Myofunctional and speech rehabilitation after orthodontic-surgical treatment of dento-maxillofacial dysgnathia

progress in orthodontics 1 3 ( 2 0 1 2 ) 57–68

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/pio

Original article

Myofunctional and speech rehabilitation after orthodontic-surgical treatment of dento-maxillofacial dysgnathia Gianluca Gallerano a , Giovanni Ruoppolo b , Alessandro Silvestri c,∗ a

DDS Degree in Dentistry (MD) Doctor of medicine; Ear, Nose and Throat Specialist (ENT); Specialist in Phoniatry; Associated Professor of Phoniatry and Audiology, Department of Sense Organs, “Sapienza” University of Rome c (MD) Doctor of Medicine; Ear, Nose and Throat Specialist (ENT); Specialist in Dentistry and Stomatology (DDS); Specialist in Orthognatodontics; Associated Professor of Orthodontics, Department of Dental Sciences,“Sapienza” University of Rome b

a r t i c l e

i n f o

a b s t r a c t

Article history:

Objectives: The lingual dysfunctions play a considerable role in the pathogenesis of

Received 6 February 2011

dentoskeletal dysmorphisms. The treatment of dento-maxillofacial dysgnathia implies

Accepted 31 August 2011

a functional rehabilitation to re-harmonize the stomatognathic system. This study aims to demonstrate the importance of a rehabilitation protocol of functional orofacial

Keywords:

parameters at the end of a surgical-orthodontic treatment in order to achieve long-term

Dento-maxillofacial dysgnathia

success.

Myofunctional therapy

Materials and methods: After orthognathic surgery, facial expression exercises and jaw exer-

Post-surgical re-education

cises are prescribed to promote the recovery of neuromuscular function. At the end of

Retainers

treatment, a sample of 30 dysgnathic patients underwent a functional evaluation of the oro-

Speech therapy

facial district to identify any lingual or articulatory dysfunctions. The information gathered led to an individual re-education program that consisted of an active myofunctionallogopedic approach integrated with appliances used as retention. Results: 19 patients needed myofunctional therapy to re-educate deglutition and tongue posture. Articulatory disorders were found in 7 patients originally suffering from Class III and/or open-bite skeletal disharmony; 5 of these completed rehabilitation with speech therapy. After rehabilitation the functional parameters were completely normalized in 12 patients; in 5 cases, partial improvements were obtained, while in 2 cases the therapy was ineffective. Conclusions: In a patient undergoing post-surgical reconsolidation of his/her functional equilibrium even an uncontrolled speech defect may lead to an instable result. Only through an interdisciplinary approach it is possible to intercept and re-educate all the functions that are not compliant with the structural changes and to eliminate a tendency to relapse of the dysgnathia. © 2011 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved.

∗

Corresponding author. Department of Dental Sciences, Viale Regina Elena 287/A - 00161 Rome, Italy. E-mail address: [email protected] (A. Silvestri). 1723-7785/$ – see front matter © 2011 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved. doi:10.1016/j.pio.2011.08.002

58

1.

progress in orthodontics 1 3 ( 2 0 1 2 ) 57–68

Introduction

Dento-maxillofacial dysgnathia must be placed in a global, morphological and functional context of the stomatognathic system, where alteration of any one of its components impacts on the others to which it is closely linked (Fig. 1). The treatment of dysgnathia involves the re-harmonization of all the components of the stomatognathic system both from a structural and functional point of view. The combination of dental malocclusion and skeletal malformation requires the use of combined orthodontic and surgical treatment. Particular attention should be given to the tongue, since orthognathic surgery leads to volumetric changes of the functional space in which it is situated and in which it carries out its functions. Changes in the morphology and function of the tongue can play a decisive role in the pathogenesis of malocclusions and sometimes also in maxillo-mandibular skeletal changes. Proffit [1,2], in particular, emphasizes the morphogenetic role of tongue posture, by claiming that the growth pattern is mostly influenced by the rest position of the soft tissues rather than by their active movement. In fact, the number of swallows per day is between 500 and 1000, and since each one lasts on average 1.5 seconds [3] it is deduced that swallowing takes place for a total of less than 30 minutes throughout the entire day [4,5]. Under this perspective, the fact that the tongue remains in its rest position for more than 20 hours per day and that a slight force applied for an extended period can move the teeth and influence the growth of the bone structure, is of greater concern. In mature individuals, the tip and the blade of the tongue while are at rest, are usually in contact with the front third of the palatal vault, in an area between the transverse palatine folds and the incisive papilla, while the edges lay on palatal dento-alveolar structures [4–6].

Fig. 1 – Functional relationship between the components of the stomatognathic apparatus (SGA): neuromuscular system (NMS), dento-periodontal apparatus (DPA), temporomandibular joint (TMJ), basal skeletal system (BSS).

However, there are numerous atypical tongue postures that are related to the pathogenesis of some dysgnathic clinical pictures: • a forward posture of the tongue can lead to an anterior open-bite by hindering the eruptive process of the teeth while a lateral posture can lead to a unilateral or bilateral posterior open-bite [7] (Fig. 2). During swallowing the interposition of the tongue between the arches can occur in order to establish a seal; • in oral breathers, a low tongue posture, associated with the low tone of the masticatory muscles, can promote tooth extrusion thereby inducing mandibular posterior rotation and encouraging the development of a long-face syndrome [5]; • in Class II malocclusion the tongue can be positioned upward and forward, resting on the upper front teeth, or it can be pulled back [5]; • in Class III malocclusion the tongue can be positioned downward and forward, pushing the mandible in a forward direction and stimulating excessive growth (Fig. 3). Furthermore, failure to act on the maxillary sutural growth may cause hypoplasia of the maxilla [5]; • in dento-alveolar biprotrusion the tongue rests against the lingual surface of both arches and it does not find effective resistance from the lip muscles [5]. The development of the dental arches and skeletal base is determined by the balance between the muscles inside the mouth that promote expansion, and the concentric action of the external muscle [8]. It is therefore important that both tongue and lips posture be maintained within physiological limits, so that a normal osteo-muscular complex develops and normal vegetative and relational functions are carried out. The tongue in rest position represents, in particular, the moment in which each functional cycle begins and terminates [5]. In presence of an abnormal rest position of the tongue, atypical deglutition and/or abnormal word articulation may develop. The vocal apparatus is made up of the lips, tongue, dental arches and palate where the phonatory air flow is interrupted in various ways, thereby articulating the phonemes, the basic sound units of language. Articulatory disorders are defined as dyslalia, divided according to their origin in “functional”, “organic”, “audiogenic” and “neurogenic” [9]. The first are the result of incorrectly set mobile structures involved in the articulatory mechanism while the latter are the consequence of morphological changes, congenital or acquired, in the resonant cavity and articulation organs [9–11]. A fully-developed dysgnathia can predispose to language disorders as it can produce changes in the shape and volume of the oral cavity [12]. On the other hand, the gradual progression to dysgnathia, provides sufficient time to implement those compensatory mechanisms that make it possible to capture correct articulatory patterns [13]. Sometimes dyslalia not only develops as a result of serious dysgnathia, to the point that it hinders adaptation mechanisms, but it also can be the result of functional changes acquired in childhood and which have not regressed due to pathological (audiogenic and neurogenic dyslalia) or environmental factors. The presumed pathogenetic role of dyslalia is debated: for Giannì [14] it plays a crucial role in the genesis of malocclusions, while according to Proffit [1,2,15], dyslalia alone

progress in orthodontics 1 3 ( 2 0 1 2 ) 57–68

59

Fig. 2 – Abnormal posture of the tongue with frontal (A) and lateral interposition (B).

cannot be the cause of malocclusions. According to Marchesan et al. [16] and to Campiotto [17] the majority of dysgnathic patients do not need a re-education because usually altered functions would fit the new shape satisfactorily not requiring a specific approach. On the other hand, D’Agostino [18] states that all his cases necessitate a re-education because in his opinion this kind of patients have functional abnormalities that surgery itself is not able to solve. Cimmino et al. [19] reported that after orthognathic surgery the functional adaptation does not occur spontaneously but a re-education is needed to correct functional attitudes otherwise irreversible. In our experience it is very important to guide the functional recovery of the stomatognatic apparatus in dysgnathic patients undergoing orthodontic treatment and maxillofacial surgery. The present study, therefore, aims to highlight the importance of neuromuscular re-education in order to achieve long-term success in the treatment of dento-maxillofacial dysgnathia. The present study will also illustrate the main post-surgical rehabilitation strategies adopted at the Orthodontic Service of the Department of Dental Sciences at the “Sapienza” University of Rome. The role that this approach should assume as part of the treatment plan

Fig. 3 – Typical lower tongue resting position in Class III dysgnathia.

will be demonstrated through the analysis of a sample of 30 patients.

2.

Materials and methods

A sample of 30 adult patients suffering from dentomaxillofacial dysgnathia subjected to orthognathic surgery in the years 2008-2009 was analyzed. Only patients with “good” and “excellent” treatment results were selected, which confirmed that the structural pathology was resolved. Complex malformations with specific involvement of the neuromuscular system, such as hemifacial microsomia and cleft lip and palate, were excluded from the sample. Table I shows a schematic layout of the “diagnosis” and “therapy” for each case. Based on the original dysgnathia, we identified three groups consisting of 8 patients with Class II skeletal relationships, 11 patients with Class III skeletal relationships and 11 patients with dentoskeletal open-bite associated or not with an alteration on the sagittal plane (2 patients with Class I skeletal relationships, 2 patients with Class II skeletal relationships and 7 patients with Class III skeletal relationships). In total therefore, there were 10 subjects with Class II skeletal relationships, 18 subjects with Class III skeletal relationships and 2 subjects with Class I skeletal relationships. All patients underwent pre-surgical orthodontics and orthognathic surgery. Due to rigid internal fixation, an intermaxillary block was not required at the end of surgery and all patients left the operating room free to open and close the mouth spontaneously. Post-surgical treatment started about 15 days after orthognathic surgery. The muscles must regain a physiological condition of tone and synergy, and the patient must gradually become aware of the proprioceptive changes in both dento-periodontal and musculo-skeletal districts. To accelerate these processes all patients were instructed to perform exercises of facial expression and simple jaw exercises. The first consisted in alternating forced smiles with lip protrusions and in inflating lips and cheeks. These exercises, to be carried out for at least 6-8 weeks [20], were aimed at extending scars and thereby strengthening muscles and lip contraction. Jaw exercises had to be performed in front of

60

Table I – *Caption: AG (Agenesis); CL (dento-skeletal class); MC (Maxillary contraction); DB (Deep-bite); ID (Intermaxillary disjunction); TMD (temporomandibular disorder); RCF (Result of condyle fracture); ELN (Envelop Lingual Nocturn of Bonnet); EX (Dental extraction); GP (Genioplasty); IN (Dental inclusion); MLD (Mandibular laterodeviation); LF (Long-face); LFI (Le Fort I osteotomy); OB (Open-bite); PO (Presurgical orthodontics); BSSO (Bilateral sagital split osteotomy); RG (Class III retainer with lingual grid); RP (Rhinoplasty); SR (Splinted retainer); SF (Short-face); ST (Speech therapy); MFT (Myofunctional therapy for lingual posture and deglutition). POST-TREATMENT OROFACIAL EVALUATION

NAME

AGE

GENDER

DIAGNOSIS

THERAPY

OPINION

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

S. M. B. A. E. F. M. A. L. A. A. M. S. P. C. S. M. A. P. E. D. M. P. C. P. A. L. M. S. R. M. M. R. M. C. T. M. G. R. I. R. F. P. D. V. E. V. S. S. W. S. D. P. V. L. E. G. C. T. S.

32 17 25 26 26 26 27 17 21 28 19 32 19 18 24 28 25 17 30 20 26 22 25 19 18 19 22 21 21 27

M F M M F F F F F M F F M M M F M M M F F F M F M F M F M F

CL*II; DB* CL II; DB; IN* 1.3,2.3,3.3,4.3 CL II; DB; SF* CL II CL II; MC* CL II; TMD* CL II CL II CL III CL III; MC CL III CL III CL III CL III; TMD; AG*1.3,2.3; MC CL III; IN 2.3 CL III; MLD* CL III; MLD; TMD CL III; MLD CL III; LDM-RCF* OB* ant.; LF* OB ant.; MLD OB ant.; CL II; LF OB ant.; CL II; MC OB ant.; CL III; TMD OB ant.; CL III OB ant.; CL III; LF OB ant.; CL III; LF OB ant-lat.; CL III; MLD OB lat.; CL III OB lat.; CL III

EX* 1.4,2.4 + PO* + BSSO*-GP* EX 1.3,2.3,3.3,4.3 + PO + BSSO-GP EX 1.8,2.8,3.8,4.8 + PO + BSSO PO + BSSO-GP PO + LFI*-BSSO PO + LFI-BSSO PO + LFI-BSSO EX 1.4,2.4 + PO + LFI-BSSO PO + LFI-BSSO PO + LFI-ID* EX. 1.8,4.8 + PO + LFI-BSSO PO + LFI-BSSO EX 3.8,4.8 + PO + LFI-BSSO PO + LFI-BSSO PO + LFI-BSSO PO + LFI-BSSO PO + BSSO EX 1.8,3.8,4.8 + PO + LFI-BSSO-RP* PO + LFI-BSSO-RP PO + LFI-BSSO PO + LFI-BSSO PO + LFI-BSSO PO + LFI EX 1.8,2.8 + PO + LFI-BSSO PO + LFI-BSSO EX 3.8,4.8 + PO + BSSO EX 1.8,2.8,3.8,4.8 + PO + LFI-BSSO EX 1.4,2.4 + PO + LFI-BSSO EX 1.5 + PO + LFI-BSSO PO + LFI-BSSO

Class II

Classe III

Open-bite

PERIORAL MUSCLES

DEGLUTITION

TONGUE POSTURE

ARTICULATION DISORDERS

EXCELLENT

NORMAL

BACKWARD

-----

NORMAL

EXCELLENT

ATYPICAL

NORMAL

/r/

UNBALANCED

GOOD

NORMAL

NORMAL

UNBALANCED

EXCELLENT

NORMAL

NORMAL

GOOD

NORMAL

BACKWARD

GOOD

ATYPICAL

NORMAL

GOOD

NORMAL

FORWARD

EXCELLENT

NORMAL

NORMAL

GOOD

NORMAL

NORMAL

-----------------------------

EXCELLENT

ATYPICAL

DOWNWARD

/t/d/

NORMAL

EXCELLENT

NORMAL

NORMAL

NORMAL

EXCELLENT

NORMAL

DOWNWARD

UNBALANCED

EXCELLENT

ATYPICAL

DOWNWARD

-------------

EXCELLENT

ATYPICAL

DOWNWARD

/s/dz/gi/

UNBALANCED

GOOD

ATYPICAL

DOWNWARD

UNBALANCED

NORMAL NORMAL UNBALANCED NORMAL NORMAL NORMAL

NORMAL

EXCELLENT

NORMAL

NORMAL

EXCELLENT

ATYPICAL

FORWARD

EXCELLENT

ATYPICAL

NORMAL

GOOD

ATYPICAL

FORWARD

---------------------------------

GOOD

ATYPICAL

FORWARD

/s/z/ /t/

UNBALANCED

EXCELLENT

ATYPICAL

DOWNWARD

UNBALANCED

EXCELLENT

ATYPICAL

DOWNWARD

---------

GOOD

ATYPICAL

FORWARD

EXCELLENT

ATYPICAL

DOWNWARD

/t/s/ /t/d/s/z/

UNBALANCED

EXCELLENT

NORMAL

FORWARD

EXCELLENT

ATYPICAL

DOWNWARD

EXCELLENT

ATYPICAL

DOWNWARD

NORMAL NORMAL UNBALANCED NORMAL UNBALANCED NORMAL UNBALANCED

NORMAL UNBALANCED

GOOD

NORMAL

NORMAL

-----

NORMAL

GOOD

ATYPICAL

DOWNWARD

/gi/

NORMAL

EXCELLENT

NORMAL

NORMAL

-----

NORMAL

RESTRAINTS

MFT*

ST

SR* SR SR SR SR SR SR SR RG* RG RG RG RG RG RG RG RG RG RG ELN* ELN ELN ELN RG RG ELN ELN RG RG RG

-----

-----

YES

YES

-------------

---------------------------------------------

YES YES ---------

YES -----

YES YES YES YES -----

YES YES -----

YES YES YES YES YES YES YES YES -----

YES -----

YES ---------------------------------

YES ---------

YES YES -------------

progress in orthodontics 1 3 ( 2 0 1 2 ) 57–68

N°

progress in orthodontics 1 3 ( 2 0 1 2 ) 57–68

61

Fig. 4 – Post-surgical functional assessment reports in dysgnathic patients (A,B).

a mirror 2 times a day for 5 minutes and they consisted in active mouth opening and closing movements on the right and left side, and slight protrusions to gently move the mandibular structure. TMJ was also monitored at this stage, to ensure that no dysfunction occurred. The post-surgical orthodontic phase usually lasted 4-6 months, at the end of which fixed appliances were removed and removable retention appliances were applied. At the end of the treatment, a comprehensive re-assessment of the cases was carried out: the radiographic and photographic records from the start to the end of the treatment were compared and the therapeutic phases analyzed so that an appraisal of the aesthetic and structural results of the treatment (poor, fair, good, excellent) could be performed. While the goal of this treatment was the global morpho-functional re-harmonization of the stomatognathic apparatus, a thorough assessment of the neuromuscular component was also necessary. The position of the tongue, deglutition and speech also had to be re-assessed carefully so that functional reconditioning with the structural changes made could be completed. Therefore, a post-surgical orofacial evaluation and rehabilitation program was carried out in collaboration with the Phoniatrics Operations Unit of the Department of Sense Organs at the “Sapienza” University of Rome. The protocol was applied to the sample of 30 adult patients. At the end of the post-surgical orthodontic phase the patients, free from the interference of orthodontic brackets,

underwent a functional assessment of the orofacial district in order to identify any dysfunction and to assess its extent. To standardize the assessment, carried out by clinical methods, the data were collected in a specially designed folder (Fig. 4). In its implementation, reference was made to the orthodontic and functional assessment folder currently in use at our Orthodontic Unit for growing patients with orthodontic relevancy. This folder was re-adapted to the anatomical and functional characteristics of adult dysgnathic patients. A brief anamnesis was followed by an analysis of the orofacial muscles focused on the anatomical and functional characteristics of the lips and tongue in static and in dynamic phase. Data collection was completed by an assessment of the phonetics carried out by a speech therapist. In Table I under the heading “orofacial post-treatment assessment” there are data concerning “deglutition”, “tongue posture”, “articulation disorders” and “perioral muscles”. The indications provided by the examination made it possible to obtain, where necessary, an individual re-education program by integrating two different strategies: on one hand an active myofunctionallogopedic approach in which the patient actively participated in correcting tongue posture and improper functions, and on the other a passive approach, with the help of re-educational aids. During the months of April-May 2011, the 19 patients subjected to myofunctional and speech therapy were re-checked

62

progress in orthodontics 1 3 ( 2 0 1 2 ) 57–68

Table II – ELN (Envelop Lingual Nocturn of Bonnet); RG (Class III retainer with lingual grid); SR (Splinted retainer); ST (Speech therapy); MFT (Myofunctional therapy for lingual posture and deglutition).

Class II

Class III

Open-bite

using the same evaluation criteria adopted after the surgicalorthodontic treatment to verify the functional status and the possible permanence of lingual function abnormalities. The results of this last assessment are reported in Table II. The re-education of tongue posture and deglutition consisted of a preliminary phase aimed at “restoring proprioception,” which follows a phase of myofunctional re-education, more properly characterized by “muscle exercises” and “functional recovery” [4]. In order to develop oral proprioception of the new oral space, the patient was asked to slide the tip of the tongue over the palate in all directions, and to differentiate between smooth areas and wrinkled areas [21]. This is important for the identification of the incisive papilla that can be facilitated by pressing it down with a blunt instrument or the tip of the index finger [6] The next exercise required the mouth to be opened, the tip of the tongue in contact with the papilla, and the back of the tongue raised and flattened against the palate. This position has to be maintained for 5 seconds before removing the tongue from the palate, with the tongue tip still on the papilla. In this way, apart from encouraging proprioception, the second tongue movement is traced during deglutition (“pharyngeal phase”). Therefore, after achieving a satisfactory result, the sequence of movements will be completed by bringing the dental arches in occlusion and swallowing the saliva. Alternatively, especially in subjects with spastic or hypotonic tongue muscles, it is

possible to use the “proprioceptive neuromuscular facilitation” (PNF) technique [4,5,22]. This is a method where the neuromuscular response evoked by stimulating various kinds of proprioceptors (for example, deep pressure on the edge or back of the tongue) would exclude a conscious understanding of posture practice [4,22] (Fig. 5). The exercises used in the PNF method favor proprioception, since they increase sensitivity of the mucous membrane and the tongue tone, making

Fig. 5 – Deep pressure on the sides of the tongue with a blunt instrument.

progress in orthodontics 1 3 ( 2 0 1 2 ) 57–68

Fig. 6 – Exercise with a single elastic for tongue posture.

the tongue narrower and improving its ability to adapt to the palatal vault. The position of the tongue is greatly influenced by its muscle tone [4,21], like during deglutition and the emission of certain phonemes, and, therefore, suitable tongue muscle tone is required. It is especially in Class III malocclusions that the tongue, apart from having a low posture, is hypotonic and therefore increased in size. In these cases, “muscle exercise” is carried out to balance the different muscle groups. The apex is toned by pushing the tongue against a tongue depressor placed in front of the mouth. In order to increase the tone of the body of the tongue, the patient is trained to “click” the tip of the tongue against the palate, while to increase the tone of the base an opposing traction is created by grabbing the tongue with a gauze and pulling. During the “functional recovery” phase to re-educate tongue posture we also use the Garliner method [5,6,23]: an intermaxillary elastic (5/16” and 6 oz) is placed on the tip of the tongue and subsequently brought into contact with the papilla, with the dental arches slightly open (Fig. 6). A variant is that another elastic is placed between the lips, thereby also strengthening lip contraction. The elastics should be kept in place for 5 minutes, 3 times a day for the first week, gradually increasing the time to one hour per day. Within 2-3 months the resting position will become automatic. Lastly, re-education of the deglutition is obtained by practicing to swallow small amounts of water collected between tongue dorsum and palate. This exercise should be initially carried out at lunch and dinner for 5 consecutive times; gradually the patient will be able to increase the amount of water held in the mouth and carry out this exercise outside meal times as well. If the patient is not able to support sufficiently the tongue against the palate, it may be useful to carry out the exercise by biting a straw placed horizontally at the level of the canines, in order to provide support for the tongue and help lift it to the level of the premaxilla [24] (Fig. 7). Language re-education begins after myofunctional treatment since the treatment could indirectly lead to an improvement of the pronunciation disorder. An adult will encounter more difficulties in correcting his/her dyslalia, which is more consolidated and deep-rooted than a child. On the other hand, together with a greater degree of cooperation, there is the advantage that by correcting the dysgnathia the anatomical structure is more consonant with the evolution of

63

Fig. 7 – Deglutition using a straw placed horizontally at the intercanine level.

phono-articulatory mechanisms. Logopedic rehabilitation includes various successive stages: brief orofacial exercises, vocalization exercises and lastly, speech therapy exercises. First of all, the patient must be aware of how the altered phoneme is produced and the way in which it should be normally produced. For the Italian language the stimulation of the phoneme proceeds in ascending order, first by proposing direct (sc) and inverse (cs) pronunciation of syllables (sc), and then proceeds with words containing the syllable in combination with other phonemes. The next step is to work on the word with the phoneme in initial, middle and end positions. At first, the repetition will be slower in order to allow for conscious positioning, after which it will become automatic through the use of redundant phrases, and subsequently common phrases. When there are various defective phonemes to be re-educated, the preference is to begin with those that are easier to simulate, until reaching those most difficult to correct (/s/r/). The dento-alveolar (/t/d/) and alveolar phonemes (/l/n/), pronounced around the level of the incisive papilla, are the least difficult to correct. An improvement of these phonemes can be obtained simply by re-establishing the physiological lingual posture. However, reinforcement exercises may be useful. The sibilant phonemes (s,z,sc) are often compromised because they require very precise movements and an extremely small air outflow channel. Various devices are used to help the patient to correct the lisp. If the phoneme is omitted, the following steps should be performed: place the tongue near the palatal surface of the lower incisors, lift the back, draw the dental arches near and gently blow into the gap between the upper incisors and the tongue. If problems persist, a utility tool may be inserted to create a central channel at the tongue dorsum and the patient is invited to blow. Alternatively, the patient may be asked to place the flattened tongue between the teeth, blow and the pull it back to draw the arches near [5]. In interdental lisp (the tongue tends to creep in between the arches when pronouncing the “s”), first of all it is necessary to press against the low position of the mandible by placing one hand under the chin and placing a tongue depressor in front of the incisors to prevent tongue protrusion [5] (Fig. 8), after which the patient will exercise as much as possible to emit a hissing sound. The re-education

64

progress in orthodontics 1 3 ( 2 0 1 2 ) 57–68

Fig. 8 – Exercise for correcting the interdental lisps.

of zed shifts must be the same as for lisps which is generally easier. The main expedient suggested to patients when practicing to pronounce the “z” is to place a piece of paper on the tip of the tongue, resting it on the upper incisors, and to try to expel it while attempting to pronounce “za”. Post-alveolar “gi” and “ci”, usually corrected after any zed shifts, are reeducated by using a tongue depressor to push down on the tip of the tongue, around mid-palate, while pronouncing the “ti” syllable [10]. Rhotacism is more often a dyslalia of functional

origin; the exercises aim to develop the /r/ gradually from other consonants, for example by rapidly emitting sounds like “tla-tla” and “hda-hda” (d preceded by exhaled breath). Clicking exercises also make it possible to restore proper lingual muscle tone, that is essential to perform the characteristic vibration of the peak at the height of the retro-incisive papilla. This can be facilitated with the aid of mechanical means: with the mouth half-open an electric toothbrush without bristles can be placed under the chin or under the tip of the tongue resting on the papilla while pronouncing the sound “trr” [25]. Bilabial (/p/b/m/) and labiodental (/f/v/) phonemes, often pre-operatively affected due to structural impediments, usually improve once the basal relations are normalized and rarely require post-surgical re-education. Restraining devices were routinely applied to the sample of 30 patients to assist with the re-education. The retainers represent an active means of restraint that can integrate the re-education phase by encouraging the dynamic stabilization of the occlusion and neuromuscular function. Based on the original dysgnathia and on the individual functional characteristics, each patient was assigned the most appropriate device. In Class II dysgnathia, that is generally associated with a lower lingual impairment, the splinted retainer was applied (in 8 patients). This retainer consisted of an upper Hawely plate, with minimum interocclusal thickness, fitted with a small retro-incisive flange to prevent mandibular displacement in the distal direction (Fig. 9). In progenic syndromes a Class III

Fig. 9 – Upper retainer with splinting of the upper arch.

Fig. 10 – Class III retainer with lingual grid and control arch for the lower front group (A,B).

progress in orthodontics 1 3 ( 2 0 1 2 ) 57–68

65

Fig. 11 – Bonnet ELN for the rehabilitation of tongue posture.

retainer was applied (in 16 patients), which consists of an upper plate in resin fitted with a retro-incisive lingual grid and a buccal retraction arch for the lower frontal group (Fig. 10). The plate should not cover the entire arch but must be horseshoe shaped and reduced to the minimum size necessary to incorporate the metal supports; the objective is to reduce the size of the oral functional space and not prevent reciprocal tactile stimulation between the tongue and palate. The vestibular retraction arch originates from the plate and continues to the lower frontal group, only touching lightly the surface of the incisors and canines so that it does not cause any retrusive action that might interfere with the neuromuscular function of the TMJ. The therapeutic action of the grid is effective mainly for the time it is applied [26], preventing tongue movement in the front portion of the lower arch and redirecting it to the top plate; furthermore, it prevents lingual interposition between the arches during deglutition. It is shaped so as to re-educate the tongue to a more backward position, guiding it with a slight incline towards the premaxilla. For this reason, it should not be too far back, but inserted behind the plate, immediately behind the upper incisors. In this manner, together with the restrictive effect, the plate with grid will also serve to re-educate tongue position. In order to obtain a re-educational effect only on the tongue, the use of Bonnet Envelop Lingual Nocturn (ENL) is indicated. In our sample, we applied this device to 6 patients (2 with simple open-bite, 2 with Class II open-bite and 2 with Class III open-bite). The aim of this device is to create an obstacle-free environment that helps the tongue to find its posture and normal function also in those patients that have stopped growing. The ELN is made of a thin intraoral resin shell which stimulates the active ascent of the tongue through a lower lingual ramp up to a hole in the opening near the palatine folds [27,28] (Fig. 11). The side flanges prevent the tongue from interposing between the arches, both in the front and posterior regions. The ELN does not a simply exercise a restrictive action but it creates also a normal architecture around the tongue, by uninstalling the primary deglutition program and reinstalling the secondary deglutition program from the very start of the therapy. The device is applied at night and a few minutes during the day (3 minutes 3 times a day) [27]. Contrary to myofunctional

therapy, based on conscious learning, the ELN takes advantage of a mechanism that starts from the patient’s unconscious and nocturnal sensory-motor to reach the cognitive awareness [28].

3.

Results

An evaluation of the sample of 30 cases is reported in Table I where it can be noted that after the structural anomalies were resolved, disrupted functions were present in many patients. In patients treated to resolve the progenism, the tongue generally continues to be hypotonic and low; the open-bite group shows a more evident tendency to interpose the tongue between the arches while in the Class II subjects lingual capabilities are less involved. 19 out of the 30 patients required an additional phase of myofunctional therapy to restore proper tongue tone and posture, a physiological deglutition, and possibly to complete the re-education of facial muscles started immediately after surgery. Most patients belonged to the open-bite group (9 of 11) and the Class III group (7 out of 11). Pronunciation disorders were detected in 7 cases and mainly concerned patients with prior Class III and/or open-bite. In the latter group there is a prevalence of distorted sibilants, in association with the interdental articulation of dento-alveolar consonants. After myofunctional treatment, 5 patients completed the re-education process, undergoing speech therapy sessions; in 2 cases, the articulatory disorder regressed after an initial myofunctional approach. The check carried out after the rehabilitation period (Table II) revealed that the functional parameters of the oro-facial district were completely normalized in 12 out of the 19 patients. Only in 2 cases the therapy was ineffective (case n◦ 18 and n◦ 27), while in 5 cases we obtained a partial improvement with persistence of atypical swallowing (2 cases), abnormal tongue posture (1 case) or altered phonemes (2 cases). About the patients who originally had a speech disorder we observed a complete resolution in 4 cases, a partial resolution with correction of dento-alveolar phonemes and persistence of abnormal sibilant phonemes in 1 case, no improvement in 2 cases.

66

4.

progress in orthodontics 1 3 ( 2 0 1 2 ) 57–68

Discussion

The functional examination to which the patients of this study were subjected showed that orofacial dysfunctions may continue to persist after surgery, suggesting the feasibility of active re-education. Functional adaptation may in fact be far from occurring spontaneously over time, because the group of muscles, and therefore the functions related to them, require long re-manipulation under the new structural conditions. In the early re-education phases the goal is to re-program muscle and dento-periodontal proprioception. Adaptation to the new occlusion is favored by the early removal after surgery of the splint used as a surgical guide and by applying intermaxillary elastics (usually one on each side measuring 3/16” and weighing 4-6 oz) that guide the jaw into the correct spatial position in the lower arch, in direct occlusal contact with the antagonist. Even in the early stages of tongue re-education the proprioceptive work is crucial and can induce an initial impetus towards using correct lingual posture, which cannot exclude a physiological deglutition pattern. Some authors [29] re-educate deglutition by placing a sequence of elastics on the tongue. We consider it useful to apply posture reeducation using a single elastic band since we believe that too many elastic bands can cause proprioceptive discomfort and reduce re-education benefits. Furthermore, since interposing a foreign body between the tongue and palate would impede proprioception [5,22,30,31], we believe that in adult patients it is useful to use elastics only in early stages of re-education. It is however very useful to practice swallowing liquids in order to reproduce the natural retropulsive swallowing mechanism. Several studies [19,32–34] show that despite the intervention, the resulting change in the oral environment is not sufficient to produce the desired effects on the phonetic quality. The explanation for this latter circumstance is clear to us; adult dysgnathic patients with language disorders, because of the sudden change in the morpho-functional balance produced by surgery, do not have the same functional adaptation capability to correct the dyslalia as individuals in the growing phase. Therefore, though aware that the treatment provides anatomical structures suitable for implementing phono-articulatory mechanisms, we believe that language recovery must be properly guided. For some authors [18,22,35,36] the re-education approach should begin before surgery. Instead, we place speech therapy-myofunctional training in the post-surgical period. In fact, we believe that pre-surgery re-education would be useless and even harmful because the neuromuscular system is still adversely affected by dysgnathia, capturing only a false functional equilibrium which, after the intervention, must be changed and adapted to new structural features. Since myofunctional treatment is intended for adult and cooperative individuals, about 10 sessions (2 per week) are sufficient. The possible language re-education phase lasts three months, but certain dyslalia such as rhotacism and lisps, may require more sessions. The evaluation of the group of patients undergoing functional rehabilitation has in fact shown the persistence in 3 cases of disturbances in the articulation of /s/, /z/ and /r/ phonemes that are more rooted in the capabilities of the individual and therefore more difficult to correct.

Generally a maintenance phase is not required but it is useful to recheck the patient after a few months to verify that automation is maintained. Naturally, re-education of lingual functions does not exclude a constant daily commitment, continuing at home those exercises proposed from time to time during the therapy. The viability of this type of protocol also lies in the age of the persons to whom it is addressed, since it involves adults that generally tend to be highly motivated and therefore willing to accept the functional changes required by the re-education treatment.

5.

Conclusions

The present study showed that in the majority dysgnathic individuals the functional habitus does not change substantially even after surgical intervention. In order to ensure the stability of the treatment results, a new structural and functional equilibrium must be achieved to avoid tendency towards relapse [37,38]. Post-surgical re-education requires a interdisciplinary approach that makes it possible to intercept and re-educate all the functions that are not compliant with the new structural picture. After surgery, the surgeon entrusts the task of guiding the functional recovery of the patient to an orthodontic specialist. The first “post-surgical re-education phase” coexists with post-surgical orthodontics and, therefore, the orthodontist is routinely involved in re-educating jaw movements and mimic muscles. Once the fixed orthodontic devices are removed, the assessment by the orthodontist is no longer sufficient and supervision is required by a professional specialized in assessing the functions of the orofacial district. In particular, the lingual capabilities should be evaluated by a voice specialist or speech pathologist who, if necessary, will implement a second “speech therapy-myofunctional reeducation phase” aimed to harmonize the centrifugal force of the tongue with the opposing forces of the peripheral muscle housing. As stated by the principle of “etiopathogenetic diagnosis” by Langlade, if the etiopathogenetic process is not discovered and removed, the result will be relapse [39]. In the treatment of dysgnathia this principle should be applied to all possible changes within the concept of multifactorial etiology [1,2]. In fact, if under normal conditions dyslalia in itself is not capable of determining apparent structural alterations, in a patient undergoing post-surgical reconsolidation of his/her functional balance, even an uncontrolled speech defect may lead to an unstable result. Only through active re-education is it possible to change all the atypical motor patterns and set new functional patterns compatible with the new structural configuration. In fact, after surgery patients tend to recall their original functional model and they are not fully aware of the new one yet. It is the responsibility of the clinician to guide the learning process and functional adaptation, ensuring that the functional and postural attitudes do not impede overall harmonious and stable treatment results.

Conflict of interest The authors have reported no conflict of interests.

progress in orthodontics 1 3 ( 2 0 1 2 ) 57–68

Riassunto Objettivi: Le disfunzioni linguali giocano un ruolo rilevante nella patogenesi dei dismorfismi dentoscheletrici. Il trattamento delle disgnazie dento-maxillo-facciali implica una riabilitazione funzionale finalizzata alla riarmonizzazione dell’apparato stomatognatico. L’obbiettivo dello studio è quello di dimostrare come, al termine del trattamento ortodontico-chirurgico, un protocollo di riabilitazione dei parametri funzionali oro-facciali sia importante per il raggiungimento del successo a lungo termine. Materiali e metodi: Dopo la chirurgia ortognatica, vengono assegnati esercizi di mimica facciale e di ginnastica mandibolare al fine di promuovere il recupero della funzionalità neuromuscolare. Al termine del trattamento, un campione di 30 pazienti disgnatici è stato sottoposto ad una valutazione funzionale del distretto oro-facciale al fine di identificare eventuali disfunzioni linguali e di articolazione del linguaggio. Le informazioni ottenute hanno permesso di ricavare un programma individuale di rieducazione che consiste in un approccio attivo logopedico-miofunzionale integrato da dispositivi usati come contenzione. Risultati: La terapia miofunzionale è stata necessaria per 19 pazienti al fine di rieducare la deglutizione e la postura linguale. Disturbi articolatori sono stati rintracciati in 7 pazienti originariamente affetti da III Classe e/o open-bite dento-scheletrici; 5 di questi hanno completato l’iter rieducativo con la rieducazione del linguaggio. Dopo la riabilitazione si è assistito alla completa normalizzazione dei parametri funzionali in 12 pazienti; in 5 casi si è ottenuto un miglioramento parziale mentre in 2 casi la terapia è risultata inefficace. Conclusioni: In un paziente in fase di riconsolidamento postchirurgico del proprio equilibrio funzionale anche un difetto del linguaggio non controllato può determinare un’instabilità del risultato. Solo attraverso un approccio interdisciplinare è possibile intercettare e rieducare tutte le funzioni non compatibili con la nuova configurazione strutturale eliminando la tendenza alla recidiva della disgnazia.

Résumé Objectifs: Les dysfonctions linguales jouent un rôle significatif sur la pathogenèse des dysmorphismes dento-squelettiques. Le traitement de la dysgnathie dento-maxillo-faciale entraîne une réhabilitation fonctionnelle dans le but de réharmoniser le système stomatognatique. Cette étude vise à démontrer l’importance d’un protocole de réhabilitation des paramètres orofaciaux fonctionnels à la fin d’un traitement orthodontique chirurgical pour obtenir un succès à long terme. Matériels et méthodes: A près chirurgie ortognathique, des exercices de l’expression faciale et de la mandibule sont prescrits pour promouvoir la récupération de la fonction neuromusculaire. A la fin du traitement, un échantillon de 30 patients dysgnatiques ont été soumis à une évaluation fonctionnelle de la region orofaciale pour identifier d’éventuelles dysfonctions linguales ou d’articulation. L’information collectée a amené à un programme de rééducation individuelle qui s’est concrétisé dans une approche logopédique active myofonctionnelle accompagnée d’appareils utilisés comme mode de rétention. Résultats: 19 patients ont eu besoin d’une thérapie myofonctionnelle pour rééduquer la déglutition et la posture de la langue. Les troubles d’articulation ont été identifiés chez 7 patients qui souffraient originairement d’une désharmonie squelettique open bite

67

et/ou Classe III; 5 de ces patients ont complété la réhabilitation avec une thérapie d’élocution. Après réhabilitation, les paramètres fonctionnels ont été complètement normalisés chez 12 patients; dans 5 cas, des améliorations partielles ont été obtenues alors que dans 2 cas la thérapie s’est avérée inefficace. Conclusions: Chez un patient soumis à reconsolidation postchirurgicale de son équilibre fonctionnel, même un défaut non contrôlé d’élocution peut déboucher sur un résultat instable. Ce n’est qu’au travers d’une approche interdisciplinaire qu’il est possible d’intercepter et de rééduquer toutes les fonctions qui ne s’accomodent pas au nouveau tableau structurel, cela éliminant aussi le risque de récidive de la dysgnathie.

Resumen ˜ un papel imporObjectivos: Las disfunciones linguales desempenan tante en la patogénesis de los dismorfismos dentoesqueléticos. El tratamiento de la disgnacia dento-maxilo-facial conlleva una rehabilitación funcional con vistas a harmonizar de nuevo el sistema estomatognático. Este estudio apunta a demostrar la importancia de un protocolo de rehabilitación de los parámetros orofaciales funcionales al final de un tratamiento ortodóncico quirúrgico para lograr un éxito a largo plazo. Materiales y métodos: Después de la cirugía ortognática, se prescriben ejercicios de expresión facial y de la mandíbula a fin de promover la recuperación de la función neuromuscular. Al finalizar el tratamiento, una muestra de 30 pacientes disgnáticos fue sometida a evaluación funcional de la región orofacial para identificar cualquier disfunción lingual o de articulación. La información recogida llevó a un programa de reeducación individual que consistió en un enfoque logopédico miofuncional integrado con aparatos utilizados como medios de retención. Resultados: 19 pacientes necesitaron terapia miofuncional para reeducar la deglución y la postura de la lengua. Fueron encontrados trastornos de articulación en 7 pacientes que sufrían originariamente de desarmonía esquelética open bite y/o Clase III; cinco pacientes completaron la rehabilitación con terapia del habla. Después de la rehabilitación, los parámetros funcionales se normalizaron en 12 pacientes; en 5 casos se consiguieron mejorías parciales mientras que en 2 casos la terapia fue inefectiva. Conclusiones: En un paciente sometido a reconsolidación posquirúrgica de su equilibrio funcional, incluso un defecto no controlado del habla puede acarrear un resultado inestable. Sólo a través de un enfoque interdisciplinario es posible interceptar y reeducar todas las funciones que no se ajustan al nuevo cuadro estructural, eliminando al tiempo el riesgo de reincidencia de la disgnacia.

references

1. Proffit WR, Fields HW, Sarver DM. Contemporary orthodontics. 4th ed. St. Louis: Mosby Elsevier; 2007. 2. Proffit WR, White RP, Sarver DM. Contemporary treatment of dentofacial deformity. St. Louis: Mosby; 2003. 3. Dahan J. I disturbi linguali nelle deformazioni mascellari, aspetto nosologico e concetti terapeutici. Mondo Ortod 1989;14:777–89. 4. Cozza P, Polimeni A, De Toffol L. Manuale di terapia miofunzionale. Milano: Elsevier Masson; 2002. 5. Levrini A. Terapia miofunzionale, rieducazione neuromuscolare integrata. Milano: Masson; 1997.

68

progress in orthodontics 1 3 ( 2 0 1 2 ) 57–68

6. Garliner D. Myofunctional therapy. Philadelphia: Saunders; 1976. 7. Moyers RE. Postnatal development of the orofacial musculature. In: Proceedings of the conference patterns of orofacial growth and development, ASHA report 6. Washington DC: American Speech and Hearing Association; 1971 p. 38–47. 8. Chateau M. Equilibrio ortodontico. In: Atti del raduno SIDO. Spoleto; 1970. 9. Lanteri C. Ortognatodonzia. Milano: Masson; 2002. 10. De Santis M. Voce e linguaggio. Padova: Piccin; 1986. 11. Montagna F, Lambini N, Piras V, Denotti G. L’ortodonzia e i suoi dispositivi, apparecchi mobili e fissi rimovibili nella pratica clinica. Milano: Elsevier Masson; 2007. 12. Böhme G. Applied phoniatry. V. Speech defects due to abnormalities of jaw and dentition. HNO 1977;25: 131–6. 13. Bloomer HH. Speech defects associated with dental malocclusions and related anomalies. In: Travis LE, editor. Handbook of speech pathology and audiology. New York: Appleton Century Crofts; 1971. p. 715–66. 14. Giannì E. La nuova ortognatodonzia, 1. Padova: Piccin; 1980. 15. Proffit WR. Equilibrium theory revisited: factors influencing position of the teeth. Angle Orthod 1978;48:175–86. 16. Marchesan IQ, Bianchini EMG. A fonoaudiologia e a cirurgia ortognática. In: Araújo A, editor. Cirurgia ortognática. São Paulo: Santos; 1999. p. 353–61. 17. Campiotto AR. Fonoaudiologia. In: Souza LCM, Silveira ME, Capellette M, Garducci M, Lino AP, editors. Cirurgia ortognatica e ortodontia. São Paulo: Santos; 1998. p. 19–30. 18. D’Agostino L. Características fonoaudiológicas nas defor-midades maxilomandibulares. In: Psillakis JM, Zanini AS, Mélega JM, Costa EA, Cruz RL, editors. Cirurgia craniomaxilofacial: osteotomias estéticas da face. Rio de Janeiro: Medsi; 1987. p. 317–23. 19. Cimmino C, Della Pietra G, Savastano G. Lo studio fonetico come proposta di studio funzionale in chirurgia ortognatica. Ortognatodonzia Italiana 1998;7:323–8. 20. Ronchi P. Dismorfie dento-facciali, trattamento ortodontico-chirurgico. Milano: Quintessenza Edizioni; 2004. 21. Chauvois A, Fournier M, Girardin M. Rieducazione delle funzioni nel trattamento ortodontico. Verona: Ed. CISCO; 1994. 22. Falk ML, Wells M, Toth S. A subcortical approach to swallow pattern therapy. Am J Orthod Dentofacial Orthop 1976;70: 419–27. 23. Garliner D. Importanza di una corretta deglutizione. San Benedetto del Tronto: Ed. Futura; 1996. 24. Yamaguchi H. Oral myofunctional therapy: essential for surgical orthodontic treatment. In: Hanson ML, Mason RM, editors. Orofacial myology: international perspectives. Springfield, Illinois: CC Thomas Publisher; 2003. p. 392–416.

25. De Filippis Cippone A. Nuovo manuale di logopedia. Trento: Edizioni Erickson; 1998. 26. Testa M, Comparelli U, Kratzenberg G. Tecniche ortodontiche, guida alla costruzione e all’utilizzo di dispositivi terapeutici. Milano: Masson; 2003. 27. Buraglio C, Volpato B, Antonioli M. L’ELN di Bruno Bonnet: indicazioni, modalità di utilizzo clinico e risultati nel trattamento di soggetti a fine crescita. Ortognatodonzia Italiana 2002;11:73–81. 28. Bonnet B. Correction de la posture linguale par l’enveloppe linguale nocturne (E.L.N.). Le Chirurgien Dentiste da France 1994;719:31–4. 29. Del Mondo S, Villari P, Laino A. Ruolo della logopedia nel trattamento post-chirurgico della sindrome progenica. In: Savastano C, Bertelé G, editors. Fase Terapeutica post-chirurgica del paziente disgnatico, Monografia SIDOP. Napoli: G. De Nicola Editore; 2004. p. 73–81. 30. Cozza P, Fidato R, Germani C, Santoro G, Siciliani G. La deglutizione atipica. Mondo Ortod 1992;17: 141–59. 31. Fournier M. La rééducation fonctionelle chez l’enfant et son controle par l’orthodontiste. Rev Orthop Dento-Faciale 1994;28:473–85. 32. Goodstein DB, Cooper D, Wallace L. The effect on speech of surgery for correction of mandibular prognathism. Oral Surg Med Rehab 1974;37:846–9. 33. Dalston RM, Vig PS. Effects of orthognatic surgery on speech: a prospective study. Am J Orthod 1984;86:291–8. 34. Lee ASY, Whitehill TL, Ciocca V, Samman N. Acoustic and perceptual analysis of the sibilant sound /s/before and after orthognathic surgery. J Oral Maxillofac Surgjavascript:AL get(this, ‘jour’, ‘J Oral Maxillofac Surg’) 2002;60:364–73. 35. Altmann EBC. Myofunctional therapy and orthognathic surgery. Int J Orofacial Myology 1987;13:2–12. 36. Campiotto AR, Freitas LP, Lima RA. Cirurgia ortognatica e fonoaudiologia. In: Lopes Filho E, editor. Tratado de fonoaudiologia. Sao Paulo: Roca; 1987. 37. McNamara JA, Carlson DS, Yellich GM, Hendricksen RP. Musculosketal adaption following orthognathic surgery. In: Carlson DS, McNamara JA, editors. Muscle adaptation in the craniofacial region, Monograph No 8, Craniofacial Growth Series. Ann Arbor: Center for Human Growth and Development, University of Michigan; 1978. 38. Carlson DS, Ellis E, Dechow PC, Nemeth PA. Short-term stability and muscle adaptation after mandibular advancement surgery with and without suprahyoid myotomy in juvenile macaca mulatta. Oral Surg Oral Med Oral Pathol 1989;68:135–49. 39. Langlade M. Diagnostic orthodontique. Paris: Maloine; 1981.