CRANIO®

The Journal of Craniomandibular & Sleep Practice

ISSN: 0886-9634 (Print) 2151-0903 (Online) Journal homepage: http://www.tandfonline.com/loi/ycra20

Full-Mouth Rehabilitation Following Treatment of

Temporomandibular Disorders and Teeth-Related
Signs and Symptoms

Ihab A. Hammad, N. Joseph Nassif & Ziad A. Salameh

To cite this article: Ihab A. Hammad, N. Joseph Nassif & Ziad A. Salameh (2005) Full-Mouth
Rehabilitation Following Treatment of Temporomandibular Disorders and Teeth-Related Signs
and Symptoms, CRANIO®, 23:4, 289-296, DOI: 10.1179/crn.2005.041

To link to this article: http://dx.doi.org/10.1179/crn.2005.041

Published online: 01 Feb 2014.

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Download by: [University of Nebraska, Lincoln] Date: 26 May 2016, At: 15:43
 CLINICAL PRACTICE

Full-Mouth Rehabilitation Following Treatment of

Temporomandibular Disorders and Teeth-Related Signs
and Symptoms
Ihab A. Hammad, B.D.S., M.S., D.Sc.; N. Joseph Nassif, D.D.S., M.S.;
Ziad A. Salameh, D.D.S., M.S.

ABSTRACT: The literature is replete with theories regarding temporomandibular disorders (TMD).
However, there is a paucity of information concerning perceived malocclusion and other teeth-related
0886-9634/2304- signs and symptoms after full-mouth rehabilitation. This clinical study was designed to evaluate the per-
289$05.00/0, THE ception of TMD patients concerning perceived malocclusion and other teeth-related signs and symp-
Downloaded by [University of Nebraska, Lincoln] at 15:43 26 May 2016

JOURNAL OF
CRANIOMANDIBULAR toms after full-mouth rehabilitation guided by the Mental Analog Scale (MAS). Among 38 patients
PRACTICE, referred for full-mouth rehabilitation, 20 were diagnosed as having TMD after reviewing a questionnaire,
Copyright © 2005
by CHROMA, Inc. recording the major complaints and symptoms, in addition to performing comprehensive clinical exami-
nation. Nonsurgical therapy was performed, including fabricating an anterior programming device, a
Manuscript received centric relation occlusal device and finally full-mouth rehabilitation by means of placing crowns on all
June 30, 2004; revised upper and/or lower teeth. All full-mouth rehabilitation procedures were performed using a fully adjustable
manuscript received
March 29, 2005; accepted articulator and mandibular movements were recorded following pantographic tracings. After full-mouth
June 24, 2005 rehabilitation, the patients were followed up at 1, 2, 4, 6, 9, and 12-month intervals, and the major signs
Address for reprint and symptoms were recorded along with adjunctive teeth-related signs and symptoms. Fisher exact
requests:
Dr. Ihab A. Hammad probability tests were applied to analyze the results (P<.05). Statistical comparisons of the MAS re-
College of Dentistry sponses before and after treatment (at 1-month recall) showed significant improvement (P<.05) for all
King Saud University
P.O. Box 60169 teeth-related signs and symptoms except for bruxism (P=.0699). Further improvement was noted at the
Riyadh 11545, 4-month recall period. However, these improvements were not statistically significant for all teeth-related
Saudi Arabia
E-Mail: signs and symptoms. No further change was noted after the 4-month recall period. There was a marked
hammadfp@yahoo.com reduction in perceived malocclusion and adjunctive teeth-related signs and symptoms during function,
only after performing occlusal equilibration of the final restorations.

Dr. Ihab Adel Hammad received a
B.D.S. degree from Alexandria University
in 1980, an M.S. degree from the Uni-
versity of Minnesota in 1985, and a D.Sc.
degree from Boston University in 1988.
He is a professor at King Saud University,
College of Dentistry, Department of Pros-
thetic Dental Sciences, Riyadh, Saudi
Arabia and at Alexandria University,
Faculty of Dentistry, Alexandria, Egypt.
Formerly, he was an assistant professor at
the University of Minnesota, Minneapolis.
He is a member of many organizations,
including the American Academy of Fixed
Prosthodontics, the New York Academy of
Sciences, and the American Association
for the Advancement of Science. He has
received several awards, including the
Stanley D. Tylman award. He is the
director of post-graduate prosthodontics
at King Saud University, College of
Dentistry.
T
he etiology of TMD is generally thought to be
related to various factors.1-11 The role of occlusal
conditions as predisposing factors in TMD has
not been thoroughly and clinically elucidated. 1,4-6,8,11
Methodological difficulties in establishing research pro-
tocols have hampered acceptance of clinical studies
involving occlusal factors.12-14
Several investigators have emphasized the etiologic
role of occlusal factors in TMD, with many advocating
occlusal therapy including fabrication of crowns.1-3,11-28 It
is suggested that there is a relationship between perceived
malocclusion (occlusal awareness) and other TMD symp-
toms.29 Approximately 75 percent of more than 10,000
patients, on a self-administered questionnaire, reported a
significant perceived malocclusion.29
Alanen, et al.,14 stated, “The hypothesis that occlusal
interferences are a necessary part in the etiology of cran-
iomandibular disorders (CMD) cannot be ruled out.”

289
 FULL-MOUTH REHABILITATION FOLLOWING TMD TREATMENT HAMMAD ET AL.

Recent clinical studies reported dramatic improvement in

patients’ TMD symptoms after the removal of lateral
eccentric occlusal interferences and establishing proper
anterior guidance.21,30 However, the literature lacks infor-
mation regarding the effects of occlusal adjustment on Table 1
TMD signs/symptoms after fabrication of multiple Comprehensive Questionnaire as Reported
crowns. on the Total Spectrum of Symptoms
Symptoms Percentage No. of
The purpose of this study was to evaluate teeth-related (n=20) (%) patients
signs and symptoms in TMD patients before and after, (1) Masticatory muscle pain 80 16
nonsurgical TMD therapy, and (2) after placing crowns Pain during mastication 60 12
on all upper and/or all lower teeth [full-mouth rehabilita- Stressful lifestyle 60 12
tion (FMR)]. TMJ(s) tired feeling 55 11
Headaches 50 10
Fatigued end of day 50 10
Materials and Methods TMJ area pain 45 9
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Opening wide (painful) 45 9

Thirty-eight (38) patients were referred to the prostho- TMJ(s) clicking 40 8
dontic clinics at King Saud University, Saudi Arabia and Clenching/bruxism* 35 7
Alexandria University, Egypt for crowning of all upper Bite/off-center, uncomfor-
table high spots* 30 6
teeth and/or all lower teeth (FMR), due to badly worn Sensitive teeth* 30 6
down teeth and/or for the purpose of improving esthetics Sore neck (stiff) 35 7
due to various factors, e.g., fluorosis. All patients were Sleeping restlessness 35 7
screened for TMD using a screening history and exami- Yawning pain 30 6
nation, guided by the forms recommended by the Tinnitus (ringing in ears) 30 6
Dizziness (vertigo) 30 6
American College of Prosthodontists.5,31,32 Patients diag- Depressed (feeling no hope
nosed for TMD received comprehensive history and of being cured) 30 6
examination following the recommendations of the Otalgia 25 5
American Equilibration Society, 33 Rieder, 34 McNeil, 5 Fluid in ears (stuffiness) 25 5
Frumker,35 and Nassif.7,31,32 Pressure or pain behind ears 25 5
Spots in front of eyes 20 4
Twenty of the 38 patients were diagnosed with TMD Sore and itchy scalp 20 4
(six months duration or longer) and were selected for this TMJ sound (crepitus) 15 3
investigation. The total number of patients selected Difficulty swallowing 10 2
included eleven females and nine males with an age range TMJ locks after opening 5 1
from 30 to 55 years. The major symptoms and total spec- *Teeth-related symptoms
trum of symptoms were recorded (Table 1). All patients
had a full set of natural teeth. Upper and lower diagnostic
casts were made for all patients. Lateral transcranial radi-
ographs, intraoral radiographs, and orthopantographs relation closure. The anterior deprogramming device was
were done. Appointments and written instructions were adjusted after marking with a 17 micron thick articulating
given after each visit. The appointments were scheduled plastic film (Accufilm II, Parkell, Farmingdale, NY) to
according to the following three stages of treatment. produce even centric relation contacts on a flat plane
Stage I: An anterior deprogramming device16,22,25,36,37 opposing the lower central incisors.16,27 All other lower
(anterior bite plane)1 was fabricated for the maxillary teeth were out of contact, with an approximately one mm
arch. Prior to the patient’s arrival, a two mm thick ther- interocclusal clearance in the second molar areas. The
moplastic clear splint material (Splint Biocryl, Great anterior inclined slopes of the acrylic resin were adjusted
Lakes Orthodontics, Tonawanda, NY) was heated and to produce a harmonious incisal guidance of approxi-
vacuum adapted to the maxillary cast and trimmed to mately 45 degrees.38
cover all maxillary teeth. 27,36 Autopolymerizing clear Stage II: After one week, the maxillary anterior depro-
acrylic resin (Splint Acrylic, Great Lake Orthodontics, gramming device was modified and converted into a cen-
Tonawanda, NY) was added to the trimmed splint in the tric relation occlusal device (CRO device) 16,22,27,35-37
anterior area. Clasps were added for retention if needed. (occlusal stabilization device) 1 by carefully adding
The bimanual manipulation technique described by autopolymerizing clear resin to the entire occlusal and
Dawson22 was used to guide the patient into a centric incisal surfaces.1,22,27 Each patient was guided into centric

290 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE OCTOBER 2005, VOL. 23, NO. 4
 HAMMAD ET AL.
relation closure using the bimanual manipulation
method.22 The occlusal device was immediately removed
from the mouth and the patient was asked to rinse with
water. After curing, using a water bath, the occlusal
device was reinserted in the mouth and precisely adjusted
after marking with articulating plastic film. This was per-
formed in order to make centric relation and centric
occlusion posterior contacts coincidental on a flat surface
with all opposing lower teeth.
Centric occlusion was adjusted to produce harmonious
anteriorly protected articulation35-39 with all lower poste-
rior teeth out of contact.27 The objective of the occlusal
adjustments was to develop a CRO device with mutually
protected occlusion.35,39 Patients were instructed to wear
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their CRO devices 24 hours a day except while eating.
Symptoms and physical sign changes/improvements
were recorded during this visit and for all following
patient appointments. Eight appointments were sched-
uled for each patient with one week between visits. At
each appointment, the maxillary CRO device was adjusted
and refined in order to reharmonize the mutually pro-
tected occlusion by removing minute reappearing occlusal
interferences.13,22,25,27
Stage III: Procedures for full-mouth occlusal rehabili-
tation were performed only after TMD signs and symp-
toms had disappeared for a period of at least eight weeks.38
The number of visits varied depending on the treatment
plan tailored to each patient. Prior to treatment, di-
agnostic casts were mounted and analyzed on a semi-
adjustable articulator. All full-mouth rehabilitations were
performed using a Denar D5A (Denar Corp., Anaheim,
CA) fully adjustable articulator (Type IV), following the
recommendations of the Committee on TMD of the
American College of Prosthodontics.40 Mandibular move-
ments were recorded following pantographic tracings.
Temporary restorations were fabricated using heat-cured
acrylic resin based on the same concepts of mutually pro-
tected occlusion 35 followed during fabrication of the
CRO device.
The CRO devices were then modified to fit the tempo-
rary restorations. During fitting of the final restorations,
occlusal equilibration procedures were performed fol-
lowing the principles established by Beyron 41 and
others.1,15,22,42-45 The restorations were then temporarily
cemented. The CRO devices were further modified to fit
the temporarily cemented final restorations. Two weeks
later, permanent cementation of the restorations was ac-
complished followed by further refinement of the occlusal
equilibration procedures.46 The patients were then fol-
lowed up at 1, 2, 4, 6, 9 and 12-month intervals. They
were instructed to gradually discontinue using their CRO
devices in order to avoid any possible side effect caused
OCTOBER 2005, VOL. 23, NO. 4
FULL-MOUTH REHABILITATION FOLLOWING TMD TREATMENT
by sudden withdrawal of the device. The discontinuance
of use occurred in all patients at no later than four weeks
after the FMR cases were completed. Changes in per-
ceived malocclusion (occlusal awareness) symptoms and
other teeth-related symptoms were recorded immediately
following permanent cementation and refinement of the
occlusion at all recall appointments.
Mental Analog Scale (MAS)
At all appointments, perceived malocclusion and other
teeth-related signs and symptoms were recorded as per-
cent improvement (Table 2) using the following method:
patients would mentally analyze and then verbalize, after
being asked by the practitioner (for each TMD symptom),
i.e., “How much improvement have you made?” One
hundred percent (100%) was recorded as total improve-
ment, 90% as almost total improvement, 75% as good
improvement, 50% as moderate or one-half improvement,
25% as slight improvement, 10% as barely improved, and
0% as no improvement.”36
It is suggested 36 that this method of recording the
degree of symptom improvement in percent increments
be termed Mental Analog Scale (MAS). This mental-
verbal method provided a more concise numerical picture
of TMD improvements, rather than using solely descrip-
tive terms, such as moderate or slight improvement.47
Results
A detailed report concerning improvements in teeth-
related symptoms/signs for all 20 patients is shown in
Table 3. Changes in the teeth-related symptoms/signs
were recorded as percent of improvement during each
visit, using the MAS method.
Table 2
Mental Analogue Scale (MAS)
Percent Patients’ mental analysis
improvement and verbal explanation
100% Total improvement (cured)
90-95% Almost total improvement
75% Good improvement
50% Moderate improvement
25% Slight improvement
10% Barely improved
0% No improvement or worsened
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 291
 FULL-MOUTH REHABILITATION FOLLOWING TMD TREATMENT HAMMAD ET AL.

Perceived Malocclusion (Occlusal Awareness)
Six of the 20 patients (30%) responded on the ques-
tionnaire (Table 1) that they perceived one or more of the
following: bite (occlusion) was uncomfortable, bite was
high or bite was off-center. Prior to full-mouth rehabilita-
tions, only one of the six afflicted patients reported that
their abnormally conscious bite sensations (perceived
malocclusion) had returned to normal, when the CRO
device was out of the mouth (such as when eating). The
other five afflicted patients continued to complain of
uncomfortable areas in their occlusion despite having had
relief of their major TMD symptoms (Table 3).
There was dramatic improvement in the patients’
occlusal comfort after initial occlusal equilibration of the
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final restorations. Three of the remaining five patients
(60%) responded, “My bite now feels normal,” or other
similar positive remarks. One patient had moderate
improvement and one patient felt no improvement. The
remaining two patients’ uncomfortable bite was subse-
quently resolved with removal of minor occlusal inter-
ferences at the two-month recall appointment.
Sensitive Teeth
Prior to FMR therapy, six of the 20 patients (30%)
indicated that they still had sensitive teeth. They were
referred to an endodontist for evaluation. Subsequently,
they became symptom free after the endodontic treatment
(Table 3).

Table 3
Percentage Improvement in Teeth-Related Signs and Symptoms at All Treatment Stages
Total #
Cured Not cured patients
MAS 100% 90-95% 75% 50% 25% 10% 0% (n=20)
Before treatment 0 0 0 0 0 0 6 6
After stage II 1 0 0 0 5 0 0 6
Perceived After stage III
malocclusion 1 mo. recall 4 0 0 1 1 0 0 6
2 mo. recall 6 0 0 0 0 0 0 6
4-12 mo. recall 6 0 0 0 0 0 0 6
Before treatment 0 0 0 0 0 0 6 6
Sensitive After stage II 0 0 0 0 0 0 0 6
teeth After stage III
1 mo. recall 6(RCT) 0 0 0 0 0 0 6
2 mo. recall 6(RCT) 0 0 0 0 0 0 6
4-12 mo. recall 6(RCT) 0 0 0 0 0 0 6
Before treatment 0 0 0 0 0 0 7 7
Bruxism/ After stage II 0 0 0 0 0 0 7 7
clenching After stage III
1 mo. recall 4 0 1 1 0 1 0 7
2 mo. recall 5 0 1 0 0 1 0 7
4-12 mo. recall 5 0 1 0 1 0 0 7
Before treatment 0 0 0 0 0 0 10 10
Difficult After stage II 0 0 0 0 0 0 10 10
lateral gliding After stage III
movements 1 mo. recall 7 2 0 0 0 0 0 10
2 mo. recall 9 0 0 0 0 0 0 10
4-12 mo. recall 9 0 0 0 0 0 0 10
Before treatment 0 0 0 0 0 0 10 10
Jaw moves After stage II 3 0 0 0 0 0 7 10
easier toward After stage III
one side 1 mo. recall 8 0 0 0 2 0 0 10
2 mo. recall 10 0 0 0 0 0 0 10
4-12 mo. recall 10 0 0 0 0 0 0 10
MAS: Mental analog scale
RCT: Root canal treated

292 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE OCTOBER 2005, VOL. 23, NO. 4
 HAMMAD ET AL.
Bruxism and Clenching
Seven of the 20 patients (35%) were aware of clench-
ing and/or bruxism upon awakening and/or during sleep-
ing hours (Table 1). No improvement was recorded prior
to initiating FMR. At the 1-month recall appointment,
following FMR and occlusal adjustment (Stage III), four
of the seven patients (57.1%) reported that they were
symptom free, two patients (28.6%) reported moderate-
to-good improvement, and one patient (14.3%) reported
that she barely improved (Table 3). During the four-
month recall appointment, five patients (71.4%) reported
they were symptom free, one patient (14.3%) reported
good improvement, and one patient (14.3%) reported
slight improvement. No further change was noted after
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the 4-month recall period for all patients included in this
study.
Ability to Make Lateral Gliding Articulation Movements
Prior to FMR, patients were asked to close into centric
occlusion (maximum intercuspation) with the posterior
teeth in light contact. Then they were told to move or
glide the lower jaw to the right (or left) side while keep-
ing the teeth in light contact.36 Ten of the 20 patients had
considerable difficulty in unlocking their occlusion in
order to perform this task. After removing occlusal inter-
ferences through equilibration procedures,41 nine of the
ten patients (90%) with so-called locked occlusion could
easily make lateral gliding articulation movements
(Table 3).30 Seven patients remarked that, with very little
effort, their jaws moved sideways easier. At the 1-month
recall appointment, nine patients reported total improve-
ment. The improvements remained un-changed until the
12-month recall appointment.
The remaining ten patients were able to make reason-
able right and left lateral gliding articulation movements
of the mandible prior to having a FMR and occlusal equi-
libration. These patients were asked, “Which direction,
right or left, does your jaw move easier with the teeth in
light contact?”36 Three patients (30%) indicated no pref-
erence; however, seven patients (70%) responded that
movement in either the right or left direction was not as
easy as in the opposite direction. These seven patients
were asked to move their mandible to the relatively diffi-
cult side, while marking the occlusion with thin ar-
ticulating plastic. In all instances, there were posterior
teeth interferences. After removing these occlusal inter-
ferences, five of the seven patients immediately respond-
ed that it was easier to move the jaw in both directions.
Further selective occlusal equilibration was performed to
refine anterior protected occlusion35 in both lateral di-
rections. Subsequently, all patients remarked that they
could make lateral gliding articulation movements in
OCTOBER 2005, VOL. 23, NO. 4
FULL-MOUTH REHABILITATION FOLLOWING TMD TREATMENT
both lateral directions with equal ease at the two-month
recall appointment (Table 3).
Statistical Analysis
Fisher exact probability tests were applied to analyze
the results. The data were placed into 2X2 tables accord-
ing to the degree of improvement as recorded in the MAS
(Table 2). To fit the 2X2 format, the responses were
combined into: cured (100% improvement) vs. not cured
(<100% improvement). The tests were applied based on
the MAS specifically relative to the individual compo-
nents of the teeth related signs and symptoms previously
discussed. Statistical comparisons of the MAS relative to
treatment responses before treatment compared to those
after stage II of treatment showed no significant improve-
ment for all of the teeth-related signs and symptoms (P
values are indicated in Table 4). However, statistical
comparisons of the MAS relative to treatment responses
before treatment compared to those at the 1-month recall
appointment (after stage III of treatment) showed signifi-
cant improvement for all of the teeth-related signs and
symptoms. Similarly, comparing MAS before stage III
(after stage II) and after stage III (at the 1-month recall
appointment) resulted in significant improvement. Further
improvement was also noted by the 4-month recall period
and remained unchanged until the 12-month recall
appointment; however, these improvements were not
statistically significant for all of the teeth-related signs
and symptoms.
Discussion
Perceived malocclusion (occlusal awareness) and
other teeth-related signs and symptoms should be rou-
tinely recorded and addressed in patients with TMD,
especially if extensive restorative, orthodontic, or fixed
prosthodontics is contemplated. 13,16,17,29,36,44 Perceived
malocclusion was found to be present in approximately
75 percent of more than 10,000 TMD patients (in one
survey).29 Addressing teeth-related factors should result
in a higher percentage of overall success in TMD ther-
apy.12,13,16,29,36,40,44,45,48,49 In the current study, five of 20
patients continued to be aware of and complain of an
uncomfortable occlusion (perceived malocclusion),
inspite of having had relief of major TMD symptoms
after wearing an anterior deprogramming device fol-
lowed by a centric relation occlusal (CRO) device. FMR
and refinement of the occlusion resulted in three of the
five patients having total improvement of the symptoms
of perceived malocclusion. Of the two remaining patients,
one had moderate improvement and one patient had no
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 293
 FULL-MOUTH REHABILITATION FOLLOWING TMD TREATMENT
Table 4
Fisher Exact Probability Test P-Values Relative to Teeth-Related Signs and
Symptoms at All Treatment Stages
Before
treatment
vs.
after stage II
Perceived malocclusion 0.5000
Sensitive teeth >0.9990
Bruxism/clenching >0.9999
Difficulty during lateral
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movements >0.9999
Jaw moves easier
toward one side 0.2105
improvement (Table 3). Wenneberg, et al.,48 reported
that a group of TMD patients wearing occlusal devices
(splints) had a higher percentage of TMD relief than a
second group of patients who had only an occlusal equili-
bration. It is possible that they would have obtained better
results if the two methods of TMD therapy had been com-
bined as reported in this study.
The inability of patients to freely make lateral gliding
articulation movements35 of the teeth is an area worthy of
scientific study.21,24,30,36,49,50 In the present study, prior to
FMR and occlusal equilibration, ten patients had diffi-
culty making lateral gliding articulation movements, with
a similar degree of ease to both sides. After FMR and
selective occlusal equilibration, nine of the ten patients
(90%) reported that they could make lateral gliding artic-
ulation movements with ease to both sides. The inability
of patients to easily make lateral gliding articulation
movements was conceivably related to the presence of
posterior occlusal interferences, which impeded an ante-
rior protected articulation (anterior guidance).21,24 Re-
moval of working and nonworking side occlusal
interferences possibly decreases noxious periodontal
proprioceptive input to the elevating masticatory
muscles, via the CNS, thus resulting in their muscle
relaxation.1,12,13,16,22,24,45
In this study, the most prevalent occlusal interferences
that inhibited lateral gliding articulation movements were
found in the most posterior tooth area (second or third
molars), both on working and nonworking sides. This
finding seems to be biomechanically logical, since these
molars are the teeth closest to the temporomandibular
joint (TMJ) fulcrum and to the antagonistic elevating
294 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE
HAMMAD ET AL.
Before After stage III
treatment After stage II vs.
vs. vs. 4-12 mos.
after stage III after stage III recall
0.0303 0.1288 0.2273
0.0011 0.0011 >0.9999
0.0699 0.0699 0.6329
0.0015 0.0015 0.3344
0.0004 0.0376 0.2353
muscles of mastication whose contraction impedes later-
al jaw movements.21,22,24
Bruxism and/or clenching habits were significantly
reduced in four of the seven patients (57.1%) having a
positive history, as recorded using the MAS (Tables 2,
3). This finding is consistent with another study21 that
reported that the bruxing habits of patients were greatly
reduced after removing lateral occlusal interferences.
Other investigators 3,36,48,51,52 reported that wearing an
occlusal device (splint) reduced bruxism tendencies.
These findings suggest that wearing an occlusal device
together with appropriate occlusal equilibration12,21,22,36,42,43
reduces bruxism tendencies. This is based upon the rea-
soning that a precisely made occlusal device acts in a
manner similar to an occlusal equilibration in intercept-
ing opposing occlusal interferences. 12,13,16, 36,39,40,44,45
It is suggested that a precisely made maxillary CRO
device, with mutually protected articulation,35 signifi-
cantly reduces parafunctional masticatory muscle
contraction and the ensuing hypercompressive, parasthe-
sia-like forces upon the periodontium.24 Subsequently,
when the patient removes his/her CRO device from the
mouth, he becomes more acutely aware whenever the op-
posing teeth are in contact. This may be due to a re-
sensitization of the periodontal proprioceptive input to
the CNS and to improved cognitive awareness. This was
the scientific rationale as to why the patients in this inves-
tigation were instructed to continue wearing their occlusal
devices immediately after FMR therapy. The patients
were asked to stop using the CRO devices, in the absence
of major TMD signs and symptoms, no later than four
weeks after the FMR cases were completed.
OCTOBER 2005, VOL. 23, NO. 4
 HAMMAD ET AL. FULL-MOUTH REHABILITATION FOLLOWING TMD TREATMENT

The favorable results evident in this investigation, 9.
resulting from the use of (1) the anterior deprogramming 10.
device, (2) the full coverage CRO device, and lastly,
11.
(3) equilibration procedures in conjunction with FMR,
may be related to the precise protocol procedures 12.
employed.12 Unless the operator has developed the ap-
propriate occlusal skills,12,13,20,22,25,36,42 including experi- 13.
ence in using the bimanual manipulation method 22 14.
to locate and/or verify centric relation, the favorable
15.
results achieved in this study may be difficult to duplicate
especially by general practitioners. Otherwise, TMD 16.
therapy should be kept at the simplest level for patients 17.
having symptoms and/or signs by prescribing self-care
18.
instructions1,5 until the patient is referred to a specialist.
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Kirveskari P, Alanen P: Scientific evidence of occlusion and craniomandibu-
lar disorders. J Orofacial Pain 1993; 7:235-240.

Experimental Design Problems
The difficulties of controlling variables in a clinical
study to evaluate occlusal therapies were discussed by
Okeson.1,3 In the current study, arthrographic evaluation
was not considered because of the invasive nature of the
procedure, the unjustified exposure to radiation, and
other economic factors.
Conclusions
Within the limitations of this study, the following con-
clusions were drawn:
1. Symptoms of perceived malocclusion were not
resolved during function unless occlusal equilibra-
tion of the final restorations was performed.
2. At the 1-month recall, the patients demonstrated
marked reduction in their adjunctive teeth-related
signs and symptoms. No further change was noted
after the 4-month recall period for all patients
included in this study.
3. Addressing teeth-related factors with occlusal ther-
apy resulted in a higher degree of improvement.
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296 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE
HAMMAD ET AL.
Dr. N. Joseph Nassif is a clinical associate professor (part time) at
Howard University College of Dentistry, Washington, DC. He also
maintains a part time practice limited to temporomandibular disorders
and removable prosthodontics. He was formerly an associate professor
at Georgetown University School of Dentistry and King Saud University
College of Dentistry, Riyadh, Saudi Arabia. Previously, Dr. Nassif was a
consultant in prosthodontics to the Surgeon General of the United States
Air Force. He is a charter fellow of the American College of
Prosthodontists and a member of several dental organizations, including
the American Equilibration Society. He has published extensively in
dental journals, including a textbook chapter (on TMD) in a 2004 publi-
cation, “Oral Medicine.”
Dr. Ziad A. Salameh received his D.D.S. degree from St. Joseph
University, College of Dental Medicine, Beirut, Lebanon in 1991 and a
Master of Sciences in Dentistry field Prosthodontics (M.Sc.-DESP) in
1996 from the same university. He joined St. Joseph University as
demonstrator in 1992, then as clinical instructor of dentistry in 1993. He
was promoted to lecturer in prosthodontics in 1997. He joined King Saud
University, College of Dentistry, Riyadh, Saudi Arabia, as a specialist in
the Department of Prosthetic Dental Sciences in 2000. Dr. Salameh has
participated in several continuing education courses locally and interna-
tionally and has given presentations locally and regionally. Currently, he
is supervising the TMD clinic of the same university.
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