49from: International Journal ofOrofacial Myology, Spedal Issue"Orofacial Myology: CUrrent Trends",volume 14, #1, March, 1988.

ORTHODONTIC PERSPECTIVESON OROFACIAL MYOFUNCTIONAL THERAPY

Robert M. Mason, Ph.D., D.M.D.Professor and Chief of Orthodontics

Division of Plastic, Reconstructive, Maxillofacial and Oral SurgeryDepartment of Surgery, Duke University Medical Center, Durham, North Carolina

Uke most other specialty areas, orthodontics has a richprofessional literature containing disagreement anddebate on a number of topics. One area of controversysince the inception of orthodontics in the late 1800s isthe relationship between tongue functions and thedevelopment of malocclusions.

Many orthodontists continue to believe strongly thattongue functions cause certain types of malocclusionsand lead to altered patterns of facial development. Othersimplicate the tongue as the cause of negative tooth posi-tion changes (or "relapse") sometimes seen following thecompletion of orthodontic treatment. On the other hand,many orthodontists express no concern that tongue func-tions contribute importantly to the problems seen in theirclinical practices.

Orofacial myofunctional therapy is a treatment regimenthat developed in response to the expressed concernsof orthodontists. For the most part, orthodontic problemscreated the need for the specialty area of orofacialmyofunctional therapy (Straub, 1951). The cyclic con-troversy in orthodontics about the role of the tongue incontributing to orthodontic problems reached a peak inthe 1970s. Following the adoption of a Position State-ment on tongue thrust by the American Speech andHearing Association, (ASHA), the House of Delegatesof the American Association of Orthodontists adoptedASHA's policy statement in 1977.

It is somewhat ironic that orthodontics, which previous-ly encouraged the development of orofacial myofunc-tional therapy, adopted a position that doubted the ef-ficacy of treatment. Despite the Position Statement, manyorthodontists continued to refer patients considered tohave myofunctionally related problems. Referrals havecontinued-where the stability of treatment is ques-tionable with regard to a variety of oral functional orpostural variations of concern to the orthodontist.

The purpose of this article is to consider some selectedaspects of current orthodontic theory and practice thatrelate to tongue thrusting and to examine the need fororofacial myofunctional therapy for a myriad of orofacialand pharyngeal variations. An attempt will be made tocharacterize current thinking and offer recommendationsfor clinical research in selected areas.

A BROADER VIEW OF TONGUE THRUSTUse of the term "tongue thrust" should probably be

prefaced by an adjective. More orthodontists now realizethat the observation of a tongue thrust or a tongue thrust

, swallow pattern represents a single observation of a

behavior in an intertwined environment of anatomical andphysiological relationships. That is, a tongue thrustswallow or a lips-apart resting position, for example, mayoccur for a single reason or combination of reasons. Thechallenge for the clinician is to identify the various fac-tors that combine to produce the observation identifiedas a variation.

Tongue thrusting during swallowing may be anecessary adaptation to maintain the size of the airwayfor successful passage of food to the esophagus. A smalloral isthmus due to enlarged faucial tonsils may obligatethe tongue to move forward as the bolus of food exitsthe oral cavity during the process of swallowing. Thesquirting forward of the tongue during such an adapta-tion may best be termed an "obligatory tongue thrustswallow," or perhaps an "adaptive tongue thrustswallow." The addition of an adjective in front of tonguethrust identifies the basis for which the observation wasmade. Until recently, few clinicians strived to describethe etiology and unique properties of each tongue thrustseen.

Some tongue thrusting, during speech or swallowing,is observed in the absence of any morphologicaldelimiting factors. When tongue thrust is present in thismanner and shows no effect on the dentition or theresting posture of the tongue, there may be no indica-tions to treat the thrusting. One exception is when treat-ment for other problems is underway. In such instances,the tongue thrust should also be eliminated. Another ex-ception to this is the presence of a cosmetically unat-tractive situation resulting in concern to patient or family.In such a case, the term "cosmetic tongue thrust" ap-propriately describes this situation. Treatment of acosmetic problem is a worthy goal of therapy but is a con-cept that has been largely ignored until recently (see thearticle by Case in this issue). Many cosmetically basedproblems have been treated in the past, but justified un-necessarily by the nebulous appellation of an "orofacialmuscle imbalance," a term to be discussed later in thisarticle.

There are many other adjectives that might approp-riately be used to describe the occurrence of a tonguethrust pattern more fully in a given patient. Terms suchas "transitional," "retained" (following surgery to clearthe airway) or "neurological tongue thrust" may bestdescribe a selected case. Whatever the reason, it isrecommended that "tongue thrust" be qualified accord-ing to examination findings in areas adjacent to thetongue.

50 International Journal of Orofacial Myology

Proffit (1986) points out that "tongue thrust" issomething of a misnomer, since it implies that the tongueis thrust forward quite forcefully. In fact, laboratoryresearch by Proffit (1972) using intraoral transducers hasrevealed that tongue thrusters do not have more tongueforce against the teeth than non-thrusters who keep thetongue tip back.

There is no doubt that not all tongue thrusting, duringspeech or swallowing, demands treatment. Ampleevidence exists to show that not all tongue thrusting pa-tients develop dental malalignment (Subtelny, 1965;Proffit, 1972). One of the most persistently controver-sial areas regarding orotacial rnyofunctional therapy is therationale for treatment of tongue thrusting where thereare no occlusal problems. Many claim that orofacialmyofunctional therapy is truly a preventive service (Snow,1986). The difficulty here is in identifying those patientswho will develop a malocclusion or facial form variationif the tongue thrusting is left unchecked. Currently, noclear criteria are available to separate adequately thosepatients who may develop a malocclusion from those thatwill not as a result of tongue thrusting. The challenge tothe clinician is to be able to predict which patients trulyneed treatment according to some strict clinical criteria.Until such criteria are developed, there are no compell-ing reasons to treat all tongue thrusts just because theyare there. A reasonable stance at present is that if speechor resting posture are being treated, an accompanyingtongue thrust should also be corrected. This enhancesthe development of a more harmonious environment fordental eruption.

From a preventive standpoint, the individual who ex-hibits a tongue thrust pattern and an anterior restingposture of the tongue would be more likely to developa malocclusion than one who tongue thrusts without aforward tongue posture. Working to reposition the tongueat rest and correct the tongue thrust are worthy goalsof treatment for younger patients as a means of en-couraging normal dental developmental processes.These concepts are discussed and supported in the ar-ticle by Pierce in this issue.

The concept of prevention in orofacial myofunctionaltherapy should come into its own following research thatcompares tongue thrusters who are separated intogroups according to the type of tongue thrust, andwhether or not there is an anterior resting posture of thetongue that accompanies the tongue thrust. The addi-tion of a forward resting position of the tongue shouldcreate many morphological conditions that can potentiallylead to dental occlusal problems. The anatornical..physiological, dental and growth characteristics of suchpatients need to be catalogued, especially in comparisonwith similar patients with tongue thrust who do not havea forward resting tongue position. Such a study shouldrepresent the definitive longitudinal documentation oftongue thrusting and its interactions with the dentition.Unfortunately, this study has not yet been conducted.The approach used in the research reported by An-drianopoulos and Hanson (1987) is a bold step in thisdirection.

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TONGUE PRESSURE AND THE DENTITIONThere have been several theories proposed to explain

why teeth and jaws assume the positions they do. Manytheories have something to do with the oral form andfunction interactions. Proffit (1973, 1978, 1986) hasreviewed past and current theories and discusses themin a logical and persuasive manner.

The current view in orthodontics is that the restingposture of the tongue has a great deal more to do withthe position of the teeth and jaws than the functions ofthe tongue in swallowing and speaking. This is also theprevailing view in orofacial myofunctional therapy. Thatdoes not imply, however, that the thrusting tongue doesnot play a role in maintaining or encouraging a faultydeveloping dental eruption pattern that is primarily in-fluenced by the resting tongue.

Resting pressure of the tongue, lips and cheeks exertforces over a relatively long period of time, hours per day.The pressures against the dentition in speaking andswallowing are of short duration and light-to-moderatemagnitude (Proffit, 1986). Thus, the most probable rela-tionship of the tongue to a malocclusion such as ananterior open bite is modification of the eruptive scheduleof the anterior teeth (Steedle and Proffit, 1985). Thepresence of a forward tongue between the anterior teethat rest impedes their normal eruption. At the same time,with the mandible hinged slightly open, the posterior teethare more free to supraerupt. The result is the develop-ment of an anterior open bite in the mixed dentitionperiod, created by a differential eruption sequence of theteeth and caused by a forward resting posture of thetongue (Bateman and Mason, 1984; Proffit, 1986). Theadded presence of a tongue thrust swallow pattern mayenhance the eruption variations, or could serve to main-tain the open bite that has occurred. It is well known thata tongue thrust swallow pattern is an expected accom-paniment of some open bite conditions (Hanson andCohen, 1973; Mason and Proffit, 1974). In addition,mastication irregularities may be noted.

EQUILIBRIUM THEORYFor the dentition to be maintained in a stable position,

either naturally or following orthodontic treatment, it isreasonable to assume that some sort of equilibrium wouldbe involved to facilitate stability of the dental arch.Historically, most orthodontists have assumed that thefactors contributing to an equilibrium were muscular. Thefocus of interest has been pressures exerted against theteeth in the horizontal dimension. On one side are themuscles of the tongue. On the other, the muscles offacial expression and mastication were presumed to"balance" with the tongue where there is a normal oc-clusion. In the presence of a tongue thrust or a maloc-clusion, many clinicians have contended that an "im-balance" of muscles is involved. This is a rather simplisticand incomplete perspective that has yielded fragmentaryinformation (see also the first article by Hanson).

The current view of those factors that may influencean equilibrium on the dentition are discussed and sum-marized by Proffit (1978, 1986). Table 1 (p. 51) in-dicates why the current focus of research interest in

MASON. Orthodontic Perspectives On Orofacial Myofunctional Therapy

developing an equilibrium equation is on the long-actingforces against the dentition. Furthermore, forces appliedvertically against the teeth seem to have more influencein contributing to tooth position than horizontal forces.More research is obviously needed to elucidate fully thefactors comprising an equilibrium and the scientific con-tributions of each.

TABLE 1Possible Equilibrium Influences:

Magnitude and Duration of Force Againstthe Teeth During Functlon* +

ForcePossible EquiMbrium Influence Magnitude DurationToothcontacts

MasticationSwallowing

VeryheavyUght

VeryshortVeryshort

Soft tissuepressureof lip,cheek,andtongue

SwallowingSpeakingResting

Moderate ShortLight VeryshortVery light Long

Moderate VariableModerate Variable

Light LongVariable Long

ExternalpressuresHabitsOrfhodontics

IntrinsicpressuresPeriodontalfibersGingivalfibers

* The longactingforcesarethecurrentfocusof researchas beingthe mostimportantcontributorsto anequilibrium.

+ Reprintedwith permissionfromProffit,1986.

Until the many factors contributing to a dentalequilibrium can be properly identified and catalogued, itseems inappropriate to describe clinical variations in thedentition as resulting from an orofacial muscle imbalance.In the search for an equilibrium, no balance of opposingmuscles has been clearly documented in normal in-dividuals. Accordingly, it does not seem prudent togenerate a therapeutic goal of balancing muscles whereno normal "balance" can be demonstrated. How woulda clinician prove that muscle balance has been achiev-ed? If the dentition is repositioned into a normal relation-ship and remains stable, the description of such eventsshould focus on tooth position. Unfortunately, no balanceof muscles can be presumed by observing a normal den-tition. This should not detract, however, from thedesirable clinical goal for the orofacial muscles to func-tion normally with the developing dental arches.

At present, the term "orofacial muscle imbalance" hasno place on an orthodontic problem list and should beavoided in clinical use (see also Hanson's first article inthis issue). Avoiding the use of misleading terminology

51

. does not imply a change in the clinical activities of thepractitioner. In no way is the value of orofacial myofunc-tional therapy impugned by avoiding descriptive termsthat have no measurable value. In fact, treatment objec-tives should be enhanced by more accurate clinicaldescriptions.

Although the term "tongue thrust swallow" may be amisnomer to some in the sense of muscular force, it doesimply a directional variation of tongue activity in swallow-ing. As such, it seems descriptive of a behavior withoutnecessarily implying an abnormal event in all who exhibitthe behavior.

There are several other terms to describe a tonguethrust swallow that inaccurately imply that an abnormalityis present. Terms such as "deviate swallow," "deviantswallow," "perverted swallow" and "infantile swallow"should be avoided due to the inaccurate and faulty im-plications inherent in their use. As Proffit points out(1986), only brain-damaged children retain a truly infan-tile swallow in which the posterior part of the tongue haslittle or no role. If food does not enter the trachea andpasses without incident into the esophagus during aswallow, the swallow can be considered normal from aphysiological standpoint. There is nothing perverted ordeviate about a physiologically normal swallow!

The implication that teeth are pushed out of normal oc-clusion into a new position of malocclusion by a tonguethrust swallow is an association that need not be madein modern clinical activity. In fact, current data (Proffit,1986) indicate that a tongue thrust swallow does notpush teeth out of alignment. In instances in which thetongue thrust contributes to or maintains a dental erup-tive or positional problem, it is currently impossible todemonstrate with instrumentation that the tongue thrustcaused the problem.

The modern view of orofacial myofunctional therapy isthat its goal is not to alter tooth position. That toothchanges occur on a routine basis in some practices isa positive event. In no way does it restrict the practiceof orofacial myofunctional therapy to de-emphasize thepossible causal relationship between a tongue thrustswallow and tooth position. By working on the tonguethrust or rest posture of tongue and lips, the oral environ-ment becomes more normal. It should follow that morenormal patterns of dental development and facial formare possible in an environment in which postures andfunctions are normal. Eliminating a tongue thrust, withconcurrent positive changes in the dental developmentor alignment, need not imply that the tongue caused theproblems seen prior to treatment, nor that elimination ofthe tongue thrust is for purposes of dental change. Theorofacial myologist's results in providing a more har-monious or normal oral environment can speak forthemselves, without the orofacial myologist being accus-ed of practicing dentistry without a license.

The main point is: There are many reasons to justifyorofacial myofunctional therapy besides a presumeddeleterious effect of a tongue thrust swallow on the den-tition. A focus on the broader concepts of posturing oflips and tongue, or normalizing the swallow pattern fora variety of associated developmental processes of the

52 International Journal of Orofacial Myology

dentition (especially vertical eruption sequencing), is amodern view of orofacial myofunctional therapy thatshould be received with enthusiasm among the orthodon-tic community. Such a view is compatible with currentorthodontic theory about the factors contributing to adental equilibrium, which can be modified by muscle ex-ercise and reposturing of muscles in repose (see alsothe first article in this issue by Hanson).

LIP AND TONGUE POSTURESThe modern orofacial myologist realizes that there is

a significant difference between tongue function andtongue and lip posturing. In the past, probably too muchemphasis was placed on therapy for a tongue thrustswallow, often at the expense of variations in tongue andlip postures. Currently, posturing is a major focus oforofacial myofunctional therapy. This in no way detractsfrom the value of treatment for a tongue thrust swallowin selected cases.

The posture of the tongue, especially forward resting,has been linked etiologically to the development of anopen bite malocclusion in the mixed dentition phase(Proffit, 1986). This event is especially encouragingwhen the lateral surfaces of the tongue are not restingover the occlusal portions of the lower posterior teeth.The posterior teeth supraerupt as the anterior teeth areimpeded in eruption.

Tongue posture can also explain, in part, the develop-ment of a Class II malocclusion in some patients. If a for-ward tongue position is characterized by overlap of thetongue with the occlusal surfaces of all lower teeth, asituation could result in which the upper teeth are morefree to erupt, whereas the lower teeth (including theposteriors) are impeded from erupting. Since teeth tendto erupt not only vertically but also in a mesial (forward)direction, the effect of a slight open mouth posture, withtongue forward and lateral margins spread over theposterior lower teeth, is the eventual creation of a ClassII malocclusion. This is related to the added, unimpededstimulation of the upper teeth to supraerupt in adownward and forward direction (Bateman and Mason,1984). Hence, a variation in resting tongue posture cancreate dental eruptive changes in the vertical plane ofspace that results in a disparity of tooth and jaw positionin the horizontal plane (Lowe et al, 1985). This has beendemonstrated in obstructive sleep apnea patients byLowe et al (1 987). A theoretical explanation of tootheruption control has been proposed by Steedle and Prof-fit (1985).

The orofacial myologist deserves a great deal of creditfor the increased focus in the past few years on treat-ment of lip posture variations. Lip incompetence, or theinability of the lips to rest comfortably together withoutsome muscle strain, is a common finding in children andin some adults who have dentofacial problems. Inchildren, lip incompetence is most often related to thefact that the lips have not fully matured in their verticalgrowth (Vig and Cohen, 1979). Lip growth continues un-til around age 17 years. As vertical lip growth progresses,the separation between the lips decreases (Vig andCohen, 1979).

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Ingervall and Eliasson (1982) demonstrated in anelectro-myographic study of the lips that orofacialmyofunctional therapy for lip incompetence has a positiveeffect on lip morphology. That is, upper and lower liplength are increased and the interlabial gap is reduced.In the control group, who had lip incompetence butreceived no therapy, the interlabial gap increased overthe period of a year. The lip training provided for the ex-perimental group did not affect tooth position over theone-year study period. These data are compatible witha separate study reported in 1975 by Barber and Bonus.Both studies show, using accepted standards ofevidence and control groups, that lip seal and lip mor-phology can be modified by orofacial myofunctionaltherapy.

There is a vast untapped clinical population that couldbenefit from therapy to reduce lip incompetence. Thesurgical population that undergoes maxillary impactionsurgery for vertical maxillary excess is an example. Manyof these patients had lip incompetence before surgeryand retain flaccid, incompetent lips after surgery. Lipexercises were found to be effective in the adaptationprocess following surgery in a pilot study reported byGrandstaff and Mason (1983). Orofacial myofunctionaltherapy for increasing the muscle tone of the lips hasbeen demonstrated to result in increases in lip length.

Thuer and Ingervall (1986) studied lip strength andresting lip pressures on the teeth in 84 children. Theirfindings suggest that the pressure from the lips on theteeth is a result of incisor position; that is, lip pressuresseem to adapt to facial morphology. There was no cor-relation found between lip strength and lip pressure. Arecent study by Hellsing and L'Estrange (1987) providesnew perspectives about lip pressure, head posture andthe mode of breathing.

The effects of orofacial myofunctional procedures onlip posture, lip tonicity, the relative amount of eversionof the lips and whatever contributions might exist regar-ding tooth position remain inadequately explored at pre-sent. This is an especially rich area for research in un-folding the natural history of influences on the dentitionby musclesat rest and in function.

ORTHODONTIC RELAPSEThe term "relapse" as applied to post-orthodontic

active treatment has taken on a very bad name. Muchof the fault with the negative connotation associated with"relapse" lies with the orthodontic community, which,until recently, has not demonstrated a good understand-ing of those factors that lead to relapse. Too often, or-thodontists have blamed the tongue when changes in thedentition following orthodontic treatment have occurredthat are not understood. The tongue has served as thescapegoat when other plausible reasons for relapse arenot recognized.

The possible relationships between orthodontic relapseand the tongue have gotten out of hand. To some or-thodontists and orofacial myologists, a word-associationtest using the stimulus word "relapse" would quickly elicitthe response "tongue." Such a restricted view of relapseshould be changed. An exception to this restricted view

MASON, Orthodontic Perspectives On Oro/acial Myo/unctional Therapy

is a careful and significant study of the relationship bet-ween tongue thrust and orthodontic relapse (An-drianopoulos and Hanson, 1987) which is summarizedin detail by Hanson in this issue.

The key to understanding the various factors that con-tribute to orthodontic relapse is appreciation of the con-cept of retention. Retention is a phase of orthodontictreatment that begins when the active orthodontic ap-pliances are removed. As Proffit (1986) points out: "Or-thodontic control of tooth position and occlusal relation-ships must be withdrawn gradually, not abruptly, if ex-cellent long-term results are to be obtained. The type ofretention should be included in the original treatmentplan" (p. 455). The point is that orthodontists should notconsider treatment to be over when the active appliancesare removed; retention is a continuation of treatment.

There are three basic reasons why all orthodontic treat-ment should be followed by some sort of retention: (1)Time is required for reorganization of the gingival andperiodontal tissues that were moved during active ortho-dontic treatment; (2) Additional growth following ortho-dontics may significantly alter teeth and jaw positions;and (3) The teeth may be relocated by orthodontics inan unstable position so that the soft tissue pressures con-stantly encourage a relapse tendency (Proffit, 1986).

Most orthodontic patients receive retention for the firsttwo reasons. If late growth occurs, for example, orofacialmyofunctional therapy may be doomed to failure as ameans of responding to vertical and horizontal changesin the jaws and teeth.

It is unfortunate that too many patients have been refer-red for orofacial myofunctional therapy because the or-thodontist thought reason (3) was involved withoutrecognizing reason (1) and (2). Often, the type of reten-tion (or lack of) has created a problem that the orofacialmyologists should not be asked to resolve. Somehow,orofacial myologists need to learn to say "no" forselected patients sent inappropriately for treatment. Bythe same token, some orthodontists need to learn toidentify more accurately the problems associated withorthodontic relapse.

The third reason for relapse, or need for retentionmerits participation of the orofacial myologist. Therapydirected toward normalizing lip and tongue postures maybe a very important part of the retention process for somepatients. The alternatives are the acceptance of relapse,or some sort of permanent retention.

The period of retention does, of necessity, differaccording to the orthodontic problem and soft tissuesituation. An example is the condition of a Class II Divi-sion I malocclusion characterized by mc;tXillarydental pro-trusion. Assuming that teeth were extracted to facilitateretracting the upper anterior teeth, retention of this situa-tion depends in large part on the resting relationship oflips and upper incisors. If the dentition is set up orthodon-tically so that, at rest, there is lip closure and the lowerlip rests against at least 2 mm of the facial surface of theupper incisors, relapse forward of the upper teeth willnot occur. This would be expected to be true whetheror not that patient had a retained tongue thrust. Theresting relationship of lower lip with upper incisors is an

53

application of growth data presented by Vig and Cohen(1979).

If orthodontic work has been completed in a Class IIDivision 1 patient and there is lip incompetence, it followslogically that some sort of orthodontic retention wouldbe required until such time that lip competence can beproduced, either with growth or through orofacialmyofunctional treatment.

The typical completed orthodontic patient is about 13years of age. Vig and Cohen's (1979) data on lip growthshow that lip separation is still evident in many childrenat this stage of development. Some separation, or lip in-competence, may continue until age 17 years or so. Itfollows from this that the completed orthodontic case thatdoes not demonstrate a lips-together resting posture andwho had some orthodontic retraction of anterior teeth isat risk for relapse by forward movement of the upper in-cisors unless a long period of retention is involved. Theonly reasonable alternative to extended retainer wear ona full-time basis is orofacial myofunctional therapy to pro-duce lip competence. The studies by Ingervall andEliasson (1982) and Barber and Bonus (1975) shouldencourage the use of orofacial myofunctional therapy forsuch patients.

Generally, most orthodontists need to be challengedto recognize potential sources of relapse and build inadjustments for possible relapse into their treatmentplans. Overcorrection of tooth position in selected casesis a time-honored method of anticipating and dealing withrelapse. Recognition of the relapse tendency with rotatedteeth corrected without sulcus slice (supracrestal cir-cumferential incision of gingival tissues around the tooth);expansion of canines during treatment; or unfavorablegrowth are but a few examples of typical causes ofrelapse (see chapters 17 and 18 in Proffit, 1986).

The nondentist orofacial myologist should not beresponsible for determining the causes of relapse. In fact,orofacial myologists should resist the temptation toassume why relapse is occurring. Without adequateradiographic records, dental casts and knowledge ofbiomechanics and the step-by-step treatment history ofthe case, the orofacial myologist is in no position to con-clude "I told you so" when relapse occurs withoutorofacial myofunctional intervention.

Few orthodontists would appreciate having anondentist conclude that a patient relapsed because ofunrecognized tongue problems. Even though this maybe the true cause of orthodontic relapse in many cases,there are more relapse patients incorrectly linked by or-thodontists and orofacial myologists to tongue thrust. Themain point is that the reasons for relapse are many, andthe identification of factors that can produce relapsebegins in the initial treatment planning process and in-volves evaluation of patient and records along the way.

ASPIRA TIONS FOR THE FUTUREThere is a great need in orthodontics and orofacial

myofunctional therapy to depolarize thinking in a numberof areas. More frequent and meaningful communicationsand interactions are indicated between orthodontists andorofacial myologists. Many basic questions need to be

54 International Journal of Orofacial Myology

resolved regarding muscle pressures at rest and duringfunction and the stability of tooth position.

Orthodontic training programs could be the focus ofsignificant research into myofunctionally related problemsand questions. A rich supply of graduate thesis materialsin orthodontics is available for mutual collaboration andclinical research. To date, most university training pro-grams in orthodontics have minimal experience withorofacial myofunctional problems and information. It isfrom such environments that the skeptics of orofacialmyofunctional therapy are largely derived. This situationdoes not lead to a full understanding of the value or limita-tions of orofacial myofunctional treatments nor the indica-tions to treat or not treaf.

Orthodontic training programs compile excellentrecords on each patient. For those patients who exhibita dental relapse tendency that is thought to be associatedwith soft tissue problems, why not turn the patient overto a certified orofacial myologist for six months? Why nothave an orofacial myologist on staff on a part-time basisto conduct clinical research? The careful selection ofqualified and IAOM certified individuals would be key tothe success of such endeavors (Barrett, 1986).Graduate student participation in the resolution of relapseusing other than fixed or removable retainers should beencouraged.

What about the orthognathic surgery patient who hadlip incompetence before surgery and retains lip in-competence after maxillary impaction or some othersurgical procedure? What contraindications are there fororofacial myofunctional therapy to develop increased liptonicity and lip competence? If the patient is desirous ofachieving lip competency as a motivation for agreeingto have orthognathic surgery, and lip competence is notproduced by surgery and does not occur spontaneous-ly after scar release about six months postoperatively,it would seem incumbent on the clinician to try anyreasonable way to achieve the desired therapeutic result.

Another area where communication between orthodon-tists and orofacial myologists can be improved is thecareful consideration of terminology used to describeclinical observations. It seems obvious that many ortho-dontists have been unimpressed by orofacial myologybecause of what is said, in the absence of actually obser-ving what can be accomplished clinically. Both groupsshould share a responsibility in this regard, since manyof the catchwords that are falling into disuse and carryemotional connotations were originally coined by or-thodontists. Clarification of vocabulary and thoroughnessof examination reporting should help alleviate some ofthe polarization that has occurred between some or-thodontists and orofacial myologists. Hanson's commentsand suggestions in the first article in this issue areespecially relevant to this situation.

Orthodontic training programs should also be chal-lenged and encouraged to direct research attention tostudying the morphology of patients with recognizedtongue and lip functional and postural variations, and thedegree to which therapeutic intervention with muscle andpostural retraining can contribute to stability of the oral-facial-pharyngeal areas.

Volume 14Number 1

The orofacial myologist needs to keep excellentrecords and strive to select patients and treatment modeson an individual basis. Improved communication withorthodontic referral sources and increased knowledgeof the details of treatment and the overall orthodontic planshould enhance treatment progress. It is also imperativethat the orofacial myologist participate in continuingeducation, as encouraged in the articles by Hanson andZimmerman. Learning to say "no" to inappropriate pa-tient referrals can follow from broadened clinical perspec-tives achieved in continuing education. On the otherhand, occasional "experts" are produced after taking oneor two short courses in orofacial myology. Orthodontistsneed to determine the qualifications, experience level andcertification status of potential referral sources (Barrett,1986).

Orofacial myofunctional therapy should not be ad-vocated out of fear that something terrible is going to hap-pen if no treatment is rendered. The cycle of reinforce-ment for this impression that all tongue thrusting needsto be treated comes, perhaps, from the observation ofrelapse in some patients. As already mentioned, thenonorthodontist should resist the temptation to getcaught up in this cycle of thinking. A positive step awayfrom the assumption that preventive treatment is alwaysworthwhile would be clinical research that clearly iden-tifies those patients at risk and in definite need of treat-ment. At present, diagnostic criteria for therapy selec-tion are, at best, sketchy. In the meantime, the indica-tions for treatment of the younger child, as presentedby Pierce in this issue, are recommended as logical andpersuasive.

The heightened recent interest by orthodontists aboutairway interference problems should motivate increasedinter-disciplinary cooperation in diagnosis and treatmentplanning (Berkinshaw et ai, 1987). Dr. Riski's emphasison documenting the breathing capabilities of suspectedairway interference patients was well stated in this issue.There is certainly a place for the orofacial myologists onthe team of individuals evaluating and treating patientswith airway interference characteristics. Teaching the pa-tient to manage nasal hygiene more effectively, treatingthe lip and tongue posture variations in the so-called"mouth breather" and attempting a variety of nonsurgicalmodifications of breathing patterning is an appropriatearea for the orofacial myologist.

Orthodontists, orofacial myologists and speechpathologists share a common interest in cosmesis thathas not been exploited extensively in the mutual treat-ment of patients. Many patients seek care for a varietyof problems with their teeth, jaws or speech out of acosmetically related concern. Both Case and Zimmer-man provide information and supporting data for a varietyof these considerations in this journal.

Although it is natural for dental examiners to focus onthe functional relationships of teeth and jaws, thecosmetic component looms very important to many pa-tients and should be addressed. Correction of the distrac-ting lips, or achieving lip competence, a more posteriorresting tongue posture or a more alert or pleasing ap-pearance are goals that any clinician would welcome for

MASON, Orthodontic Perspectives On Oro/acial Myo/unctional Therapy

their patients. The adaptation of patient to morphologyis a process that involves coordination of specialties,depending on expertise. Orofacial myofunctional andspeech treatments for such problems are appropriate in-clusions in an overall treatment plan for an orthodonticpatient.

One of the special skills that an effective orofacialmyologist must have is the ability to motivate patients.Motivation is a necessary inclusion in orofacial myofunc- .tional therapies, since many exercises are repetitive andare practiced in the home. The materials in the articleby Zimmerman should expand the horizons of the or-thodontist to the motivational principles and proceduressome orofacial myologists and speech pathologistsemploy with mutual patients. Some of the "compliance"problems in orthodontics, which basically represent pa-tient motivation problems, can be solved effectively if a

55

team approach is utilized. A willingness to combine ap-propriate speech and orofacial myofunctional and or-thodontic treatments and to communicate about mutualmotivational problems with such patients is needed.

SUMMARYThe Challenges presented in this article, for the ortho-

dontist who has largely ignored orofacial myofunctionaltherapy and for the orofacial myologist who may havebeen more enthusiastic about claims than evidencedeserves, are intended to encourage understanding andimprove communication between professionals. Effortsto consider orofacial myofunctional variations in a broaderperspective should result in added recognition oforofacial myofunctional therapy, while also improving pa-tient care.

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