For instance, an allergy that has not been addressed may cause nasal congestion, which may cause a chronic open mouth posture, which is linked to poor palatal develop-ment and TMJ instability, which is linked to less than ideal orthodontic results, prolonged use of retainers and even sleep disorders and surgery. Parental involvement and the patient’s preferences and values are crucial variables, as often some dietary and life-style changes are needed to arrest the noxious cascade, and these changes need to be implemented by the patient. Preventing OMDs benefits patients, orthodontists, and third party payers because it intercepts situations that could derail the normal growth and development of a harmonious orofacial complex. Preventing OMDs also makes sense in the global health discourse, because millions of people are emerging from poverty world-wide and they are exposed to the same perks of more affluent countries and therefore they may develop OMDs at an unprecedented number, although the economic ability to take care of the consequences is not growing on par with the disorders. Finally, in cases where an orofa-cial myologist is not available, an array of oral appliances and habit trainers have been employed for years 70, 71 . However, in cases where multiple OMDs are present or undi-agnosed, results have been mixed at best 62, 72 , as the habit tends to persist once the appliance is removed and the patients have not been taught the correct tongue posture. habits by modifying their dura-tion, frequency and intensity. b Changing orofacial muscle movements to the desired and optimal pattern. b Ensuring the generalization of a correct pattern and function (same optimal behavior in differ-ent contexts) b Ensuring the habituation of a correct pattern and function (same optimal behavior in differ-ent times) All these principles are imple-mented through motivational techniques 73 customized by the therapist and honed by profes-sional experience 74, 75 . Some tech-niques imply self-awareness and patient education 76, 77, 78 while other techniques derive from the field of dysphagia treatment 79, 56 or speech articulation treatment 80, 5 . From a neurophysiological stand-point, the patients need to inter-nalize the correct pattern of orofa-cial movements, and keep approx-imating to that behavior through repetition over time, for the results to be stable 81, 82, 83, 84, 85, 86 . In recent years, studies have been conducted on the minimum number of therapy sessions neces-sary to cause a physiological change in orofacial muscles and on the need to build in follow-ups in the therapy cycle to identify and correct possible functional relapses 87 . There are very specific neurophysiological principles behind the process of acquisition of a correct muscle pattern, its generalization and habit-uation 88, 89, 90, 91, 92, 93, 94, 95 . Interrupting therapy too soon may cause a regression and disappearance of the newly acquired functional pattern 96, 87 , just like interrupting orthodontic treatment too soon may invalidate the gains to date. Orofacial myofunctional therapy requires specific skills because the muscles of the face and mouth are different, anatomically and physio-logically, from muscles of the limbs and the trunk. Orofacial muscles share multiple functions like breath-ing, eating, speaking, exploring etc. and those functions are imple-TREATMENT OF OMDs Just like when orthodontic treat-ment is dictated by anatomical and physiological constraints, so too is orofacial myofunctional therapy because the changes in functions are dictated by anatomical constraints (like a restricted palate shape or a restricted lingual frenum) and by physiological constraints (like the absence or reduction of nasal breathing). The principles of therapy are: b Eliminating or drastically reducing orofacial noxious 40 March/April 2012 JAOS mented by changing the position or shape of the muscles. However, even the most skilled therapist might face some OMDs that cannot be eliminated by orofacial myofunc-tional therapy alone, but may require a coordinated intervention by the orthodontist first, as in the case of a restricted palate (a maxil-lary transverse deficiency), an exces-sive overjet or an open bite. A visit to an oral surgeon may also be the first step in treatment, in the case of a restricted lingual frenum, while other times the first step might be the need to see the allergist, the ENT or the osteopathic physician. Therefore a multidisci-plinary approach is absolutely necessary 97 as the timing of the vari-ous therapies needs to be decided as a team, after a full evaluation of the patient is completed and a list of goals has been approved by the patient. Myofunctional therapy may occur before orthodontics, during orthodontics or after orthodontics. Just like form and function influ-ence each other, orthodontics and orofacial myofunctional therapy also influence each other. Identifying OMDs, striving to prevent them or treating them in a multidisciplinary approach should be a part of the standard of care in a dental or orthodontic office, in orofacial myology and in speech pathology as the anatomical changes brought forth by the orthodontist’s treatment are more stable when muscles and function patterns are optimized. Conversely, appropriate functions happen in appropriate spaces and so speech pathologists or orofacial myologists need to work closely with orthodon-tists as they are expanding palates or reducing excessive overjets before starting myofunctional therapy. By being aware of the intricate relationship between orofacial struc-tures and orofacial functions orthodontist and other professional working within the same area can coordinate care with an orofacial myofunctional therapist for the benefit of the patient and treatment success and stability. Editor’s Note: Article references are avail-able upon request or for download in the digital version at www.orthodontics.com.
Journal of the American Orthodontic Society March-April 2012: Page 40
