Orofacial myofunctional therapy program for individuals undergoing orthognathic surgery

ABSTRACT

Purpose:

to present an Orofacial Myofunctional Therapy Program for individuals submitted to orthognathic surgery.

Methods:

3 different steps were performed: the first involved preparation of the initial program, by reviewing the literature on the therapeutic process after surgery; the second comprised the application of the initial program by two speech therapists qualified in orofacial motricity, to 21 individuals, after orthognathic surgery, who suggested changes in the initial protocol, resulting in a second version; on the third and last stage, the content of the Therapy Program was analyzed regarding the content, by three speech therapists specialists in Orofacial Motricity and further changes were made.

Results:

the Therapy Program was developed based on 38 scientific papers, whose application by the speech therapists resulted in changes, taking into account the facial typology and dento-occlusal conditions, storage of saline, detailing of the goals of proposed activities and elongation of the upper lip. After the experts’ suggestions, the final version consisted of 12 sessions, the first being assessment, 10 sessions of therapy once a week, involving myofunctional exercises, sensorial stimulation and functional training, and the last session for re-assessment.

Conclusion:

it was possible to develop a Myofunctional Orofacial Therapy Program aimed at individuals submitted to orthognathic surgery, to be validated in future studies.

Keywords:
Myofunctional Therapy; Orthognathic Surgery; Speech, Language and Hearing Sciences

RESUMO

Objetivo:

apresentar um Programa de Terapia Miofuncional Orofacial para indivíduos submetidos à cirurgia ortognática.

Métodos:

foram realizadas 3 etapas distintas: a primeira envolveu a elaboração do programa inicial a partir da revisão da literatura sobre o processo terapêutico após a cirurgia; a segunda a aplicação do programa inicial por duas fonoaudiólogas especialistas em motricidade orofacial em 21 indivíduos, após ortognática, que sugeriram modificações no protocolo inicial, resultando numa segunda versão; na terceira e última etapa, o mesmo foi analisado quanto ao conteúdo por três fonoaudiólogas especialistas em Motricidade Orofacial e novas modificações foram realizadas.

Resultado:

o programa foi elaborado com base em 38 trabalhos científicos, cuja aplicação pelas fonoaudiólogas resultou em modificações considerando a tipologia facial e as condições dento-oclusais, armazenamento do soro fisiológico; detalhamento dos objetivos das atividades propostas e alongamento do lábio superior. Após as sugestões das especialistas a versão final foi constituída de 12 sessões, sendo a primeira avaliação, 10 sessões de terapia uma vez por semana, envolvendo exercícios miofuncionais, estimulação sensorial e treino funcional, sendo a última sessão de reavaliação.

Conclusão:

foi possível desenvolver um Programa de Terapia Miofuncional Orofacial para indivíduos submetidos à cirurgia ortognática, sendo necessário que o mesmo seja validado.

Descritores:
Terapia Miofuncional; Cirurgia Ortognática; Fonoaudiologia

Introduction

Dentofacial deformity (DFD) is defined as a facial and dental disproportion that is severe enough to affect the quality of life of an individual ^1-5.

The correction of DFD at completion of craniofacial growth and development involves orthodontic treatment followed by orthognathic surgery ⁵. The surgical procedure allows correction of facial disproportions of the mandible, maxilla and/or mentalis, as well as asymmetries ⁶. However, it leads to variation in the structural balance of the facial skeleton, which may result in signs and symptoms of temporomandibular dysfunction (TMD) ^7-11 and changes in orofacial musculature and functions ^11,12.

Based on information related to the treatment planning of the DFD, the speech therapist may perform the therapy aimed at preparing the musculature involved in the surgical procedure, as well as to eliminate harmful oral habits and address cases of habitual mouth respiration, signs and symptoms of TMD and / or other conditions not related with the DFD ¹³. After surgery, speech therapy aims to reduce the facial edema, stimulate the orofacial sensitivity, facial mimic and range of mandibular movements, with gradual reintroduction of food consistencies and adjustment of orofacial functions within the limits of each case ¹⁴.

The literature on myofunctional therapy after orthognathic surgery presents the aspects to be addressed ^15,16 and case reports ¹¹. So far, only one scientific study was found that demonstrated Orofacial Myofunctional Rehabilitation in 19 individuals, using a protocol that proved the efficacy of treatment after orthognathic surgery ¹⁷.

Most patients seek for treatment for the deformity unaware of the role of speech therapist in an orthognathic surgery team, and many teams are still unaware of such performance. Additionally, the diagnosis and treatment of these individuals should be conducted by interdisciplinary teams, aiming to understand the adaptation and disorders presented, as well as the therapeutic possibilities in the different stages of orthodontic-surgical treatment ¹⁸, highlighting the need to direct the action of specialists in Orofacial Motricity working in this field.

Thus, the objective of this study was to present a proposal of myofunctional therapy program for individuals submitted to orthognathic surgery.

Methods

Initially, a 10-year literature review was conducted including national and international manuscripts, books, monographs, dissertations, theses, case reports and articles related to this subject published in the databases Science Direct, Pubmed, Scielo and Bireme, besides the Google Scholar search engine. The following terms were used in Portuguese and English: dentofacial deformity, orthognathic surgery, severe malocclusion, orthodontic-surgical treatment, myofunctional therapy, myofunctional rehabilitation and speech therapy.

The material was initially selected by title, followed by reading the abstract and then the full texts, analyzing the objectives, number and gender of participants, study method and results achieved. Studies that did not reach the objectives or whose full texts were not found were excluded.

Development of the protocol comprised three distinct stages, the first based on the literature found, resulting in the initial version of the myofunctional therapy protocol. For that purpose, the most frequent aspects described in texts addressing the therapeutic process after surgery were selected, as well as those considered relevant according to the clinical experience of the protocol designers.

This initial version was applied by two speech therapists specialists in orofacial motricity in 21 patients submitted to orthognathic surgery, being 10 individuals for speech therapist A and other 11 for speech therapist B, aiming to verify the feasibility of the instrument. Among these, eight presented DFD pattern II and 13 pattern III, who were submitted to Le Fort I osteotomy, sagittal/vertical ramus and chin surgery. Referrals for speech therapy were performed by the surgeons between 30 and 45 days after surgery.

After application of this first protocol, it was changed from the experience of myofunctional orofacial intervention, aiming to enhance the understanding and application of proposed exercises. Then, these suggestions were analyzed by the authors, some of which were accepted and some were rejected, resulting in a second version of the therapy protocol.

In the third and last stage, it was analyzed as to the content by three speech therapists specialists in Orofacial Motricity, with at least five years of experience in the care of individuals with dentofacial deformity submitted to orthognathic surgery, considering the number of sessions proposed, the division of objectives, selected exercises, relationship between objectives and exercises, clear description of procedures, proposed assessments, additional explanatory information, and overview of the protocol.

The necessary changes were made based on the results achieved in the third stage, yielding the final version of the protocol.

Results

The number of publications found by search on the different databases is presented in Figure 1.

Figure 1:
Results of search performed in databases on orofacial myofunctional therapy for individuals undergoing orthognathic surgery.

Among the 108 papers found, 64 were full texts, among which 26 were excluded, remaining 38 papers for the study, as observed in Figure 2.

Figure 2:
Summary of search performed.

The initial version of the Orofacial Myofunctional Therapy Protocol was designed based on therapy proposals presented in the selected papers.

After application of the first version of therapy program by the speech therapists, the authors accepted suggestions that led to inclusion of information to further elucidate the description of items comprising the second version of the Protocol, as follows:

1. consider the facial typology and dento-occlusal conditions, even after orthognathic surgery;

2. include care on the storage of saline solution;

3. provide details on the objectives of proposed activities;

4. add one more strategy for elongation of the upper lip, such as keeping a rubber tube in the upper vestibule elongating the upper lip, whose thickness depends on the need of each patient.

Thereafter, the proposed therapy was analyzed by three experts that suggested changes in the Protocol, most of which were accepted:

1. consider the types of surgical procedures to guide the aspects addressed in the therapy;

2. rule out mobility of the upper facial third;

3. elongate the muscle after training the mobility of facial mimic to avoid formation of wrinkles;

4. elucidate the suggested movement for tongue mobility;

5. change the term “Protocol” by “Therapy Program”.

This led to the final version, proposing 12 weekly sessions, being one assessment before treatment onset and one re-assessment after therapy completion, as well as 10 sessions of Orofacial Myofunctional Therapy (Figures 3 and 4).

Figure 3 presents the approaches of Orofacial Myofunctional Therapy per week, and the suggested exercises are presented in detail in Figure 4.

Figure 3:
Orofacial myofunctional therapy program after orthognathic surgery

Figure 4:
Details of exercises proposed in the Orofacial Myofunctional Therapy Program

Discussion

Considering that speech-language rehabilitation in cases submitted to orthognathic surgery aims at favoring the orofacial and cervical functions for muscular balance, reducing the risk of relapse caused by maintenance of inadequate functional patterns, the present study aimed to develop an Orofacial Myofunctional Therapy Program to guide professionals in the intervention on such patients. According to Pimenta et al. (2000) ¹⁹, the use of protocols tends to improve the care, favor the use of scientifically based practices, minimize the variability of information and approaches between team members, as well as to establish limits of action and cooperation between the different professionals.

Regarding the results of search on databases on speech-language therapy in individuals submitted to orthognathic surgery, studies on adaptation of the stomatognathic system were found ^11,20,21, as well as case reports ^22,23. Other studies theoretically demonstrated the speech-language intervention in the different stages of care to patients submitted to this type of surgery, yet without presenting a program or protocol ^11,24-28. Additionally, one study demonstrated the functional response of mastication after speech therapy intervention in patients submitted to orthognathic surgery ²⁹, in which the investigators applied a treatment protocol whose objectives were similar to those proposed in this paper, yet without description of the therapeutic procedures.

Thus, the first step in establishing the therapy program comprised a literature review with selection of 38 papers, from which the aspects to be addressed in the therapy were defined, as follows: increased strength and mobility of the lips, tongue and cheeks ^30-32; perception of the stomatognathic system ^11,29; adaptation of the habitual posture of the lips, tongue and mandible; exercises for mandibular mobility ^11,29; adequacy of respiratory functions ^11,29,31-33; mastication ^11,29,32,33; swallowing ^11,29,30 and speech ^11,29,31,33. These aspects were distributed in a program comprising 12 sessions to be held once a week, while another study designed a program of 6 sessions ²⁸, yet with a technical focus only on masticatory function, which explains the greater number of sessions proposed in this paper.

The first version of the program was applied by two speech therapists in 21 patients. This experience of application resulted in changes, so that the program presented a clearer language, favoring the understanding of proposals and leading to the second version. No study found in the literature described the process of designing protocols and programs of orofacial myofunctional therapy to allow comparison of such results. However, the application of assessment protocols by specialists has been described as an important step in the development of such assessment tools ^34-38.

In the third stage, after changes, the program was sent to three specialists for analysis; this process was also performed in another study ¹¹, in which the case studies, assessments and reassessments, as well as checking of all final data were reviewed and monitored by three speech therapists with more than 10 years of experience in the field. The changes suggested by the examiners allowed to consider the types of surgical procedures to guide the aspects addressed in therapy ³⁹; rule out mobility of the upper facial third; elongate the muscles after training the mobility of facial mimic to avoid formation of wrinkles; and to better elucidate the movements suggested for tongue mobility.

The limitations of the therapy program herein presented should be taken into account, considering the types of surgeries performed and the individual characteristics of each patient (neuromuscular, bone and mucosa repair, temporomandibular dysfunctions, evolution of orthodontic treatment), which determines individual approaches, in which the program is a proposal of foundations of myofunctional work for this population.

It should be considered that, for intervention in cases submitted to orthognathic surgery, it is necessary to have knowledge on the anatomical, functional, surgical and orthodontic aspects, as well as close contact with the orthodontist and maxillofacial surgeon, to seek information about the evolution of cases and thus adapt the speech therapy treatment for each patient. Finally, it should be highlighted that selection of proposed exercises should take into account the moment when the patient is referred for speech therapy, the process of remodeling of temporomandibular joints after orthognathic surgery, as well as the time of bone consolidation and the response of healing of each patient.

Finally, the American Speech-Language-Hearing Association - ASHA (2004) ⁴⁰ published recommendations regarding the need for evidence-based practices, advocating the use of validated protocols for diagnosis and therapy. To verify the total validity of an instrument, it should be composed of three parts: content validity, criterion validity and construct validity. Thus, it is necessary to continue the present study for validation of the myofunctional treatment proposal related to orthognathic surgery herein presented.

Conclusion

It was possible to develop an Orofacial Myofunctional Therapy Program comprising myofunctional exercises, sensorial stimulation and functional training, aimed at individuals submitted to orthognathic surgery, to be validated in future studies.

Referências

• ¹
  Rusanen J, Lahti S, Tolvanen M, Pirttiniemi P. Quality of life in patients with severe malocclusion before treatment. Eur J Orthod. 2010;32(1):43-8.
• ²
  Choi WS, Lee S, McGrath C, Samman N. Change in quality of life after combined orthodontic-surgical treatment of dentofacial deformities. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109(1):46-51.
• ³
  Khadka A, Liu Y, Li J, Zhu S, Luo E, Feng G et al. Changes in quality of life after orthognathic surgery: a comparison based on the involvement of the occlusion. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;112(6):719-25.
• ⁴
  Bortoluzzi MC, Manfro R, Soares IC, Presta AA. Cross-cultural adaptation of the orthognathic quality of life questionnaire (OQLQ) in a Brazilian sample of patients with dentofacial deformities. Med Oral Patol Oral Cir Bucal. 2011;16(5):694-9.
• ⁵
  Proffit WR, White RP Júnior, Sarver DM, editores. Tratamento contemporâneo de deformidades dentofaciais. Porto Alegre: Artmed; 2005.
• ⁶
  Juggins KJ, Nixon F, Cunningham SJ. Patient - and clinician-perceived need for orthognathic surgery. Am J Orthod Dentofacial Orthop. 2005;128(6):697-702.
• ⁷
  Farella M, Michelotti A, Bocchino T, Cimino R, Laino A, Steenks MH. Effects of orthognathic surgery for class III maloclusion on signs and symptoms of temporomandibular disorders ando n pressure pain thresholds of the jaw muscles. Int J Oral Maxillofac Surg. 2007;36(7):583-7.
• ⁸
  Pahkala RH, Kellokoski JK. Surgical-orthodontic treatment and patients' functional and psychosocial well-being. Am J Orthod Dentofacial Orthop. 2007;132(2):158-64.
• ⁹
  Oland J, Jensen J, Melsen B. Factors of importance for the functional outcome in orthognathic surgery patients: a prospective study of 118 patients. J Oral Maxillofac Surg. 2010;68(9):2221-31.
• ¹⁰
  Silva MMA, Ferreira AT, Migliorucci RR, Nary Filho H, Berretin-Felix G. Influência do tratamento ortodôntico-cirúrgico nos sinais e sintomas de disfunção temporomandibular em indivíduos com deformidades dentofaciais. Rev Soc Bras Fonoaudiol. 2011;16(1):80-4.
• ¹¹
  Pereira JBA, Bianchini EMG. Caracterização das funções estomatognáticas e disfunções temporomandibulares pré e pós cirurgia ortognática e reabilitação fonoaudiológica da deformidade dentofacial classe II esquelética. Rev. CEFAC. 2011; 13(6):1086-94.
• ¹²
  Felicio CM, Trawitzki LVV. Interfaces da Medicina, Odontologia e fonoaudiologia no complexo cérvico-cranio-facial. Sao Paulo: Pró-fono, 2009.
• ¹³
  Berretin-Felix G, Jorge TM, Genaro KF. Intervenção Fonoaudiológica em pacientes submetidos à cirurgia ortognática. In: Ferreira LP, Befi-Lopes DM, Limongi SCO, organizadores. Tratado de Fonoaudiologia. São Paulo: Roca; 2004. p 494-511.
• ¹⁴
  Trawitzki LVV, Felício CM; Puppin-Rontani RM, Matsumoto MAN, Vitti M. Mastigação e atividade eletromiográfica em crianças com mordida cruzada posterior. Rev. CEFAC. 2009;11(3):334-40.
• ¹⁵
  Morelli JMG. Cirurgia Ortognática: atuação fonoaudiológica no pré e pós operatório. (Monografia). Itajaí(SC): Centro de Especializaçao em Fonoaudiologia Clínica - CEFAC, 2001.
• ¹⁶
  Saccomanno S, Antonini G, D'Alatri L, D'Angelantonio M, Fiorita A, Deli R. Causal Relationship between malocclusion and oral muscles dysfunction: a model of approach. Eur J Paediatr Dent. 2012;13(4):321-3.
• ¹⁷
  Gallerano G, Ruoppolo G, Silvestri A. Myofunctional and speech rehabilitation after orthodontic-surgical treatment of dento-maxillofacial dysgnathia. Prog Orthod. 2012;13(1):57-68.
• ¹⁸
  Santos-ColuchI GG, Oliveira MAJ, Prado DGA, Passos DCBOF, Migliorucci RR, Abramides DV et al. Cirurgia Ortognática. In: Pernambuco LA, Silva HJ, Souza LBR, Magalhães Júnior HV e Cavalcanti RVA. (Org.). Atividades em motricidade orofacial. 1 ed.: Livraria e Editora Revinter Ltda, 2011, v. 1. p. 73-94.
• ¹⁹
  Pimenta CAM, Pastana ICASS, Ieda C, Karina Sichieri K, Gonçalves MRCB et al. Guia para a construção de protocolos assistenciais de enfermagem. COREN-São Paulo. 2015.
• ²⁰
  Pereira AC, Jorge TM, Ribeiro Júnior PD, Berretin-Felix G. Características das funções orais de indivíduos com má oclusão Classe III e diferentes tipos faciais. Rev Dent Press Ortodon Ortopedi Facial. 2005;10(6):111-9.
• ²¹
  Coutinho TA, Abath MB, Campos GJL, Antunes AZ, Carvalho RWF. Adaptações do sistema estomatognático em indivíduos com desproporções maxilo-mandibulares: revisão da literatura. Rev Soc Bras Fonoaudiol. 2009;14(2):257-9.
• ²²
  Fraga JA, Vasconcellos RJH. Acompanhamento fonoaudiológico pré e pós-cirurgia ortognática: relato de caso. Rev Soc Bras Fonoaudiol. 2008;13(3):233-9.
• ²³
  Berretin-Felix G, Passos DCBOF, Migliorucci RR, Nary Filho H. Tratamento miofuncional orofacial após cirurgia ortognática: relato de caso. In: XX Congresso Brasileiro de Fononoudiologia; 2012, Brasília, DF. Anais do XX Congresso Brasileiro de Fononoudiologia, 2012. v 1, p.3328-3328.
• ²⁴
  Marchesan IQ, Bianchini EMG. A fonoaudiologia e a cirurgia ortognática. In: Araujo A. Cirurgia Ortognática. São Paulo: Santos; 1999. p. 351-62.
• ²⁵
  Ribeiro MC. Atuação fonoaudiológica no pré e pós-operatório em cirurgia ortognática. [Monografia] Botucatu (SP): Centro de Especialização em Fonoaudiologia Clínica - CEFAC, 1999.
• ²⁶
  Fernandes AL. Cirurgia Ortognática: Um estudo sobre a atuação fonoaudiológica. [Monografia] Rio de Janeiro (RJ): Centro de Especialização em Fonoaudiologia Clínica - CEFAC, 2000.
• ²⁷
  Berretin-Felix G, Passos DCBOF, Migliorucci RR, Nary HF. Tratamento Miofuncional OrofaciaL após cirurgia ortognática: Relato de Caso. In: XX Congresso Brasileiro de Fonoaudiologia, 2013, Brasília.
• ²⁸
  Mangilli LD. Programa de avaliação e tratamento fonoaudiológico para a reabilitação da função mastigatória de indivíduos submetidos à cirurgia ortognática por deformidade dentofacial. [Tese] São Paulo (SP): Faculdade de Medicina da Universidade de São Paulo, 2012.
• ²⁹
  Smithpeter J, Covell DJ. Relapse of anterior open bites treated with orthodontic appliances with and without orofacial myofunctional therapy. Am J Orthod Dentofacial Orthop. 2010;137(5):605-14.
• ³⁰
  Marson A, Tessitore A, Sakano E, Nemr K. Efetividade da fonoterapia e proposta de intervenção breve em respiradores orais. Rev. CEFAC. 2012;14(6):1153-66.
• ³¹
  Kijak E, Lietz-Kijak D, Sliwinski Z, Fraczak B. Muscle activity in the course of rehabilitation of masticatory motor system functional disorders. Postepy Hig Med Dosw. 2013;27(67):507-16.
• ³²
  Suzuki H, Watanabe A, Akihiro Y, Takao M, Ikematsu T, Kimoto S. Pilot study to assess the potential of oral myofunctional therapy for improving respiration during sleep. J Prosthodont Res. 2013;57(3):195-9.
• ³³
  Felício CM, Ferreira CLP. Protocol of orofacial myofunctional evaluation with scores. Int J Pediatr Otorhinolaryngol. 2008;72(3):367-75.
• ³⁴
  Genaro KF, Berretin-Felix G, Rehder MIBC, Marchesan IQ. Avaliação Miofuncional Orofacial - protocolo MBGR. Rev. CEFAC. 2009;11(2):237-55.
• ³⁵
  Felício CM, Folha GA, Ferreira CL, Medeiros AP. Expanded protocol of orofacial myofunctional evaluation with scores: validity and reliability. Int J Pediatr Otorhinolaryngol. 2010;74(11):1230-9.
• ³⁶
  Lima MRF. Validação do Protocolo de Avaliação Miofuncional Orofacial com Escalas para Idosos e Relação com o Índice de Saúde Oral. 2012. [Dissertação] Ribeirão Preto (SP): Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, 2012.
• ³⁷
  Marchesan IQ, Berretin-Félix G, Genaro KF. MBGR protocol of orofacial myofunctional evaluation with scores. Int J Orofacial Myology. 2012;38:38-77.
• ³⁸
  Ribas MO, Reis LFG, França BHS, Lima AAS. Cirurgia ortognática: orientações legais aos ortodontistas e cirurgiões bucofaciais. Rev Dent Press Ortodon Ortopedi Facial. 2005;10(6):75-83.
• ³⁹
  Martins GA. Sobre Confiabilidade e Validade. RBGN. 2006;8(20):1-12
• ⁴⁰
  Perroca MG, Gaidzinski RR. Análise da validade de constructo do instrumento de classificação da pacientes proposto por Perroca. Rev Latino-am Enfermagem. 2004;12(1):83-91.

Publication Dates

• Publication in this collection
  Mar 2017

History

• Received
  26 Jan 2017
• Accepted
  20 Mar 2017