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Orofacial myofunctional therapy program for individuals undergoing orthognathic surgery/Programa de terapia miofuncional orofacial para individuos submetidos a cirurgia ortognatica.

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.

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.

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:

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

* include care on the storage of saline solution;

* provide details on the objectives of proposed activities;

* 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:

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

* rule out mobility of the upper facial third;

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

* elucidate the suggested movement for tongue mobility;

* 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.

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, which should yet to be validated in future studies.

doi: 10.1590/1982-021620171921317

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[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 intervencao breve em respiradores orais. Rev. CEFAC. 2012; 14(6):1153-66.

[31.] Kijak E, Lietz-Kijak D, Sliwinski Z, Frqczak 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.] Felicio CM, Ferreira CLP. Protocol of orofacial myofunctional evaluation with scores. Int J Pediatr Otorhinolaryngol. 2008; 72(3):367-75.

[34.] Genaro KF, Berretin-Felix, Rehder MIBC, Marchesan IQ. Avaliacao Miofuncional Orofacial protocolo MBGR. Rev. CEFAC. 2009; 11(2):237-55.

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[36.] Lima MRF. Validacao do Protocolo de Avaliacao Miofuncional Orofacial com Escalas para Idosos e Relacao com o Indice de Saude Oral. 2012. [Dissertacao] Ribeirao Preto (SP): Faculdade de Medicina de Ribeirao Preto, Universidade de Sao Paulo, 2012.

[37.] Marchesan IQ, Berretin-Felix G, Genaro KF. MBGR protocol of orofacial myofunctional evaluation with scores. Int J Orofacial Myology. 2012; 38:38-77.

[38.] Ribas MO, Reis LFG, Franca BHS, Lima AAS. Cirurgia ortognatica: orientacoes legais aos ortodontistas e cirurgioes bucofaciais. Rev Dent Press Ortodon Ortopedi Facial. 2005; 10(6):75-83.

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Renata Resina Migliorucci (1)

Dannyelle Christinny Bezerra de Oliveira Freitas Passos (1)

Giedre Berretin-Felix (2)

(1) Faculdade de Odontologia de Bauru, Universidade de Sao Paulo--USP Bauru (SP), Brasil

(2) Departamento de Fonoaudiologia da Faculdade de Odontologia de Bauru, Universidade de Sao Paulo--USP Bauru (SP), Brasil.

Conflict of interest: non-existent

Received on: January 26, 2017

Accepted on: March 20, 2017

Mailing address:

Renata Resina Migliorucci Instituto HNARY

Al Doutor Octavio Pinheiro Brisolla, 12067 Vila Nova Cidade Universitaria--Bauru, SP CEP: 17012-191

E-mail: renataresina@gmail.com

Caption: Figure 2. Summary of search performed
Figure 1. Results of search performed in databases on orofacial
myofunctional therapy for individuals undergoing orthognathic surgery

ENTRY KEYWORDS                             DATABASES / SEARCH ENGINE

                                           Science   Pubmed   Scielo
                                           Direct

Deformidade dentofacial Dentofacial         1,882     644       23
deformities

Cirurgia Ortognatica Orthognathic           5,263    1,269      58
Surgery

Ma oclusao severa Severe malocclusion       3,281     624       10

Tratamento ortodontico-cirurgico            5,686      59       24
Orthodontic-surgicaJ treatment

Terapia miofuncional Myofunctional            2       160       19
therapy

Fonoterapia Speech therapy                 23,995    6,093     113

Reabilitacao Miofuncional Myofunctional       1       146       0
rehabilitation

ENTRY KEYWORDS                             DATABASES /         Total
                                           SEARCH ENGINE

                                           Google    Bireme
                                           Scholar

Deformidade dentofacial Dentofacial         5,170      30      7,749
deformities

Cirurgia Ortognatica Orthognathic           9,750     210     16,550
Surgery

Ma oclusao severa Severe malocclusion      10,900      48     14,863

Tratamento ortodontico-cirurgico           195,000     39     200,808
Orthodontic-surgicaJ treatment

Terapia miofuncional Myofunctional         21,500     288     21,969
therapy

Fonoterapia Speech therapy                 23,700    1,579    55,480

Reabilitacao Miofuncional Myofunctional     3,610      56      3,813
rehabilitation

Figure 3. Orofacial myofunctional therapy program after
orthognathic surgery

OVERALL INSTRUCTIONS

Therapy program initiated 30 days after surgery with duration of
three months, comprising one session per week.

FIRST WEEK

* Application of Clinical History and Orofacial Myofunctional
Assessment Protocols.

* Record keeping (photographs and video recordings).

* Explanation on the orofacial myofunctional
adaptations/dysfunctions presented by the patient before and after
orthognathic surgery.

* Explanation about the therapeutic process.

SECOND WEEK

* Promotion of awareness and perception on harmful oral habits with
indication of strategies to eliminate them, including mobile alarm
and records that may be promptly seen by the patient (working desk,
computer, car, restroom, headboard, fridge, close to the TV and
others).

* Promotion of awareness on alterations in tone, mobility,
sensitivity and orofacial functions presented by the patient. For
that purpose, show photographs and video recordings of the patient,
as well as static and dynamic images illustrating the normality of
anatomical and physiological aspects of the stomatognathic system.
Ask the patient to identify differences between his or her records
and the normal standards. Explain the causes of
alterations/adaptations found and the need to restore the orofacial
functions.

* Perception on the respiratory type and mode presented by the
patient presented by the patient.

* Respiratory training (type and/or mode).

* Stimulation of sensitivity.

* Mobility exercises.

* Counseling on home accomplishment of strategies for:

--stimulation of sensitivity;

--respiratory training;

--training of habitual positioning of mandible, lips and tongue at
rest;

--mobility exercises.

THIRD WEEK

* Perception of change in the frequency and duration of harmful
oral habits.

* Perception of change in respiratory function.

* Respiratory training (type and/or mode).

* Perception of habitual positioning of mandible, lips and tongue
at rest.

* Training of habitual positioning of mandible, lips and tongue at
rest.

* Mobility exercises.

* Tone exercises.

* Perception of masticatory pattern performed by the patient and
awareness on the new pattern to be achieved.

* Training of simultaneous bilateral mastication.

* Counseling on home accomplishment of strategies for:

--stimulation of sensitivity;

--respiratory and mastication training;

--training of habitual positioning of mandible, lips and tongue at
rest;

--mobility and tone exercises.

FOURTH WEEK

* Perception of change in the frequency and duration of harmful
oral habits.

* Perception of change in respiratory and masticatory functions.

* Respiratory training (type and/or mode).

* Training of habitual positioning of mandible, lips and tongue at
rest.

* Mobility exercises.

* Tone exercises.

* Training of simultaneous bilateral mastication.

* Perception of masticatory pattern performed by the patient and
awareness on the new pattern to be achieved.

* Training of function of the mandible, lips and tongue during
swallowing of solid foods.

* Counseling on home accomplishment of strategies for:

--stimulation of sensitivity;

--respiratory, mastication and swallowing training;

--training of habitual positioning of mandible, lips and tongue at
rest;

--mobility and tone exercises.

FIFTH WEEK

* Perception of change in the frequency and duration of harmful
oral habits.

* Perception of change in respiratory, masticatory and swallowing
functions.

* Respiratory training (type and/or mode).

* Training of habitual positioning of mandible, lips and tongue at
rest.

* Mobility exercises.

* Tone exercises.

* Training of simultaneous/alternate bilateral mastication
(dependent on dento-occlusal condition, temporomandibular joints
and mandibular movements).

* Training of function of the mandible, lips and tongue during
swallowing of solid and liquid foods.

* Counseling on home accomplishment of strategies for:

--stimulation of sensitivity;

--respiratory, mastication and swallowing training;

--training of habitual positioning of mandible, lips and tongue at
rest;

--mobility and tone exercises.

SIXTH / SEVENTH / EIGHTH WEEKS

* Perception of change in the frequency and duration of harmful
oral habits.

* Perception of change in respiratory, masticatory and swallowing
functions.

* Mobility exercises.

* Tone exercises.

* Training of simultaneous/alternate bilateral mastication.

* Training of function of the mandible, lips and tongue during
swallowing of solid and liquid foods and saliva.

* Perception on the speech pattern performed by the patient and
promotion of awareness on the correct pattern.

* Speech training (phonetic).

* Counseling on home accomplishment of strategies for:

--stimulation of sensitivity;

--tone exercises;

--monitoring of respiratory, masticatory and swallowing functions;

--speech training (phonetic).

NINTH / TENTH / ELEVENTH WEEKS

* Perception of change in the frequency and duration of harmful
oral habits, sensitivity and orofacial functions.

* Training of simultaneous/alternate bilateral mastication.

* Training of swallowing of liquid and solid foods.

* Speech training (phonetic).

* Counseling on monitoring of orofacial functions.

* Counseling for the accomplishment of strategies for stimulation
of sensitivity at home, if necessary.

TWELFTH WEEK

Reapplication of protocols for assessment and recording
(photographs and video recordings).

Patient's perception on his or her improvement.

Counseling and definition of approach.

Note: During application of the Therapy Program, the clinician
should be attentive to signs and symptoms of temporomandibular
dysfunction and consider these aspects in the therapeutic planning.

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

SENSITIVITY

Objective/Reason        Strategies/             Frequency and
                        Accomplishment          Duration of Exercises

Stimulate the           Mouth rinsing with      Perform 3 sequences
orofacial               tepid water, followed   of application of
sensitivity,            by cool water.          opposite and
directing the process                           alternate stimuli,
of functional           Apply tepid water on    with 5-second
reorganization by       facial regions with     duration each and
sensitive afferent      altered sensitivity,    15-second interval
information.            followed by cool        between series.
                        water.

                        Stimulate the face
                        with cotton, followed
                        by rough sponge, on
                        altered regions.

MOBILITY

Objective/Reason        Strategies/             Frequency and
                        Accomplishment          Duration of Exercises

                        Lips:

Increase the mobility   --ask for alternate
of mimic and facial     movements of
expression muscles      protraction of closed
and tongue, allowing    lips and retraction
coordinate and          of open lips;
accurate muscle
recruitment for         --ask for clicking
adequate performance    movements with the
of orofacial            lips protracted
functions.              (smack).

                        Tongue:

                        --ask for               Perform 3 series of
                        anteroposterior         10 to 15 movements,
                        tongue movements on     at a rhythm of one
                        the palate;             movement per second,
                                                with 10--to 15-
                        --ask for tongue        second interval
                        lateral movements       between series.
                        inside the oral
                        cavity, alternately
                        touching the right
                        and left buccal
                        mucosa, keeping the
                        lips occluded and the
                        mandible lowered with
                        stability;

                        --ask for
                        lateralization of a
                        dietary candy in the
                        oral cavity,
                        alternately
                        transferring it from
                        the right to the left
                        buccal region.

                        Mandible:               Note: in the presence
                                                of asymmetry between
                        --ask for mouth         movements performed
                        opening and closure     on the right and
                        movements keeping the   left, ask for
                        tongue tip on the       maintenance of
                        incisive papilla as a   movement to the side
                        guide;                  with greater
                                                difficulty during 5
                        --ask for mouth         to 10 seconds at
                        opening and closure     completion of each
                        movements keeping the   series.
                        tongue tip on the
                        incisive papilla as a
                        guide, keeping the
                        mouth open for 10 to
                        30 seconds at
                        completion of each
                        series of movements;

                        --ask for alternate
                        lateral mandibular
                        movements to the
                        right and left,
                        keeping a tongue
                        depressor between the
                        tooth occlusal
                        surfaces as a guide.

                        ** It should be
                        emphasized that the
                        patient should
                        perform this exercise
                        looking at the
                        mirror, monitoring
                        the mouth opening and
                        closure movements,
                        which should occur
                        without deviations or
                        deflection.

Note:                   For exercises targeted to the suprahyoid
                        muscles, the surgical movement performed
                        should be considered. Mandibular protrusive
                        movements are indicated in cases of
                        mandibular advancement. Cases of mandibular
                        setback should perform exercises recruiting
                        the mandibular retrusion muscles.

TONE

Objective/Reason        Strategies/             Frequency and
                        Accomplishment          Duration of Exercises

Increase the tone of    Lips:
lips, tongue and
cheeks, allowing        --upper: apply          Perform 3 series of 5
muscle strength and     resistance with a       to 30 seconds of
force for adequate      tongue depressor        sustained
performance of          against the buccal      contraction, with 5-
orofacial functions.    vestibule in three      -to 30-second
                        positions: central      interval between
                        and right and left      series.
                        laterals;

                        --lower: apply
                        resistance with a
                        tongue depressor
                        against the buccal
                        vestibule in three
                        positions: central
                        and right and left
                        laterals.

                        Tongue:

                        --apply resistance      Note: in the presence
                        with a tongue           of tone asymmetry,
                        depressor against the   ask for maintenance
                        upper and lateral       of muscle contraction
                        tongue regions;         for twice the time on
                                                the weakest side.
                        --ask for tongue
                        sharpening inside the
                        oral cavity;

                        --ask for tongue
                        backward movement
                        inside the oral
                        cavity.

                        * After full
                        maxillary bone repair

                        ** After full
                        mandibular bone
                        repair

                        Cheeks: apply
                        resistance with a
                        tongue depressor
                        against the buccal
                        region on 3 bundles
                        of the buccinator
                        muscle.

Reduce the mentalis     Perform slow and deep   Perform 3 series of
tone, allowing          massage in the          10 to 30 seconds with
deactivation of         direction of fibers     10--to 30-second
muscle recruitment      of the mentalis         interval between
during functions        muscle.                 series.

LIP MORPHOLOGY

Objective/Reason        Strategies/             Frequency and
                        Accomplishment          Duration of Exercises

                        Upper lip:

Elongate the upper      --perform massage       Perform 3 series of
lip and eliminate       using two fingers to    10 massages with 10-
eversion of the lower   elongate the philtrum   second interval
lip, aiming to          and upper orbicularis   between series.
promote adequate lip    oris, initiating from
closure during          the nose base           Perform 3 series of
orofacial functions     downwards. Position     10 to 30 seconds with
                        one finger in the       10--to 30-second
                        buccal vestibule and    interval between
                        the other in the same   series.
                        direction, yet
                        externally.

                        --keep a 5-mm thick
                        rubber tube on the
                        upper vestibule,
                        elongating the upper
                        lip*. If necessary
                        and-or indicated, a
                        9-mm rubber tube may
                        be used. In the
                        presence of
                        contraction of the
                        mentalis muscle,
                        apply massage to the
                        mentalis during the
                        exercise.

                        Lower lip *:

                        --ask the patient to    Perform 3 series of
                        gently bite the lower   10 to 30 seconds with
                        lip with the            10--to 30-second
                        maxillary teeth, when   interval between
                        the patient should      series.
                        hold and maintain the
                        lower lip.

                        * These exercises
                        should be monitored
                        to avoid compensatory
                        mandibular movements.

HABITUAL POSITIONING OF MANDIBLE, LIPS AND TONGUE

Objective/Reason        Strategies/             Frequency and
                        Accomplishment          Duration of Exercises

Adjust the habitual     Ask the patient,        Place records that
positioning of the      during specific         may be promptly seen
mandible, lips and      activities, to          by the patient
tongue, allowing        maintain:               (working desk,
maintenance of nasal                            computer, car,
respiration and         --the mandible          restroom, headboard,
adequate tone           raised, yet without     fridge, close to the
achieved by orofacial   tooth contact,          TV and others).
myofunctional           keeping the free
exercises.              functional space;

                        --the lips in contact
                        or slightly apart;

                        --the tongue behind
                        the maxillary or
                        mandibular teeth,
                        with the tongue tip
                        touching the alveolar
                        region.

                        * The facial typology
                        and dento-occlusal
                        conditions should be
                        considered, even
                        after orthognathic
                        surgery.

RESPIRATION

Objective/Reason        Strategies/             Frequency and
                        Accomplishment          Duration of Exercises

                        Clean the nostrils
                        with saline *:

                        --apply saline
                        solution at room
                        temperature in the
                        nostrils, slowly
                        aspirating;
                        following, blow the
                        nose gently, one
                        nostril at a time.

Nasal hydration and     * Care with the         Perform 3 to 4 times
hygiene.                saline solution:        a day, every day.
                        store in the
                        refrigerator; renew
                        at every 07 days; do
                        not allow the dropper
                        to contact the saline
                        flask (place the
                        saline to be used for
                        cleaning in a small
                        cup and discard the
                        remaining solution).

Increase the local      Perform finger          Perform 5 series of 5
blood and lymph         massage on the nasal    to 10 circular
circulation to          alae, maintaining the   movements with 30-
improve the nasal       two index fingers at    second interval
aeration.               the nasal ala region,   between series.
                        with up-down and
                        front-back circular
                        movements.

Stimulate the nasal     Ask sealing of one      Perform 3 series of
respiration.            nostril followed by     sequences of
                        deep inspiration.       inspiration/
                        Alternate the nostril   expiration,
                        sealing and ask for     alternating the side
                        expiration.             of nostril sealing

Train the lower         Ask the patient,        Perform 3 series of 5
middle respiration      lying back and with     respirations with to
                        the hands on the        30--to 60-second
                        abdomen, to perform     interval between
                        nasal inspiration       series.
                        expanding the
                        diaphragm region,
                        followed by deep and
                        slow expiration.

Note                    The exercises for
                        nasal respiration
                        should be performed
                        in cases without
                        signs of nasal
                        obstruction.

MASTICATION *

Objective/Reason        Strategies/             Frequency and
                        Accomplishment          Duration of Exercises

Adjust the              --ask for monitoring    Perform masticatory
masticatory pattern,    of the function of      training during one
aiming at maintenance   orbicularis oris,       meal per day.
of orofacial            mentalis and/or
functional and          buccinator muscles
esthetic balance.       during mastication,
                        as well as the speed
                        applied to perform
                        the function.

                        --ask for
                        simultaneous
                        bilateral
                        mastication: bite the
                        food with the
                        anterior teeth (after
                        allowed by the
                        surgeon), initiate by
                        the mastication
                        preference side,
                        distribute the food
                        on the occlusal
                        aspect of posterior
                        teeth bilaterally and
                        masticate on both
                        sides for some time,
                        at one cycle per
                        second.

                        --ask for alternate
                        bilateral mastication
                        (in the absence of
                        occlusal
                        interferences, signs
                        or symptoms of
                        temporomandibular
                        dysfunction): bite
                        with the anterior
                        teeth, initiate by
                        the mastication
                        preference side and
                        alternate the
                        mastication side
                        systematically, at
                        one cycle per second.

                        * the consistency of
                        foods will depend on
                        the guidance of the
                        maxillofacial
                        surgeon.

                        * the alternate
                        bilateral mastication
                        will depend on the
                        evolution of
                        orthodontic
                        treatment.

SWALLOWING

Objective/Reason        Strategies/             Frequency and
                        Accomplishment          Duration of Exercises

Adjust the swallowing   Solid food: ask for     Perform training
pattern, aiming at      swallowing of solid     during one meal per
maintenance of          foods sequentially to   day.
orofacial functional    the masticatory
and esthetic balance.   training, guiding
                        maintenance of
                        mandibular stability,
                        labial occlusion and
                        tongue positioning
                        against the palate
                        during swallowing.

                        Liquid food *:

                        --directed              Perform training with
                        swallowing: ask to      one glass of water 3
                        place some water in     times a day.
                        the mouth and
                        maintain the mandible
                        stable, lips
                        occluded, with tongue
                        movements in contact
                        with the palate.

                        --habitual
                        swallowing: ask for
                        water swallowing
                        sequentially,
                        controlling the
                        tongue positioning
                        and movement.
                        Initially employ a
                        small cup (coffee)
                        and increase the cup
                        according to the
                        patient's
                        performance.

                        * employ other
                        liquids besides
                        water, as juices of
                        varied flavors.

                        Saliva: ask for         Note the swallowing
                        voluntary control of    of saliva stimulated
                        tongue positioning on   by a dietary candy 3
                        the palate during       times a day.
                        swallowing of saliva.

SPEECH

Objective/Reason        Strategies/             Frequency and
                        Accomplishment          Duration of Exercises

Adjust the phonetic     --ask for production    Perform training of
aspects of speech and   of isolated phonemes,   articulatory
facial expressivity,    followed by             production in
aiming at maintenance   syllables, words and    specific activities
of orofacial            sentences.              combined with the
functional and                                  patient.
esthetic balance.       --ask for monitoring
                        of production of
                        target phoneme in
                        directed speech
                        activities.

                        --employ auditory (in
                        case of distortions)
                        and visual
                        biofeedback (for
                        monitoring of
                        recruitment of mimic
                        and facial expression
                        muscles).

                        * Attention should be
                        given to the
                        mandibular movements
                        (projection or
                        deviations) during
                        speech.
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Article Details
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Author:Migliorucci, Renata Resina; de Oliveira Freitas Passos, Dannyelle Christinny Bezerra; Berretin-Felix
Publication:Revista CEFAC: Atualizacao Cientifica em Fonoaudiologia e Educacao
Article Type:Ensayo
Date:Mar 1, 2017
Words:5581
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