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5 Treatment
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Orofacial Myofunctional Therapy
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CarlosO’Connor-Reina, FranciscaBorrmann,
andLauraRodriguez-Alcala
Abbreviations
AHI Apnea–hypopnea index
CP Control pause
DISE Drug-induced sleep endoscopy
ENT Ear, nose, throat specialist
ESS Epworth sleepiness scale
g/cm2 Grams per square centimeter
IOPI Iowa oral performance instrument
kps Kilopascals
OMD Orofacial muscle disorder
OMT Orofacial myofunctional therapy
OSA Obstructive sleep apnea
Pcrit Upper airway collapsibility
RCT Randomized controlled trial
SDB Sleep-disordered breathing
TDS Tongue digital spoon.
UA Upper airway
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C. O’Connor-Reina (*) · L. Rodriguez-Alcala
Otolaryngology Department, Hospital Quironsalud Marbella, Málaga, Spain
e-mail: carlos.oconnor@quironsalud.es
F. Borrmann
Otolaryngology Department, Hospital Italiano Buenos Aires, Buenos Aires, Argentina
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 3- 031- 35225- 6_6.
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
P. M. Baptista et al. (eds.), Obstructive Sleep Apnea,
https://doi.org/10.1007/978-3-031-35225-6_6
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C. O’Connor-Reina et al.
6.1 Concept
Orofacial myofunctional therapy (OMT) is used for the diagnosis and treatment of
orofacial muscular disorders (OMDs) [1]. OMDs are one or a combination of the
following:
• Abnormal sucking habit of the thumb, nger, lip, or tongue.
• Resting posture and inappropriate opening of the mouth and lips (lip seal
incompetence).
• Interdental protrusion of the tongue at rest.
• Resting protrusion of the tongue against the maxillary incisors.
• Position of the tongue in posterior lateral or interdental rest.
6.2 Inadequate Tongue Thrust When Speaking or
Swallowing (Atypical Swallowing)
Patient with atypical swallowing (Video 1).
The orofacial muscle complex must be balanced, and proper development will
ensure well-formed craniofacial structures.
An imbalance in the orofacial muscle complex in childhood will probably result
in an imbalance in the pharynx muscles, promoting sleep-disordered breathing
(SDB) in adulthood. Swallowing involves accurate muscle coordination, and all Ear
Nose, and Throat specialists (ENT) should be aware of this process.
Normal swallowing proceeds in the following way:
• The tongue tip is placed just posterior to the maxillary incisors.
• The midpoint of the tongue is raised to the roof of the mouth.
• The tongue moves against the hard palate in a posterior direction, tipping at a 45°
angle so that the rear part of the tongue is against the pharyngeal wall.
• Simultaneously, with the tongue’s action in the swallowing position, the buccina-
tor and the master muscles exert lateral force against the dentition.
6.3 The Orbicularis Oris Muscle Exerts aPosterior Force
Against theUpper Anterior Teeth
The swallowing act is repeated approximately 2000 times a day, and if it is not done
correctly, functional issues will be converted into anatomical issues problems that
will have pathological consequences.
The three major muscle groups affecting occlusion during the swallowing act are:
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Fig. 6.1 Sagittal view
from tongue and pharynx
muscles
Fig. 6.2 Balance between
orbicular oris, masseter,
and mentalis muscles
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• The tongue is the only muscle in the body attached to only one end. The tongue
muscle functions during the act of swallowing as a moving force, as an impeding
force, or as both a moving force and an impeding force.
• The masseter and buccinator muscles are activated each time the patient swal-
lows. Failure to activate these muscles is caused either by the placement of the
tongue between the teeth during deglutition or by poor posterior occlusion.
• The orbicularis oris muscle, acts as a stabilizing inuence on the dentition. The
lips are the natural anterior retainers for the teeth. Patients who exhibit weak
orbicularis oris muscles due to functional or organic problems inevitably exhibit
a poor occlusal relationship [2] (Figs.6.1, 6.2, and 6.3).
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Fig. 6.3 Forces from
tongue and orofacial
muscles pulling backward
and upward starting the
deglutition process. See a
connection with hamulus
with pharynx muscles
C. O’Connor-Reina et al.
6.4 Background
The treatment of SDB by OMT is a relatively recent discovery (2005) of accidental
origin. Participants in a randomized controlled trial (RCT) who practiced the didgeridoo for an average of 20min per day, 5days a week for 4months, demonstrated
a reduction in their apnea–hypopnea index (AHI) of 6.2 events/h [3]. Interestingly,
in this study, there was no reference to any OMT.Instead, the study focused on
training or electrostimulation of the upper airway muscles (UA) with the expectation that the intervention would reduce UA collapsibility during sleep.
There are very few publications with enough credible scientic evidence that can
be presented. A critical study is a recent meta-analysis by Megphara [4], in which
OMT’s effectiveness and usefulness in treating obstructive sleep apnea (OSA) are
demonstrated. This study, carried out in 237 patients with OSA, showed that oropharyngeal exercises caused a reduction in the AHI from 28.0 ± 16.2/h to
18.6 ± 13.1/h, an increase in the minimum oxygen saturation by 2.5%, with an
improvement in the subjective parameters of sleepiness as shown by a decrease in
the Epworth Sleepiness Scale (ESS) from 12.71±5.73 to 8.78±5.80. These results
demonstrate the benet of performing the OMT exercise regimen.
Our group published an RCT [5] following the intervention in 18 patients with
severe OSA; the AHI decreased by 53.4% from 44.7 (range 33.8–55.6) to 20.88
(14.02–27.7) events/hour (P<0.001). The oxygen desaturation index decreased by
46.5% from 36.31 (27.19–43.43) to 19.4 (12.9–25.98) events/hour (P=0.003). The
ESS score decreased from 10.33 (8.71–12.24) to 5.37 (3.45–7.28) in the treated
group (P<0.001), but the Pittsburgh Sleep Quality Index did not change signicantly (Fig. 6.4). AHI results in control and study groups after using OMT in
severe OSA.
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Fig. 6.4 AHI results in control and study groups after using OMT in severe OSA
Carrasco etal. [6] reported that the available evidence demonstrates a positive
effect of OMT in reducing OSA in adults as assessed using polysomnography and
clinical variables. The available evidence is solid for the impact of OMT on snoring
reduction in adults. However, there is no evidence to support the use of OMT to treat
UA resistance syndrome, including how long the effects last or which OMT protocol is better in children or adults. Despite these knowledge gaps, the available evidence indicates that OMT is safe. Therefore, the available evidence for the use and
safety of OMT suggests that it should initially be offered as a noninvasive therapy
for patients with SDB.
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6.5 The Pathophysiological Basis ofOSA
andMuscle Control
The reason patients with OSA are less able to contract their muscles is unknown [7].
Poor neural coordination during sleep, inefcient muscle contraction due to
excess fat or muscle hypertrophy, changes in ber type, and a greater propensity to
fatigue have all been observed [8].
Patients with OSA have less muscular effectiveness than healthy patients [9].
Patients with OSA suffer from lingual apraxia. Apraxia is the inability to perform
specic movements with the tongue. They also suffer from stereognosis, or the failure to identify specic geometrical shapes inside the mouth with the tongue [10].
Patients with OSA have lower muscle tone than healthy individuals [11]. Muscle
tone measured with certain instruments showed lower strength than in healthy
controls.
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C. O’Connor-Reina et al.
6.6 Myofunctional Examination
What should an ENT specialist know about an OMD? First, as explained in other
chapters of this book, a correct anatomical examination of the patient must be
performed.
As in all therapies, it is paramount to know how to identify whether the patient is
suitable for the treatment and to refer them to a speech therapist. This can only be
achieved through systematic examination and a functional approach.
An examination of OSA patients must focus on two main questions, what is the
location of their tongue, and how are they breathing. Simultaneously we must
observe their posture both, standing, and sitting.
6.6.1 Breathing
How does our patient breathe? First, we must pay attention to how our patient
breathes and whether they breathe primarily through their nose or mouth. Once any
obstacles in the UA have been removed through surgery (e.g., septoplasty), the ENT
doctor must ensure that the patient is using the organ that has just been unblocked.
Studies carried out with Rhesus monkeys [12], and anatomical models [13] based
on orthodontic changes show that persistent oral breathing leads to long-term orofacial malformations. It has also been shown that sustained oral breathing is associated with SDB [14]. Correct breathing implies that it should be done mainly through
the nostrils, and should always be silent, with inspiration and expiration cycles happening through the nose no more than 15 times per minute. We can ask our patients
to hold their breath and measure the time they stay without breathing or their control
pause (CP). Patients with a low CP probably suffer from a loop gain phenotype of
OSA, and surgical treatment will not be effective [15].
ENTs must recognize hyperventilation syndrome in OSA patients. This manifests in patients with clear nostrils who complain of unsatisfactory nasal breathing.
They exhibit a high number of breaths per minute, which cause respiratory alkalosis, hindering the release of oxygen in tissues by red blood cells and causing a false
sensation of breathlessness in the patient [16]. It is related to empty nose syndrome;
therefore, the use of the validated Nijmegen questionnaire is recommended for
diagnosis [17]. Cases in which the patient does not breathe in such a way indicate a
disorder that requires specialized re-education, such as the Buteyko method with a
specialized therapist.
6.6.2 Tongue Position
Close attention must be paid to the tongue position when the mouth is closed. A
tongue at rest must always be positioned above the upper incisors, on the incisive
papilla, and swallowing must start from this point. Anything that involves another
tongue position is abnormal. Nasal breathing is certain if the tongue remains in an
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Fig. 6.5 Tongue as center
of solar system (upper
airway muscles)
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upright position, even when the mouth is open. The tongue should be considered the
main objective of the myofunctional evaluation, just as the sun is the center of the
solar system (Fig.6.5). Tongue as the center of the solar system (UA muscles).
6.6.3 Bite Classification
The position of the teeth or type of bite is very important for the patient’s optimal
health. A common cause of bad bite “malocclusion” is childhood habits such as
thumb sucking, tongue thrusting, pacier use beyond age 3, and prolonged bottle use.
Most common bite problems:
• Primary canine relationship. According to the Angle classication: Class I: nor-
mocclusion, this is the correct position where the rst molar should t above and
slightly in front of the lower rst molar. Class II; the upper rst molar occludes
far in front of the lower rst molar. Class III: the upper rst molar is wedged
behind the lower rst molar. The lower rst molar.
• Crossbite: crossbite when the position of the upper teeth is slightly in front of the
lower teeth; on the contrary, with the lower teeth forward when closing the
mouth, causing the chin to protrude.
• Open bite: does not allow the teeth to come together at some point in the dental
arches. It usually occurs in the front, although it can also affect the back teeth. It
is due to genetic reasons or the constant repetition of a habit, making the chewing
and speaking process difcult.
• Overbite (OVB): overbite is the overlapping of the upper front teeth concerning
the position of the lower teeth. It is recorded as normal, reduced (<2mm), or
increased (>4mm).
The study of malocclusion should be considered since there is an association
between snoring and crossbite. The presence of a posterior crossbite is related to the
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altered balance between the tongue and cheeks. On the other hand, mouth breathing
is associated with a decrease in the prominence and width of the nose. These facial
features could reduce upper airway space resulting in obstructive apnea events [18].
C. O’Connor-Reina et al.
6.6.4 Tongue Tie
Pathological tongue tie, or ankyloglossia, is a limiting factor for the success of
OMT.For some authors, its relationship with OSA is controversial [19]. There are
two types of tongue tie described in the literature:
The anterior tongue tie is a vertical fold of mucous membrane that joins the anterior part of the tongue to the oor of the tongue at its center.
The posterior tongue tie, which is not recognized by some authors [19] consists
of abnormal collagen bers located in the submucosa that form membranous structures that follow from the anterior frenulum, deep into the tongue stratus. For some
authors, it is known as a submucosal frenulum.
Approximately 2%–12% of the world’s population has a tongue tie [20]. It is a
hereditary disorder. The presence of a tongue tie in childhood is a suggestive factor
for possible SDB [21]. The reasons why a tongue tie can cause SDB are as follows.
OSA is related to the abnormal collapse of the UA during sleep. This anomaly
occurs in children and adults when sleeping, where a change in the tone of the pharyngeal muscles and the reex response also occurs. Position and intrinsic factors
such as critical oxygen level (Pcrit) and other extrinsic factors cause an increase in
nocturnal collapse that occurs while lying on one’s back.
The three extrinsic factors that affect the retropalatal and retroglossal spaces are
fat deposits, lymphoid tissues subject to chronic inammation (tonsils and adenoids), and craniofacial structures that inuence the size of the UA.Craniofacial
structures are also subject to environmental inuences and the genetic context.
Genetic abnormalities at birth cannot affect the UA until a certain growth stage.
Environmental factors produce their effect in a more latent way and inuence the
appearance of OSA after many years of acting silently and inadvertently. On the
other hand, environmental anomalies interact with genetic expression, revealing
genetic traits [22]. Just as nasal breathing is essential for the growth of orofacial
structures, so is the tongue’s. At birth, the tongue is located high on the palate and
through activities such as swallowing, chewing, and sucking. It causes stimulation
of the intermaxillary synchondrosis, that is active until 13–15years of age, causing
a normal orofacial growth that should be associated with nasal breathing. A short
tongue frenulum is associated with swallowing difculties during infancy and
speech problems in older children. It is also associated with oral breathing, which
causes bite abnormalities that require orthodontic treatment. These alterations modify the airway size, increasing the risk of OSA [23, 24].
The anterior tongue frenulum can be examined by the following several different
protocols. One of these is the Marchesani protocol [25], in which the patient is
asked to place the tongue behind the maxillary incisors and open the mouth without
taking it off. A measurement of the mouth opening is performed, then asking the
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