M y o f u n c t i o n a l Th e r a p y

A Novel Treatment of Pediatric

Sleep-Disordered Breathing
Joy L. Moeller, BS, RDHa,*,
Licia Coceani Paskay, MS, CCC-SLPa,
Michael L. Gelb, DDS, MSb

KEYWORDS
 Myofunctional  Sleep  Breathing  Nasal  Tongue  Posture  Neuroplasticity  Assessment

KEY POINTS
 Orofacial myofunctional therapy (OMT) is a noninvasive option for the treatment of sleep-disordered
breathing (SDB) in children.
 OMT has the potential to become an important alternative to other available nonsurgical treatment
modalities.
 Early identification and correction of mouth breathing are recommended as early as the first year of
life.
 Removing the tonsils and adenoids does not always change the breathing pattern from oral to
nasal, if the habit of mouth breathing has not been corrected.
 Myofunctional therapists use a variety of supportive techniques to promote self-awareness and
positive habits and to prevent the dysfunctions that characterize pediatric SDB.

INTRODUCTION used myofunctional therapy as an adjunctive

noninvasive treatment of temporomandibular joint
Orofacial myofunctional therapy (OMT) is defined disorders (TMJD).
as the treatment of dysfunctions of the muscles In the last few years2,3 myofunctional therapy
of the face and mouth, with the purpose of correct- has also been proposed as a potentially important
ing orofacial functions, such as chewing and swal- component of the multidisciplinary treatment of
lowing, and promoting nasal breathing. OMT has obstructive sleep apnea (OSA). The use of OMT
been used for many years to repattern and change as a noninvasive option for the treatment of
the function of the oral and facial muscles and to sleep-disordered breathing (SDB) in children in
eliminate oral habits, such as prolonged thumb- particular represents a new and novel application
sucking and nail biting, tongue thrusting, open of this well-established therapeutic approach and
mouth at rest posture, incorrect mastication, and has the potential to become an important alterna-
poor oral rest postures of the tongue and lips.1 tive to other available nonsurgical treatment mo-
Physicians, dentists, and orthodontists have also dalities, such as positive airway pressure and

Disclosures: Paid lecturer for the Academy of Orofacial Myofunctional Therapy (AOMT), personally related to
the AOMT Managing Director a main shareholder, Marc Moeller; Vice-president of the Academy of the 501(c)3
Academy of Applied Myofunctional Sciences (AAMS) (J.L. Moeller); Licia Coceani Paskay is a paid lecturer for
sleep.theclinics.com

the AOMT and President of the 501(c)3 AAMS (L.C. Paskay); No conflicts of interest (M.L. Gelb).
a
Academy of Orofacial Myofunctional Therapy (AOMT), 910 Via de la Paz #106, Pacific Palisades, CA 90272,
USA; b Department of Oral Medicine and Pathology, Tufts University School of Dental Medicine, NYU, 635
Madison Avenue, 19th Floor B/W: 59th & 60th Street, New York, NY 10022, USA
* Corresponding author.
E-mail address: [email protected]

Sleep Med Clin 9 (2014) 235–243

http://dx.doi.org/10.1016/j.jsmc.2014.03.002
1556-407X/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
236 Moeller et al

oral appliances. This article outlines the develop- posture. The increase in mouth breathing is asso-
ment and clinical application of OMT, discusses ciated with less time spent with tongue to the pal-
the rationale for its application to SDB, and pre- ate, and therefore, with narrowing of the maxilla
sents evidence supporting this treatment as it re- and an increased facial height. This downward
lates to prevention, assessment, and treatment and backward rotation of the maxilla and mandible
of pediatric SDB. is a powerful predictor of SDB as well as TMJD
and malocclusion. A variety of researchers, clini-
HISTORY OF OMT cians, and anthropologists have identified an un-
derdeveloped maxilla as being the root cause of
The history of myofunctional therapy in the United malocclusion and naso-oropharyngeal constric-
States goes back to the early 1900s and parallels tion. Early identification of mouth breathing is
orthodontic treatment.4 In the 1950s to 1960s, Wal- therefore recommended as early as the first year
ter Straub,5,6 an orthodontist, wrote numerous arti- of life.
cles on malfunctions of the tongue and abnormal Although the primary function of the genioglos-
swallowing habits and their relationship to ortho- sus muscle is to protect the patency of the upper
dontics and speech. He thought a major cause airway, an improper oral resting posture of the
of oral problems was bottle-feeding. Inspired by tongue will have a negative influence on the devel-
the work of Walter Straub, Roy Langer, Marvin opment of the oral cavity and the airway.9 The
Hanson, and Richard Barrett in the 1970s and anatomy of the upper airway in turn guides the
1980s, Daniel Garliner7,8 was the first to recom- growth and development of the nasomaxillary
mend a therapeutic routine for nighttime sleeping complex, mandible, temporomandibular joint,
consisting of keeping the lips together and the and ultimately, the occlusion of the teeth; thus,
tongue up on the palate. Subsequently, 2 speech malocclusion and facial dysmorphism may be
pathologists from Brazil, Irene Marchesan and the result of compensation for a narrowed airway
Ester Bianchini, studied with Daniel Garliner in the (Fig. 1).
1980s and went back to Brazil, where they created
a university program for speech pathologists
Genioglossus Muscle Stabilizing the Airway
centered on treating orofacial myofunctional disor-
ders. Today, there are over 30 universities with PhD There are several etiologic factors that have been
programs in myofunctional therapy and many pro- linked in varying degrees to the development of
grams that focus on sleep disorders and myofunc- SDB in children, which have implications for the
tional therapy. potential utility of OMT as a therapeutic interven-
tion; these implications include feeding methods,
RATIONALE: DEVELOPMENT OF THE UPPER oral habits, craniofacial abnormalities, hypertro-
AIRWAY phic tonsils and adenoids, chronic mouth breath-
ing sleep position, and restricted frenum. For
As man evolved to an upright posture, the larynx example, bottle-feeding has been shown to be a
descended, the forebrain grew, and the facial major contributing factor to an anterior open bite
framework retreated, as the nasal airway became in the primary dentition,10 whereas overuse of
diminished in size and function. This evolution is spouted (“sippy”) cups may also contribute to a
one reason humans do not have the olfactory abil- low tongue-rest posture, thereby leading to a nar-
ity of other mammals. As the cranial base angle row high palate. Oral habits such as the habitual
flexed, the maxilla was compressed and the para- use of a thumb or pacifier may also lead to a
nasal sinus size was reduced, creating millions of low tongue rest posture and OMD. It has been
sinus sufferers as well as other facial changes. noted that the frequency, intensity, and duration
The flattened maxilla and longer face is a rela- of oral habits and mouth-soothing devices may
tively recent phenomenon seen in humans, differ- lead to OMDs. When the thumb or another object
entiating man from primates. The decrease in is in the mouth often and/or for a prolonged period
nose volume associated with cranial base flexing of time, as a self-soothing strategy for example, it
may have increased high upper airway resistance applies pressure against the palate, and the
and increased the potential for collapse further tongue may develop a low rest posture. Also,
down in the oropharynx. Man was no longer an incorrect pressure exerted on the jaws may lead
obligate nose breather, and with increased de- to airway problems and a TMJD. Other oral habits
mands, mouth breathing was born. This trend of such as finger-sucking, nail biting, lip biting or
mouth breathing, downward migration of the licking, and tongue sucking may develop in in-
tongue base and descent of the hyoid, is associ- fancy and persist into adulthood, leading to
ated with retrognathic changes in mandibular malocclusion.11
 Myofunctional Therapy for Pediatric Breathing 237

Fig. 1. Genioglossus Muscle Stabiliz-

ing the Airways. (From Mathur R,
Mortimore IL, Jan MA, et al. Effect
of breathing, pressure and posture
on palatoglossal and genioglossal
tone. Clin Sci 1995;89:441–45; with
permission.)

Mouth breathing or an open mouth at rest may decreased disease severity. The study reports that
be one cause of OMDs. If the mouth is open, the the apnea/hypopnea index (AHI) was reduced by
tongue usually rests down and forward. This posi- 39% in those patients, after 3 months of myofunc-
tion may cause an abnormal growth pattern, which tional therapy. More recently, a series of studies on
may lead to a forward head and neck posture, the application of myofunctional therapy of SDB in
malocclusion, and SDB.12 Mouth breathing also children from Stanford University showed that the
involves lack of lip closure, which is necessary addition of myofunctional therapy to adenotonsil-
for jaw stability and to create the intraoral negative lectomy or palatal expansion reduced the risk of
pressure necessary to hold the tongue in place. reoccurrence of SDB. A retrospective investigation
Moreover, in mouth breathing there is a lack of by Guilleminault and colleagues3 evaluated the
tongue-to-palate contact, necessary to create application of myofunctional therapy along with
the “suction-cup” effect that holds the tongue in adenotonsillectomy and orthodontic treatment. In
place and prevents it from falling into the pharynx. patients who received myofunctional therapy, the
Hypertrophic tonsils and adenoids may also AHI and the oxygen desaturation were normalized,
lead to OMD and SDB. If the palatine tonsils are whereas most subjects who did not receive
hypertrophic, the tongue is prevented from swal- myofunctional therapy experienced a relapse in
lowing properly, forcing the tongue to come for- both the AHI and the mean minimum oxygen satu-
ward during the swallow and to rest forward and ration. The authors conclude that the absence of
down. However, removing the tonsils and ade- myofascial (myofunctional) treatment is associ-
noids does not always change the breathing ated with an increased risk of SDB recurrence.
pattern from oral to nasal, especially in the long- Although studies that show a specific effect of
term. A myofunctional therapist may be needed myofunctional therapy on children’s sleep is rela-
to assist the child in retraining the function of the tively small, research supporting that OMT indeed
tongue, in breathing, chewing, and swallowing, normalizes the basic orofacial functions involved
and to eliminate maladaptive oral habits. Finally, in SDB16,17 is more robust. For example, Izu and
restricted lingual or labial frena may cause an colleagues18 found that oral breathers were more
OMD13; if the tongue is not able to create a vac- likely to have snoring and OSAs and suffer from ad-
uum seal on the palate, then a high and narrow enotonsillitis and otological symptoms. Cunha and
palate may result, which is considered to be a colleagues19 found that breathing abnormalities in
risk factor for OSA (Fig. 2).14 children not only alter sleep but affect chewing and
Several studies support an empiric basis for my- food intake. Normalizing orofacial functions in chil-
ofunctional therapy in the treatment of SDB in dren also requires time. Marson and colleagues20
adults. In an often-referenced study, Guimarães demonstrated the effectiveness of an OMT
and colleagues15 reported not only reduced symp- program to normalize nasal breathing with peak re-
toms of sleep apnea but also objective evidence of sults at 12 weeks, whereas Gallo and Campiotto,21
238 Moeller et al

Fig. 2. Determining the need for a Lingual Frenectomy: Mobility Test.

using a similar protocol, found nasal breathing was overlap but retain some individual characteristics
normalized after about 10 sessions. depending on the background of the therapist.
Moreover, myofunctional therapists are trained to
CLINICAL ASSESSMENT identify other underlying orofacial dysfunctions
that are affected or are a contributing factor in
Every health professional who works with patients sleep disorders.
with sleep disorders has different tools available As part of the standard evaluation, the orofacial
for assessment, based on their needs, scope of myofunctional therapist takes a thorough medical
practice, and preferences. Myofunctional thera- and developmental history, with an emphasis on
pists, as a multidisciplinary group of professionals, SDB risk factors. Important components of the
use various tools and practices, which often assessment include identification of oral habits
that interfere with a proper oral rest posture,
recognition of the incorrect rest position of the
tongue, determination of incorrect swallow, labial
and lingual frenum restriction and inadequate lip
seal, and evaluation of functional head and neck
posture (after age 3–4 years) (Figs. 3–14).

Fig. 3. Thumb habit. Fig. 4. Tongue thrust.

 Myofunctional Therapy for Pediatric Breathing 239

Fig. 8. Open lips at rest: may be flacid, swollen or

cracked.

Fig. 5. Tongue rest position.

Fig. 6. Over-developed mentalis muscle.

Fig. 9. High narrow palate.

Fig. 7. Tense peri-oral muscles. Fig. 10. Forward head posture.

240 Moeller et al

Fig. 11. Scalloped tongue.

Treatment
Fig. 13. Restricted labial and lingual frena.
Treatment consists of habit elimination and
behavior modification, jaw stabilization exercises, diaphragmatic breathing and create a lip
repatterning the oral facial muscles and changing seal (in the absence of airway blockages
their function for optimal nasal breathing, oral or allergies), so that the lips are closed
rest position, chewing, and swallowing. There are during the night. Therapy then continues
4 basic components to the treatment: with training the blade of the tongue to go
to the “spot,” which is located posterior
1. Restoring Proper Rest Oral Posture
to the first rugae or ridge posterior to the
The first step is to educate the patient about
maxillary central incisors on the palate.
problematic oral habits they may have and
This therapy will also help to substitute
how to modify or eliminate the behavior, in
the thumb with the tongue if necessary.
terms of reduced frequency, duration, and
2. Repatterning of Facial Muscles
the intensity of the habit. Myofunctional
Next, the therapist will work with a sequential
therapists use a variety of supportive tech-
set of exercises to activate and then repat-
niques to allow the patient to first
tern the oral facial muscles. Therapists
understand the damage being done and
work with the muscles of mastication,
then to solicit a commitment to change,
which support the mandible and which
even in young children. Then, the patient
is supported with rewards and positive
reinforcement from both the family and
the therapist. Therapists then will introduce

Fig. 12. Restricted labial and lingual frena. Fig. 14. Restricted labial and lingual frena.
 Myofunctional Therapy for Pediatric Breathing 241

aid the proper position of the genioglossus brain stops or reduces nourishing those muscles
at night. Then, additional training ad- and hypotonia may follow. Two studies23 indicated
dresses the orbicularis oris as well as the that loss of prolonged sensory input translates to a
intrinsic and extrinsic tongue muscles, the reduction of the somatocortical representation,
buccinators, and the perioral muscles. such as in children with a habitual open mouth dur-
3. Teaching Proper Chewing and Swallowing ing the day and at night.
Next, proper chewing and swallowing is
gradually introduced. Proper oral posture Use it and improve it
is reinforced even during sleep, with sub- Myofunctional therapy revolves around the princi-
conscious auto-suggestion and biofeed- ple of improving a function through repetition,
back. Success is evaluated using the metacognition, and awareness. For example, the
Mallampati score, the grade of tongue tongue is repositioned and trained to contact the
scalloping, relaxation, or activation of the palate comfortably, thus providing the natural
perioral muscles, as well as attaining a lip negative pressure (suction) that keeps the tongue,
seal and palatal tongue rest position during and especially the genioglossus, in the proper po-
both the day and the night. sition during sleep.15,24
4. Functional posture training
Plasticity is experience specific
Myofunctional therapists are trained to pro-
This principle suggests that the success of some
mote a functional head position during
therapy protocols for sleep disorders15 relies on
sleep, to avoid the jaw being in close prox-
targeting the very muscles that are hypofunction-
imity to the chest because this position
ing at night, such as the soft palate, tongue, and
may contribute to SDB. Also, OMTs
pharyngeal walls.
instruct patients to hold an upright head
and neck posture, especially during the Repetition matters
swallowing process. “Practice” improves performance by creating,
maintaining, and expanding new neural areas cor-
If myofunctional therapists suspect that the responding to the new behavior. In myofunctional
“tongue-tie” (or lip-tie) is contributing to a child’s therapy repetition is paramount so that a new
SDB, they will evaluate both the labial and the behavior, such as the tongue position or lips
lingual frena, usually after a few weeks of exercises closure, is rehearsed every day and every evening
to ensure that full range of motion of the tongue until the new habit is formed.
and lips is possible. If the restriction remains, the
patient is referred to a physician or dentist who is Intensity matters
comfortable doing the surgery. After the release, Ideally, patients should practice neuromuscular
the patient must immediately do exercises to exercises every day; otherwise, the intensity of
assure proper function of the tongue. Otherwise, the neuromuscular change does not generalize
more revisions may be required. to the night hours.
The key to successful treatment is to establish a
Time matters
rapport with the pediatric patient and the caregiver
According to Fisher and Sullivan,16,25 the training
and to motivate and monitor the outcome on a
modality that is most effective is protracted and
weekly basis for several months and then gradu-
continuous, as opposed to brief and intermittent.
ally reduce the frequency of appointments to
Therefore, patients may need to be kept in therapy
once a month. The therapist must also enlist the
or follow-up mode for a prolonged period of time
assistance of the parent or caregiver to become
(usually 1 year, but 2 years is better for
the “therapist” at home to assure a successful
habituation).
result.
Because myofunctional therapy relies on active Salience matters
patient participation, OMTs use several tech- The need to motivate the patient by increasing the
niques that are based on the 10 principles of neu- saliency or importance of therapy is a central
roplasticity.22 Neuroplasticity means the ability of element, because the higher the motivation and
the brain to change, following physiologic or path- understanding of the reason some exercises
ologic input, generating an adaptive response. need to be performed daily, the more likely the pa-
These principles include the following. tient will perform the exercises prescribed.

Use it or lose it Age matters

In general, because muscle function requires en- Children are in the best condition to transform
ergy, if the muscles are not properly used, the sensory-motor inputs into correct functions and
242 Moeller et al

Fig. 15. (A) and (B) Airway Centric Ô Philosophy.

make them a life-long habit. In children, not only is the treatment as well as the prevention of SDB in
neuroplasticity at its best but also muscles and the pediatric population, the potential benefits of
soft tissues drive the development of bones including a myofunctional therapist in a team
through principles of the functional matrix and approach should not be underestimated.
epigenetic influences.17,26
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