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Myofunctional Therapy Part 4: Prevention and treatment of dentofacial and

oronasal disorders

Article in European Journal of Paediatric Dentistry · December 2021

DOI: 10.23804/ejpd.2021.22.04.12

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 EJPD 2021 CLINICAL FOCUS
S. Saccomanno1, G. Berretin-Felix 2,
L. Coceani Paskay3, R. J. Manenti1, V. Quinzi1
Myofunctional
Therapy
1
Department of Health, Life and Environmental Science, University
of L’Aquila, L’Aquila, Italy
2
University of São Paulo, Brazil, Department of Phonoaudiology,
Faculty of Odontology in Bauru (USP-FOB), Bauru, Brasil
Part 4: Prevention 3
Academy of Orofacial Myofunctional Therapy (AOMT), Pacific
Palisades, USA

and treatment
E-mail: [email protected]
of dentofacial and
oronasal disorders DOI: 10.23804/ejpd.2021.22.04.12

Abstract manipulation. Then it is important to properly wean a child to

allow the integration of the orosensory and motor systems,
as even a young child is able to manipulate “adult food” and
The orofacial functions of breathing, swallowing, learn how to chew and swallow safely [Rapley, 2015],
mastication and speech allow for harmonious craniofacial considering that for most of human existence “baby food”
growth and development. Correct development must was unknown [Boyd et al., 2021a, 2021b]. However, it is never
be promoted from birth, and myofunctional therapy is too late to prevent further OMDs even when the child is at an
an excellent tool for the prevention and treatment of age where orthodontic therapy may be needed. Prevention
craniofacial and oronasal disorders. of OMDs is a life-long endeavour.

Assessment
KEYWORDS Prevention, Dentofacial oronasal
disorders, Myofunctional therapy, Myofunctional, Specific tools are necessary to reach a diagnosis of
Protocols. myofunctional disorders. There are general protocols, such as
the validated Protocol of Orofacial Myofunctional Evaluation
with Scores (OMES) (De Felìcio et al., 2008], which has been
expanded [De Felìcio et al., 2010], adapted for adults [De Felìcio
Introduction et al., 2012], for the elderly [De Felìcio et al., 2017], as well as
for patients with obstructive sleep apnoea [Folha et al., 2015;
In order to chew, swallow and speak, different structures Gelb et al., 2021]. Another comprehensive myofunctional
of the stomatognathic system are involved, supported by the protocol, is the MBGR Protocol [Marchesan et al., 2012], which
central nervous system. The coordination between oral was developed in the Portuguese language and trans-culturally
functions and breathing is essential to provide efficiency and adapted into English. It was validated to assess patients with
safety during feeding, as well as effectiveness during speech. temporomandibular disorders [Bueno et al., 2020], and later
Also, nasal breathing is paramount to stimulate balanced was expanded to assess individuals with a cleft lip and palate
dentofacial development, to maintain adequate muscle tone [Graziani et al., 2019]. Also, there are specific protocols which
of intra- and extra-oral soft tissues, and to allow a fundamental can be applied to a lingual frenulum examination, validated for
treatment of the breathing that supplies body vital functions. infants [Martinelli et al., 2016] and developed for patients starting
Many factors may interfere with dentofacial development, from 6 years of age and older [Marchesan, 2012] (Table 1, 2).
such as oral breathing, ankyloglossia, prolonged nutritive and/ The data provided by the myofunctional clinical examination
or non-nutritive sucking habits, with a greater influence of allow the clinician to better understand the presence of
the genetic characteristics. Thus, early detection and treatment morphological and functional changes, and the relationship
of these conditions are fundamental to prevent morphological between them, i.e., cause and effect.
and myofunctional disorders [Paglia, 2021]. Subjects presenting dentofacial anomalies show more
disturbances concerning breathing [Paglia, 2019], chewing,
swallowing, speech, dental occlusion, compared to those with
Prevention balanced dentofacial morphology, and the damage to these
oronasal functions impairs the quality of life of these subjects
Prevention of orofacial myofunctional disorders (OMDs) [Saccomanno et al., 2012; Migliorucci et al., 2015] (Fig. 1–6).
begins at birth with an accurate evaluation to detect a restricted In addition, the oral and laryngeal motor control is also
lingual frenum and assess latching abilities and optimal impaired in patients presenting dentofacial deformities [Steven,
breastfeeding. It is successful and prolonged breastfeeding 2012]. Hence, the prevention of dentofacial structural
that promotes the tone and coordination of all the orofacial malformations is very important, in order to avoid
muscles for more “adult” functions, such as chewing and food myofunctional disorders [Boyd et al., 2021a, 2021b].

332 European Journal of Paediatric Dentistry vol. 22/4-2021

 EJPD 2021 CLINICAL FOCUS MYOFUNCTIONAL THERAPY

Structures Diagnostics Therapy Functions Diagnostics Therapy

Nose ENT evaluation, Glatzel mirror, Nasal hygiene, breathing Chewing Colorimetric tests (gum, OMT, orthodontic therapy,
Ronsenthal test, Gudin test, repatterining, surgery, capsules), SEMG, OMES, oral health, food textures
Cottle sign OMT MBGR
Swallowing Barium fluoroscopy, OMT, swallowing therapy
Lips IOPI, OMES, MBGR Breathing repatterning, bedside assessment, (by specialized SLPs)
OMT, lip bumper fMRI, OMES, MBGR
Cheeks OMES, MBGR, IOPI OMT, kinesio-taping Sucking Breathing assessment, Frenotomy, frenectomy,
sucking/swallowing lactation consultation,
Mandible/ CBCT, MRI Orthodontic treatments,
timing norms, reflex multidisciplinary
TMJ surgery, bites/splints,
integration approach, OMT
OMT
Orthodontic treatment, Breathing Spirometric and RPE, breathing retraining,
Dentition Classifications: Angle’s,
OMT, surgery, rhinometric tests, nasal hygiene, OMT
McNamara’s, Bjiork’s, Petrovic’s
Glatzel’s mirror, Cottle’s
etc.
sign, Rosenthal’s test,
Tongue IOPI, OMES, MBGR OMT PAFORE protocol
Soft Palate Visual inspection, cranial nerve Surgery, OMT Sleep PSG, Mallampati, MAD, CPAP, OMT, sleep
testing Friedman, STOP- hygiene, behavioral
Hard Palate Width standard measurements, RPE, DOME, MARPE, BANG and BEARS treatment
McNamara’s and Pont’s Index removable orthodontic questionnaires, BMI, ESS
devices, corticotomy,
maxillary surgery TABLE 2 List of common, but not exhaustive, options of diagnostic
Facial SEMG, OMES, MBGR OMT, kinesio-taping and therapy tools/protocols for orofacial and nasal functions.
Muscles
Chewing SEMG, OMES, MBGR, TENS, OMT When a myofunctional alteration derives from a
Muscles colorimetric beads morphological condition and functional adaptations are
Frenula Martinelli, Marchesan protocol, Frenotomy, frenectomy, established, then the correction of the form comes first in the
ATLF (Hazelbaker), Kotlow etc. OMT treatment plan. For example, a nasal obstruction must be
solved first, thus allowing the use of the nostrils during the
Saliva Test for salivary output, tongue Dietary options, OMT,
inspiration and the exhalation process, as well as the breathing
depressor test chewing, medications,
saliva substitutes coordination between nasal and oral functions. On the other
hand, there must be a harmonic dentomaxillary relationship
Tonsils/ Tonsils/adenoid Brodsky scale, Surgery (TA), RPE, dietary
Adenoids allergy tests modifications, breathing achieved with a dental/orthodontic treatment for the speech
re-education therapist to guide the reorganisation of tongue function,
Others — Check for Eustachian tube/ Multidisciplinary
during chewing, swallowing and speech. Moreover,
middle ear dysfunction. approach. myofunctional therapy is necessary to provide stability for any
— Check for visual/eyesight dental treatment, as it reorganises oronasal functions according
problems related to head to the new morphological condition [Botzer et al., 2021].
posture.
— Check for postural issues
affecting head/neck/ Myofunctional therapy
shoulders.
— Perform at least a cursory
During myofunctional therapy, strength, mobility and
cranial nerves functionality
test.
muscle coordination are improved, in order to provide an
— Perform a sensory qualitative adequate performance during oral functions. The chewing
and quantitative test muscles must have enough tone for the mandible to be
— Perform a qualitative sensory stabilised during swallowing, mobility for it to perform
test (QST) masticatory movements and for adequate strength to provide
efficient chewing. The tongue must show free movements,
as well as an adequate contraction of the intrinsic muscles,
TABLE 1 List of common, but not exhaustive, options of diagnostic in order to move the food bolus onto the dental occlusal
and therapy tools/protocols for orofacial structures. surfaces, to organise and move the food bolus during the
oral phase of swallowing. The tongue must be able to form

FIG 1, 2 Examples of malocclusion as a result of a structural issue due to orofacial and nasal dysfunctions.

European Journal of Paediatric Dentistry vol. 22/4-2021 333

 SACCOMANNO S. ET AL.

FIG. 3, 4 Examples of dark circles under the eyes (venous pooling) in children with chronic oral breathing.

FIG. 5, 6 Examples of habitual oral posture, suggesting nasal and orofacial dysfunctions.

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