Good morning,

I have a 23 year old female patient. She originally did not like the appearance of her teeth, she had a dark tooth #9 with history of RCT, short laterals (about 2 mm shorter than centrals), and an Anterior Open Bite. She was asymptomatic, unremarkable muscle and joint exam. We decided to do 8 porcelain veneers #5-12. We had the lab fabricate a diagnostic wax-up using a Facebow record, and I sent them a Centric Relation record using a Leaf Gauge because she did not have a repeatable biting position in MIP - I did this by placing enough leaves where she had an initial point of contact, then added 1 leaf and took a bilateral bite record in that position with Futar-D. I received the diagnostic wax-up and putty matrix for the provisionals. I prepared, impressed and temporized #5-12 with Luxatemp Ultra, and I adjusted her occlusion. I did not hear from the patient for the next 3 weeks, and when she presented yesterday for the final permanents, she stated she had bilateral "jaw pain". She has had to take Motrin every night, otherwise she could not sleep. She thought it was normal and didn't think to call prior to the insertion appointment. These were my findings:

- Bilateral Tender masseters, both pterygoids tender but left side more than right

- Hurts the most at night by the time she gets home from work

- But No ache in the morning

- No pain or discomfort when chewing

- She states that she has been touching only on the right side when she bites

- She states that her lower jaw always veered to the right

- Originally #7 and 10 were about 2 mm shorter than centrals and did not touch lowers when she would go into protrusive, however now they do touch with provisionals - not sure if this has anything to do with her pain

- Seems like she is favoring - deviating to her right

- In "MIP": #2 touches the most (heaviest marks) - 2 points which are mesiopalatal and midpalatal.

#3 single point palatal

#5 single point palatal

#13 single point palatal

#14 and 15 DO NOT touch

- In CR: I checked with Leaf Gauge, the first point of contact is on upper left: #14 and 15 on palatal cusps

I did not feel comfortable removing her temporaries and inserting the permanents and was not certain what to do. My initial thought was to equilibrate/adjust her occlusion on #14 and 15 stated above, based on the CR bite, or to insert the permanents to see if perhaps they fit differently, and then adjust as needed from there. Can someone please help or have any suggestions? Thank you!