Orofacial myofunctional therapy associated with the use of the stimulating palatal plate in children with trisomy 21: case studies

Ferreira, Jéssica Ellen de Almeida; Almeida, Bruna Rezende Santos de; Deps, Tahyná Duda; Pretti, Henrique; Furlan, Renata Maria Moreira Moraes

doi:10.1590/2317-1782/20232021231en

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Case Report • CoDAS 35 (5) • 2023 • https://doi.org/10.1590/2317-1782/20232021231en copy

Orofacial myofunctional therapy associated with the use of the stimulating palatal plate in children with trisomy 21: case studies

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Individuals with trisomy 21 may have muscle hypotonia of the speech articulation organs, an enlarged protruding tongue positioned on the floor of the mouth, and a lack of lip closure. The stimulating palatal plate is an intraoral appliance that, associated with myofunctional therapy, aims to improve these children’s habitual lip and tongue posture. This study aimed to present the cases of four male children with trisomy 21, with a mean age of 6.7 and a standard deviation of 7.8 months, who used the stimulating palatal plate in association with myofunctional therapy. The children used the plate for 6 months and did exercises based on the orofacial regulation therapy, and their parents received instructions on feeding them and removing deleterious oral habits. In the first session and at the end of the treatment, each child’s face was video-recorded for 5 minutes at rest, and two researchers analyzed independently their habitual tongue and lip posture. Participants who began the treatment earlier and had the most severe postural changes had greater tongue and lip posture improvement.

Keywords:
Down Syndrome; Muscle Hypotonia; Rehabilitation; Myofunctional Therapy; Orthotic Devices

Participant (age)	Main findings of the myofunctional assessment
Participant 1 (6 months)	Lip and tongue tonus: decreased.
	Tongue posture: on the floor of the mouth.
	Lip posture: sometimes open, sometimes closed.
	Diet: liquid food in a baby bottle and mashed fruits served on a small plastic spoon, without complaints. Breastfeeding up to 3 months old.
	Deleterious sucking habits: absent.
	Teeth: absent.
Participant 2 (1 month)	Lip and tongue tonus: decreased.
	Tongue posture: on the lower lip.
	Lip posture: open.
	Diet: Breastfeeding complemented with infant formula, without complaints.
	Deleterious sucking habits: absent.
	Teeth: absent.
Participant 3 (18 months)	Lip and tongue tonus: decreased.
	Tongue posture: intercalating between the tongue on the lower lip and inside the oral cavity but lowered on the floor of the mouth.
	Lip posture: open.
	Diet: solid, liquid, and pureed food, with occasional complaints of choking with solid foods.
	Deleterious sucking habits: absent.
	Teeth: present upper and lower central incisors.
Participant 4 (2 months)	Lip and tongue tonus: decreased.
	Tongue posture: on the lower lip.
	Lip posture: open.
	Diet: breastfeeding complemented with infant formula; complaints of choking.
	Deleterious sucking habits: pacifier.
	Teeth: absent.

Exercise	Description	Repetition
1) Strengthening the masseter	Sliding the fingertips of both hands from the angle of the mandible up toward the eyes.	10 times each movement
2) Stretching the upper lip	Sliding the tips of the index fingers and thumbs down from the center of the upper lip to the commissures.	10 times each movement
3) Stretching the lower lip	Sliding the tips of the index fingers and thumbs up from the center of the lower lip to the commissures.	10 times each movement
4) Stimulating the lower nasal motor zone	Pressing the index finger horizontally above the upper lip and vibrating it up and backward.	10 times each movement
5) stimulating the lip motor zone	Pressing the tips of the index fingers on the zygomaticus major muscle, simultaneously vibrating and pulling it.	10 times each movement
6) Stimulating the chin motor zone	Placing the index finger under the face and the thumb on the chin and making downward movements, simultaneously pressing and vibrating them.	10 times each movement
7) Stimulating the tongue motor zone	Pressing the thumb or index finger under the face, in the submandibular region of the neck, and vibrating intermittently.	10 times each movement
8) Tongue vibration	Pressing the index finger over the tongue and vibrating it intermittently. Then, perform mandible control.	20 times each movement
9) Lifting the tip of the tongue	Placing the index finger behind the lower gingiva (without touching the teeth) and the thumb in the submandibular region, then lifting the tip of the index finger to take the tongue near the upper teeth. Then, perform mandible control.	10 times each movement
10) Tongue tapering	Touching the lateral margins of the tongue backward with the index finger or a toothbrush.	10 times on each side of the tongue
11) Lip vibration	Flexing the finger joints to cup the hand, placing it over the child’s lips carefully not to hinder nose breathing. Then pressing the lips and face with a vacuum effect and vibrating upward.	20 times each movement
12) Mandible control	Placing the index finger on the chin, the middle finger below the mandible, and the thumb along the border of the mandible and resting the head on the arm.	Whenever the child needs alignment.

Assessment moment	Participant	Age (months)	Lip posture
			Closed		Parted		Open
			Time (min)	%	Timed (min)	%	Time (min)	%
Beginning of the treatment	1	6	191	66.1	37	12.8	61	21.1
	2	1	1	0.4	2.5	0.9	269	98.7
	3	18	9.5	4.3	7.5	3.4	205	92.3
	4	2	8	3.3	7	2.9	226.5	93.8
After 6 months of treatment	1	12	37	16.7	78	35.3	106	48.0
	2	7	1	0.7	28.5	20.6	109	78.7
	3	24	10	5.7	19.5	11.1	146	83.2
	4	8	9.5	8.2	73	62.7	34	29.2

Assessment moment	Participant	Age (months)	Tongue posture
			Inside the oral cavity		Between the alveolar ridges		On the lower lip		Severe protrusion
			Time (min)	%	Time (min)	%	Time (min)	%	Time (min)	%
Beginning of the treatment	1	6	271.5	93.3	9.5	3.3	0.5	0.2	9.5	3.3
	2	1	0	0.0	14	5.5	218.5	86.5	20	7.9
	3	18	87	40.4	48	22.3	79	36.7	1.5	0.7
	4	2	14.5	6.1	7	2.9	186	77.7	32	13.4
End of the treatment	1	12	168	83.6	29.5	14.7	2.5	1.2	1	0.5
	2	7	7.5	4.2	68	38.3	102	57.5	0	0
	3	24	55.5	30	34	18.4	94.5	51.1	1	0.5
	4	8	36	30.8	53.5	45.7	24.5	20.9	3	2.6

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[1] Conflict of interests: nothing to declare