and the clicking in the joint disappeared.

On clinical examination, a soft end feel was observed with pain on forced mouth opening; however, palpation of the TMJ area did not elicit pain. Mouth opening was reduced to 25mm and the patient had to protrude the mandible to an edge-to-edge position to open the mouth further.

On intraoral examination wear facets were seen on the palatal surfaces of maxillary incisors, incisal and labial surfaces of mandibular incisors (Figures 1f, 1g). A class I molar relationship was seen on both sides and a deep bite (6 mm) was present. Tooth #14 and 24 were in scissor bite. The maxillary incisors were upright (Figures 1c, 1d and 1e). The patient was able to close in a maximal intercuspal position easily and repeatedly (MIP) with no evident deflection.