Being invited to the Myobrace Summit as a speaker was an unforgettable experience, also and above all for the discussion that took place between the various public speakers, where everyone brought their own expertise and experience.
Every time we learn something new, we ourselves become something new
I felt the need to put some thoughts on paper, and I would like to share them with you, or at least leave them in writing, because you know, verba volant, scripta manent.
I state that, during the degree course in Dentistry and Dental Prosthetics, I had not received any notion of Myofunctional Therapy. Nothing. I have no idea if things have changed now, but I haven’t investigated thoroughly.
A little by chance I then discovered that the teaching of Myofunctional Therapy is not even present in the degree course in Speech Therapy, or, to be more precise, it is at the discretion of the universities. There are universities that have made the teaching of myofunctional therapy a distinctive trait, I would even say an excellence, others that don’t teach it, leaving the student with the opportunity to train in the subject with postgraduate courses and Masters.
Initially this thing struck me a lot, but then I almost saw a parallelism with the world of dentistry.
The professional goal of the speech therapist is the restoration of speech. The goal of dentistry is the restoration of occlusion. Myofunctional imbalances are the leading cause of malocclusion and I believe they influence speech impairment as well.
There is certainly in common that more must be done at an academic level on both fronts, and fortunately commendable initiatives are emerging, at least as regards the world of speech therapy, for example I am thinking of the Master in Orofacial Motricity of the Humanitas University Consortium.
But speech therapy, a very interesting and fascinating subject, is not my field: let’s stay in the “dentistry world“. For years we have worked and rehabilitated the mouths of our patients pretending not to see the so-called elephant in the room. Surely an increasingly large number of colleagues, although still a minority, approach their orthodontic cases with an ever more attentive sensitivity to the myofunctional imbalances of the patient, especially those in the pediatric age. But it shouldn’t be a peculiarity of the orthodontist alone.
Why do I prefer to talk about myofunctional dentistry and not myofunctional orthodontics?
The myofunctional rehabilitation of the middle and lower third of the face is essential not only in ortho-pedodontics, but also in gnathology and prosthetics! Let’s think, for example, of the responsibility we assume when we decide where to place a dental implant: once inserted, it will no longer be possible to move it. When we go to prosthetic it, will it be able to stay in tune with that patient’s myofunctions and with his occlusion, and with growth and aging?
Think about this. We specialize in dentistry and dental prosthetics. The words “dental prosthesis” enters into the very definition of the degree course, no room for doubt. But we don’t know anything about myofunctional therapy. And what does it have to do with it? I’ll tell you about it with an example: the patient arrives with the classic disaster in his mouth, missing elements here and there, some eroded … He’s fine but he would like to restore the occlusion. And what we do? Let’s try to understand why that mouth has shrunk like that, by looking for the underlying cause that generated that problem? And since there are often myofunctional imbalances in these mouths, do we go and check that everything is in order before designing our prosthetic products? No, maybe someone does, but very few. Instead, we try to restore the occlusion and add the missing elements trying to leave the patient’s occlusion exactly as it was. If we’re lucky, everything will go well, because it means that the patient’s occlusion was consistent with his myofunctional balance. Rare. Perhaps we will have an asymptomatic readjustment between occlusion and myofunctions. What if this doesn’t happen? We will then begin to experience a series of problems and the patient will become symptomatic. Sick. You will probably never know because the patient will usually go to the osteopath or physiotherapist first. Let us always remember that occlusion, and therefore malocclusion, is an effect!
The main factor in the balance of the teeth seems to be the pressure that the tongue and lips exert at rest, and the forces that are generated on the periodontal ligament, together with the forces related to the eruption of the teeth. Forces related to occlusion probably also play a role in determining the vertical height of teeth during eruption. Respiratory function influences the development of the skull, maxilla, mandible and the position of the tongue, and therefore influences the balance of the teeth
William R. Proffit (1936 – 2018) Author of the book: Contemporary Orthodontics
As in orthodontics, so also in prosthetics, it is necessary first of all to start from a myofunctional analysis of the patient’s face and mouth. We need to be certain that the prosthetic problem was not caused by a myofunctional imbalance and factor this into our rehabilitation plan.
My orthodontic treatments are always orthodontic-functional, as are prosthetic rehabilitations. If a mouth has myofunctional imbalances, you have to be very careful where you put your teeth, implants, and in advance it would be much better to re-functionalize that mouth, before having to run into a series of subsequent problems.
And so, we get to the point: how?
With a Myofunctional Therapy focused on restoring breathing, if necessary, and on re-educating the muscles that caused the malocclusion. There are very valid protocols to be able to do this. Myoresearch has developed a highly effective and efficient one, used worldwide, for growing patients and adult patients.
And the next question is: who needs to be enabled to carry out these myofunctional therapy protocols?
Here too the answer, from my point of view, is very simple: for everything concerning the development of the middle and lower third of a face, and which can give benefits as regards the restoration of the correct occlusion of the patient, both from the functionally and aesthetically, the dentist/orthodontist remains the main responsible for the treatment.
Then everyone is free to organize themselves as they see feel comfortable. There are more or less three ways:
- Do everything yourself, including myofunctional therapy for patients. That’s how I started, because I needed to fully understand and know what I made my patients do, and it’s only by “getting my hands dirty” that I was able to fully understand what, until then, at most I was passively influencing, wearing the preformed devices one hour a day and overnight. Even today it is me myself who occasionally checks the exercises, and I am, together with my sister, the only certified Myobrace Educetor in Italy, at least until today.
- Delegate the staff of the practice (who will have previously undergone a training course, in my case held by myself) under my direct responsibility following a precise protocol to individualize Myofunctional Therapy based on the needs of that particular patient, adult or child. This is how I work today.
- Making use of an external figure to whom the patient must be previously functionalized, or of an internal figure with whom to work as a team, who however must be perfectly aligned with the therapeutic objectives of the dentist / orthodontist, aimed at restoring the occlusion. This is how many colleagues who make use of specialized speech therapists work.
Truth to be told, I’ve now opened a speech therapy center myself, which works closely with myofunctional educators in the Myobrace Activities Center. To the myofunctional therapy that I have performed through the Myobrace Activities protocol, by the Myobrace Educators, we combine specific exercises done by the speech therapists for speech rehabilitation, when necessary. There is a lot of contamination between the two fields, and that’s very good.
What I would certainly find absurd and very wrong is the concept that the dentist who performs Myofunctional Therapy in his office, personally or by delegating a figure properly trained by him under his responsibility, is in some way exercising an abuse of his profession. I personally would never set about correcting an altered phonatory verbal articulation, the resolution of which is not up to me, but, if I intercept it, I send the patient to the attention of a speech therapist. I wouldn’t even know where to start! But I know one thing, from experience: many children who undergo myofunctional orthodontic treatments, and who carry out Myobrace Activities, followed by me and my specialized staff, are also treated by speech therapists and other specialists, because in these subjects the malocclusion that does not there is never the only problem. Thanks to the correct application of the protocol, we are able to restore correct breathing in these subjects, by letting the air pass through the upper airways, we correct the posture of the tongue, swallowing, lip incompetence, we heal sleep disturbances, all of this making use of dedicated rooms and everything that the company makes available to us, such as interactive apps for mobile phones and tablets. This greatly facilitates the work of all the other specialists involved in restoring the patient’s health, primarily speech therapists of course, but also osteopaths, pediatricians, otolaryngologists, all figures with whom I find myself networking to obtain full and complete recovery of the patient, and that they send me other patients!
Personally, I feel very comfortable using Myobrace devices and applying their protocol, which is based on Myobrace Activities and the use of dedicated rooms (we were the first Myobrace Providers in Italy). Over the years and with experience, I have also found a way to add some interesting implementations, such as the use of Novafon, to obtain increasingly predictable results.
But I decide, helped by the protocol, which therapy to perform, which myofunctional therapy exercises to give more importance to that patient, with which preformed devices to have him perform them, whether to surgically remove a lingual and/or vestibular frenulum with a LASER that prevents correct motor movement orofacial, because it is I who will then have to perform the surgery, and in fact knowing the principles of myofunctional therapy helps me decide whether or not it is really necessary to resort to the surgery. We dentists are responsible for the treatment, as orthodontists if it is an orthodontic treatment, or as dentists if it concerns the prosthetic or implant prosthetic restoration of the occlusion.
We are responsible to our patients for our successes and failures.
At the Summit someone said that I represent a virtuous example for the application of Myofunctional Therapy with all the orthodontic patients I treat, both pediatric and adult. This makes me realize how much work there is to be done in this direction. Should be the norm. I know, it’s a very radical paradigm shift to put myofunctional imbalances upstream of malocclusion, but that’s how it is. There is a lot of work to do and there is room for everyone, dentists, prosthetists, gnathologists, orthodontists, speech therapists, otorhinolaryngologists, pediatricians, everyone can benefit from the knowledge and application of the principles of myofunctional therapy, each for his own sector competence. This includes knowing how to diagnose but also knowing how to treat. Myofunctional therapy concerning the middle and lower third of the face is too transversal, it cannot and must not be the prerogative of a single category. We hope that many schools will be born where you can learn myofunctional therapy, but inclusive for everyone. If myofunctional therapy can help speech therapists correct the impaired phonatory articulation of speech, the Masters in Orofacial Motility for speech therapists are welcome, but it would be nice if they were also open to dentists, and other medical and paramedical figures who can benefit from them in their profession.
There are companies in the world that are very active in training, one of these is Myoresearch. If all the professionals in the world who have embraced the “Myofunctional way” have been operating with this system treatment for years, with great satisfaction for their patients, it means that their protocol works well as it is set up. You don’t improvise world leaders, you become one with merit, and we have to recognize it.
In Italy we are well aware that the reality of dentists (about 60,000) consists mainly of the so-called single-professional practices formed by the dentist, who is also the medical director, and his staff. The number of multi-specialist centers is constantly increasing, but they are still few. The dentist is the first doctor who can intercept malocclusions in children, almost always caused by underlying myofunctional imbalances, one of which is oral breathing, which is very important to correct in growing patients! If the dentist decides to update his work protocol by embracing a treatment system that involves the use of preformed silicone appliances and exercises for his little patients to be performed, with the help of his suitably trained practice staff, to cure the malocclusion together with the dysfunction that caused it, he must be able to do it, happy, at peace with himself and with the world and with the entire scientific community, for the good he is doing to the community, for the health of our children. Imagine if all dentists did this.
Re-reading the article I saw that I often stressed the importance of occlusion. I conclude with this provocation: is occlusion really that important? Or maybe there are other parameters to correct even at the expense of a “perfect” occlusion, in order to have a healthy mouth?
Dr. Vincenzo Giorgino
P.S. Is tongue in mouth the elephant in the room? 😀