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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4421_Библиотеки_им_академика_М_И_Перельмана.pdf
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Z. Brown and D. E. Perez
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Post-surgical Myofunctional
Therapy andPhysical Therapy
JoyL.Moeller, CynthiaPeterson, LiciaCoceaniPaskay,
SamanthaD.Weaver, andSoroushZaghi
Contents
31.1 Paradigm – 511
31.2 Preoperative – 511
31.3 Acute Post-surgical – 511
31.4 Long-Term Post-surgical – 511
31.5 Other Benets ofMyofunctional Therapy – 512
31
31.6 Who Are Myofunctional Therapists andWhere Can One
FindaWell-Trained Therapist? – 512
References – 513
© Springer Nature Switzerland AG 2021
K. B. Kim et al. (eds.), Management of Obstructive Sleep Apnea, https://doi.org/10.1007/978-3-030-54146-0_31
508
J. L. Moeller et al.
31
Core Message
Rehabilitation by a skilled team of professionals is critical
to optimizing long-term success and can signicantly
improve airway patency, functional, orthodontic, and aesthetic outcomes after surgery. This book chapter provides
an introductory overview to help the practitioner appreciate the role of pre- and postoperative therapies in the care
of patients who undergo orthognathic surgery for treatment of sleep apnea.
Maxillomandibular advancement (MMA) is a highly
effective surgical option for obstructive sleep apnea
(OSA) that achieves enlargement of the upper airway by
physically expanding the facial skeletal framework [1, 2].
After surgery, however, patients may develop swelling,
facial numbness, oral incompetence, drooling, difculty
with mouth opening, and nasal obstruction [3].
Myofunctional and physical therapy can be used before
surgery to identify and eliminate potential barriers to
successful outcomes, work to identify hurtful habits,
educate and empower the patient, and begin to establish
healthy habits, postures, and movement patterns. Postsurgical therapy helps maximize the benets of surgery
by restoring motion, strength, and establishing healthy
postures, habits, and normal oral and masticatory function, as well as to re-pattern the stomatognathic functions of the oral facial muscles [4] which can improve
long-term outcomes (see .
Fig.31.1).
Myofunctional therapy is the neurologic re- education
of the oral and facial muscles to promote healthy orofa-
cial habits. It is a rehabilitation therapy program that
focuses on optimizing chewing, swallowing, orofacial
posture, and nasal breathing. Restoration of these basic
functions is important to maximize patient satisfaction,
long-term success, and quality of life after jaw surgery.
In the United States, a postgraduate course in myofunctional therapy is taught to medical doctors, dentists,
dental hygienists, physical therapists, speech language
pathologists, occupational therapists, and osteopaths. It
will be important that professionals on the rehabilitation
team work within their scope of practice but are trained
in and working toward the healthy functions now
referred to in the research as myofunctional therapy.
Physical therapy for the jaw can include myofunctional therapy with proper postgraduate training, and
can optimize surgical results by providing skilled manual,
neuromuscular and myofascial techniques and customized treatments, training and therapeutic techniques to
decrease pain and inammation, restore mobility, stability, strength and function of the joints, nerves and muscles, improve posture and alignment of the spine and
cranium, and a healthy resting position of the mandible.
The rehabilitation team should work collaboratively
with the surgeon to develop and implement mutually
agreed upon patient care protocols. Modalities used
may vary as outlined by surgeon preference, therapist
experience, and each state’s professional practice act.
A preoperative assessment is performed prior to surgery to evaluate for the presence of tongue thrust, ankyloglossia, poor oral rest posture, and other signs of
. Fig. 31.1 Myofunctional therapy as adjunct to surgery: improved facial aesthetics, symmetry, and posture
Post-surgical Myofunctional Therapy andPhysical Therapy
509
31
. Fig. 31.1 (continued)
orofacial myofunctional disorders as well as postural
dysfunction, hypermobility and mal-alignment, and
bone, joint, muscle, fascia, or nervous system dysfunctions that may need to be addressed or taken into consideration. Patients are taught to:
5 Practice nasal breathing day and night
5 Develop a lip seal
5 Achieve and maintain palatal tongue rest posture
5 Practice bilateral chewing (with clearance from the
oral surgeon) and healthy swallow
5 Maintain healthy balanced postures, including sleep
and eating posture
5 Avoid hurtful habits and parafunctions by
5 Keeping hands and objects away from the face
5 Eliminating lip biting and clenching teeth
Indeed, constant pressure on the teeth from the tongue
due to poor oral rest posture and/or tongue thrusting
during swallow may have a dramatic effect on the dental
occlusion and alignment of teeth within the mouth [4].
To maximize surgical results and minimize relapse, it is
essential to address the dysfunctions that likely contributed to the need for surgical intervention in the rst place.
Ideally, pre-surgical therapy including myofunctional
therapy is initiated two to three months prior to surgery
to create a foundation for the post- surgical long-term
phase of care. Post-surgical rehabilitation that includes a
sequential series of therapeutic techniques described as
myofunctional therapy is then essential to optimize the
results of surgery and avoid relapse (see . Fig.31.2).
Post-surgical therapy aims to help rehabilitate the
patient in both the acute and long-term phases of recovery after jaw surgery. In the acute setting, the objectives
of postoperative therapy may include the following:
5 Improve facial sensation, proprioception, and neural
networks
5 Reinforce nasal saline rinses and encourage nasal
breathing
5 Encourage proper swallowing, chewing, and feeding
techniques
31
510
J. L. Moeller et al.
. Fig. 31.2 Orthodontic relapse after jaw surgery treated with
myofunctional therapy via retraining of the orofacial muscles and
improving tongue resting posture
5 Avoid maladaptive orofacial habits (touching the
face, resting the jaw on the hands, applying
asymmetric pressure to the surgical osteotomy and
xation site)
5 Improve the resting position of the tongue by
isolating and activating different tongue muscles
5 Promote stabilization of the mandible and avoid
over-opening
5 Teach symmetrical muscle patterns that promote a
stable orthodontic result
5 Establish healthy sleep habits and hygiene
Dental hygienists practicing myofunctional therapy are
also able to provide oral care for the patient to reduce
inammation in the tissues surrounding the oral appliances using various rinses such as chlorhexidine and
uorides with soft brushes. Nutritional counseling as to
the consistency of foods and identication of foods with
a high value of nutrients is valuable to assist the patient
into optimal healing. Because of the hygienists’ knowledge of dentistry, nutrition, and occlusion, they can
communicate between the orthodontist and oral surgeon effectively. They can support and motivate the
patient to think positively about the result while in the
healing phase and may decrease patient’s anxiety.
Speech and language pathologists (SLPs) can be
helpful in assisting patients before and after any surgery to the face, mouth, and often to the nose and the
pharynx. By applying diagnostic principles and myofunctional therapy techniques, SLPs address any
impact the surgery may have on oral functions such as
chewing, swallowing, and resting position of tongue
and lips. In addition, SLPs may provide patients with
nasal breathing techniques, as well as voice and speech
articulation therapy when needed as they may be
impacted by surgery.
Chewing functions are always disrupted by MMA
surgery and quite often patients are left to recover chewing spontaneously and they are recommended to eat soft
foods, which is as necessary an approach as avoiding
load bearing on a fractured leg. However, most patients
do not receive formal instructions on how to properly
recover chewing with the unfortunate result of being on
soft diet longer than is necessary. It would be akin to
having a broken leg and never receive physical therapy
to recover proper gait.
Chewing involves many neuro-muscular-occlusal
circuits which surgery usually disrupts. Therapy techniques to normalize chewing might include chewing on
silicon wafers or tubes or sticks (sham chewing), which
allow a balanced and gradable activation of the buccinators, masseters, and temporalis muscles, which can
also be toned before surgery and then re-patterned
post-surgery.
Since, in the very beginning, just after signicant
MMA surgery, most meals are to be consumed in liquid
form, a proper activation of the buccinators and the
orbicularis oris may promote a more efcient sucking
through straws or from spoons. Toning and strengthening these muscles prior to surgery can assist with postsurgery recovery.
Nasal breathing is fundamental to preserve a proper
lip seal but often, even after the rhino-maxillary surgery
provided the physical space for better breathing, nasal
breathing is still not spontaneous because nasal breathing is a complex neuro-chemical-muscular activity that
needs to be taught or taught again after extensive surgery, as the neuro-sensory parameters changed.
Moreover, breathing is involved with voice, not just as
the ow of air creates sounds but also as the oronasal
cavities create resonance.
Surgery involving the soft palate, like uvulo-palatopharyngo-plasty (UPPP), often creates a temporary but
signicant loss of air through the nose during speech, so
that sounds that require a build-up of oral pressure,
such as /p/, /b/, /t/, /d/, /k/, or /g/, cannot be properly
produced as the air escapes through the nose because
the soft palate is not isolating properly the various cavities. SLPs, through specic exercises can assist the
patient in recovering the functionality of the soft palate.
Post-surgical Myofunctional Therapy andPhysical Therapy
511
31
Although speech-language pathologists, physical
therapists, and dental hygienists may take care of
patients from birth to old age, for patients who undergo
MMA or other sleep surgery, they may still need to
receive postgraduate training in myofunctional therapy.
31.1 Paradigm
Myofunctional therapy exercises should be individually
customized and performed under the guidance of a professional trained in orofacial myofunctional therapy and
who has had extra training as to habit awareness and
elimination, breathing education, and proper pre- and
post-orthognathic goals. In general, the postorthognathic surgery paradigm includes the following
elements and practice exercises.
31.2 Preoperative
1. Baseline assessments are acquired. Measurements of
tongue and lip strength, rest posture of the tongue,
ability of the patient to breathe through their nose,
history of habits, oral facial pain symptoms, tongue
and orbicularis oris restricted tissues, swallowing
and chewing difculties, facial symmetry, diet survey,
functional speech and posture problems, photos and
videos, palate width, Mallampati/Friedman scores,
and screening for abnormal tissues.
2. Begin teaching principles and practice of proper oro-
facial rest posture, tongue placement, bilateral chew-
ing, proper swallowing, and begin nasal breathing
education with diaphragmatic muscle activation,
reduced, relaxed breathing as much as the patient is
able, nasal hygiene, isolation and activation of the
tongue muscles, range of motion of the lips, buccina-
tors, and zygomatic muscles, and reviewing func-
tional posture therapeutic techniques.
3. If ankyloglossia is present, the patient should be
enrolled in pre-frenuloplasty myofunctional therapy,
undergo surgical release of the lingual frenulum, and
then complete post-frenuloplasty exercises for
4–6weeks before embarking on maxillary mandibu-
lar advancement surgery.
4. Myofunctional therapy exercises should be
STOPPED prior to dental impressions and CT scan
for virtual surgical planning. The exercises prescribed
may in fact signicantly affect the alignment of the
teeth and thereby affect the accuracy of intraopera-
tive surgical splints.
5. Physical therapy to identify myofascial restrictions,
and work to improve asymmetries of the cranium,
mandible, spine, or pelvis that could adversely impact
surgical outcomes.
6. Identify and establish a plan to eliminate postural
dysfunction and hurtful habits with the appropriate
manual techniques, training, or interventions.
7. Fascia, scar, and injury assessment.
31.3 Acute Post-surgical
Techniques are individualized and are specic to each
patient’s functions. These are a few of many techniques
used:
1. Brush (use feather, soft brushes, or washrag) to stim-
ulate cheeks, lips, and tongue (5minutes, 3x/day).
2. Puff air into cheeks. Count to 5 on 4 sides (ve
times, 3x/day).
3. Range-of-motion exercises. Say “EEO OOH AHH”
(fteen times, 3x/day).
4. Tube chew (gently), start with 30seconds and work
up to 2minutes with lightweight surgical tubes cut
into two-inch lengths. Encourage bilateral chewing.
Re-engage the muscles of mastication and avoid
atrophy of the muscles.
5. Power pucker (20 times, 3x/day). Close lips, lip seal,
suck back and release. This may assist in controlling
excess saliva.
6. Diet: Increase textures slowly. Start with thin liq-
uids, then thick liquids, then soft food, increase up
to more solid.
7. Follow modalities and techniques to decrease pain
and inammation.
8. Limit range of motion to rotation, avoiding transla-
tion (Richardson JK reference).
9. Intraoral massage and myofascial release.
10. Nerve desensitization and re- education.
11. Scar tissue management and mobilization.
12. Exercise sequential progressions to improve func-
tion, strength, and stability.
13. Emphasize on healthy sleep hygiene and habits.
14. Postural activities and self-cervical mobility exer-
cises.
15. If jaw joint replacement was performed, the patient
and therapist must work together to assist the
patient to be cognizant of lateral movements with
both normal functions and the exercise protocols.
Many patients/therapists are not aware of habits
and movements that could cause discomfort in the
muscles surrounding the joints.
31.4 Long-Term Post-surgical
Habituation of these healthy habits and movement patterns will be essential to prevent relapse and return to
those dysfunctions that contributed to the need for surgery (see . Fig. 31.3). Multidisciplinary approach to
31
512
J. L. Moeller et al.
. Fig. 31.3 CT scan before and after MMA+GTA surgery show-
ing improper tongue resting positioning. There is now more room for
the tongue with the enlarged facial skeleton framework, but the
tongue relapses to the preoperative position with a propensity for
management that includes myofunctional therapy,
speech therapy, and physical therapy can alleviate the
burden of managing postoperative complications from
the surgery and signicantly increase patient outcomes
and satisfaction. Optimal results are achieved when the
therapy is initiated 3–4 months (depending on the surgeon’s preference) preoperatively and continued for at
least 6months and ideally 1 year after surgery.
31.5 Other Benets ofMyofunctional
Therapy
Recurrent or persistent OSA after maxillary mandibular
advancement surgery can be frustrating for both patients
and practitioners alike. OSA relapse after maxillary
mandibular advancement surgery is not uncommon.
Among those patients who have been cured of sleep
apnea with jaw surgery, recurrent OSA has been reported
even 10–15years after surgery [1]. The most predominant
site of obstruction among these patients with persistent
or recurrent OSA is the tongue-base [5]. Myofunctional
therapy is an effective adjunct to sleep apnea surgery
that has been shown to further reduce the AHI by
approximately 50% in adults and 62% in children.
Myofunctional therapy rehabilitates the tone of the
posterior inferior displacement. Myofunctional therapy will help
him learn to position his tongue anteriorly and superiorly to rest
against the hard palate
genioglossus muscle to prevent tongue-base collapse [6]
and promotes closed-mouth nasal breathing [7]. It is a
highly effective, noninvasive, and much safer alternative
to other potential interventions (such as tongue- base
reduction and tongue-base suspension) for patients with
persistent OSA after MMA surgery, especially among
those with upper airway resistance and/or mild- tomoderate sleep apnea.
31.6 Who Are Myofunctional Therapists
andWhere Can One Find aWell-Trained
Therapist?
In different countries, different professionals have taken
postgraduate training. In the United States, dental
hygienists, physical therapists, osteopathic physicians,
occupational therapists, or speech pathologists are likely
candidates for the postgraduate training. Surgeons in
the United States could encourage physical therapists
they work with to do additional training in myofunctional therapy. In Brazil, it is mostly done by speech
pathologists. In Japan, many dental hygienists have
received the training. In other countries, it may be a
combination of dental professionals, physical therapists,
or speech pathologists.
Post-surgical Myofunctional Therapy andPhysical Therapy
513
31
The relationship between therapist and patient is the
one in which trust, support, and motivation are all intertwined so the patient feels they have their concerns
addressed and are proactive about getting back into
“shape” (procedures that a doctor might not have time
for). Along with ongoing physiologic and emotional
support and sleep hygiene, the therapist is the linchpin
for the best possible surgical outcome/result, especially
in the long term.
References
1. Zaghi S, Holty J-EC, Certal V, etal. Maxillomandibular advancement for treatment of obstructive sleep apnea: a meta-analysis.
JAMA Otolaryngol–Head Neck Surg. 2016;142(1):58–66.
2. Liu SY-C, Huon L-K, Iwasaki T, et al. Efcacy of
Maxillomandibular advancement examined with drug-induced
sleep endoscopy and computational uid dynamics airow modeling. Otolaryngol Head Neck Surg. 2016;154(1):189–95.
3. Camacho M, Liu SY, Certal V, Capasso R, Powell NB, Riley
RW. Large maxillomandibular advancements for obstructive
sleep apnea: an operative technique evolved over 30 years. J
Cranio- Maxillofac Surg. 2015;43(7):1113–8.
4. Moeller JL.Orofacial myofunctional therapy: What is OMT? Why
is it important to ortho care? J Am Orthodont Soc. 2009; Spring
2009. (http://www. myoworks. net/upload/JAOSspr09_Moell_prf2.
pdf).
5. Liu SY-C, Huon L-K, Powell NB, etal. Lateral pharyngeal wall
tension after maxillomandibular advancement for obstructive
sleep apnea is a marker for surgical success: observations from
drug-induced sleep endoscopy. J Oral Maxillofac Surg.
2015;73(8):1575–82.
6. Mathur R, Mortimore IL, Jan MA, Douglas NJ. Effect of
breathing, pressure and posture on palatoglossal and genioglossal tone. Clin Sci. 1995;89(4):441–5.
7. Moeller JL, Paskay LC, Gelb ML. Myofunctional therapy: a
novel treatment of pediatric sleep-disordered breathing. Sleep
Med Clin. 2014;9(2):235–43.
Complications Associated
withMaxillomandibular
Advancement
RezaMovahed, JosephW.Ivory, andFrankDelatour
Contents
32.1 Collaborative Prevention andManagement
ofComplications–517
32.1.1 First Complications Reported inthe1970s – 517
32.1.2 Eective Provider–Patient Risk Communication andShared
Decision-Making – 517
515
32
32.2 Why Complications Matter inMMA – 518
32.2.1 Psychological Challenges andPatient Satisfaction – 518
32.2.2 Evolution ofFixation Materials andRelated Complications – 519
32.2.3 Mortality – 520
32.2.4 Short- andLong-Term Safety and Eectiveness
ofMMA inContext–520
32.2.5 Long-Term Follow-Up, Risk ofTreatment Failure,
andComplications–521
32.2.6 Anatomic Complexity Adds toProcedural Diculty – 521
32.2.7 Dierences in Surgical Procedures Leads to Dierences
in Recovery Time – 522
32.2.8 Identication ofAt-Risk Populations – 522
32.2.9 Obesity andNeck Circumference – 522
32.3 Intraoperative andPostoperative Complications – 523
32.3.1 Intraoperative Hemorrhage – 523
32.3.2 Hemorrhage Control: Hypotensive Vs. Normotensive
Anesthesia – 523
32.3.3 Postoperative Hemorrhage – 524
32.3.4 Potential Complications ofLe Fort I Segmental Osteotomy – 527
© Springer Nature Switzerland AG 2021
K. B. Kim et al. (eds.), Management of Obstructive Sleep Apnea, https://doi.org/10.1007/978-3-030-54146-0_32
32.3.5 Postoperative Nausea andVomiting – 531
32.3.6 Bad Splits – 532
32.3.7 Infections – 534
32.3.8 Neurologic Injury – 534
32.3.9 Venous Thromboembolism (VTE) – 535
32.3.10 Relapse andRisks Leading toReoperation – 535
32.3.11 Risks intheSurgery-First Orthognathic Approach – 536
32.3.12 Nasal Morphology Issues – 537
32.3.13 Impact ofOrthognathic Surgery onOral Health – 538
32.4 Conclusion – 538
References – 539