progress in orthodontics 1 3 ( 2 0 1 2 ) 57–68

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journal homepage: www.elsevier.com/locate/pio

Original article

Myofunctional and speech rehabilitation after

orthodontic-surgical treatment of dento-maxillofacial
dysgnathia

Gianluca Gallerano a , Giovanni Ruoppolo b , Alessandro Silvestri c,∗

a DDS Degree in Dentistry
b (MD) Doctor of medicine; Ear, Nose and Throat Specialist (ENT); Specialist in Phoniatry;
Associated Professor of Phoniatry and Audiology, Department of Sense Organs, “Sapienza” University of Rome
c (MD) Doctor of Medicine; Ear, Nose and Throat Specialist (ENT); Specialist in Dentistry and Stomatology (DDS);

Specialist in Orthognatodontics; Associated Professor of Orthodontics, Department of Dental Sciences,“Sapienza” University of Rome

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: The lingual dysfunctions play a considerable role in the pathogenesis of
Received 6 February 2011 dentoskeletal dysmorphisms. The treatment of dento-maxillofacial dysgnathia implies
Accepted 31 August 2011 a functional rehabilitation to re-harmonize the stomatognathic system. This study
aims to demonstrate the importance of a rehabilitation protocol of functional orofacial
Keywords: parameters at the end of a surgical-orthodontic treatment in order to achieve long-term
Dento-maxillofacial dysgnathia success.
Myofunctional therapy Materials and methods: After orthognathic surgery, facial expression exercises and jaw exer-
Post-surgical re-education cises are prescribed to promote the recovery of neuromuscular function. At the end of
Retainers treatment, a sample of 30 dysgnathic patients underwent a functional evaluation of the oro-
Speech therapy facial district to identify any lingual or articulatory dysfunctions. The information gathered
led to an individual re-education program that consisted of an active myofunctional-
logopedic approach integrated with appliances used as retention.
Results: 19 patients needed myofunctional therapy to re-educate deglutition and tongue
posture. Articulatory disorders were found in 7 patients originally suffering from Class III
and/or open-bite skeletal disharmony; 5 of these completed rehabilitation with speech
therapy. After rehabilitation the functional parameters were completely normalized in
12 patients; in 5 cases, partial improvements were obtained, while in 2 cases the therapy was
ineffective.
Conclusions: In a patient undergoing post-surgical reconsolidation of his/her functional equi-
librium even an uncontrolled speech defect may lead to an instable result. Only through an
interdisciplinary approach it is possible to intercept and re-educate all the functions that
are not compliant with the structural changes and to eliminate a tendency to relapse of the
dysgnathia.
© 2011 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved.

∗
Corresponding author. Department of Dental Sciences, Viale Regina Elena 287/A - 00161 Rome, Italy.
E-mail address: alessandro.silvestri@uniroma1.it (A. Silvestri).
1723-7785/$ – see front matter © 2011 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved.
doi:10.1016/j.pio.2011.08.002
58 progress in orthodontics 1 3 ( 2 0 1 2 ) 57–68
1. Introduction
Dento-maxillofacial dysgnathia must be placed in a global,
morphological and functional context of the stomatognathic
system, where alteration of any one of its components
impacts on the others to which it is closely linked (Fig. 1). The
treatment of dysgnathia involves the re-harmonization of all
the components of the stomatognathic system both from a
structural and functional point of view. The combination of
dental malocclusion and skeletal malformation requires the
use of combined orthodontic and surgical treatment. Particu-
lar attention should be given to the tongue, since orthognathic
surgery leads to volumetric changes of the functional space
in which it is situated and in which it carries out its functions.
Changes in the morphology and function of the tongue can
play a decisive role in the pathogenesis of malocclusions
and sometimes also in maxillo-mandibular skeletal changes.
Proffit [1,2], in particular, emphasizes the morphogenetic
role of tongue posture, by claiming that the growth pattern
is mostly influenced by the rest position of the soft tissues
rather than by their active movement. In fact, the number of
swallows per day is between 500 and 1000, and since each one
lasts on average 1.5 seconds [3] it is deduced that swallowing
takes place for a total of less than 30 minutes throughout
the entire day [4,5]. Under this perspective, the fact that the
tongue remains in its rest position for more than 20 hours
per day and that a slight force applied for an extended period
can move the teeth and influence the growth of the bone
structure, is of greater concern. In mature individuals, the tip
and the blade of the tongue while are at rest, are usually in
contact with the front third of the palatal vault, in an area
between the transverse palatine folds and the incisive papilla,
while the edges lay on palatal dento-alveolar structures [4–6].
Fig. 1 – Functional relationship between the components
of the stomatognathic apparatus (SGA): neuromuscular
system (NMS), dento-periodontal apparatus (DPA),
temporomandibular joint (TMJ), basal skeletal system (BSS).
However, there are numerous atypical tongue postures that
are related to the pathogenesis of some dysgnathic clinical
pictures:
• a forward posture of the tongue can lead to an anterior
open-bite by hindering the eruptive process of the teeth
while a lateral posture can lead to a unilateral or bilateral
posterior open-bite [7] (Fig. 2). During swallowing the inter-
position of the tongue between the arches can occur in order
to establish a seal;
• in oral breathers, a low tongue posture, associated with the
low tone of the masticatory muscles, can promote tooth
extrusion thereby inducing mandibular posterior rotation
and encouraging the development of a long-face syndrome
[5];
• in Class II malocclusion the tongue can be positioned
upward and forward, resting on the upper front teeth, or
it can be pulled back [5];
• in Class III malocclusion the tongue can be positioned
downward and forward, pushing the mandible in a forward
direction and stimulating excessive growth (Fig. 3). Further-
more, failure to act on the maxillary sutural growth may
cause hypoplasia of the maxilla [5];
• in dento-alveolar biprotrusion the tongue rests against the
lingual surface of both arches and it does not find effective
resistance from the lip muscles [5].
The development of the dental arches and skeletal base is
determined by the balance between the muscles inside the
mouth that promote expansion, and the concentric action of
the external muscle [8]. It is therefore important that both
tongue and lips posture be maintained within physiological
limits, so that a normal osteo-muscular complex develops and
normal vegetative and relational functions are carried out. The
tongue in rest position represents, in particular, the moment
in which each functional cycle begins and terminates [5]. In
presence of an abnormal rest position of the tongue, atypical
deglutition and/or abnormal word articulation may develop.
The vocal apparatus is made up of the lips, tongue, dental
arches and palate where the phonatory air flow is interrupted
in various ways, thereby articulating the phonemes, the basic
sound units of language. Articulatory disorders are defined
as dyslalia, divided according to their origin in “functional”,
“organic”, “audiogenic” and “neurogenic” [9]. The first are the
result of incorrectly set mobile structures involved in the artic-
ulatory mechanism while the latter are the consequence of
morphological changes, congenital or acquired, in the reso-
nant cavity and articulation organs [9–11]. A fully-developed
dysgnathia can predispose to language disorders as it can pro-
duce changes in the shape and volume of the oral cavity [12].
On the other hand, the gradual progression to dysgnathia,
provides sufficient time to implement those compensatory
mechanisms that make it possible to capture correct articu-
latory patterns [13]. Sometimes dyslalia not only develops as
a result of serious dysgnathia, to the point that it hinders adap-
tation mechanisms, but it also can be the result of functional
changes acquired in childhood and which have not regressed
due to pathological (audiogenic and neurogenic dyslalia) or
environmental factors.
The presumed pathogenetic role of dyslalia is debated:
for Giannì [14] it plays a crucial role in the genesis of mal-
occlusions, while according to Proffit [1,2,15], dyslalia alone
 progress in orthodontics 1 3 ( 2 0 1 2 ) 57–68
Fig. 2 – Abnormal posture of the tongue with frontal (A) and lateral interposition (B).
cannot be the cause of malocclusions. According to Marchesan
et al. [16] and to Campiotto [17] the majority of dysgnathic
patients do not need a re-education because usually altered
functions would fit the new shape satisfactorily not requir-
ing a specific approach. On the other hand, D’Agostino [18]
states that all his cases necessitate a re-education because in
his opinion this kind of patients have functional abnormal-
ities that surgery itself is not able to solve. Cimmino et al.
[19] reported that after orthognathic surgery the functional
adaptation does not occur spontaneously but a re-education is
needed to correct functional attitudes otherwise irreversible.
In our experience it is very important to guide the func-
tional recovery of the stomatognatic apparatus in dysgnathic
patients undergoing orthodontic treatment and maxillofacial
surgery.
The present study, therefore, aims to highlight the impor-
tance of neuromuscular re-education in order to achieve
long-term success in the treatment of dento-maxillofacial
dysgnathia. The present study will also illustrate the
main post-surgical rehabilitation strategies adopted at the
Orthodontic Service of the Department of Dental Sciences
at the “Sapienza” University of Rome. The role that this
approach should assume as part of the treatment plan
Fig. 3 – Typical lower tongue resting position in Class III
dysgnathia.
59
will be demonstrated through the analysis of a sample of
30 patients.
2. Materials and methods
A sample of 30 adult patients suffering from dento-
maxillofacial dysgnathia subjected to orthognathic surgery in
the years 2008-2009 was analyzed. Only patients with “good”
and “excellent” treatment results were selected, which con-
firmed that the structural pathology was resolved. Complex
malformations with specific involvement of the neuromus-
cular system, such as hemifacial microsomia and cleft lip
and palate, were excluded from the sample. Table I shows a
schematic layout of the “diagnosis” and “therapy” for each
case. Based on the original dysgnathia, we identified three
groups consisting of 8 patients with Class II skeletal rela-
tionships, 11 patients with Class III skeletal relationships
and 11 patients with dentoskeletal open-bite associated or
not with an alteration on the sagittal plane (2 patients with
Class I skeletal relationships, 2 patients with Class II skeletal
relationships and 7 patients with Class III skeletal relation-
ships). In total therefore, there were 10 subjects with Class II
skeletal relationships, 18 subjects with Class III skeletal rela-
tionships and 2 subjects with Class I skeletal relationships.
All patients underwent pre-surgical orthodontics and orthog-
nathic surgery.
Due to rigid internal fixation, an intermaxillary block was
not required at the end of surgery and all patients left the
operating room free to open and close the mouth sponta-
neously. Post-surgical treatment started about 15 days after
orthognathic surgery. The muscles must regain a physiological
condition of tone and synergy, and the patient must grad-
ually become aware of the proprioceptive changes in both
dento-periodontal and musculo-skeletal districts. To acceler-
ate these processes all patients were instructed to perform
exercises of facial expression and simple jaw exercises. The
first consisted in alternating forced smiles with lip protru-
sions and in inflating lips and cheeks. These exercises, to
be carried out for at least 6-8 weeks [20], were aimed at
extending scars and thereby strengthening muscles and lip
contraction. Jaw exercises had to be performed in front of
 60
Table I – *Caption: AG (Agenesis); CL (dento-skeletal class); MC (Maxillary contraction); DB (Deep-bite); ID (Intermaxillary disjunction); TMD (temporomandibular
disorder); RCF (Result of condyle fracture); ELN (Envelop Lingual Nocturn of Bonnet); EX (Dental extraction); GP (Genioplasty); IN (Dental inclusion); MLD (Mandibular
laterodeviation); LF (Long-face); LFI (Le Fort I osteotomy); OB (Open-bite); PO (Presurgical orthodontics); BSSO (Bilateral sagital split osteotomy); RG (Class III retainer with
lingual grid); RP (Rhinoplasty); SR (Splinted retainer); SF (Short-face); ST (Speech therapy); MFT (Myofunctional therapy for lingual posture and deglutition).

POST-TREATMENT OROFACIAL EVALUATION

N° NAME AGE GENDER DIAGNOSIS THERAPY OPINION DEGLUTITION TONGUE ARTICULATION PERIORAL RESTRAINTS MFT* ST
POSTURE DISORDERS MUSCLES

1 S. M. 32 M CL*II; DB* EX* 1.4,2.4 + PO* + BSSO*-GP* EXCELLENT NORMAL BACKWARD ----- NORMAL SR* ----- -----
2 B. A. 17 F CL II; DB; IN* 1.3,2.3,3.3,4.3 EX 1.3,2.3,3.3,4.3 + PO + BSSO-GP EXCELLENT ATYPICAL NORMAL /r/ UNBALANCED SR YES YES
3 E. F. 25 M CL II; DB; SF* EX 1.8,2.8,3.8,4.8 + PO + BSSO GOOD NORMAL NORMAL ----- UNBALANCED SR ----- -----
4 M. A. 26 M CL II PO + BSSO-GP EXCELLENT NORMAL NORMAL ----- NORMAL SR ----- -----
5 L. A. 26 F CL II; MC* PO + LFI*-BSSO GOOD NORMAL BACKWARD ----- NORMAL SR ----- -----
6 A. M. 26 F CL II; TMD* PO + LFI-BSSO GOOD ATYPICAL NORMAL ----- UNBALANCED SR YES -----

progress in orthodontics 1 3 ( 2 0 1 2 ) 57–68

7 S. P. 27 F CL II PO + LFI-BSSO GOOD NORMAL FORWARD ----- NORMAL SR YES -----
8 C. S. 17 F CL II EX 1.4,2.4 + PO + LFI-BSSO EXCELLENT NORMAL NORMAL ----- NORMAL SR ----- -----
9 M. A. 21 F CL III PO + LFI-BSSO GOOD NORMAL NORMAL ----- NORMAL RG* ----- -----
10 P. E. 28 M CL III; MC PO + LFI-ID* EXCELLENT ATYPICAL DOWNWARD /t/d/ NORMAL RG YES -----
11 D. M. 19 F CL III EX. 1.8,4.8 + PO + LFI-BSSO EXCELLENT NORMAL NORMAL ----- NORMAL RG ----- -----
12 P. C. 32 F CL III PO + LFI-BSSO EXCELLENT NORMAL DOWNWARD ----- UNBALANCED RG YES -----
13 P. A. 19 M CL III EX 3.8,4.8 + PO + LFI-BSSO EXCELLENT ATYPICAL DOWNWARD ----- NORMAL RG YES -----
14 L. M. 18 M CL III; TMD; AG*1.3,2.3; MC PO + LFI-BSSO EXCELLENT ATYPICAL DOWNWARD /s/dz/gi/ UNBALANCED RG YES YES
15 S. R. 24 M CL III; IN 2.3 PO + LFI-BSSO GOOD ATYPICAL DOWNWARD ----- UNBALANCED RG YES -----
16 M. M. 28 F CL III; MLD* PO + LFI-BSSO EXCELLENT NORMAL FORWARD ----- NORMAL RG ----- -----
17 R. M. 25 M CL III; MLD; TMD PO + BSSO EXCELLENT ATYPICAL DOWNWARD ----- NORMAL RG YES -----
18 C. T. 17 M CL III; MLD EX 1.8,3.8,4.8 + PO + LFI-BSSO-RP* EXCELLENT ATYPICAL DOWNWARD ----- UNBALANCED RG YES -----
19 M. G. 30 M CL III; LDM-RCF* PO + LFI-BSSO-RP EXCELLENT NORMAL NORMAL ----- NORMAL RG ----- -----
20 R. I. 20 F OB* ant.; LF* PO + LFI-BSSO EXCELLENT ATYPICAL FORWARD ----- UNBALANCED ELN* YES -----
21 R. F. 26 F OB ant.; MLD PO + LFI-BSSO EXCELLENT ATYPICAL NORMAL ----- NORMAL ELN YES -----
22 P. D. 22 F OB ant.; CL II; LF PO + LFI-BSSO GOOD ATYPICAL FORWARD ----- UNBALANCED ELN YES -----
23 V. E. 25 M OB ant.; CL II; MC PO + LFI GOOD ATYPICAL FORWARD /s/z/ /t/ UNBALANCED ELN YES YES
24 V. S. 19 F OB ant.; CL III; TMD EX 1.8,2.8 + PO + LFI-BSSO EXCELLENT ATYPICAL DOWNWARD ----- UNBALANCED RG YES -----
25 S. W. 18 M OB ant.; CL III PO + LFI-BSSO EXCELLENT ATYPICAL DOWNWARD ----- NORMAL RG YES -----
26 S. D. 19 F OB ant.; CL III; LF EX 3.8,4.8 + PO + BSSO GOOD ATYPICAL FORWARD /t/s/ UNBALANCED ELN YES YES
27 P. V. 22 M OB ant.; CL III; LF EX 1.8,2.8,3.8,4.8 + PO + LFI-BSSO EXCELLENT ATYPICAL DOWNWARD /t/d/s/z/ UNBALANCED ELN YES YES
28 L. E. 21 F OB ant-lat.; CL III; MLD EX 1.4,2.4 + PO + LFI-BSSO GOOD NORMAL NORMAL ----- NORMAL RG ----- -----
29 G. C. 21 M OB lat.; CL III EX 1.5 + PO + LFI-BSSO GOOD ATYPICAL DOWNWARD /gi/ NORMAL RG YES -----
30 T. S. 27 F OB lat.; CL III PO + LFI-BSSO EXCELLENT NORMAL NORMAL ----- NORMAL RG ----- -----

Class II Classe III Open-bite

 progress in orthodontics 1 3 ( 2 0 1 2 ) 57–68
Fig. 4 – Post-surgical functional assessment reports in dysgnathic patients (A,B).
a mirror 2 times a day for 5 minutes and they consisted in
active mouth opening and closing movements on the right
and left side, and slight protrusions to gently move the
mandibular structure. TMJ was also monitored at this stage,
to ensure that no dysfunction occurred. The post-surgical
orthodontic phase usually lasted 4-6 months, at the end of
which fixed appliances were removed and removable reten-
tion appliances were applied. At the end of the treatment, a
comprehensive re-assessment of the cases was carried out:
the radiographic and photographic records from the start to
the end of the treatment were compared and the therapeu-
tic phases analyzed so that an appraisal of the aesthetic and
structural results of the treatment (poor, fair, good, excel-
lent) could be performed. While the goal of this treatment
was the global morpho-functional re-harmonization of the
stomatognathic apparatus, a thorough assessment of the neu-
romuscular component was also necessary. The position of
the tongue, deglutition and speech also had to be re-assessed
carefully so that functional reconditioning with the structural
changes made could be completed. Therefore, a post-surgical
orofacial evaluation and rehabilitation program was carried
out in collaboration with the Phoniatrics Operations Unit of
the Department of Sense Organs at the “Sapienza” University
of Rome. The protocol was applied to the sample of 30 adult
patients. At the end of the post-surgical orthodontic phase the
patients, free from the interference of orthodontic brackets,
61
underwent a functional assessment of the orofacial district
in order to identify any dysfunction and to assess its extent.
To standardize the assessment, carried out by clinical meth-
ods, the data were collected in a specially designed folder
(Fig. 4). In its implementation, reference was made to the
orthodontic and functional assessment folder currently in use
at our Orthodontic Unit for growing patients with orthodon-
tic relevancy. This folder was re-adapted to the anatomical
and functional characteristics of adult dysgnathic patients. A
brief anamnesis was followed by an analysis of the orofacial
muscles focused on the anatomical and functional character-
istics of the lips and tongue in static and in dynamic phase.
Data collection was completed by an assessment of the pho-
netics carried out by a speech therapist. In Table I under the
heading “orofacial post-treatment assessment” there are data
concerning “deglutition”, “tongue posture”, “articulation dis-
orders” and “perioral muscles”. The indications provided by
the examination made it possible to obtain, where neces-
sary, an individual re-education program by integrating two
different strategies: on one hand an active myofunctional-
logopedic approach in which the patient actively participated
in correcting tongue posture and improper functions,
and on the other a passive approach, with the help of
re-educational aids.
During the months of April-May 2011, the 19 patients sub-
jected to myofunctional and speech therapy were re-checked
62 progress in orthodontics 1 3 ( 2 0 1 2 ) 57–68

Table II – ELN (Envelop Lingual Nocturn of Bonnet); RG (Class III retainer with lingual grid); SR (Splinted retainer); ST
(Speech therapy); MFT (Myofunctional therapy for lingual posture and deglutition).

Class II Class III Open-bite

using the same evaluation criteria adopted after the surgical- possible to use the “proprioceptive neuromuscular facilita-
orthodontic treatment to verify the functional status and the tion” (PNF) technique [4,5,22]. This is a method where the
possible permanence of lingual function abnormalities. The neuromuscular response evoked by stimulating various kinds
results of this last assessment are reported in Table II. of proprioceptors (for example, deep pressure on the edge or
The re-education of tongue posture and deglutition consisted back of the tongue) would exclude a conscious understand-
of a preliminary phase aimed at “restoring proprioception,” ing of posture practice [4,22] (Fig. 5). The exercises used in the
which follows a phase of myofunctional re-education, more PNF method favor proprioception, since they increase sensi-
properly characterized by “muscle exercises” and “functional tivity of the mucous membrane and the tongue tone, making
recovery” [4]. In order to develop oral proprioception of the
new oral space, the patient was asked to slide the tip of the
tongue over the palate in all directions, and to differentiate
between smooth areas and wrinkled areas [21]. This is impor-
tant for the identification of the incisive papilla that can be
facilitated by pressing it down with a blunt instrument or
the tip of the index finger [6] The next exercise required the
mouth to be opened, the tip of the tongue in contact with
the papilla, and the back of the tongue raised and flattened
against the palate. This position has to be maintained for
5 seconds before removing the tongue from the palate, with
the tongue tip still on the papilla. In this way, apart from
encouraging proprioception, the second tongue movement
is traced during deglutition (“pharyngeal phase”). Therefore,
after achieving a satisfactory result, the sequence of move-
ments will be completed by bringing the dental arches in
occlusion and swallowing the saliva. Alternatively, especially Fig. 5 – Deep pressure on the sides of the tongue with
in subjects with spastic or hypotonic tongue muscles, it is a blunt instrument.
 progress in orthodontics 1 3 ( 2 0 1 2 ) 57–68
Fig. 6 – Exercise with a single elastic for tongue posture.
the tongue narrower and improving its ability to adapt to
the palatal vault. The position of the tongue is greatly influ-
enced by its muscle tone [4,21], like during deglutition and
the emission of certain phonemes, and, therefore, suitable
tongue muscle tone is required. It is especially in Class III mal-
occlusions that the tongue, apart from having a low posture,
is hypotonic and therefore increased in size. In these cases,
“muscle exercise” is carried out to balance the different mus-
cle groups. The apex is toned by pushing the tongue against
a tongue depressor placed in front of the mouth. In order to
increase the tone of the body of the tongue, the patient is
trained to “click” the tip of the tongue against the palate, while
to increase the tone of the base an opposing traction is created
by grabbing the tongue with a gauze and pulling. During the
“functional recovery” phase to re-educate tongue posture we
also use the Garliner method [5,6,23]: an intermaxillary elastic
(5/16” and 6 oz) is placed on the tip of the tongue and subse-
quently brought into contact with the papilla, with the dental
arches slightly open (Fig. 6). A variant is that another elastic
is placed between the lips, thereby also strengthening lip con-
traction. The elastics should be kept in place for 5 minutes,
3 times a day for the first week, gradually increasing the time
to one hour per day. Within 2-3 months the resting position
will become automatic. Lastly, re-education of the deglutition
is obtained by practicing to swallow small amounts of water
collected between tongue dorsum and palate. This exercise
should be initially carried out at lunch and dinner for 5 consec-
utive times; gradually the patient will be able to increase the
amount of water held in the mouth and carry out this exercise
outside meal times as well. If the patient is not able to sup-
port sufficiently the tongue against the palate, it may be useful
to carry out the exercise by biting a straw placed horizontally
at the level of the canines, in order to provide support for the
tongue and help lift it to the level of the premaxilla [24] (Fig. 7).
Language re-education begins after myofunctional treatment
since the treatment could indirectly lead to an improvement
of the pronunciation disorder. An adult will encounter more
difficulties in correcting his/her dyslalia, which is more
consolidated and deep-rooted than a child. On the other
hand, together with a greater degree of cooperation, there
is the advantage that by correcting the dysgnathia the
anatomical structure is more consonant with the evolution of
63
Fig. 7 – Deglutition using a straw placed horizontally at the
intercanine level.
phono-articulatory mechanisms. Logopedic rehabilitation
includes various successive stages: brief orofacial exercises,
vocalization exercises and lastly, speech therapy exercises.
First of all, the patient must be aware of how the altered
phoneme is produced and the way in which it should be
normally produced. For the Italian language the stimula-
tion of the phoneme proceeds in ascending order, first by
proposing direct (sc) and inverse (cs) pronunciation of sylla-
bles (sc), and then proceeds with words containing the syllable
in combination with other phonemes. The next step is to work
on the word with the phoneme in initial, middle and end posi-
tions. At first, the repetition will be slower in order to allow for
conscious positioning, after which it will become automatic
through the use of redundant phrases, and subsequently com-
mon phrases. When there are various defective phonemes to
be re-educated, the preference is to begin with those that are
easier to simulate, until reaching those most difficult to cor-
rect (/s/r/). The dento-alveolar (/t/d/) and alveolar phonemes
(/l/n/), pronounced around the level of the incisive papilla,
are the least difficult to correct. An improvement of these
phonemes can be obtained simply by re-establishing the
physiological lingual posture. However, reinforcement exer-
cises may be useful. The sibilant phonemes (s,z,sc) are often
compromised because they require very precise movements
and an extremely small air outflow channel. Various devices
are used to help the patient to correct the lisp. If the phoneme
is omitted, the following steps should be performed: place the
tongue near the palatal surface of the lower incisors, lift the
back, draw the dental arches near and gently blow into the
gap between the upper incisors and the tongue. If problems
persist, a utility tool may be inserted to create a central chan-
nel at the tongue dorsum and the patient is invited to blow.
Alternatively, the patient may be asked to place the flattened
tongue between the teeth, blow and the pull it back to draw
the arches near [5]. In interdental lisp (the tongue tends to
creep in between the arches when pronouncing the “s”), first
of all it is necessary to press against the low position of the
mandible by placing one hand under the chin and placing a
tongue depressor in front of the incisors to prevent tongue
protrusion [5] (Fig. 8), after which the patient will exercise as
much as possible to emit a hissing sound. The re-education
64 progress in orthodontics 1 3 ( 2 0 1 2 ) 57–68
Fig. 8 – Exercise for correcting the interdental lisps.
of zed shifts must be the same as for lisps which is generally
easier. The main expedient suggested to patients when prac-
ticing to pronounce the “z” is to place a piece of paper on the
tip of the tongue, resting it on the upper incisors, and to try
to expel it while attempting to pronounce “za”. Post-alveolar
“gi” and “ci”, usually corrected after any zed shifts, are re-
educated by using a tongue depressor to push down on the tip
of the tongue, around mid-palate, while pronouncing the “ti”
syllable [10]. Rhotacism is more often a dyslalia of functional
Fig. 9 – Upper retainer with splinting of the upper arch.
Fig. 10 – Class III retainer with lingual grid and control arch for the lower front group (A,B).
origin; the exercises aim to develop the /r/ gradually from
other consonants, for example by rapidly emitting sounds like
“tla-tla” and “hda-hda” (d preceded by exhaled breath). Click-
ing exercises also make it possible to restore proper lingual
muscle tone, that is essential to perform the characteristic
vibration of the peak at the height of the retro-incisive papilla.
This can be facilitated with the aid of mechanical means:
with the mouth half-open an electric toothbrush without
bristles can be placed under the chin or under the tip of the
tongue resting on the papilla while pronouncing the sound
“trr” [25]. Bilabial (/p/b/m/) and labiodental (/f/v/) phonemes,
often pre-operatively affected due to structural impediments,
usually improve once the basal relations are normalized and
rarely require post-surgical re-education.
Restraining devices were routinely applied to the sample
of 30 patients to assist with the re-education. The retainers
represent an active means of restraint that can integrate the
re-education phase by encouraging the dynamic stabilization
of the occlusion and neuromuscular function. Based on the
original dysgnathia and on the individual functional char-
acteristics, each patient was assigned the most appropriate
device. In Class II dysgnathia, that is generally associated with
a lower lingual impairment, the splinted retainer was applied (in
8 patients). This retainer consisted of an upper Hawely plate,
with minimum interocclusal thickness, fitted with a small
retro-incisive flange to prevent mandibular displacement in
the distal direction (Fig. 9). In progenic syndromes a Class III
 progress in orthodontics 1 3 ( 2 0 1 2 ) 57–68
Fig. 11 – Bonnet ELN for the rehabilitation of tongue posture.
retainer was applied (in 16 patients), which consists of an upper
plate in resin fitted with a retro-incisive lingual grid and a
buccal retraction arch for the lower frontal group (Fig. 10). The
plate should not cover the entire arch but must be horseshoe
shaped and reduced to the minimum size necessary to incor-
porate the metal supports; the objective is to reduce the size
of the oral functional space and not prevent reciprocal tactile
stimulation between the tongue and palate. The vestibular
retraction arch originates from the plate and continues to the
lower frontal group, only touching lightly the surface of the
incisors and canines so that it does not cause any retrusive
action that might interfere with the neuromuscular function
of the TMJ. The therapeutic action of the grid is effective
mainly for the time it is applied [26], preventing tongue move-
ment in the front portion of the lower arch and redirecting it
to the top plate; furthermore, it prevents lingual interposition
between the arches during deglutition. It is shaped so as to
re-educate the tongue to a more backward position, guiding it
with a slight incline towards the premaxilla. For this reason,
it should not be too far back, but inserted behind the plate,
immediately behind the upper incisors. In this manner,
together with the restrictive effect, the plate with grid will
also serve to re-educate tongue position. In order to obtain
a re-educational effect only on the tongue, the use of Bonnet
Envelop Lingual Nocturn (ENL) is indicated. In our sample, we
applied this device to 6 patients (2 with simple open-bite, 2
with Class II open-bite and 2 with Class III open-bite). The aim
of this device is to create an obstacle-free environment that
helps the tongue to find its posture and normal function also
in those patients that have stopped growing. The ELN is made
of a thin intraoral resin shell which stimulates the active
ascent of the tongue through a lower lingual ramp up to a hole
in the opening near the palatine folds [27,28] (Fig. 11). The
side flanges prevent the tongue from interposing between the
arches, both in the front and posterior regions. The ELN does
not a simply exercise a restrictive action but it creates also
a normal architecture around the tongue, by uninstalling the
primary deglutition program and reinstalling the secondary
deglutition program from the very start of the therapy. The
device is applied at night and a few minutes during the
day (3 minutes 3 times a day) [27]. Contrary to myofunctional
65
therapy, based on conscious learning, the ELN takes advantage
of a mechanism that starts from the patient’s unconscious and
nocturnal sensory-motor to reach the cognitive awareness
[28].
3. Results
An evaluation of the sample of 30 cases is reported in Table I
where it can be noted that after the structural anomalies were
resolved, disrupted functions were present in many patients.
In patients treated to resolve the progenism, the tongue
generally continues to be hypotonic and low; the open-bite
group shows a more evident tendency to interpose the tongue
between the arches while in the Class II subjects lingual capa-
bilities are less involved. 19 out of the 30 patients required
an additional phase of myofunctional therapy to restore
proper tongue tone and posture, a physiological deglutition,
and possibly to complete the re-education of facial muscles
started immediately after surgery. Most patients belonged
to the open-bite group (9 of 11) and the Class III group
(7 out of 11). Pronunciation disorders were detected in 7 cases
and mainly concerned patients with prior Class III and/or
open-bite. In the latter group there is a prevalence of distorted
sibilants, in association with the interdental articulation of
dento-alveolar consonants. After myofunctional treatment,
5 patients completed the re-education process, undergoing
speech therapy sessions; in 2 cases, the articulatory disorder
regressed after an initial myofunctional approach.
The check carried out after the rehabilitation period
(Table II) revealed that the functional parameters of the
oro-facial district were completely normalized in 12 out of the
19 patients. Only in 2 cases the therapy was ineffective
(case n◦ 18 and n◦ 27), while in 5 cases we obtained a par-
tial improvement with persistence of atypical swallowing
(2 cases), abnormal tongue posture (1 case) or altered
phonemes (2 cases). About the patients who originally had
a speech disorder we observed a complete resolution in
4 cases, a partial resolution with correction of dento-alveolar
phonemes and persistence of abnormal sibilant phonemes in
1 case, no improvement in 2 cases.
66 progress in orthodontics 1 3 ( 2 0 1 2 ) 57–68
4. Discussion
The functional examination to which the patients of this
study were subjected showed that orofacial dysfunctions may
continue to persist after surgery, suggesting the feasibility of
active re-education. Functional adaptation may in fact be far
from occurring spontaneously over time, because the group of
muscles, and therefore the functions related to them, require
long re-manipulation under the new structural conditions. In
the early re-education phases the goal is to re-program mus-
cle and dento-periodontal proprioception. Adaptation to the
new occlusion is favored by the early removal after surgery of
the splint used as a surgical guide and by applying intermax-
illary elastics (usually one on each side measuring 3/16” and
weighing 4-6 oz) that guide the jaw into the correct spatial
position in the lower arch, in direct occlusal contact with the
antagonist. Even in the early stages of tongue re-education
the proprioceptive work is crucial and can induce an initial
impetus towards using correct lingual posture, which cannot
exclude a physiological deglutition pattern. Some authors
[29] re-educate deglutition by placing a sequence of elastics
on the tongue. We consider it useful to apply posture re-
education using a single elastic band since we believe that too
many elastic bands can cause proprioceptive discomfort and
reduce re-education benefits. Furthermore, since interposing
a foreign body between the tongue and palate would impede
proprioception [5,22,30,31], we believe that in adult patients it
is useful to use elastics only in early stages of re-education. It
is however very useful to practice swallowing liquids in order
to reproduce the natural retropulsive swallowing mechanism.
Several studies [19,32–34] show that despite the intervention,
the resulting change in the oral environment is not sufficient
to produce the desired effects on the phonetic quality. The
explanation for this latter circumstance is clear to us; adult
dysgnathic patients with language disorders, because of the
sudden change in the morpho-functional balance produced by
surgery, do not have the same functional adaptation capabil-
ity to correct the dyslalia as individuals in the growing phase.
Therefore, though aware that the treatment provides anatom-
ical structures suitable for implementing phono-articulatory
mechanisms, we believe that language recovery must be prop-
erly guided. For some authors [18,22,35,36] the re-education
approach should begin before surgery. Instead, we place
speech therapy-myofunctional training in the post-surgical
period. In fact, we believe that pre-surgery re-education would
be useless and even harmful because the neuromuscular sys-
tem is still adversely affected by dysgnathia, capturing only
a false functional equilibrium which, after the intervention,
must be changed and adapted to new structural features.
Since myofunctional treatment is intended for adult and
cooperative individuals, about 10 sessions (2 per week) are
sufficient. The possible language re-education phase lasts
three months, but certain dyslalia such as rhotacism and
lisps, may require more sessions. The evaluation of the group
of patients undergoing functional rehabilitation has in fact
shown the persistence in 3 cases of disturbances in the artic-
ulation of /s/, /z/ and /r/ phonemes that are more rooted in
the capabilities of the individual and therefore more difficult
to correct.
Generally a maintenance phase is not required but it is use-
ful to recheck the patient after a few months to verify that
automation is maintained. Naturally, re-education of lingual
functions does not exclude a constant daily commitment, con-
tinuing at home those exercises proposed from time to time
during the therapy. The viability of this type of protocol also
lies in the age of the persons to whom it is addressed, since it
involves adults that generally tend to be highly motivated and
therefore willing to accept the functional changes required by
the re-education treatment.
5. Conclusions
The present study showed that in the majority dysgnathic
individuals the functional habitus does not change substan-
tially even after surgical intervention. In order to ensure
the stability of the treatment results, a new structural and
functional equilibrium must be achieved to avoid tendency
towards relapse [37,38]. Post-surgical re-education requires a
interdisciplinary approach that makes it possible to intercept
and re-educate all the functions that are not compliant with
the new structural picture. After surgery, the surgeon entrusts
the task of guiding the functional recovery of the patient to
an orthodontic specialist. The first “post-surgical re-education
phase” coexists with post-surgical orthodontics and, there-
fore, the orthodontist is routinely involved in re-educating jaw
movements and mimic muscles. Once the fixed orthodontic
devices are removed, the assessment by the orthodontist is no
longer sufficient and supervision is required by a professional
specialized in assessing the functions of the orofacial dis-
trict. In particular, the lingual capabilities should be evaluated
by a voice specialist or speech pathologist who, if necessary,
will implement a second “speech therapy-myofunctional re-
education phase” aimed to harmonize the centrifugal force of
the tongue with the opposing forces of the peripheral mus-
cle housing. As stated by the principle of “etiopathogenetic
diagnosis” by Langlade, if the etiopathogenetic process is not
discovered and removed, the result will be relapse [39]. In
the treatment of dysgnathia this principle should be applied
to all possible changes within the concept of multifactorial
etiology [1,2]. In fact, if under normal conditions dyslalia in
itself is not capable of determining apparent structural alter-
ations, in a patient undergoing post-surgical reconsolidation
of his/her functional balance, even an uncontrolled speech
defect may lead to an unstable result. Only through active
re-education is it possible to change all the atypical motor
patterns and set new functional patterns compatible with the
new structural configuration. In fact, after surgery patients
tend to recall their original functional model and they are
not fully aware of the new one yet. It is the responsibility
of the clinician to guide the learning process and functional
adaptation, ensuring that the functional and postural atti-
tudes do not impede overall harmonious and stable treatment
results.
Conflict of interest
The authors have reported no conflict of interests.
 progress in orthodontics 1 3 ( 2 0 1 2 ) 57–68 67

Riassunto et/ou Classe III; 5 de ces patients ont complété la réhabilitation

avec une thérapie d’élocution. Après réhabilitation, les paramètres
Objettivi: Le disfunzioni linguali giocano un ruolo rilevante
fonctionnels ont été complètement normalisés chez 12 patients; dans
nella patogenesi dei dismorfismi dentoscheletrici. Il trattamento
5 cas, des améliorations partielles ont été obtenues alors que dans
delle disgnazie dento-maxillo-facciali implica una riabilitazione
2 cas la thérapie s’est avérée inefficace.
funzionale finalizzata alla riarmonizzazione dell’apparato
Conclusions: Chez un patient soumis à reconsolidation post-
stomatognatico. L’obbiettivo dello studio è quello di dimostrare
chirurgicale de son équilibre fonctionnel, même un défaut non
come, al termine del trattamento ortodontico-chirurgico, un pro-
contrôlé d’élocution peut déboucher sur un résultat instable. Ce n’est
tocollo di riabilitazione dei parametri funzionali oro-facciali sia
qu’au travers d’une approche interdisciplinaire qu’il est possible
importante per il raggiungimento del successo a lungo termine.
d’intercepter et de rééduquer toutes les fonctions qui ne s’accomodent
Materiali e metodi: Dopo la chirurgia ortognatica, vengono
pas au nouveau tableau structurel, cela éliminant aussi le risque de
assegnati esercizi di mimica facciale e di ginnastica mandibolare al
récidive de la dysgnathie.
fine di promuovere il recupero della funzionalità neuromuscolare. Al
termine del trattamento, un campione di 30 pazienti disgnatici è stato
sottoposto ad una valutazione funzionale del distretto oro-facciale al Resumen
fine di identificare eventuali disfunzioni linguali e di articolazione del
Objectivos: Las disfunciones linguales desempeñan un papel impor-
linguaggio. Le informazioni ottenute hanno permesso di ricavare un
tante en la patogénesis de los dismorfismos dentoesqueléticos.
programma individuale di rieducazione che consiste in un approccio
El tratamiento de la disgnacia dento-maxilo-facial conlleva una
attivo logopedico-miofunzionale integrato da dispositivi usati come
rehabilitación funcional con vistas a harmonizar de nuevo el sistema
contenzione.
estomatognático. Este estudio apunta a demostrar la importancia
Risultati: La terapia miofunzionale è stata necessaria per
de un protocolo de rehabilitación de los parámetros orofaciales fun-
19 pazienti al fine di rieducare la deglutizione e la postura lin-
cionales al final de un tratamiento ortodóncico quirúrgico para lograr
guale. Disturbi articolatori sono stati rintracciati in 7 pazienti
un éxito a largo plazo.
originariamente affetti da III Classe e/o open-bite dento-scheletrici;
Materiales y métodos: Después de la cirugía ortognática, se pre-
5 di questi hanno completato l’iter rieducativo con la rieducazione
scriben ejercicios de expresión facial y de la mandíbula a fin de
del linguaggio. Dopo la riabilitazione si è assistito alla completa nor-
promover la recuperación de la función neuromuscular. Al finalizar el
malizzazione dei parametri funzionali in 12 pazienti; in 5 casi si
tratamiento, una muestra de 30 pacientes disgnáticos fue sometida a
è ottenuto un miglioramento parziale mentre in 2 casi la terapia è
evaluación funcional de la región orofacial para identificar cualquier
risultata inefficace.
disfunción lingual o de articulación. La información recogida llevó a
Conclusioni: In un paziente in fase di riconsolidamento post-
un programa de reeducación individual que consistió en un enfoque
chirurgico del proprio equilibrio funzionale anche un difetto del
logopédico miofuncional integrado con aparatos utilizados como
linguaggio non controllato può determinare un’instabilità del risul-
medios de retención.
tato. Solo attraverso un approccio interdisciplinare è possibile
Resultados: 19 pacientes necesitaron terapia miofuncional para
intercettare e rieducare tutte le funzioni non compatibili con la nuova
reeducar la deglución y la postura de la lengua. Fueron encontrados
configurazione strutturale eliminando la tendenza alla recidiva della
trastornos de articulación en 7 pacientes que sufrían originariamente
disgnazia.
de desarmonía esquelética open bite y/o Clase III; cinco pacientes
completaron la rehabilitación con terapia del habla. Después de
Résumé
la rehabilitación, los parámetros funcionales se normalizaron en
Objectifs: Les dysfonctions linguales jouent un rôle significatif sur la 12 pacientes; en 5 casos se consiguieron mejorías parciales mientras
pathogenèse des dysmorphismes dento-squelettiques. Le traitement que en 2 casos la terapia fue inefectiva.
de la dysgnathie dento-maxillo-faciale entraîne une réhabilitation Conclusiones: En un paciente sometido a reconsolidación
fonctionnelle dans le but de réharmoniser le système stomatogna- posquirúrgica de su equilibrio funcional, incluso un defecto no con-
tique. Cette étude vise à démontrer l’importance d’un protocole de trolado del habla puede acarrear un resultado inestable. Sólo a través
réhabilitation des paramètres orofaciaux fonctionnels à la fin d’un de un enfoque interdisciplinario es posible interceptar y reeducar
traitement orthodontique chirurgical pour obtenir un succès à long todas las funciones que no se ajustan al nuevo cuadro estructural,
terme. eliminando al tiempo el riesgo de reincidencia de la disgnacia.
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