European Archives of Oto-Rhino-Laryngology

https://doi.org/10.1007/s00405-020-05994-w

LARYNGOLOGY

The efficacy of myofunctional therapy in patients with atypical

swallowing
G. Begnoni1 · C. Dellavia1 · G. Pellegrini1 · L. Scarponi2 · A. Schindler2 · N. Pizzorni2

Received: 20 February 2020 / Accepted: 15 April 2020

© Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Purpose  The myofunctional treatment (MFT) is a conventional therapy in the treatment of oral disease like atypical swallow-
ing (AS). Functional (standardized surface electromyographic analysis—ssEMG) and clinical (“orofacial muscular evalua-
tion with score” protocol—OMES) analyses were conducted to detect the effects of MFT (10 weeks session) in a group of
patients with AS.
Methods  ssEMG was performed to analyze the activity of masseter (MM), temporalis (TA), and submental (SM) muscles
before (T1) and after (T2) the MFT in a group of 15 patients. OMES was completed at the same timepoints. A Student-t
test was carried out to detect differences between T1 and T2 for ssEMG data, and a signed RANK test was used for OMES
ones. One-way ANOVA variance test was performed to detect any differences between the different couples of muscles at
each timepoint.
Results  After MFT, patients showed a shorter duration of the whole act of swallowing (p < .0001), higher intensity of the SM
activity (p < .01) than at T1. At T2 masticatory muscles showed lower values for the activation index (ANOVA, p < .0001)
and for the spike position (ANOVA, p < .01) than SM. The OMES protocol showed a significant increase for the total evalu-
ation score (p < .01), appearance-posture (p < .01) and functions (p < .001).
Conclusions  MFT permits a shortening of the muscular activation pattern and an increase in SM activity.
The improvement of oral functionalities is possible and identifiable thanks to the use of standardized protocols.

Keywords  Atypical swallowing · Tongue thrust · Myofunctional therapy · Logopedic treatment · Surface
electromyography · OMES protocol

Introduction
* G. Begnoni
giacomo.begnoni@unimi.it
Atypical swallowing (AS) has been defined as an oral dys-
C. Dellavia function that occurs when the correct swallowing maturation
claudia.dellavia@unimi.it
does not take place and the typical characteristics of infantile
G. Pellegrini swallowing, as the tongue thrust, persist even after 6 years
gaia.pellegrini@unimi.it
of age [1]. The etiology of AS is multifactorial. In fact, bad
L. Scarponi habits, environmental and hereditary factors, and oral and
scarponi.letizia@asst‑fbf‑sacco.it
allergic diseases could be involved in its onset [1, 2].
A. Schindler The treatment modalities provided to correct AS
antonio.schindler@unimi.it
can be passive (orthodontic) or active (myofunctional
N. Pizzorni therapy-MFT).
nicole.pizzorni@unimi.it
Orthodontic devices (cribs, palatal spurs, ELN, habit cor-
1
Department of Biomedical, Surgical and Dental Sciences, rector) aim to close the anterior open bite, to reconstitute an
University of Milan, via Luigi Mangiagalli 31, 20136 Milan, anterior contact, and to stop the dental thrust [1, 3].
Italy On the other hand, MFT is based on the education of all
2
Department of Biomedical and Clinical Sciences, Luigi the multi-functions involved in the stomatognathic appara-
Sacco”, University of Milan, Via Gian Battista Grassi 57, tus: swallowing, breathing, chewing, speech articulation,
Milan, Italy

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esthetics, and sensory activities [4]. All these specialized
functions belong to the same system, called “oral functions”.
The speech therapist has to take into consideration all these
functions as they are characterized by mutual interactions.
The object of the MFT is the treatment of orofacial myo-
functional disorders (OMD) that include alterations and dys-
functions of orofacial musculature that interfere with the
growth, development, and functions of the stomatognathic
apparatus [5]. During the MFT, the speech therapist must
establish the correct function by eliminating the deviated
pattern, creating new motor images, adopting them, and
making them automatic.
Considering the growing demand and the increasing
attention to oral-facial disorders, it is necessary to define
qualitative and quantitative parameters that allow to diag-
nose the disorder, to set prognosis, and evaluate the effects
of MFT in a standardized manner.
In recent years many assessment protocols have been
proposed for the detection of OMD, but only few have been
validated: the Nordic Orofacial Test–Screening (NOT-S)
[6], the protocol of orofacial myofunctional evaluation with
scores (OMES) [7], OMES-Expanded [8] and OMES-Italian
version [5]. The OMES is a tool for orofacial structure and
function assessment that allows to quantify the clinician’s
perception assigning a numerical value to the observed
behaviors and functions. Therefore, it has been recom-
mended for evidence-based practice [5].
On the other side, quantitative evaluations about the
effects of MFT on the tongue strength have been analyzed
through bulb pressure sensors (e.g. Iowa Oral Performance
Instrument—IOPI—device [9], electropalatography [10],
and surface electromyographic (sEMG) analysis [11]. sEMG
can be considered as a fast, easy, and non-invasive method
to assess the muscular activation pattern and the duration
of activation and is particularly suitable for the analysis of
the oral phase of swallowing due to the superficial posi-
tion of the muscles involved in this function. Nevertheless,
there are two aspects that need to be pointed out. The first
is linked to the age of the subjects. In fact, the occlusal con-
tacts provided in the mixed dentition do not allow such a
stable proprioceptive response like the adult one, or at least
as the second dentition completed [12]. The second is linked
to the controversial opinions about the clinical application
of sEMG. In fact, both technical and biological factors can
influence the registered signal and make comparative and
longitudinal evaluations difficult to be conducted [12–15]
However, the use of standardized sEMG (ssEMG) protocols
eliminates such factors [16]. Reliable and standardized pro-
tocol for the activity of masseter (MM), anterior temporalis
(TA) and submental muscles (SM) during maximal volun-
tary clench and mastication has been conducted previuosly
[12, 13].
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European Archives of Oto-Rhino-Laryngology
Recently, a standardized surface electromyography
(ssEMG) protocol during swallowing has been performed
[13]. First data about the activity of MM, TA, and SM dur-
ing saliva swallowing detected [15] in healthy adult patients
and in adolescents with and without AS have been acquired
[17]. In the adolescents, a different muscular activity pat-
tern seemed to be observed between patients with and
without AS: patients with AS showed lower activity index
(IMPACT) of SM and longer duration of activity of all the
couples of muscles analyzed than normal patients [17].
The aim of this study was to analyze the effects of MFT
on the muscular function and behavior in a group of patients
with AS and second dentition completed. The hypothesis
was that MFT may be effective in establishing a physiologic
muscular activation pattern of MM, TA, and SM and a phys-
iologic swallowing behavior.
Materials and methods
A longitudinal prospective cohort study was conducted. A
surface electromyographic (sEMG) exam and an oral motor
clinical assessment were performed according to standard-
ized protocols [5, 15] before (T1) and after (T2) the MFT.
Patients’ recruitment
A total of 18 patients with AS were recruited at the Phoni-
atric Unit of the Phoniatric Unit of the University Hospital
Luigi Sacco of Milan.
The diagnosis of normal or atypical swallowing was based
on the clinical judgement of a phoniatrician with > 15 years
of experience in the field, by observing the patients dur-
ing swallowing. The same phoniatrician assessed all the
patients. Hyperactivation of lips or of orbicularis muscles,
facial muscle tension, and an abnormal movement of head
and mandible inclined the operator towards the diagnosis of
atypical swallowing. If the presence of tongue thrust was
observed without any doubts and was associated with the
myofunctional alterations already listed, the diagnosis was
considered definitive. Tongue thrust was defined as the pro-
trusion of the tongue between upper and lower incisors or
cuspids during swallowing [17].
Inclusion criteria for this group were: second dentition
completed with at least 28 teeth present, no temporo-man-
dibular disorders (TMD), no oral bad habits, overjet, and
overbite between 0 and 5 mm, dental crowding inferior to
6 mm and AS.
Exclusion criteria were: no periodontal disease, no lateral
crossbite, no active medication intake, no active orthodontic
therapy, no occlusal overlay, no fixed prosthetic, no active
European Archives of Oto-Rhino-Laryngology
caries, no endodontic treatment, and no conservative or oral
surgical therapy within the past 3 months.
The MFT was performed by a speech therapist based on
the Garliner method [2] at the Phoniatric Unit of the Univer-
sity Hospital Luigi Sacco of Milan. According to Garliner’s
method, MFT consisted of 10 weekly sessions of 45 min
each and daily exercises at home. The therapies were carried
on by the same operator.
At the end of the ten sessions, patients were re-assessed
by the phoniatrician, who diagnosed the AS. The treatment
was considered completed if normal swallowing behavior
was achieved, based on the criteria used for the diagnosis.
The study was carried out according to declaration of
Helsinki. All patients enrolled to this study were invited
to sign an informant consent and the study protocol was
approved by the local ethic committee of University of
Milan (Code: DG-EMG-2016).
Instrumentations
sEMG analysis
sEMG activity was recorded using a computerized instru-
ment (Easymyo; 3 Technology S.r.l., Udine, Italy) whose
electrode type and procedure of analysis have been described
previously [15, 17].
The bipolar surface electrodes (21 × 41  mm, 20  mm
inter–electrode distance; F3010; Fiab, Firenze, Italy) were
positioned on the muscular bellies parallel to muscular fib-
ers as follows:
1. MM. The electrodes were fixed parallel to the exocan-
thion–gonion line and with the upper pole of the elec-
trode under the tragus–labial commissural line.
2. TA. The electrodes were fixed vertically along the ante-
rior margin of the muscle (corresponding to the frontal–
parietal suture).
3. SM. The electrodes were placed in the submental area,
paramedian to the midline and lightly diverging, 1 cm
posterior to the mental symphysis.
A disposable reference electrode was applied to the fore-
head or on the earlobe. To reduce skin impedance, the skin
was carefully cleaned prior to electrode placement, allowing
the conductive paste to adequately moisten the skin.
sEMG measurements
At each appointment (T1 and T2) the sEMG analysis was
composed of three sets:
1. Masticatory muscle standardization procedures: two
10-mm-thick cotton rolls were positioned on the man-
dibular second premolars/first molars of each partici-
pant, and a 5-s maximum voluntary contraction (MVC)
was recorded to standardize TA and MM sEMG signal.
The mean sEMG potential obtained in the first acqui-
sition was set at 100%, and all further sEMG poten-
tials were expressed as a percentage of this value (μV/
μV × 100).
2. Submental muscle standardization procedures: partici-
pants were asked to push their tongue to the best of their
ability (without teeth clenching) against the palate, and
a 5-s sEMG SM activity was recorded. All further SM
sEMG potentials were expressed as a percentage of this
value (μV/ μV × 100).
3. Saliva swallowing: after drinking 20 cc of water, the
participants were asked to wait 30 s, bring their teeth
in contact during swallowing the saliva spontaneously
accumulated and keep them in rest position (with no
occlusal contacts) at the end; a 5-s sEMG activity was
recorded. The acquisition was recorded after the patients
were made confident with the exercise to be performed.
For each acquisition, the 3-s period with more stable
signal was automatically selected by the dedicated soft-
ware that calculated the Simple Moving Average. During
the tests, participants were asked to perform the tasks to
the best of their ability, to avoid head and neck movements,
and to maintain a relaxed facial expression to reduce cross-
talks. During the recordings, participants sat in a comfort-
able office type chair with a straight posture, feet flat on the
floor, and arms resting on their legs. All acquisitions were
made by the same operator.
sEMG data analysis
The ssEMG waves were amplified, digitalized, digitally fil-
tered, and interfaced with a computer which presented the
data graphically and recorded them on magnetic media for
further quantitative and qualitative analyses. Two indexes
were computed:
1. POC (%, percentage overlapping coefficient): this index
represents the symmetrical activation of each couple of
muscles ranging between 0 and 100%. When two paired
muscles (MM, TA, SM) contract with perfect symmetry,
a POC of 100% is obtained. Details on the calculation
of the POC index have been described in our previous
study [12].
2. IMPACT (%, standardized activity index): activity index
that quantifies the total muscular recruitment of each
couple of muscles (MM, TA, SM) during swallowing
relative to the standardization procedures (see above),
13

computing the mean total muscle activities as the inte-
grated areas of the sEMG potentials over time. Details
on the calculation of the IMPACT index have been
described in our previous study [18].
From the swallowing wave of each muscle the follow-
ing extra measurements were derived:
3. Duration of activation of each couple of muscles (MM,
TA, SM): considered as the interval in which muscle
activity was higher than 10% of its standardization pro-
cedure. Values below this threshold were considered
muscular basal activity as reported previously [15].
4. Duration of the whole swallowing test: described as the
interval between the beginning of the first muscle (MM,
TA or SM) activation and the end of the last muscle
activation (MM, TA or SM).
5. Position of the spike of each couple of muscles relatively
to its total duration of activity: reported as a percentage
of the duration of the activation of each couple of mus-
cles; when a continuous wave is present, and the spike
position is unclear, it is considered as the middle point
between the start and the end of the electromyographi-
cal wave. The term “spike” indicates the electromyo-
graphical wave with the highest amplitude in the period
observed.
6. Intensity of the spike of each couple of muscles: the
percentage of activity of MM, TA, SM relative to the
standardization procedures expressed in correspondence
of the spike point during swallowing (Fig. 1).
Fig. 1  A–F, A’–F’, example of an electromyographical signal of the
muscles activated during saliva swallowing before (T1) and after (T2)
the myofunctional treatment. X-axis: time (ms), Y-axis: intensity of
activation (μV/μV × 100). A–A’, right anterior temporalis muscle;
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European Archives of Oto-Rhino-Laryngology
OMES analysis
The OMES is a validated protocol for the clinical evaluation
that allows the examiner to express numerically, on a gradu-
ated scale, the clinical judgement on oro-facial structures
and functions.
This protocol allows to differentiate subjects with and
without orofacial myofunctional disorders, guiding treat-
ment planning and providing outcome measures [5, 8, 19,
20].
It is divided into four sections plus a total score:
1. Appearance and posture: this section assesses the sym-
metry of the face, the position of the lips at rest, the
posture of the jaw, cheeks, tongue. Rating score from 6
(severely deviant) to 18 (perfect function).
2. Mobility: the examiner rates the ability of the patient to
perform movements (protrusion, lateralization, eleva-
tion, stretching) with the lips, tongue, jaw, and cheeks.
Rating score from 19 (severely deviant) to 57 (perfect
function).
3. Functions: the section assesses the orofacial functioning
during breathing (nasal, oro-nasal, or oral) and swallow-
ing (labial behavior, lingual position, presence of dys-
functional behaviors and swallowing efficiency). Rating
score from 5 (severely deviant) to 18 (perfect function).
4. Mastication: biting, masticatory laterality, and the pres-
ence of dysfunctional behaviors during mastication are
assessed. Rating score from 2 (severely deviant) to 10
(perfect function).
5. Total OMES: the total score is obtained by summing
the scores of the previous sections. Rating score from
32 (severely deviant) to 103 (perfect function).
B–B’, left anterior temporalis muscle; C–C’, right masseter muscle;
D–D’, left masseter muscle; E–E’, right submental muscles; F–Fì, left
submental muscles
European Archives of Oto-Rhino-Laryngology
Statistical evaluation
Descriptive statistics were computed for all ssEMG
indexes for swallowing and for the OMES scores. To
compare the changes relative to the electromyographic
parameters between T1 and T2 a student t test for paired
data was performed,
whereas to compare the changes of the clinical assess-
ment between T1 and T2, a signed RANK test was
performed.
In addition, to detect any significant differences within
each timepoint between the different couples of muscles
(TA, MM, SM) mean values were compared by one-way
ANOVA analyses of variance, followed by post hoc tests
[17].
The null hypothesis was that no differences in the dura-
tion and the intensity of activation of the different couples
of muscles would be detectable. For all statistical tests, sig-
nificance was set at 5%, with a beta error (Type II) larger
than 0.95 [16].
Sample size calculation was performed using α 5% and
the power of sample 80%. For the variability the value of
0.33  s (standard deviation of the normalized difference
between total duration of swallowing act in AS and healthy
patients) obtained in previous papers was considered [15].
The minimum significant value considered was 25%. Based
on these data, a sample size of 15 patients was calculated.
As possible drop out was suspected, the sample number was
increased by three patients (20%). Thus, 18 patients were
recruited.
Results
Among the 18 patients recruited, two patients showed
poor compliance and did not complete the MFT, while one
patient started orthodontic therapy before the end of MFT.
Thus, a final group of 15 (4 males and 11 females, mean
age 17.72 ± 5.21 years) patients with AS during deglutition
was enrolled for this study. Ten patients were adolescents
(4 males and 6 females, mean age 14.75 ± 1.60 years) and
five were young adults (3 females and 2 males, mean age
23.66 ± 4.80 years).
A complete recovery was observed by the phoniatrician
for all the patients that underwent the MFT at the end of the
treatment (10 sessions).
sEMG
In Table  1, ssEMG values at T1 and T2 are reported
together with the corresponding significant changes. In
addition, the one-way ANOVA significant values between
MM, TA, and SM at each timepoint (T1 and T2) are
depicted.
At T1 the mean values for POC index showed a lower
symmetrical activation for MM (72.97%) and TA (74.94%)
than for SM (79.10%). At T2 the values of MM and TA
increased without significant differences. For SM, the mean
values at T1 and T2 were similar and closer to 80%. No
differences were detected between the different couples of
muscles at T1 and T2 with ANOVA test.
Concerning the IMPACT index, values recorded for TA,
MM and SM at T1 were similar and did not show any sig-
nificant differences. A decrease in the mean values of MM
(p <  .05) and TA (not significant) occurred at T2. Differ-
ently, the IMPACT value of SM increased (p <  .01). In addi-
tion, a meaningful difference between the activity indexes
of the different couples of muscles (one-way ANOVA,
p <  .0001) at T2 was recorded. In particular, the observed
pattern was characterized by a low activity of MM (9.93%),
a moderate activity of TA (17.85%) and high activity of SM
(30.67%).
A common trend affects the mean values of the duration
of activation of each couple of muscles involved. In fact, all
the couples of muscles analyzed showed a decrease in the
time of activation. These results were significant for MM
(p <  .05) and SM (p <  .01). Also, the whole duration of the
swallowing act decreased significantly (p < .01) passing from
2.25 to 1.73 s after the MFT. The durations of activation of
each couple of muscle were statistically different both at T1
(ANOVA, p. < 05) and at T2 (ANOVA, p <  .01). At each
timepoint, MM and TA showed significant lower duration
than SM.
With regard to the position and intensity of the spike,
Fig. 2 provides an example of the analysis performed and
the changes that occurred between T1 and T2.
At T1 the muscular recruitment model provides a first
activation of masseters that showed an activation time of
1.53 s with a spike position at 38% and a spike intensity
of 48%; TA followed showing an activation time of 1.69 s
with a spike position at 46% and spike intensity of 46%.
The last couple of muscles that reached the maximum spike
activity were SM with a duration of about 2.11 s; the spike
position was at 48% with an activity of 76%. No differences
were detected between the spike positions of the different
couples of muscles at T1, whereas a significant difference
was detected at the same timepoint for the spike intensity of
MM (48%) and TA (46%) that resulted significantly lower
than SM (76%) at the one-way ANOVA test (p <  .0001).
At T2, the duration of activation for each couple of mus-
cles decreased. The spike position was not altered for MM
and SM, while it was decreased for TA passing from 46
to 38%. Significant differences between the different cou-
ples of muscles were found for the spike position (ANOVA,
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Table 1  Standardized ssEMG indexes during saliva swallowing are shown

Index Muscles Couples T1 One way ANOVA (T1) T2 One way ANOVA (T2) Student t
test T2 vs
T1

POC (%) TA Mean 74.95 NS 76.02 NS NS

SD 9.77 3.47
MM Mean 72.97 74.67 NS
SD 14.55 10.77
SM Mean 79.10 78.66 NS
SD 7.92 5.06
IMPACT (%) TA Mean 22.79 NS 17.85a  < .0001*** NS
SD 16.06 8.69
MM Mean 17.06 9.93b  < .05*
SD 9.96 6.54
SM Mean 22.09 30.67c  < .01**
SD 5.81 8.50
Duration (s) TA Mean 1.69a  < .05* 1.32a  < .01** NS
SD 0.68 0.35
MM Mean 1.53a 1.09a  < .05*
SD 0.62 0.37
SM Mean 2.11b 1.58b  < .01**
SD 0.37 0.36
Duration TOT (s) Mean 2.25 1.73  < .01**
SD 0.49 0.32
Spike position (%) TA Mean 46.69 NS 38.09a  < .01** NS
SD 15.94 12.39
MM Mean 38.3 36.47 a NS
SD 16.06 12.49
SM Mean 48.13 52.51 b NS
SD 13.13 12.79
Intensity of the Spike (%) TA Mean 46.31a  < .0001*** 55.20a  < .0001*** NS
SD 17.16 15.48
MM Mean 48.13a 44.93a NS
SD 21.93 19.45
SM Mean 76.63b 77.40b NS
SD 8.82 10.83

POC (%), impact (%), duration of activation of each couple of muscles (s) (masseter muscles MM, temporalis muscles TA and submental mus-
cles SM), duration of the whole exercise (TOT) (s), spike position (%) (calculated as a percentage of the duration of activation of each couple
of muscles), intensity of the spike (%), mean and standard deviation (SD) for MM, TA and SM. Student t test for paired data was performed
between T1 and T2 and significance was set at 5% (p < .05)
A one-way ANOVA was performed between MM, TA and SM muscles at T1 and T2 for all electromyographic indexes. Probability of one-way
analysis of variance; NS not significant, p > .05 (p < .001***, p < .01**, and p < .05*). Means with different superscripts (a or b) differ at post hoc
tests

p <  .01) with a shorter spike position of masticatory muscles
(MM-36%, TA-38%) than SM (52%).
Analogously, the spike activity did not alter at T2 for
MM and SM, while it was increased for TA passing from
46 to 55%. Also, significant difference between the differ-
ent couples of muscles was detected for the spike intensity
(ANOVA, p <  .0001) at T2, with lower activity of mastica-
tory muscles (MM-44%, TA-55%) than SM (77%).
The changes in the spike position and the spike activity
were not significant between T1 and T2 according to the
values obtained from the Student t test.
OMES
In Table 2, OMES scores (scales) at T1 and T2 are reported
together with the corresponding significant changes.

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Fig. 2  Graphic representing the time and the intensity of the spike of axis and intensity of activity (%) on the ordinates axis. MM, masse-
activation of each couple of muscles during saliva swallowing at T1 ter; SM, submental muscles; TA, anterior temporalis. “X” is located
(Fig.  2a) and T2 (Fig.  2b), considering mean values. MM, TA and on the x axis at the time of the end of the swallowing act
SM are reported with different colors. Duration (s) on the abscissae

Table 2  OMES indexes (scales) Parameters Range T1 T2 Signed RANK test

with proper range of values
Mean SD Mean SD

Appearance and posture 6–18 14.60 2.10 16.47 1.36  < .01**

Mobility 19–57 52.60 4.79 54.47 2.90  < .05*
Functions 5–18 13.00 1.73 16.93 1.22  < .001***
Mastication 2–10 7.80 1.82 8.47 1.30 NS
Total OMES 32–103 88.00 8.41 96.33 4.30  < .01**

Means and standard deviations (SD) before (T1) and after (T2) the MFT; signed RANK test was performed
between T1 and T2 and significance was set at 5% (p < .05): p < .001***, p < .01**, and p < .05*

All the sections showed an increase in the mean values
from T1 to T2 with a general reduction of the standard devi-
ations. The comparison between T1 and T2 was found to
be significant for the subscales “Appearance and posture”
(p < .01), “Mobility” (p < .05), and “Functions” (p < .0001).
Furthermore, the total OMES score showed a significant
increase at T2 (p < .01), suggesting that a general benefit
for the whole orofacial behavior was obtained thanks to the
MFT. In Table 3, the OMES subscales are reported with the
corresponding descriptive statistic.
Discussion
For the first time, the effects of the MFT were investigated in
a group of patients with AS and second dentition by combin-
ing both quantitative (ssEMG) and qualitative (OMES) out-
comes. A novel protocol of standardized ssEMG assessment
of the oral phase of swallowing function [13] was used to
quantify the effects of MFT on muscular activation. Results
suggest that MFT is an effective treatment to improve oro-
facial behavior during swallowing and enables to partially
approach physiological muscular activation patterns during
this task, at least in the short period.
Concerning the ssEMG results, the primary outcome was
related to the duration of muscular activation during swal-
lowing. The duration significantly decreased after the MFT,
moving from 2.25 to 1.73 s. This value reached the aver-
age duration value obtained in our previous study in normal
adult subjects [15], but is longer than the average duration
value observed in young normal patients [17] (1.30 s). These
data suggest that the improvement allowed by the MFT does
not guarantee a complete normalization of the function.
Regarding the POC index, a symmetrical activation of
about 80–85% for each couple of muscles is considered good
[12]. In the present study, POC indexes of all the investigated
muscles assessed at each timepoint showed a lower level of
symmetry in the activation compared to those recorded dur-
ing clenching [13] and in normal patients [15, 17]. These
data confirm the findings by Eslamian and Leilazpour on
children with AS. The authors reported that these patients
show systematically inaccurate tongue movements and poor
movement coordination that do not guarantee to equalize the
function of the healthy children without AS [21].

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Table 3  OMES indexes Parameters T1 T2

(subscales) with proper range
of values Appearance and posture Range Mean SD Mean SD

Posture of lips 1–3 2.60 0.51 2.80 0.41

Vertical posture of mandible 1–3 2.27 0.59 2.67 0.49
Appearance of cheeks 1–3 2.67 0.49 2.87 0.35
Appearance of face 1–3 2.47 0.52 2.80 0.41
Posture of the tongue 1–3 2.40 0.63 2.80 0.41
Appearance of the hard palate 1–3 2.20 0.68 2.53 0.64
Total 6–18 14.60 2.10 16.47 1.36
Median 15 16
Interquartile range 13.5–15.5 15–18
Mobility
Protrusion of the lips 1–3 2.80 0.41 3.00 0.00
Retrusion of the lips 1–3 2.60 0.51 2.87 0.35
Lateral movement of the lips (right) 1–3 2.53 0.83 2.53 0.74
Lateral movement of the lips (left) 1–3 2.60 0.74 2.67 0.49
Protrusion of the tongue 1–3 2.60 0.51 2.93 0.26
Retrusion of the tongue 1–3 2.93 0.26 2.80 0.56
Lateral movement of the mandible (right) 1–3 2.80 0.41 2.93 0.26
Lateral movement of the mandible (left) 1–3 2.80 0.41 2.93 0.26
Elevation of the tongue 1–3 2.53 0.74 2.60 0.51
Backward movement of the mandible 1–3 2.87 0.35 2.93 0.26
Opening movement of the mandible 1–3 3.00 0.00 3.00 0.00
Closure movement of the mandible 1–3 3.00 0.00 3.00 0.00
Lateral movement of the mandible (right) 1–3 2.73 0.46 2.87 0.35
Lateral movement of the mandible (right) 1–3 2.80 0.41 2.93 0.26
Protrusion of the mandible 1–3 2.87 0.35 2.93 0.26
Inflate the cheeks 1–3 2.93 0.26 3.00 0.00
Sucking cheeks 1–3 2.80 0.41 2.87 0.35
Move the cheeks backward 1–3 2.67 0.49 2.80 0.41
Moving air from right to left cheek 1–3 2.73 0.59 2.87 0.52
Total 19–57 52.60 4.79 54.47 2.90
Median 54 56
Interquartile range 52–56 52–57
Functions
Breathing 1–3 2.00 0.76 2.73 0.59
Swallowing: labial movement 1–3 2.13 0.64 2.80 0.41
Swallowing: tongue movement 1–3 1.93 0.59 2.93 0.26
Other signs: head movement 0–1 0.73 0.46 0.80 0.41
Other signs: facial muscles behavior 0–1 0.47 0.52 0.93 0.26
Other signs: food out of the lips 0–1 0.87 0.35 0.93 0.26
Efficacy of swallowing: solid bolus 1–3 2.27 0.59 2.80 0.41
Efficacy of swallowing: liquid bolus 1–3 2.60 0.74 3.00 0.00
Total 5–18 13.00 1.73 16.93 1.22
Median 13 17
Interquartile range 12–13.5 16.5–18
Mastication
Biting 1–3 2.60 0.63 2.67 0.49
Mastication movement 1–4 2.67 1.18 3.20 1.01
Other signs: head movement 0–1 0.87 0.35 0.93 0.26
Other signs: altered posture 0–1 0.93 0.26 1.00 0.00

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European Archives of Oto-Rhino-Laryngology
Table 3  (continued) Parameters
Appearance and posture
Other signs: food out of the lips
Total
Median
Interquartile range
Total OMES
Median
Interquartile range
Means and standard deviations (SD) before (T1) and after (T2) the MFT; median and the interval between
the first and third quartile (interquartile range) were calculated for the subscores and the total score
The activation index (IMPACT) shows that the activity
of masticatory muscles decreases after MFT, whereas the
activity of SM significantly increases, although the distri-
bution yield a high standard deviation. This finding is in
accordance with previous studies [15, 17, 22] that showed
that SM seems to be more involved during swallowing in
normal subjects than in AS patients.
The decreasing IMPACT of masticatory muscles sug-
gests that, after MFT, MM and TA just allow the initial
dental contact during oral phase of swallowing, thus per-
mitting the swallowing reflex to be carried on by the SM.
It is interesting that the sum of the IMPACT indexes
at T1 and T2 did not differ significantly (61.94 at T1
and 58.44 at T2). Therefore, it seems that MFT does not
decrease the total muscular activity but rather allows a re-
distribution of the muscular activity between the muscles
analyzed.
The “spike intensity” did not change significantly from
T1 to T2 and it was always characterized by a significant
lower intensity of the masticatory muscles (MM and TA)
than SM at both T1 (46% for TA, 48% for MM, 76% for SM)
and T2 (55% for TA, 44% for MM, 77% for SM). These data
are similar to the ones obtained in healthy subjects (57% for
TA, 50% for MM, 73% for SM) [17].
Vice versa, the “spike position” of the different couples
of muscles changed after MFT. In fact, at T1, no differences
were detected between the spike positions of the different
couples of muscles (46% for TA, 38% for MM, 48% for
SM), whereas, at T2, a significant difference was observed
between masticatory muscles and SM: the spike positions
of TA and MM were anticipated (38% for TA, 36% for MM)
and the spike position of SM was postponed (52%). This
confirms the results observed in healthy subjects character-
ized by an earlier activation of masticatory muscles than
SM [15, 17].
In summary, a shortening in the duration of activation, an
increase in the activity of SM, and a general redistribution of
the muscular activity toward the “healthy model” have been
observed thanks to the ssEMG analysis.
T1 T2
Range Mean SD Mean SD
0–1 0.73 0.46 0.67 0.49
2–10 7.80 1.82 8.47 1.30
8 8
6.5–9.5 8–9
32–103 88.00 8.41 96.33 4.30
89 98
75.5–94 91.5–99
To analyze the changes on oro-facial structures and func-
tions, the Italian version of the OMES protocol was used in
order to provide a semi-quantitative measure of the quali-
tative clinical judgement. The validity of the OMES had
already been tested for clinical applications but in a differ-
ent population than the one targeted in the present study
[19]. In our sample, the MFT showed a significant effect on
the oro-facial structures and function as measured by the
OMES “Appearance and posture”, “Mobility”, and “Func-
tions” subscales.
The OMES protocol allowed to detect the positive effects
of the MFT on the coordination between orofacial muscles,
tongue, lips and masticatory muscles during deglutition was
provided, thus confirming the theoretical principles under-
lying the benefits induced by this therapy [2, 22, 23] and
suggesting that after MFT the new functional scheme has
been memorized and the greater awareness involves greater
control and greater commitment during swallowing.
According to Van Dyck [9] after MFT not all the children
perform a correct swallow, thus indicating that in some cases
longer training or longer time is needed to achieve a correct
conscious swallow. In the present study the 10 sessions were
sufficient to achieve and generalize the normal swallowing
oral pattern. However, the myofunctional protocol has to be
adapted to the needs of every individual [2, 9].
In the present work, all the patients treated satisfied the
requirement of a correct swallowing activity from a func-
tional point of view, without the need of orthodontic therapy
to improve the function. Nevertheless, as previously sug-
gested [24], also in this case orthodontic treatment should
follow the MFT to provide a better occlusal stability over
time.
In this study we detected the effects provided by the
MFT in a group of patients showing AS despite of the tim-
ing of treatment. In fact, the literature lacks on evidence
about the priority between orthodontics or MFT, with
contrasting experts’ opinions on this issue [1]. According
to Mason, in case a posterior crossbite occurs, orthodon-
tics should be performed before MFT [25]. According to
13

Proffit, the priority should be given in assessing a frontal
dental contact [1]. The ideal age to start the MFT is still
debated. Some authors recommend MFT treatment before
the age of 10 years [26, 27]. However, others suggest to
wait at least until patients are 10 years of age because of
the possibility of spontaneous closure of the AOB [1].
Also, we have focused on patients with second dentition
completed because they show a greater skeletal develop-
ment, a higher compliance and a better occlusal stability
than patients with mixed dentition. Therefore, they better
fit with the characteristics required to carry on this study
and to obtain more reliable results.
Patients with AS show impaired gnostic sensibility of
the tongue [28, 29]. Even if it has still to be determined
whether oral sensory perception can be improved with
MFT [9], we can speculate that this training may help to
create a new motor scheme involving different muscles
coordinated by the cortex and subcortex deglutition cent-
ers. As already suggested, the neuro-physiological basis
for correction of the AS consists in a neuromuscular adap-
tation based on a somato-sensitive feedback [30].
Unfortunately, the absence of long-term data in this
study and from other researches reporting positive effects
of MFT [21, 31, 32] does not allow to define with certainty
its effectiveness over time.
Nevertheless, ssEMG device and OMES protocol con-
firm themselves to be fast, valid, reliable method that
quantitatively and qualitatively permit the clinician to
obtain useful information for diagnosis [20] and to meas-
ure the effects of treatment in patients with OMD.
Finally, further research is needed to understand fac-
tors influencing the outcome of OMD, in order to better
define the timing and the criteria to select the appropriate
patients.
Conclusions
Atypical swallowing confirms itself as a functional anom-
aly of the stomatognathic system, able to affect both the
activity and the duration of all the muscles involved. MFT
appears to be significant in improving functional perfor-
mance, by the redistribution of muscular activity between
the different couples of muscles involved and by reducing
the duration of the total swallowing act.
Acknowledgements  The authors would like to acknowledge Giorgia
Crimi and Monica Vanoncini for their valuable work in data collection.
Funding  The work was supported by the Department of Biomedical
Surgical and Oral Sciences and the Department of Clinical and Bio-
medical Sciences “L. Sacco” of the University of Milan.
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European Archives of Oto-Rhino-Laryngology
Compliance with ethical standards 
Conflict of interest  The Author declare they have no conflict of inter-
est.
Ethical approval  All procedures performed in studies involving human
participants were in accordance with the ethical standards of the insti-
tutional and national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
Informed consent  All patients enrolled to this study were invited to
sign an informant consent and the study protocol was approved by the
local ethic committee of University of Milan (Code: DG-EMG-2016).
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