Neuromuscular rehabilitation of functions 

Neuromuscular rehabilitation of functions 

Introduction : 

Neuromuscular rehabilitation aims to modify the defective CNM with or without equipment, both at rest and during function, by using intrinsic muscular forces, in order to achieve harmonious growth without resorting to direct mechanical action devices.

However, this therapy has certain limitations related to biological data and therapeutic means. Therefore, its clinical application requires special attention from the orthodontist, who must give capital importance to the clinical examination, in order to make the correct diagnosis and establish the most appropriate therapy.

1. Reminders: 

1.1- interaction: form – function: 

There is a very close correlation between the morphology of a structure and the functional matrix, one is modified under the influence of the other. As a result, two major currents are distinguished: a first: mechanistic, and a second: functionalist:

1.1.1- Mechanist theory (Americans): 

The unanimous of this theory think that function follows form, that is to say that dysmorphoses are at the origin of dysfunctions. They advocate the correction of these dysmorphoses by the use of mechanical forces. The restoration of the function will be done simultaneously.

1.1.2- Theory of functionalists (Europeans): 

In this theory, it is function that creates form. According to ROUX, skeletal development disorders originate from postural defects and dysfunctions of the support apparatus. The morphogenetic activity of soft tissues (functional matrix) guides growth and remodels:

• On the one hand, the alveolo-dental system (CHÂTEAU corridor)
• On the other hand, the bony bases   determine the ratio of the maxillae. 

1.2- Functional anomalies:

The balance between antagonistic muscles during orofacial functions results in harmonious alveolar and skeletal development:

This balance is broken in the case where there exists:

-A dysfunction: Remember that a function is an activity carried out for the purpose of survival and adaptation to the environment of a living element, an organ or a system. Dysfunction is a disorder and a poor performance of the function that can be pathogenic.

-A parafunction: refers to a vicious habit, voluntary or unconscious, which is not necessary for life such as: thumb or object sucking, lip sucking, nail biting, bruxism, mimicry, mandibular prolapse, etc.

-A postural disorder: which designates an erroneous situation of the organ or skeleton at rest, this can concern:

The facial envelope: lips and cheeks.

The tongue: in relation to its shape, volume, and the insertion of its frenulum as well as the presence of vegetation or tonsillar hypertrophy in the pharyngeal region.

The craniospinal complex: that is, the way the head is supported by the spine. Some children who have difficulty breathing through their nose instead move their mandible forward, often with their head between their shoulders, leaning forward, with a fairly short neck.

2. Principles of neuromuscular rehabilitation:

Functional rehabilitation is any therapy that consists of correcting a dysfunction causing a dysmorphosis or eliminating a parafunction or a tic likely to disrupt good oral-dental balance. 

1.  Goals of functional rehabilitation:

Functional rehabilitation can be used in a preventive, interceptive, curative or restraint framework, with the following common objectives:

• Correction of abnormal neuromuscular behaviors (dyspraxias) in order to acquire new automatisms, and continue to normalize functions
• Restoration of a physiological functional environment by creating conditions for exercising a physiology that does not generate morphogenetic disorders: 
• Removal of pathological interpositions (lips, tongues, cheeks, fingers, objects). 

2. Means of functional rehabilitation 

Functional therapy uses non-mechanical methods early on and can resort to mechanical therapy (apparatus) at an advanced age.

1. Non-mechanical functional rehabilitation (or therapy):
2. Myotherapy: this is a form of gymnastics aimed at increasing muscle power and improving the function of certain deficient muscles: it therefore allows the dento-facial balance to be modified in the desired direction. 

It requires the voluntary collaboration of the subject, because the exercises are quite repetitive and the results take quite a long time to obtain, which makes it very random for most people. 

It consists of a series of muscular contractions, and the contractions must be broad, relatively slow, separated by short pauses, repeated ten to thirty times, until a feeling of slight local fatigue, and at a frequency of 3 to 4 times per day.

At what times? :

• It is desirable before orthodontic treatment to prevent the worsening of certain already existing deformations.
• It is difficult to undertake before the age of 8 or 9 (cooperation of the patient).
• Myotherapy remains possible at any age, especially when the oral environment is modified.

The disadvantages:

• Myotherapy must be continued throughout life. As soon as it is stopped, the muscles resume their initial function, unlike functional rehabilitation, the result of which is definitive once the normal circuit is established.
• It only gives results if it becomes a habitual attitude and not an intermittent daily exercise. 

Techniques:

• Mandible thruster gymnastics: 

In the case of retrognathia: Voluntarily and slowly move the mandible forward as much as possible and keep it propelled for 10 seconds, the movement should be repeated 10 times. 

Independently of this conscious myotherapy, certain passive devices (notably splints) cause unconscious muscular propulsion of the mandible throughout the day, and powerful intermaxillary tractions do the same.

• Gymnastics of the masticatory muscles: 

Toning of these muscles is done by myotensive exercises by chewing fluoride gum. This masseter muscle building can also be done by asking the patient to clench their teeth.

• Labial muscle gymnastics: 

This is required in the event of:

• Superior proalveolus.
• Lip occlusion due to shortness of the upper lip.
• Mouth breathing.
• Muscle hypotonia. 

Exercises for both lips: 

Cross-curricular exercises:

They consist of bringing the corners closer together, while an exerciser or simply 2 fingers oppose this movement with a slight pull directed outwards.

Vertical exercises: 

They consist of grasping between the lips (lips only) a metal disc or blade 3 to 4 cm long, 2-3 mm thick, and holding it horizontally for one minute at the beginning; the duration of the exercise and the weight of the disc are gradually increased. This exercise can also be done with a wooden tongue depressor held between the lips.

Exercises by GARLINER method

A button is placed vertically in the vestibule; previously, a thread will have been placed in the hole of the button. The two strands must come out on the same side, the patient pulls on the thread, the lips by their junction must hold the button in place.

Upper lip exercises: 

Upper lip toning exercise: 

The patient should hold his lower lip firmly, with his fingers as low as possible. He closes his mouth with his upper lip alone, lowering it as low as possible, 

Lower lip exercises: 

This involves raising the lower lip as high as possible on the upper lip and pressing it down firmly. This allows you to:

• Tone the lower lip
• Stretch the labiomental groove 
• Cause interesting mandibular propulsion
• Open the wings of the nose. 
• Buccinator gymnastics: 

The exercise consists of contracting the buccinator by stretching the corners of the lips ”  to make the smile from ear to ear  “, the teeth must be in occlusion without clenching during the exercise. 

• Gymnastics of the labio-mental musculature: 

The patient is asked to inflate this area as if he were inflating his cheeks, the air should smooth out the furrow and make it disappear. 

• Toning the floor of the mouth: 

Piston exercise 

• The patient controls his mylohyoid and geniohyoid muscles, which are essential for swallowing.
• The patient’s head is in a natural position relative to the spine. The patient must place the tip of his tongue on the most posterior palatine papillae, pressing very hard (pressure for 2 to 3 seconds then release) and repeat this exercise ten times in a row.
• He then places his fingers on the basilar edge of the mandible so that he feels the contraction. 
• Tongue toning
• Horse step exercise (clacking):

You are asked to click your tongue to imitate the sound of a horse’s hooves, 20 times in a row at first, then more as you progress.

To increase the difficulty, the patient will be asked to alternate distinctly the two sounds “clac” and “cloc”. In case of difficulty, do not hesitate to explain that the front part of the tongue must stick to the palate and detach itself like a suction cup. 

• Language support: 

Ask to push on a spoon or tongue depressor with the tip of the tongue held straight. 

• MACARY respiratory myotherapy: 

It is indicated in hypotonic and hyperdivergent mouth breathers.

The exercises are done using a 3mm square section rubber band, the length of the forearm. Each band ends at its end with a ring that fits over the thumb and at the other end with a small sort of very elongated hook that fits into 2 small rings on the bimaxillary retractor at the level of the canines. 

Breathing exercises during these movements ventilate the upper airways and excite nasal breathing. 

Neuromuscular rehabilitation of functions 

2. Functional rehabilitation without equipment:

b.1. Rehabilitation of breathing: functional rehabilitation of breathing is only possible if the airways are clear.

• Different exercises recommended:

The child tries to breathe gently through the nose in lip occlusion, in supine position, with eyes closed. He concentrates on the air, its path (abdominal breathing), his tongue, the different smells.

Work on the nasal muscles: do the pig, the rabbit (contraction of the upper nostril and labial lifters), dilate the nostrils by opposing them with the index finger and thumb. 

Adapted exercises: blow out a candle, head straight, flame on the axis of the nasal breath to extinguish it (by blocking the right and left nostrils alternately). 

       b.2. Swallowing rehabilitation

The child must first learn to place the tip and edges of his tongue on the palatine mucosa in the appropriate place, which the rehabilitation therapist sensitizes using a finger. 

He must then occlude the jaws in the usual position, then join the lips without exaggerated contraction. 

He then swallows his saliva without opening his dental arches, without moving the edges and tip of his tongue and without contracting his labio-jugal muscular strap. 

Swallowing rehabilitation techniques:

• Swallowing saliva: raise awareness of the existence of atypical swallowing, practice in front of a mirror a series of swallows with tight arches and lips apart in order to visualize its progress. 
• Swallowing liquids (sip): after acquiring salivary swallowing, the child swallows a small glass of water in successive sips, taking care to prevent water from leaking out (good tongue support).
• Swallowing solids: same work, the texture of the food will thicken from gelatinous (custards), to “soft” (compotes), then solid.

b.3. Rehabilitation of phonation: 

Rehabilitation of phonation must be carried out in conjunction with that of swallowing, since they are governed by the same neuromuscular effectors.

This correction concerns audible disorders (example: whistling, lisping), but also inaudible disorders (presenting only abnormal supports

It consists of:

• 1st step: to have all the consonants pronounced successively, to recognize those which are defective then we teach the subject to pronounce the consonant in its pure state, by showing him the correct supports when pronouncing the phonemes.
• Step 2: When the patient gets there, he must end the prolonged sound with a vowel. The patient is then asked to repeat these phonemes while being very aware of the supports.
• 3rd step: once the previous step is completed, we gradually shorten the consonant. Then, we will gradually move on to reading aloud words, then entire sentences, always monitoring the effector organ

b.4. Chewing rehabilitation: 

For preventive purposes, an adapted diet is recommended (a diet rich in fiber, of hard consistency that would force the child to perform correct chewing movements and therefore energize his masticatory system) and the removal of all painful carious foci responsible for a deviation or disruption of the masticatory function.  

        b.5. Rehabilitation of parafunctions:

Nothing replaces a gentle psychological approach to the child, by drawing his attention to the bad influence of his harmful habits. When a thumb sucker, for example, presents himself, the practitioner tries to support his words by showing him the casts of a child for whom the damage caused is more important than his own, who in a few months without a device (cast before and after) made his gap disappear by simply stopping sucking his thumb. The operator can even give him the means to stop his tic (which has become automatic), such as the use of adhesive bandages around the thumb, which allows the child to realize it in case of forgetfulness. 

2. Functional rehabilitation with equipment:

This is an education of neuro-muscular behavior through the use of a device that will aim to correct dyspraxia. This is used as a second intention, when the re-education of neuro-muscular behavior without equipment proves ineffective or useless. Several devices are available to us to overcome these behavioral disorders:

1. The nocturnal lingual envelope (NLE):

Also called a “slide” or “night tongue tunnel,” the ELN educates the tongue toward a “secondary” motor function that adapts to the pre-corrected anatomical framework. The tongue becomes the natural functional apparatus of the oral cavity. 

Description: it is made up of the following elements:

• Anterior selective opening  : creating a tactile target for the tongue, anterior palatine, median sagittal, retro-incisive papillary. 
• The anterior slide  : which blocks the anterior lingual motor route by depriving lingual contact with the lips. 
• The lateral walls of the tunnel: which block the lateral lingual motor route by deprivation of the jugal tactile environment. 

Indications: 

Indicated in all dysmorphoses of lingual origin, because it acts as a functional re-educator and dento-alveolo-skeletal corrector by suppressing malformative forces.

2. The pearl of TUCAT

It is a pearl placed in the region of the incisive papilla of a palatal plate or a palatal loop welded to 2 rings. This can rotate freely around its fixed axis, allowing the tongue to play with it, and to adopt a new posture in function and at rest. 

3. The lingual lodge / anti-thumb grid:

In the form of resin panels or anti-tongue grids or MERLE hedgehog plates, these devices hinder speech and do not always prevent the passage of the tongue, but act as reminder devices.

These types of devices directly combat the effect of dysfunction (tongue) or parafunction (thumb sucking). 

Indications: functional gaping, thumb sucking, with insufficient lingual and/or psychological maturation. 

4. interception screens:

These are oral screens designed to eliminate interpositions and avoid muscular pressures (at the level of the lips, cheeks, tongue). They allow the muscular envelope (centripetal or centrifugal) to be moved away from the alveolar processes and teeth. This improves the morphology of the arches by modifying the value of muscular pressures.

• Lip-Bumper: 

It is a bumper, which reduces the muscular pressure of the lower lip on the lower incisors (lingualized by hypertonicity of the lower lip, or interposition of this same lip between the incisors). 

It consists of a rigid vestibular arch 0.9 mm (.036 inch) in diameter, spaced from the vestibular surface of the teeth, with a stop on the horizontal molar tubes. The anterior region of the arch is covered with a plastic tube, or a resin band so that the lip can rest without being injured;

Effects: 

• A vestibulo-version of the lower incisors. The pressure of the lower lip is no longer exerted, only that of the tongue persists.
• Blocking or distalization of the molars by transmission of labial pressure to the molar level.
• The side fins: 

On a palatal plate or as an extension of an activator, they allow correction of lingual interposition unilaterally or bilaterally (one or two wings). 

• Plate with vestibular screen: 

Consisting of a resin or rubber strip, placed between the vestibular dental surfaces and the inner face of the lips and cheeks to prevent lip biting and sucking, thumb sucking and tongue interposition.

The device can also be used against habitual mouth breathing with defective lip occlusion. The individual vestibular plate will thus have progressively obstructed orifices. 

• The PLANAS slopes  

It is a device that allows for alternate unilateral chewing in mouths that are initially completely out of balance. This is called “Neuro-Occlusal Rehabilitation.” 

Neuromuscular rehabilitation of functions 

3. Functional orthopedics of the jaws:

Definition :

Functional orthopedics is a therapy intended to modify or activate a function to modify the shape of a structure.

It is a therapeutic concept in which the tissue modifications necessary for the correction of dental malpositions or intermaxillary disharmonies are obtained through functional stimuli related to these same organs. It is therefore based on the use of muscular functions in the correction of the skeletal form.

Mandibular propulsion is a living example of this, whether it is done with an appliance or any device, the aim is to reposition the mandible thanks to the action of the muscles which surround it (propulsors).

principles:

In the treatment of functional anomalies, the essential principle is to intervene early enough because certain orthodontic or orthopedic anomalies having functional characteristics at the beginning, can be the cause of deformations if they are not corrected before the end of the growth phase. Trying to correct a morphological anomaly with a functional appliance after this phase would only be a waste of time and energy. 

In functional orthopedics, it is therefore considered that the chances of correcting a functional disorder are better when the orthopedic intervention is carried out during the growth and development phase.

Orthopedic devices:

Activators: these are most often propulsion devices, their action according to CHATEAU is more or less pure, that is to say that to their more or less great functional role is added a mechanical role tending to vestibulate the lower teeth in particular the incisors. Let us cite in particular: hyper propulsors, all bimaxillary functional devices, 

BALTERS Bionator:

• Description: This is a rigid monobloc, providing bi-maxillary blocking and comprising:

• A resin body reduced to the maximum.
• A palatal loop in the contact area between the tongue and the palate allowing lingual stimulation.
• A vestibular arch to which protective screens can be added, which extend laterally by buccinator loops, ensuring the distance of the musculature. 

Neuromuscular rehabilitation of functions 

• BIMLER device:

Bimler’s appliances are built to be bouncy, encouraging the patient’s jaw movements like chewing gum. 

This is the so-called ”  chewing gum effect” . Then, they convert the force of these movements not only into a stimulation of maxillary growth , but can also be equipped with interdental springs to perform quite targeted dental corrections and all at the same time, without pain or risks.

• FRANKEL function regulator:
• Description :

It is a functional removable device which was called in 1966 (by FRANKEL), the “function corrector”. It will later become “function regulator”. 

This device features:

• A lyre-shaped transpalatine arch.
• A lingual shield with resin and buckles on the lingual surfaces of the incisors
• Lateral vestibular screens
• Lip balls 
• A vestibular headband
• The HERBST device:

• The Herbst® appliance consists of a bilateral telescopic hinge, attached to the distal part of the maxilla and the mesial part of the mandible. It is the length of the telescopic tube that prevents the mandible from returning to its original position. This appliance allows movements in all other directions.
• Neuromuscular rehabilitation of functions 

Limits of functional rehabilitation:

1. Age Considerations:

• Therapeutics must be carried out during the growth period, 
• Functional rehabilitation takes place around 8 to 10 years of age during the period of development of the child’s logical thinking, before the end of brain engramming. This is so that the child understands what is expected of him.
• Emotional maturity to stop thumb sucking.

2. Human considerations:

• Requires significant cooperation from the patient (regular wearing of the device) and from the family (discipline, long treatment).
• The practitioner must know how to motivate them.
• Functional therapy is contraindicated in cases of psychological or respiratory problems (asthma).
• Functional therapy is indicated in cases of financial problems (less expensive), problems of distance from the office (appointments more spaced out).

3. Considerations related to the type of dysmorphosis:

• This must be a secondary skeletal shift for which removal of the functional etiology can result in stable correction.
• Functional therapy is indicated in:
  • Class I with functional mandibular laterodeviation, with interposition.
  • Class II due to mandibular retrognathia, with facial normo or hypodivergence, of mixed etiology.
  • Functional class III if treatment is early.
• Functional therapy cannot be applied in the presence of anatomical obstacles hindering the functional rehabilitation procedure such as: macroglossia, short lingual frenulum, nasal obstructions, etc.

4. Dental System Considerations:

Functional therapy cannot be undertaken in the event of:

• Dysplasia or poor hygiene.
• Linguoversion of the upper incisors.
• Vestibuloversion of the lower incisors.
• Severe overbite.
• Important DDM: which requires functional processing to be carried out at a later stage.

5. Stability of results:

The results appear to be long-lasting when a functional deficit is responsible for the dysmorphosis. However, when the functional abnormality becomes anatomized, it will be difficult or even impossible to achieve success in this functional rehabilitation without mechanical intervention (orthodontics, orthopedics or surgery). Functional therapy can only serve as a means of contention in these cases, to prevent recurrence and maintain the results.

Neuromuscular rehabilitation of functions 

  Wisdom teeth can be painful if they are misplaced.
Composite fillings are aesthetic and durable.
Bleeding gums can be a sign of gingivitis.
Orthodontic treatments correct misaligned teeth.
Dental implants provide a permanent solution for missing teeth.
Scaling removes tartar and prevents gum disease.
Good dental hygiene starts with brushing twice a day.
 

Neuromuscular rehabilitation of functions