Function Junction · practice. Moss’ Functional Matrix Theory provides added support to the...

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O rofacial Myology/Orofacial Myofunctional Therapy is the study and therapeutic treatment approach of utilizing the junction between nature’s muscular and behavioral forces and the normalizing bio- adaptability of the soft and hard tissues in the orofacial environment. This “Function Junction” takes place between the functional relationships of the orofacial musculature; func- tional use and movement patterning of the mandible; orofacial parafunc- tional behavior elimination abilities; resting postures of the tongue, lips, and mandible; establishment of an adequate dental freeway space; and the nasal respiration impact on the hard and soft tissues of the dental and orofacial structures (form). 1-7 The Function Junction harnesses orofacial and oromotor forces in a therapeutic retraining manner to eliminate harmful behaviors. Thera- peutic exercises are both physical and psycho-physiologic. These exer- cises are the initiating facilitators creating a neuro-muscular impact. Change occurs by retraining and/or eliminating negative biologic and physiologic forces applied to the orofacial environment, dentition, temporomandibular joint region, and along with retraining move- ments of the tongue, lips and mandible affecting functional speak- ing patterns. “Function” refers to the movements and patterning impact of the orofacial muscle balances and harmony of the oromotor behaviors. These include habituated oromotor movement patterns of the tongue, lips and jaw, in addition to correcting resting postures, establishing the dental freeway space, and facilitating nasal respiration. It also includes the impact of parafunctional habits and orofacial behaviors exerted on the dentition and the surrounding head/neck environment. 1, 2 & 4-7 The Epigenetic Versus Bio-physiologic Debate Discussions have been long- standing and circular, especially when considering the impact of “Function” on the “Form” or vice- versa. This circular conversation occurs most often in relation to orthodontic mechanotherapy. Posi- tions are taken whether it is more epigenetic (form) or bio-physiologic (environmental/function). 3-8, 13-18, 25-28, 30 Opinions still vary whether it is the form influencing growth and development and requiring the function to become adaptive, or if it is the morphological function influ- encing the growth, development, and stabilization of the form. 4, 6-8, 13-15, 25-28 Decades of debate to vali- date or disprove still leave the orthodontic clinician in the middle trying to figure out if they must choose a side or ignore the issue. Some take a firm stance on one side, while others view Function and Form as a significantly inter- dependent dynamic process where one must be taken into full consid- eration when addressing the other. 2-20, 23-28, 31, 34-35 28 May/June 2012 JAOS Utilizing Nature’s Bio-Adaptability of Soft and Hard Tissues The Function Junction: Function Junction: Functional Matrix Theory (Moss, DDS, MS) Functional and environmental influences impact the growth and develop- ment of the facial arches. Malocclusions are influenced by imbalances of airway flow, rest- ing postures, oromotor imbal- ances, chewing and swallowing patterns, incorrect forces of the lips, tongue, musculature, and genetic imprints. By Kimberly K. Benkert, RDH, BSDH, MPH, COM, FAADH Bio-Adaptive Theory

Transcript of Function Junction · practice. Moss’ Functional Matrix Theory provides added support to the...

Page 1: Function Junction · practice. Moss’ Functional Matrix Theory provides added support to the inter-relational dependence focused in a multi-dimensional manner. Moss states one cannot

Orofacial Myology/OrofacialMyofunctional Therapy isthe study and therapeutictreatment approach of

utilizing the junction betweennature’s muscular and behavioralforces and the normalizing bio-adaptability of the soft and hardtissues in the orofacial environment.This “Function Junction” takes placebetween the functional relationshipsof the orofacial musculature; func-tional use and movement patterningof the mandible; orofacial parafunc-tional behavior elimination abilities;resting postures of the tongue, lips,and mandible; establishment of anadequate dental freeway space; andthe nasal respiration impact on thehard and soft tissues of the dentaland orofacial structures (form).1-7

The Function Junction harnessesorofacial and oromotor forces in atherapeutic retraining manner toeliminate harmful behaviors. Thera-peutic exercises are both physicaland psycho-physiologic. These exer-cises are the initiating facilitatorscreating a neuro-muscular impact.Change occurs by retraining and/oreliminating negative biologic andphysiologic forces applied to theorofacial environment, dentition,temporomandibular joint region,

and along with retraining move-ments of the tongue, lips andmandible affecting functional speak-ing patterns. “Function” refers tothe movements and patterningimpact of the orofacial musclebalances and harmony of theoromotor behaviors. These includehabituated oromotor movementpatterns of the tongue, lips and jaw,in addition to correcting restingpostures, establishing the dentalfreeway space, and facilitating nasalrespiration. It also includes theimpact of parafunctional habits andorofacial behaviors exerted on thedentition and the surroundinghead/neck environment.1, 2 & 4-7

The Epigenetic Versus Bio-physiologic Debate

Discussions have been long-standing and circular, especiallywhen considering the impact of“Function” on the “Form” or vice-versa. This circular conversationoccurs most often in relation toorthodontic mechanotherapy. Posi-tions are taken whether it is moreepigenetic (form) or bio-physiologic(environmental/function).3-8, 13-18,

25-28, 30 Opinions still vary whetherit is the form influencing growthand development and requiring the

function to become adaptive, or if itis the morphological function influ-encing the growth, development,and stabilization of the form.4, 6-8,

13-15, 25-28 Decades of debate to vali-date or disprove still leave theorthodontic clinician in the middletrying to figure out if they mustchoose a side or ignore the issue.Some take a firm stance on oneside, while others view Functionand Form as a significantly inter-dependent dynamic process whereone must be taken into full consid-eration when addressing the other.2-20, 23-28, 31, 34-35

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Utilizing Nature’s Bio-Adaptability of Soft and Hard Tissues

TheFunctionJunction:FunctionJunction:

Functional Matrix Theory (Moss, DDS, MS) – Functionaland environmental influencesimpact the growth and develop-ment of the facial arches.

Malocclusions are influenced byimbalances of airway flow, rest-ing postures, oromotor imbal-ances, chewing and swallowingpatterns, incorrect forces of thelips, tongue, musculature, andgenetic imprints.

By Kimberly K. Benkert, RDH, BSDH, MPH, COM, FAADH

Bio-Adaptive Theory

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Regardless of one’s initial stance,hopefully the question of how thefunction impacts the form (and viceversa) is considered and incorpo-rated into the critical decisionmaking process with eachorthodontic case. The challengefacing orthodontic clinicians isusing evidence-based research alongwith individualized patient treat-ment goals to establish a harmo-nious interplay between the func-tion, form, orthodontics, and ortho-pedic therapy…. and having itlast!6, 21 Anatomist, Harry Sicher,advocated the importance of“Normalizing the intricate balancebetween the teeth, skeletal andmuscular system”.7 Sicher describescreating a balance that includesestablishing and maintaining adental (oral) freeway space. A dental(oral) freeway space is the mandibu-lar resting posture maintaining a 2-3 mm posterior (molar) inter-dental(inter-occlusal) space with approxi-mately 4-5 mm maintained in theanterior (incisal). When themandible sits in its physiologic rest-ing posture, the tongue is resting onthe palate (Fig.1) with the dentalfreeway space maintained and thelips lightly closed at rest. Abalanced equilibrium is reachedbetween the external forces of thelips, facial and masticatory muscula-ture against the dentition and theinternal resting posture of thetongue against the palate whilenormal nasal respiration takesplace. Maintaining the dental free-way space allows the uninterruptedphysiologic eruption of the teeth.He conveyed that clinicians need tobecome biological anatomists andmore fully take the biologic-physio-logic systems into account duringtreatment.6, 7

Moving Forward Basedon Evidence

Scholars support and recognizemaintaining normalized function ischallenging if orofacial or oromotordysfunction is present. Orofacialmyology is a treatment considera-tion that fits nicely with orthodon-tics. Orofacial Myofunctional Ther-apy methodologies address theorofacial and oromotor functional

issues creating the negative environ-mental impact. The literature indi-cates a clear need to incorporatefunctional issues and include treat-ment for orofacial myofunctionaldisorders in order to be able tocreate the ideal occlusion, and thenmaintain its stability within theorofacial and dental environmentover the long-term. The scientificevidence depicting function signifi-cantly impacting form continues tobuild through the literature. 4-8,10,

16, 25-29, 32, 53 Orthodontic practition-ers’ attitudes are also movingtowards using evidence-based diag-nosis and treatment morefrequently to assist with their clini-cal decision-making processes.21, 22

Utilizing an evidence-basedapproach to address the interrela-tionship between function andform diminishes the debate, evenamong skeptics.

The last three decades of support-ing evidence in the literature shiftsfrom debate towards discussions ofhow to best deal with negative func-tional impacts.2, 5, 6, 12, 16, 29-32, 34, 42-

47, 53 This requires a paradigm shiftfor some practitioners in theirthoughts and treatment processes. Itbecomes easier to understand asmultiple sources in dentistry andmedicine continue adding to theclinical and behavioral evidencedocumenting that orofacialmyofunctional therapies serve aspreventive, interceptive and thera-peutic interventions.1, 2, 5, 6, 16, 24, 31,

53, 54 Theories present that separa-tion of the two philosophies of“Function VS Form” and “Form VSFunction” is not only difficult, butactually unwise to ignore in clinicalpractice. Moss’ Functional MatrixTheory provides added support tothe inter-relational dependencefocused in a multi-dimensional

manner. Moss states one cannotseparate the environmental (muscu-lar and behavioral) impact on thestructural (epigenetic form), andvice versa.25- 28 Kondo demonstratescases, followed for 25 years, retaintheir orthodontic correctiveintegrity when coupled with orofa-cial myofunctional therapies.6

History and Scope of CareIndividuals have been address-

ing orofacial/oromotor dysfunctionwith orofacial muscle exercise sincethe early 1900’s. Providing aprogram of therapeutics becamebetter known in the 1950’sthrough Walter Straub’s efforts,and became an organized specialtyfocus in the1970’s through theorganizational formation of theInternational Association of Orofa-cial Myology (IAOM).2, 4, 6, 7, 9-12, 16,

19-20, 35-40 An interdisciplinary teamapproach keeps the patient at thecenter of all of the treatmentmodalities and leads to the moststable outcomes.2, 6, 12, 16, 53 Adisparity exists in the number ofcertified orofacial myologists incomparison to the numbers ofindividuals who would benefitfrom potential treatment.This posesa significant dilemma for orthodon-tists not in close proximity to anorofacial myologist. Leaving orofa-cial myofunctional disordersuntreated increases the risk factorsfor orthodontic relapse. A biggerdilemma exists when the orofacialmyofunctional disorders remainunnoticed and referral is non-exis-tent. For the practitioner observingand recognizing dysfunction andthen taking no action, it places thepractitioner in an ethical, moral,and potential legal dilemma.48, 49,

50 In the scenario of non-recogni-tion, it places the practitioner inan even more vulnerable clinicalliability position for potentialrelapse.6, 7, 31, 53, 54 Based on experi-ence levels, some orofacial myolo-gists are capable of offering tele-therapy via video conferencingwith patients unable to travel to atherapist’s office. It is an excellenttherapeutic option for practitionerswithout an orofacial myologist inthe immediate area.

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h l h d d f

Lingual-Palatal Tongue Rest Posture (The Spot)

Fig. 1

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Shifting ParadigmsMany practitioners go through a

clinical paradigm shift to includeorofacial myofunctional therapeuticsinto their assessment and treatmentplanning. It becomes not only aphilosophical journey of discovery forsome, but also one of how and whento work with an orofacial myologist.This paradigm shift occurs especiallyif past orthodontic treatment reliancewas only on mechanotherapies. Somepractitioners have an easier transitionincorporating these concepts intotheir conceptual treatment frameworkif the concept of ‘muscle and/orbehavioral therapy’ was gleaned atsome point in their formative educa-tion prior to licensure in their profes-sion. Those individuals more quicklyrecognize they need to identify andlocate a licensed professional trainedand certified in Orofacial Myology.Others come to this realization afternoting relapses in beautifully finishedcases where growth patterns cannotbe blamed. In either case, the journeyleads to the same end goals: provid-ing comprehensive patient care toestablish a healthy and balancedorofacial structure, function, andbehaviors with healthy respirationleading to the long term stability ofthe dento- and orofacial environmentwhile also achieving the desiredaesthetic results.

Conceding MeansIncreased Success

Conceding that function has thepotential to positively impact the

form allows the orthodontic practi-tioner to take advantage of orofacialmyofunctional capacity, especiallywhen included as a consideration ininitial treatment planning. Onecannot ignore the impact of properorofacial and oromotor functionalprocesses coupled with proper respi-ration on the dentition and peri-odontium.33, 54 They are dynamicprocesses. These bio-physiologicprocesses continue impacting theon-going and evolving dento- andcranio-facial environment over alifetime.6 Delving into recognizing,treating, and harnessing theprocess’ potential appears morefrequently in the scientific literaturewith messages also being deliveredfrom speaker’s podiums. Dentistry,dental hygiene, and orofacial myol-ogy are each making strides adding‘Function’ to the body of knowl-edge and transferring of the infor-mation for practitioner’s use.6, 34, 41-

47, 53 Orthodontic practitioners arealso improving in their own assess-ment abilities of orofacial myofunc-tional disorders, functional dyspha-gia, oromotor dysfunction,temporomandibular musculardysfunction, and respiration issuesas the scientific evidence supportingorofacial myology increases.

Clinicians are increasing theirfocus on the overall impact on thedentition and the orofacial environ-ment, and how/when to incorpo-rate orofacial myofunctional thera-pies to make cases be more predica-ble.31, 43-45, 47, 52 This increases the

orthodontic practitioner’s ability tomonitor, treat, successfullycomplete, and maintain orthodon-tic and TMD cases with less relapseand retreatment. Early recognitionof orofacial myofunctional issuesand OMT ensures a smoother andmore effective mechano- and/ordental therapeutic process whileachieving long-term stability goalswith greater efficiency.

Defining Moments andCreating Parameters

Understanding a definition ofOrofacial Myology (OM) is essentialwhen conducting a comprehensiveorofacial myofunctional andtemporomandibular muscularassessment and examination andintroducing these concepts to thepatient. Defining OM/OMT allowsone to label the dysfunction notedmore clearly and place it into inter-national coding and nomenclaturesystems. Benkert defines orofacialmyology as: OrofacialMyology/Myofunctional Therapy isthe treatment of the orofacialmusculature to improve musclebalance and tonicity with establish-ment of correct activities of thetongue, lips, and mandible so thatnormal growth and developmentmay take place in a homeostaticenvironment. It includes treatmentof parafunctional habits for theelimination of noxious oral habitsand behaviors, temporomandibularmuscular dysfunction, bruxism,clenching, muscle bracing, andrange of motion (ROM) activities ofthe mandible, and/or posturalhabits.1, 2, 5, 29, 31 The core ofthis definition was adopted by theIAOM Board of Directors andMembership in 1992 and supportedthe development of the AmericanDental Hygienists’ Association(ADHA) 1992 policy statementunder the area of Practice, PatientCare Services 9-92: The ADHAacknowledges that the scope ofdental hygiene practice includes theassessment and evaluation of orofa-cial myofunctional disorders; andfurther advocates that dentalhygienists complete advanced clini-cal and didactic continuing educa-tion prior to providing treatment.

SShhiifftff iing PParaddiigms form allows the orthodontic practi

� The philosophy of “muscle wins” is fundamental to allphases of mechano-therapies used in orthodontics.

� Bio-adaptive theories along with muscle and respirationoriented therapeutics are influencing the long term successand stable outcomes of oral health treatments associated withmalocclusions, muscular TMD, periodontics, and cosmeticrestorative therapies.

�Oromotor issues, functional dysphagia, rest posturing oftongue, lips and mandible, creation of an appropriate freewayspace and elimination of parafunctional habit patters is requiredfor long term stabilization and balanced oromotor and func-tional patterns.

Orofacial Myology

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In 1993 the American Associationof Orthodontics adopted a policystatement indicating the benefits ofOMT treatment, but acknowledgingthe need for more research.

The parameter of treatmentprovided by the orofacial myologistdepends on their formative coreprofessional accredited education andlicensure, and the extent of theirpost-licensure didactic and clinicaltraining in areas of orofacial myol-ogy, dentistry, dental hygiene, speechfunction, and other areas ofmedicine. However, in general treat-ment may include:

� Correction of resting posturesof the tongue, lips, andmandible;

� Establishing a consistent oral(dental) freeway space;

� Balancing and equalizing themuscle function and tonicityof the tongue, lips, muscles ofmastication and deglutitionand including muscles of theface, head and neck;

� Encouraging nasal breathingand normalized respiration;

� Eliminating oralhabits/behaviors and oromo-tor/orofacial functionalbehaviors negatively affectingmuscle tone and/or impactingthe growth and developmentof the face and dentition(non-nutritive sucking andnoxious oral habits, dual bitepatterns, establishing oromo-tor consistencies);

� Correcting abnormal chewingand deviated swallowingpatterns; correcting musculardeficiencies of resting posturesof the tongue, lips, mandible,head and neck; correcting‘tongue thrusting’ swallowing(preparatory and oral phases);eliminating parafunctionalhabit patterns that may causedestruction of the dentition(especially bruxism, musclebracing, and/or clenching);providing neuromuscularreeducation and retraining toeliminate impairment inmuscle tone and function;

eliminating deviated range ofmotion muscular and func-tional deviations of themandible, especially thoserelated to resting postures,chewing, open/closurepatterns, speech functionalmovements/patterning of thetongue, lips and mandible,and orofacial/oromotor func-tions of related activities ofdaily living.1, 2, 5, 6, 7, 11, 12, 16,

20, 24, 42, 45, 47, 57-59

OM concepts and principles arerooted between professional domainsin dentistry, dental hygiene, physicalmedicine, and speech pathology.Many professionals still refer to orofa-cial myology as ‘tongue thrust ther-apy’. Most call it ‘myofunctional ther-apy’. Others call it ‘myofascial ther-apy’. Some even report it as ‘oralphysical therapy, oral physiotherapy,or oral posturology’ for the face, headand neck. References to treatingorofacial myofunctional disorders(OMD) appearing in the literaturealso reference many names. The bestname determined by the IAOM tooffer and promote to a patient is:orofacial myology or orofacialmyofunctional therapy. It seems tosay it all. Nomenclature consistencyfacilitates communication andresearch across professional domains.It also allows consistency for interna-tional coding and insurance submis-sions. Professionals including dentistsand most of the dental specialties,dental hygienists, physicians,otolaryngologists, speech patholo-gists, along with physicians, ENTs,osteopaths, physical therapists, occu-pational therapists, massage thera-pists, chiropractors, and naturopathsare increasing their awareness andunderstanding of orofacial myofunc-tional and functional oromotorissues, TMD, respiration, and sleepapnea’s impact on the orofacial envi-ronment and total health.

Best Practice - Incorporatinga Process of Care

Behavioral studies add to theevidence that function can impactform across categories of age, race,culture, and pre-/post-orthodonticsin a similar manner.6, 16, 31, 44, 53

The challenge of discovery for each

clinician/practitioner begins in asimilar manner. It happens throughexperience gained by treating casesutilizing orofacial myofunctionaltherapy while a pre-licensed profes-sional student, or figuring it out byoneself once in clinical practicethrough trial and error. Best prac-tice, regardless of when one beginsthis journey, requires each caseconsidered for treatment utilize aprocess of care. Best practiceprocess of care includes:

� Completing a comprehensiveassessment and examination.

� Developing a differential diag-nosis.

� Incorporating both functionand form into the treatmentplanning process.

� Implementing an inter-disci-plinary therapeutic approach.

� Continuing an on-goingevaluation process throughthe habituation/rehabilita-tion phases.

clinician/practitioner begins in a

Assessment &Examination

Structural

Anatomical: airway/head,neck, face, dentition

Muscular: capacity/tonicity

Neurological response:motor/sensory

Functional

Resting postures/Mastication,

Deglutition, ROM/Speech patterning

Behavioral

Habit patterns – present or past

Parafunctionalhabits/patterns

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Maintaining the long-term stabil-ity of orthodontics and orofacialorthopedics is achieved by combiningthe orthodontic process and orofacialmyofunctional therapy with routinemonitoring until full habituation isachieved.6, 31, 32, 53 Mechanotherapyshould be approached along withfacilitating the individual’s neuromus-cular and bio-physiologic capacitywhile reducing, redirecting, and elim-inating all negative orofacial/oromo-tor myofunctional disorders, orofacialmuscular imbalances, and noxiousparafunctional behaviors. Musclesalways win! So, it is better to workwith them than be surprised by their

ability to unravel things later!4, 6, 7, 16,

31 Incorporating orofacial myofunc-tional therapy as a fundamentalelement in the treatment planningwhen orofacial myofunctional disor-ders, oromotor imbalances, or para-functional orofacial/oromotor behav-iors are identified assists in success-fully completing and producing moredesirable outcomes. Addressing long-term stability actually should beginduring the assessment and examina-tion process by recognizing all factorsthat can present issues down theroad. Cases with functional disordersdetected at any stage of the pre- orpost-treatment process will benefit

from incorporating orofacialmyofunctional therapy and facilitateachieving stability. However, incor-porating orofacial myofunctionaltherapy as early as possible, or evenbefore orthodontics are initiated, isusually advised as a best practice inorder to reduce/eliminate the risk oforofacial functional imbalances/inter-ferences impeding or slowing theorthodontic process, or as a worsecase scenario, leading to orthodonticrelapse. One of the few times youwould not begin orofacial myofunc-tional therapy prior to or simultane-ously at the onset of orthodontics is ifthe overjet is so severe that the lipscannot close to maintain a lip seal(even a very strained one) or if theopen bite is severely excessive. Evenwith skeletal orthognathic surgicalcases, it is best to do a portion of theOMT prior to the surgery and thencontinue again following the surgery.Therapy proceeds more smoothlywith therapeutic goals achieved morequickly once the structural environ-ment (form) is slightly moreconducive.2, 6, 7, 12, 16

Determining Need (Figs. 2 &3)The comprehensive orofacial

myofunctional assessment andexamination reveals the presence ofstructural, functional and behav-ioral clinical deviations. These mostoften are identified and related to:

� Orofacial myofunctionaldisorders (OMD).

� Incorrect resting postures ofthe tongue, lips, and mandible.

� Bruxism, clenching, musclebracing symptoms (and theoral/dental freeway space).

� Functional dysphagia:related to the preparatoryand oral phases of the swal-lowing pattern: biting,chewing, and/or incorrectswallowing (what used tobe called the ‘tongue thrust swallow’).

� Orofacial related parafunc-tional behaviors (bruxism,muscle-bracing, clenching).

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Assess Functional & Structural

Various Open Mouth Resting Postures, MandibularFunctional Deviation, Incompetent Lips, Tongue Resting

Postures & "Tongue Thrust" Swallow Patterns

Fig. 2

Fig. 3

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� Facial muscle spasms fromover-closure/over-extension ofthe dental freeway space.

� Tight lingual or labial frenums,and associated dysfunction ofthe lips, tongue.

� Oral behaviors (non-nutritivesucking of thumbs, fingers,pacifiers; extended sippy-cupuse; chronic chewing/biting ofnails, clothes or hair, chronicpen/pencil chewing, lip &cheek biting/chewing, lipsucking/propping, unilateraland/or deviated chewingpatterns, etc.).

� Respiration functional issues(open mouth posturingand/or mouth breathing, overenlarged tonsils & adenoids,engorged inferior nasalturbinates, deviated septum,untreated allergies, otherairway issues).

� Oromotor dysfunction, espe-cially in the ROM of themandible (range of motiondeviations in the functionalmovements/patterning of themandible) including functionalshifts and dual biting patterns,oromotor planning issues.

� Muscular/functional temporo-mandibular dysfunction (TMD)– pain, clicking, poppingsymptoms in the temporo-mandibular joint region.

� Functional speaking patterndeviations (mechano-functionalpatterning movement devia-tions of the tongue, lips, andjaw during speaking); ‘funny-looking’ speaking patternsNote: A lisping patternmay/may not be present.

� Unresolvable speech distur-bances that are more func-tionally related than articula-tion related.

Raising the Bar on theStandard of Care

The orthodontic assessment andexamination process that includes a

comprehensive orofacial myofunc-tional assessment and examinationraises the bar on the standard ofcare delivered to the patient. Thecomprehensive orofacial myofunc-tional assessment portion may becompleted by the dentist/orthodon-tist, or it is a great time to incorpo-rate the orofacial myologist intothe process to provide a compre-hensive assessment and examina-tion. A comprehensive assessmentand examination includes taking acomprehensive medical and dentalhistory; dental occlusal assessmentwith measurements and Angle clas-sification; determining the severityof orofacial myofunctional disor-ders (OMD); assessing for func-tional dysphagia (difficulty in thepreparatory and oral phases ofchewing and swallowing); observ-ing resting postures of tongue, lips,mandible with philtrum, lip,lingual frenum stretch, inter-labialgap and lip resistance measure-ments; identifying and measuringthe freeway space; determining thepresence of noxious oral behaviors;assessing the impact of temporo-mandibular muscle dysfunction(TMD) including palpation ofmusculature and imaging; utilizinga self-reported pain scale if pain ispresent; assessing and measuringthe range of motion (ROM) andmuscular patterning of themandible; measuring postural (CO),functional (CR), and speaking devi-ations of the mandible; identifyingfunctional deviations in themechanic-physiologic movement ofthe tongue, lips and jaw duringspeaking patterns (as related todental interferences, occlusal andincisal attrition patterns, or ante-rior/lateral functional patterns);assessing attrition of the dentitionrelated to parafunctional patternsof bruxism, muscle bracing andmeasuring abfractions, or clench-ing; assessing the periodontiumimpact of bruxism, bracing, andclenching; assessing orofacialmuscle dysfunction on oralhygiene; assessing the oral andnasal airway with a visual inspec-tion6, 55, 56 and utilizing a sleepapnea questionnaire if symptomsare present.

What are the Goals?Addressing adjunctive issues of

OMD, oral behaviors, and muscularTMD increases orthodontic treat-ment planning potential forsuccessful outcomes and remainscritical to facilitating long-termstability. The on-going evaluationof functional patterns continuesthrough treatment and post-treat-ment phases.2, 6, 12 Orofacialmyofunctional and neuro-muscularretraining encourages habituationand adaptation to new neuro-muscular patterns. It is most idealto begin OMT in cases where thedysfunction is more severe prior tothe onset of orthodontics. It alsousually makes the early orthodon-tics move at a more predictablespeed. Oral habits, especially digitor lip sucking should be eliminatedprior to beginning ortho to elimi-nate potential orthodontic interfer-ence. If the patient is referred whilethe orthodontics are in progress, itis best to do so with enough timeremaining prior to debanding toallow for new patterns to becomewell-established. If referral is madeafter relapse is noticed, it is wise tostrongly refer as soon as relapseappears. When caught early enoughin a relapse situation, often correct-ing the function will allow thedentition to return to its pre-debanded orthodontic form. Ifretreatment is planned for anorthodontic relapse case, OMTshould be initiated prior to retreat-ment. However, habit patterns maybe successfully corrected at anypoint along the lifetime continuumof pre- to post-orthodontics.2, 6, 30,

31, 53 Establishing new orofacialmyofunctional patterns is similar toa rehabilitative process. Habitua-tion levels increase in depth thelonger and more often the newpatterns/functions are correctlyrepeated.6, 31, 53

Who ProvidesOMT Treatment?

Orofacial Myologists focus ontreatment issues related to theorofacial/oromotor functional,dento-facial functional aspects, andoral-related parafunctional andbehavioral issues. In the US, referral

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for orofacial myofunctional therapyis primarily to a Registered DentalHygienist (RDH), Dentist (DDS), orSpeech Pathologist (SLP) specificallytrained in Orofacial Myology.39 TheInternational Association of Orofa-cial Myology (IAOM) recognizes theeducation and licensure of the RDH,DDS, and SLP as the pre-requisiteeducation for training and becom-ing certified in Orofacial Myology.The IAOM is the international,inter-disciplinary association ofRDH, DDS, and SLP professionalsfrom around the globe who practicein the specialty-focused area ofOrofacial Myology or participate as

a supporting member. The IAOM iscurrently the only certifying body.Institutional education, both didac-tic and clinical, is scant in US andCanadian dental, dental hygiene,and speech pathology programs dueto 1) other curricular demands, and2) lack of faculty trained and certi-fied in the specialty area. Countries,such as Japan and Brazil, are moreroutinely including orofacialmyofunctional therapy (OMT)within their formative professionaleducational programs in dentalhygiene, dentistry, and speechpathology. In the US and Canada,didactic and clinical training

courses are still mostly taught on aprofessional continuing educationbasis. Courses are available in semi-nar format, internship style, andweb-based.2, 51 Many other coun-tries are recently discovering theconcepts of orofacial myology andrecognize this as a desirable practicearea to assist their patients.5, 15, 40-46

How Long Is Therapy andWhat Happens? (Figs. 4 & 5)

Depending on the degree oforofacial/oromotor dysfunction, anaverage orofacial myology programwill consist of weekly appoint-ments, approximately 30-60minutes in length (depending onappointment goals) and may rangefrom 3-7 sessions (visits) to approxi-mately 24-32 sessions (visits) over a12-24 month period. Appointmentsare usually weekly for the intensivetherapy program, depending onseverity and when the patient is ina neuro-muscular retraining, muscletoning and development, andmuscle conditioning phase.Dysfunctional processes are brokendown into all of the bio-physiologicmovements and activities of dailyliving (ADLs). Each muscle groupactivity, functional movement, andmuscle functional pattern isretrained using correct bio-physio-logic movements, patterning, andactions in a normalized mannerwhile incorporating dental conceptsof centric occlusion (CO), centricrest (CR), and balancing functionaluse of anterior, posterior, and lateralgroup actions and being mindful ofspeech concepts of tongue position-ing for the on/off glide of thetongue on the palate and mandibu-lar range of motion (ROM) mechan-ical movements during speaking.Lingual frenum stretching isaddressed through exercise and/orreferral for a frenectomy with exer-cises pre-and post-procedure. ROMpatterning of the mandible incorpo-rates normalized jaw mechanics andestablishing an appropriate dentalfreeway space with an emphasisplaced on nasal breathing and lipsclosed, muscularly relaxed restingposture. The intrinsic and extrinsicmuscles of the tongue, soft palate,lips, facial muscles, muscles of

36 May/y J/ une 2012 JAOS

for orofacial myofuff nctional therapy a supporting member The IAOM is

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mastication, and neck muscles withhyoid elevation are exercised asneeded to achieve treatment goals.As needed, chewing and swallowingexercises are incorporated, alongwith noxious oral habits and para-functional habits addressed. Manyarticulation errors (lisping patterns)improve significantly once thetongue, lips, and mandibularpatterns function correctly. Ifspeech articulation is an issue, aRDH orofacial myologist will coor-dinate treatment with a speechpathologist to address non-self-correcting errors. The appointmentschedule decreases as habituationincreases and exercises are weanedwhile maintaining corrected func-tion. Appointments decrease to anannual re-evaluation for 1-5 yearsfollowing the completion of acomprehensive therapeutic programto monitor long-term stability.Digit sucking habits eliminatecompletely or significantly comeunder control on their way toextinction within the first 24-72hours of the therapy program. It isliterally a ‘Quit in A Day’ behaviormodification program for 80-90% ofthe individuals, however, continuedmonitoring for 30-60 days with a 3or 6 month recheck insures fullextinction of the behavioral habit,allows monitoring of naturalchanges to the form, and followsbest practice of behavior modifica-tion principles and theories. A TMDpatient with pain symptoms or apatient with special needs treatmentprogram may take less/more timethan other OMD patients tocomplete, based on treatment goalsand case complexity.2, 6, 9-12, 16, 31, 34,

45, 46, 53

Most parafunctional patterns areaddressed during the course of anorofacial myofunctional therapeuticprogram. The background and train-ing of the orofacial myologist willdetermine the extent and ability toaddress the orofacial myofunctionaldisorders and parafunctional habitspresent. Not all orofacial myologistsare trained to address muscular TMDand parafunctional habits/patterns.As with any case assessment, thetime and intensity of treatment isdetermined by the severity and

complexity of the orofacialmyofunctional disorders. As a bestpractice, orthodontists should alsoinclude the orofacial myologist inthe re-evaluation of the patient for1-3 years following the completionof an orthodontics and orofacialmyofunctional therapy program.2, 6,

53 On the longer term of 4-6 ormore years following completion ofan OMT program (in the US) thegeneral dentist and dental hygienistcontinue monitoring the long-termstabilization.6, 20, 24

Moving Forward Orthodontic practitioners are

increasingly aware of negativechanges created in the dento-facial environment due to inter-ferences, destruction, damage,and unwanted change in thedentition, dental arches, TMJfunctional patterning, and pres-ence of parafunctional habits andpatterns. These orofacialmyofunctional behaviors makeorthodontic treatment more diffi-cult, delay the normal progressionof treatment, and leave beauti-fully completed cases at risk in anunstable neuro-muscular environ-ment. Tongue and orofacialmuscular ‘issues’ can occur in anyarea of the face/head/neck. OMDand muscular TMD can impactthe mouth and face in an ante-rior, lateral, and/or posteriorpattern on a unilateral or bi-lateral basis. Dysfunction is recog-nized as abnormal movementsand functional patterning of thetongue, lips, and mandible occur-ring during resting postures;chewing; swallowing of liquidsand foods; during speaking; sleep-ing; abnormal jaw muscular andpostural patterning, noxious oralrelated behaviors, or parafunc-tional habit patterns.

Orofacial myofunctional thera-pies (OMT) can positively impactand/or eliminate these disordersand dysfunction. OMT was mostcommonly called ‘tongue thrust-ing’, however orofacial myofunc-tional therapy more completelyencompasses the issues. Therapyinvolves establishing correct orofa-cial muscle tone, creating a

balanced equilibrium and harmonyin the functional resting posture,chewing patterns, swallowingpattern, and functional speakingpatterning utilizing the tongue, lips,mandible, perioral musculature,cheeks, and head/neck orofacialenvironment in a correct bio-physi-ologic manner as they relate tomaintaining a dental freeway space,neuro-muscular stimulus/responses,activities of daily living involvingsitting at rest, mastication (chew-ing) and deglutition (swallowing)issues, eliminating functionaldysphagia (preparatory, oral, and insome cases the pharyngeal phase),functional eating and feeding, sizeof food bites and bolus formation,saliva/food/liquid transfers, elimina-tion of digit (thumb/finger) andother non-nutritive (pacifier, sippy-cup) sucking habits, and additionalrelated noxious oral habits (nailbiting/object chewing), along withaddressing the parafunctional oralhabits/behaviors of bruxism, musclebracing, clenching, and inappropri-ate ROM patterning (range ofmotion) of the mandible.

Therapy incorporates appropri-ate use of a patent nasal breathingpattern and patent airway mainte-nance; works well with theorthodontic practitioner to elimi-nate muscular and functional

38 May/June 2012 JAOS

balanced equilibrium and harmony

American Associationof Orthodontics(AAO) – Policy State-ment adopted 1993

American DentalHygienists’ Associa-tion (ADHA) – PolicyStatement 9-92 adopted1992

American Speech,Hearing-LanguageAssociation (ASHA) –Policy and PositionStatement adopted 1991

OrofacialMyology Policy

Statements

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tooth movement interferences;assists in maintaining arch expan-sion by achieving correct tongueand jaw posturing with pressuresexerted by the tongue on the hardpalate and developing a lingual-alveolar seal/pressure with correctlateral and posterior-lateral pres-sures of the tongue; focuses oneliminating labial (lip) incompe-tency through lip neuro-musculartoning and/or lip stretching exer-cises; addresses dentofacial func-tional abnormalities and the func-tional impact on the growth/devel-opment of the face and dentition.

The IAOM defined a collateralscope of practice (1993) in order tocreate a commonality among healthprofessionals who participate orengage in activities related to OMDand OMT. The essence of the scopeof practice provided basic state-ments of agreement on what cran-iofacial conditions were most rela-tive to orofacial myology. The

licensed professional backgroundand training of the orofacial myolo-gist practitioner will determine theextent of the services and treatmentoffered. The American Speech-Hear-ing Language Association, Scope ofPractice, Task 9.0, lists areas a SLPmay not engage in providing treat-ment of parafunctional problemsrelated to temporomandibular jointdisorders and myofascial paindysfunction, craniosacral manipula-tion or practices within the scope ofphysical therapy, practices related tothe reduction of medical condi-tions, such as sleep apnea.51 TheAmerican Dental Hygienists’ Associ-ation policies and code of ethics donot include limitations placed onpatient services offered to thehead/face/neck by a registereddental hygienist, support the USSurgeon General’s ‘Call to Action’on Oral Health in America, and aresupportive of the recommendationsin the Health People documents.48

ConclusionWith such a variety of orofacial

labels and issues to observe, it is nowonder why many orthodonticpractitioners become confused orconcerned about this topic. Most areinterested in how to address theseissues for their patients. Embarkingon this journey begins with deter-mining if your practice needsinclude orofacial myofunctionaltherapy. The next step is identifyingthe licensed professional you wantto work with in a collaborativemanner to provide therapeuticservices either within your ownoffice or on a referral basis to theiroffice. Then it’s time to begin collab-orating on patient assessment,examination, treatment planning,implementation of coordinatingprograms, and continue a joint eval-uation throughout treatment andduring the habituation/follow-upphases. The rest of this story endswith providing collaborative care forpatients, reducing your treatmentrisk factors, and enjoying the results!Contact Kimberly Benkert [email protected] or (708) 309-3844 for information regardingtraining seminars and lectures.

Disclaimer: Kimberly Benkertteaches OMD/TMD seminars andoffers training courses nationallyand internationally. Her clinicaloffices are located in suburbanChicago. She is a past president ofthe ADHA, former IAOM Boardmember and OM CertificationExaminer, and achieved Fellowshipstatus (FAADH) in Orofacial Myol-ogy and TMD with the AADH.Benkert is CEO of MYO USA, Inc.and Midwest Orofacial Myology.MYO USA, Inc. is the US and Cana-dian distributor of the MYOMunchie, peri-oral, oromotor chew-ing brush. Benkert has a financialinterest in the sale of the MYOMunchie in the US and Canada.She may be reached at 708-309-3844or [email protected]

Editor’s Note: Articlereferences are available

upon request or fordownload in thedigital version at

www.orthodontics.com.

40 May/June 2012 JAOS

tooth movement interferences; licensed professional background

� Chart and document all orofacial myofunctional and TM

functional deviations along with parafunctional

habits/patterns.

� Collaboratively co-treat patients with a RDH or SLP certi-

fied in Orofacial Myology (COM) to achieve balanced

function and increase long-term stability.

� Take an orofacial myology course for self-knowledge and

gain additional oromotor/oral health perspectives.

� Intern for a day with a COM to understand how Orofa-

cial Myofunctional Therapies fit specifically into your

practice treatment needs.

� Encourage local dental hygiene programs to add didactic

and clinical training course materials on OMD/TMD and

parafunctional habit elimination.

� Request CE programs be offered through your

professional association.

� Visit the IAOM website for a certified therapist in your

area: www.iaom.com.

Benkert Pearls