b Facial muscle spasms from over-closure/over-extension of the dental freeway space. b Tight lingual or labial frenums, and associated dysfunction of the lips, tongue. b Oral behaviors (non-nutritive sucking of thumbs, fingers, pacifiers; extended sippy-cup use; chronic chewing/biting of nails, clothes or hair, chronic pen/pencil chewing, lip & cheek biting/chewing, lip sucking/propping, unilateral and/or deviated chewing patterns, etc.). b Respiration functional issues (open mouth posturing and/or mouth breathing, over enlarged tonsils & adenoids, engorged inferior nasal turbinates, deviated septum, untreated allergies, other airway issues). b Oromotor dysfunction, espe-cially in the ROM of the mandible (range of motion deviations in the functional movements/patterning of the mandible) including functional shifts and dual biting patterns, oromotor planning issues. b Muscular/functional temporo-mandibular dysfunction (TMD) – pain, clicking, popping symptoms in the temporo-mandibular joint region. b Functional speaking pattern deviations (mechano-functional patterning movement devia-tions of the tongue, lips, and jaw during speaking); ‘funny-looking’ speaking patterns Note: A lisping pattern may/may not be present. b Unresolvable speech distur-bances that are more func-tionally related than articula-tion related. Raising the Bar on the Standard of Care The orthodontic assessment and examination process that includes a 34 May/June 2012 JAOS comprehensive orofacial myofunc-tional assessment and examination raises the bar on the standard of care delivered to the patient. The comprehensive orofacial myofunc-tional assessment portion may be completed by the dentist/orthodon-tist, or it is a great time to incorpo-rate the orofacial myologist into the process to provide a compre-hensive assessment and examina-tion. A comprehensive assessment and examination includes taking a comprehensive medical and dental history; dental occlusal assessment with measurements and Angle clas-sification; determining the severity of orofacial myofunctional disor-ders (OMD); assessing for func-tional dysphagia (difficulty in the preparatory and oral phases of chewing and swallowing); observ-ing resting postures of tongue, lips, mandible with philtrum, lip, lingual frenum stretch, inter-labial gap and lip resistance measure-ments; identifying and measuring the freeway space; determining the presence of noxious oral behaviors; assessing the impact of temporo-mandibular muscle dysfunction (TMD) including palpation of musculature and imaging; utilizing a self-reported pain scale if pain is present; assessing and measuring the range of motion (ROM) and muscular patterning of the mandible; measuring postural (CO), functional (CR), and speaking devi-ations of the mandible; identifying functional deviations in the mechanic-physiologic movement of the tongue, lips and jaw during speaking patterns (as related to dental interferences, occlusal and incisal attrition patterns, or ante-rior/lateral functional patterns); assessing attrition of the dentition related to parafunctional patterns of bruxism, muscle bracing and measuring abfractions, or clench-ing; assessing the periodontium impact of bruxism, bracing, and clenching; assessing orofacial muscle dysfunction on oral hygiene; assessing the oral and nasal airway with a visual inspec-tion 6, 55, 56 and utilizing a sleep apnea questionnaire if symptoms are present. What are the Goals? Addressing adjunctive issues of OMD, oral behaviors, and muscular TMD increases orthodontic treat-ment planning potential for successful outcomes and remains critical to facilitating long-term stability. The on-going evaluation of functional patterns continues through treatment and post-treat-ment phases. 2, 6, 12 Orofacial myofunctional and neuro-muscular retraining encourages habituation and adaptation to new neuro-muscular patterns. It is most ideal to begin OMT in cases where the dysfunction is more severe prior to the onset of orthodontics. It also usually makes the early orthodon-tics move at a more predictable speed. Oral habits, especially digit or lip sucking should be eliminated prior to beginning ortho to elimi-nate potential orthodontic interfer-ence. If the patient is referred while the orthodontics are in progress, it is best to do so with enough time remaining prior to debanding to allow for new patterns to become well-established. If referral is made after relapse is noticed, it is wise to strongly refer as soon as relapse appears. When caught early enough in a relapse situation, often correct-ing the function will allow the dentition to return to its pre-debanded orthodontic form. If retreatment is planned for an orthodontic relapse case, OMT should be initiated prior to retreat-ment. However, habit patterns may be successfully corrected at any point along the lifetime continuum of pre-to post-orthodontics. 2, 6, 30, 31, 53 Establishing new orofacial myofunctional patterns is similar to a rehabilitative process. Habitua-tion levels increase in depth the longer and more often the new patterns/functions are correctly repeated. 6, 31, 53 Who Provides OMT Treatment? Orofacial Myologists focus on treatment issues related to the orofacial/oromotor functional, dento-facial functional aspects, and oral-related parafunctional and behavioral issues. In the US, referral
Journal of the American Orthodontic Society May-June 2012: Page 34
