A 65-year-old Caucasian female presented to the prosthodontic postdoctoral clinic of Boston University Henry M. Goldman School of Dental Medicine. Her chief complaint was feeling like her bite is off after having crowns on her lower front teeth and chronic jaw pain in the TMJ area. She also complained about headaches and neck and shoulder pain for a duration of 12 months.

The patient had a history of orthodontic treatment at age 15 and stopped treatment one year later. The patient described the treatment for moving her bite from Angle Occlusal Class III to Class I. At age 30, tooth #30 (mandibular first molar, ADA system) was extracted without any restorations. The patient reported a head-on collision at age 40 in which she hit her face on a basketball and lost tooth #25 without mentioning any fracture or trauma at the bone. A six-unit fix partial denture from #27–26 × 24–23–22 was fabricated. The patient reported the first jaw pain after this treatment, and the pain subsided after a few months. At age 50, the patient was treated with veneers from #5–11 because of cosmetic issues. Three years later, the veneered teeth #8, 9, and 10 were broken, and porcelain crowns were fabricated. Three years later, teeth #9 and #10 porcelain crowns were broken, and root canal treatment, cast post and core, and porcelain fused to metal crowns were fabricated. The patient complained of jaw pain after every dental treatment, and the pain subsided after a few months.

The patient reported no current prescription and no over-the-counter use of medication prior to her visit. The patient was diagnosed with TMD by a physician who also gave a preliminary diagnosis of fibromyalgia and therefore referred her to a dentist.

During the exam, the patient exhibited a symmetric maxillofacial structure in the frontal view and an average lower facial height. Extra-orally, her profile was slightly convex with an extrusive lower lip. The intra-oral exam found tooth #3 super-erupted, multiple broken restorations, facial gingival recession, and number of teeth rotations. Her upper dental midline was coincident with the face midline. The lower dental midline deviated 2 mm to the left.

The occlusal plane on the right side was uneven with the super-erupted tooth #3. The occlusal plane on the left side was flat. The patient displayed Angle Class I molar and canine relationship. Group-function articulation transitioning to canine-protected articulation was presented on both sides. On the right side, non-working contacts were presented between teeth #3 and 31 while in the left lateral excursion. In protrusion, there was no occlusion of the posterior teeth with #8 and 25, and 26 in contact. In general, the patient had 2 mm overbite, 1mm overjet, and 2 mm interocclusal rest space.

The patient mentioned that she had been suffering from TMJ issues her whole life, including symptoms of clicking and pain. History revealed that her jaw pain was on the left side with clicking and popping with jaw range of motion. The patient reported constant pain in the left frontal aspect of her head that she rated at a 7/10 on a numeric pain scale. She had a pain increase in chewing, and nothing reduced it. The patient also complained about a migraine-type headache, neck pain with tiredness, sore neck muscles, and shoulder aches.

Cone beam computed tomography was taken using Galileos Comfort (Sirona, Galileos, Bensheim, Germany) with a patient bite on the Fusion Bite tray, which had eight radiopaque markers as landmarks for the superimposition of CBCT and JMT data. SICAT JMT+ was used to record patient mandibular movement strictly following manufacturer manuals (11). The patient’s jaw movement was recorded including jaw opening and closing movements to and from the habitual intercuspal position, lateral and protrusive movements, border movement, and chewing.

The CBCT and JMT data were loaded into the SICAT Function software. Mandibular and glenoid fossa segmentation was performed, and the software extracted CBCT data and merged it with the corresponding jaw motion data. The system then presents a 3D image of the patient−specific mandibular movement on the screen.

Full−arch optical impressions of the patient were obtained with an intraoral scanner (Sirona, CEREC Omnicam). The images were imported and merged with the CBCT data simultaneously with the mandibular and condylar segmentation in SICAT Function software. This procedure gives the possibility to assess the dynamic occlusion and mandibular movement in interaction with TMJ function.

First, CBCT images in the TMJ area were used to analyze the shape and potential wear in the condyle and fossa. The patient’s condyles were not in a bilaterally symmetric shape. The right condyle was slightly flat compared with the left on the anterior surface, and the fossa was bilaterally symmetric, which indicated wear and tear of the condyles (Figure 4).

Next, the jaw opening-closing movements and lateral-protrusive movements were analyzed. The results showed the maximal mouth opening at 38.9 mm, slightly smaller than the average range (12). The lateral right movement was 10.8 mm, and the lateral left movement was 8.4 mm in incisal. This result supported the clinical findings of the non-working contact on the right side. The protrusion movement was 6.8 mm, which was significantly smaller than the normal range and indicated that the patient had limited protrusion movement (Figure 5).

Finally, the border movement data were used to analyze the vibration and stabilization of the jaw. In a segmental view, this patient showed asymmetry in border movement. In the right border movement, the patient could not move smoothly and evenly. This result marched the asymmetric shape of the condyle and revealed the damage of the TMJs in both bone and connecting tissue. Meanwhile, the patient could not repeat the jaw motion properly, which was another evidence leading to the dysfunction of TMJs (Figure 6).