The Oromaxillofacial Rehabilitation in Orthodontic-Surgical Protocols

DOI: 10.1051/odfen/2015044 J Dentofacial Anom Orthod 2016;19:203 © The authors

The oromaxillofacial rehabilitation in orthodontic-surgical protocols

Th. Gouzland1,2, M. Fournier1 1 Kinesiologist, specializing in oromaxillofacial rehabilitation 2 Educator

SUMMARY Oro-maxillo-facial rehabilitation is an ancient practice that has developed over recent years through research and integration with physiotherapists in multidisciplinary teams, as is the case with orthodontic- surgical procedures. At the same time, the progress made in orthognathic and orthodontic surgery over the last 20 years encourages more and more patients to undergo surgery. Preoperative treatment is based on early assessment and preparation for optimal surgical conditions to come up with a functional plan. A short stay in a hospital, focusing on rehabilitation, is recommended. During the postoperative phase, the key objectives are to ensure the muscles and arteries all function perfectly, acceptance of the new face, and the immediate correction of any orofacial dyspraxia that has occurred during myofunctional therapy. The various specialists in this multidisciplinary team must constantly be in communication. The importance of postoperative physiotherapy will be illustrated by a study consisting of 35 cases of maxillomandibular osteotomy with orthodontic preparation and monitoring. The purpose of this study is to show occurrence of suboccipital and cervical muscle tensions as well as masticatory muscles. Then we will be able to see the importance of these practices, the impact on recovery, the impact on posture and how best to treat.

KEYWORDS Physiotherapy, orthognathic surgery, orthodontic, myofunctional therapy, muscles, posture

INTRODUCTION

The progress made in the techniques and comfortable recovery. This fits into and the results obtained by coupling the current social view where one’s orthognathic surgery with orthodontics image is given greater importance. allows the specialists to fix any func- Similarly, a lot of research has been tional and esthetic problems in patients conducted on well-being and physical affected by facial dysmorphia or major balance, which includes occlusal bal- occlusal disorders. The patients benefit ance and balancing muscular tension. from a less-invasive surgery, with short- As a result, more and more patients are er recovery times and a more functional opting to have surgery.

Address for correspondence: Article received: 30-09-2015. Thierry Gouzland Accepted for publication: 30-10-2015. Polyclinique Bordeaux-Tondu 145 rue du Tondu This is an Open Access article distributed under the terms of the Creative Commons Attribution 33082 Bordeaux Cedex License (http://creativecommons.org/licenses/by/4.0), E-mail: [email protected] which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1

Article available at https://www.jdao-journal.org or https://doi.org/10.1051/odfen/2015044 TH. GOUZLAND, M. FOURNIER

The role of rehabilitation and techniques in the area and with medicine in general. In 2015, a new definition was adopted by the National While the face is growing, the cor- Assembly. Such terms as: preven- relation between form and function tion, health promotion, diagnosis, and is well documented22,25,28. This facial university research emerged, but of growth is influenced by predetermined particular importance was the “treat- genetic factors but also by acquired ment of movement disorders and de- epigenetic factors. A correlation ex- ficiencies or alterations in functional ists between the face and its orofacial capacity,” which corresponds to the functions. The structure allows the treatment of the orofacial sphere. The function to proceed and the function professional, following a diagnostic as- will then be modeled on the structure. sessment, has the freedom to choose A good functional dynamic facilitates what to do and takes responsibility for a harmonious morphology. Similarly, his actions. dysfunctions contribute to the devel- opment of dysmorphic disorders. The orthognathic surgical teams coordi- Orofacial myofunctional nate with precise treatment plans to rehabilitation create new facial architecture and to restore an ideal dental occlusion. The As with any orthopedic surgery, re- desired occlusal balance and dental habilitative care provides a comfort- alignment are linked to muscular bal- able postoperative recovery in terms ance and functional orofacial symme- of managing the pain, schedule, and try13. However, if orofacial dyspraxia quality of life of the patients. However, is not corrected, there is an increased the complexity of the cephalic region risk of delaying recovery or even caus- requires specific training. The face is a ing a relapse10,12. The kinesiologist, the vitally important functional site. Signifi- specialist in oromaxillofacial rehabilita- cant functions of the face include res- tion, should be placed at the center of piration, chewing, swallowing, speak- the multidisciplinary team. Knowledge ing, and displaying emotions, and the of the techniques and skills of each face is linked to overall posture. Any specialist as well as communication dysfunction will negatively affect this within the group are vital to obtaining functional equilibrium. Even if it falls the best results and to continue opti- within our field of expertise and profes- mizing the care of the patients. sional nomenclature, the acquisition of specific anatomical, physiopathologi- Kinesiology cal, and technical skills is still necessary. These will add to our physical The official definition, dating from therapy abilities as well as our general 1946, describes the profession as par- approach to the patient and the spe- amedical, oriented toward massage. cific vision of the kinesiologist. This became completely obsolete over Although interest in this specialty is the years, especially because it was developing, there are only a few trained out of touch with the developments kinesiologists. Orofacial myofunctional

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rehabilitation, referred to as myofunc- a hindrance to movement. This makes tional therapy in the English-speaking it easier to choose the type of exercise world, is often referred to as lingual according to the function or action of rehabilitation in France. This term ap- the muscle being treated. When it pears to be quite narrow as our focus comes to contracted, spastic, or hy- is not only on lingual dyspraxia but also pertonic muscles, muscle relaxation is on the platysma facial muscles, the necessary. This can be achieved with masticatory muscles, the temporo- physical therapy using the techniques mandibular joints (TMJs) and so on. It described by Alvarado2. We can also is, therefore, the vision of this maxil- draw upon Schultz’s relaxation tech- lofacial specialty which originated in niques (known as autogenic training), France in the 1960s with Mr Fournier10. cited by Girard and Leroux13 and also After obtaining his degree, Mr Fournier by Alvarado1. This type of technique met Professor Delaire, a maxillofacial is also efficient in fixing certain par- surgeon. His problem was managing afunctions, such as bruxism. Regard- the tongue in the event of orthognath- ing the functional aspects, erroneous ic surgical relapse. Over time and with functions must be reprogrammed the support of Professor Delaire, these and above all must be automatized. concepts and approaches to therapy This capacity for the acquisition or were developed. Meanwhile, in the modification of new motor patterns ‘70s and ‘80s, in the United States, is explained by the brain’s neuronal Straub and Garliner developed their plasticity. Moeller and Paskay25 have work on facial exercises with faults in prepared some guidelines concerning pronunciation as their main focus. this process. First of all, the function must be used regularly or else the Physiology cortical representation of somatosen- sation of these muscles is decreased. Physiological knowledge improves The movement must be as specific our understanding of the mechanisms as possible and must be repeated so associated with rehabilitation. When it that it becomes natural. It must also comes to the muscular components, be increased in intensity to maintain the functional equilibrium between its long-term well-being. They also dis- the agonistic and antagonistic muscles cuss transference—i.e., when a func- must be re-established. In cases of tion is automatized, other associated muscular hypotonia, a muscular rein- functions improve. Interference, on forcement is carried out, which is well the other hand, is a return to the er- outlined by Guimaraes14. Reinforce- roneous movement that continues to ment without movement is isometric be triggered despite the functional cor- and with movement is isotonic. An iso- rection. Therefore the kinesiologist can tonic movement is deemed concentric use all these guidelines to find a func- if the muscle contracts or eccentric if tional balance during the orthodontic the muscle extends. It is, therefore, treatment and the recovery.

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PREOPERATIVE PHASE orthodontist can request the assis- tance of the kinesiologist a lot earlier in Once the orthognathic surgical deci- the process if he judges that a patient sion is decided upon by both the ortho- has a dysfunction that may interfere dontist and the surgeon, the treatment with his treatment. This phase lasts plan is put in place. The orthodontist an average of 18 months, rehabilita- now tries to align the dental arches in tion can begin at any point during this anticipation of a osteotomy. The objec- period. We note that an early assess- tive of rehabilitation will be to partici- ment improves how best to organize pate in the patient’s musculoarticular the time management. This is to avoid function (Fig. 1). Treatment is organ- having, for example, urgent surgical ized following the initial assessment4. preparation just 1 month before sur- The surgeon requests an assessment gery. Inversely, in the case of a favora- of the orofacial dyspraxia to evaluate ble assessment, rehabilitation may be the severity of the dysfunction and delayed to immediately before hospi- the postoperative risks. However, the talization.

Figure 1 Coordinated surgical physical and orthodontic sequence of the patient.

4 Gouzland Th., Fournier M. The oromaxillofacial rehabilitation in orthodontic-surgical protocols THE OROMAXILLOFACIAL REHABILITATION IN ORTHODONTIC-SURGICAL PROTOCOLS

Assessment and diagnosis

An evaluation of the different orofacial functions, as well as an evaluation of the musculoskeletal system, can show whether preoperative rehabilitation is needed, facilitate the organization of time, and individualize our therapeutic strategy for each patient. Being aware of the dysfunctions shown by these tests is the basis for all corrections. Figure 2 Class III lingual position. Tongue placed Resting posture of the tongue on the buccal floor, tip against the mandibular incisors. With all dyspraxias, the key aspect neither intraoral proprioception nor is the resting position of the tongue as awareness of tongue mobility. described by Fournier10. The difference 8 in pressure recorded by Engelke in the Ventilation or Breathing subpalatal zone permits a true effort- less at-rest position where the apex of Often mistakenly referred to as res- the tongue is on the retroincisive pala- piration, ventilation is gaseous flow tal papillae. Depending on the type of movement. It should be naso-nasal dur- dysmorphia, characteristic positions ing the day and at night, while resting have been found11: in class II division 2, and while physically exerting oneself. the apex is placed on the floor of the A mixed or orally exclusive ventila- mouth or on the lower incisors with tion is frequently encountered and is the two posterior tiers placed on the attributed to dysmorphia as well as to palates. In class III, the tongue is low, bad habits. (Fig. 3a). spread out on the floor of the mouth. It is nonphysiological, acquired, and 31 In class III, it is low, spread out on the pathological. F. Susanibar describes a base of the cheek (Fig. 2). In open bites, complete series of evaluations of the the tongue is interposed between the mechanics associated with ventila- dental arches. Coded by Marchesan23, tion. In addition, Rosenthal’s functional 29 the lingual frenum test highlights its test and Guedin’s nasal dyssynergy possible shortness. Very often one en- test exist. We are in agreement with 31 counters tongues presenting absolute Susanibar who advocates a modified macroglossia, with a distorted content– Mallampati test (Fig. 4). The tongue container relationship. Though rare, must not be pulled when inspecting cases of lingual immaturity can be eas- the available space in the oral cavity. All ily identified in patients who possess other findings such as snoring, nightly

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drooling, or dryness of the mouth are muscles. When a dysfunction related evaluated. to deglutition is present, there may be labial aspiration, cheek salivation, Labial Function and tongue propulsion, on the teeth Analysis of the spontaneous labial or even inter-arch. There is often a dys- position and the assessment of the synergy associated with the mastica- orbicularis oris muscle in the lips pro- tor muscles which no longer stabilize vides evidence of possible labial incom- the mandible in the position of maxi- petence. A hypotonic lower lip can be mal intercuspation. The pressure now accompanied by a retracted upper lip, exerted on the teeth close to 1500 a marked chin furrow and even an in- times per day is significant and can re- voluntary contraction of the mentalis in sult in a relapse. labio-mental synkinesis. (Fig. 3b). Phonation Deglutition Phonation is also associated with The function of deglutition is closely the resting position of the tongue. Nor- linked to the resting position of the mally, there is no contact between the tongue. Peristaltic movement in the tongue and teeth. On the palatals, we anteroposterior direction must be should see lingual ascension close to done without contraction of the para- retroincisive palatal papillae and not on sitic musculature, of the platysma fa- the teeth. If any erroneous whistling cial muscles or contraction of the neck or hissing occurs, inter-arch pulsion

Figure 3 (a) Buccal or mixed ventilation. (b) Labiomental synkinesis: mental reflex contraction during voluntary lip-closing.

6 Gouzland Th., Fournier M. The oromaxillofacial rehabilitation in orthodontic-surgical protocols THE OROMAXILLOFACIAL REHABILITATION IN ORTHODONTIC-SURGICAL PROTOCOLS

Figure 4 Modified Mallampati Scoring. (a) Score 1 with dental impression on the lateral edges of the tongue. (b) Score 4 with ogival palatal arch.

should be checked. The pressure ex- are numerous and are often found erted on the teeth is a bit constraining in stressful social and professional but it is important here to take note of situations. Be aware that correcting the relationship between the different these motor patterns and practicing functions not only in terms of the as- relaxation techniques will decrease sessment but also the treatment. their onset and intensity.

Parafunctions They can be the root cause of excessive muscle tension, even tempo- romandibular dysfunction (TMD), but can equally be the cause of a range of orofacial dyspraxias. We may notice a pattern of nail-biting, lip-biting or cheek-biting, finger-sucking, tongue sucking, and excessive chewing of chewing-gum. Centered bruxism (jaw clenching) or off-centered (teeth grinding; Fig. 5) can lead to postoper- Figure 5 ative complications. These bad habits Aftereffects of Bruxism.

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The Musculoskeletal System conjunction with the findings of the The kinematics of the TMJs is ana- other members of the team. Some lyzed quantitatively and qualitatively. patients have previously had rehabili- The amplitude of different move- tative kinesiology or speech therapy in ments is measured. We should in- adolescence. These patients already vestigate the presence of lateral know how everything should function deviations and articular sounds or but have not automatized them. It will pains. Palpation of the masticatory be a bit more difficult to analyze these muscles and mandible depressor functions and make them work. muscles indicates possible muscle It is a question of becoming aware of contractures. The existence of a pre- the area and the different structures in- vious TMD can make following these volved in addition to the dysfunctions. guidelines more difficult. Treating this The patient who understands will dysfunction improves comfort during participate more actively and will au- orthodontia. Relaxing the muscle ten- tomatically integrate these elements sion facilitates the work of the sur- more readily. In a class III scenario, lin- geon and makes the postoperative gual rebound work must be done. In effects more tolerable. the class II case, the emphasis is on apical exercises and relaxing the back Posture of the tongue (Fig. 6). In the case of open bites, the mo- A postural analysis should be tor pattern of the tongue must be performed. We will look at the worked so that it stops interposing different anatomical, neurological, itself, thereby facilitating the job of and functional linkages between the orthodontist (Fig. 7). Lingual au- the masticatory apparatus and the tomatization is not possible when patient’s posture, mostly cervical but there is significant dysmorphia37 be- also general. This analysis is done cause the architectural changes mod- morphostatically and if possible on a ify the intraoral proprioception. This is posture and gait analysis platform. confirmed during the postoperative phase. Nasal ventilation recovery pro- Rehabilitation vides postoperative comfort because of intermaxillary blocking and pre- In terms of the assessment, if the vents any relapse in the long term. patient seems balanced, a simple de- If the main reason for surgery is the layed preoperative consultation could presence of obstructive sleep apnea– suffice, even if the morphological hypopnea syndrome (OSAHS), this changes will still require postopera- work takes precedence. If necessary, tive effort. Depending on the points abdomino–diaphragmatic breathing highlighted during the evaluation, must be corrected and nasal hygiene the treatment plan is put in place in must be promoted.

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Figure 6 Example of a progressive reinforcement exercise of the lingual apex. (a) Incorrect position, tip hypotonic, back and base of the tongue hypertonic: the tongue is squashed. (b) Tongue in the correct position, the tip is toned, patient makes use of orbicularis lip muscle.

(Fig. 8). The aim is for preoperative muscle equilibrium and normaliza- tion of the mandibular kinematics as far as possible. Technically, deep intraoral and extraoral massages are required as well as the removal of tension on the trigger points. Relaxa- tion by stretching or even contract- relax relief of muscle tension are

Figure 7 Tongue creeps into the open bite not only in phonation and deglutition but also at rest.

In the case of OSAHS, work is also Figure 8 done on the retrobasilingual zone and Example of velar and retrobasilingual velar reinforcement can be performed. reinforcement in the case of OSAHS.

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necessary. The hypotonia of the an- ing, eating, nasal hygiene etc. We tagonistic muscles can be reinforced. will then teach and make the patient However, if there is room, manage- aware of the resting position of the ment of the parafunctions must be tongue. A breathing task is then per- included. formed as well as the alleviation or removal of muscle tension.

Preoperative consultation splint. The goal of rehabilitation during If a single consultation must be held this phase is to make the postopera- because of logistics, organization, or tive stage as comfortable as possible other reasons, it must be this one. It for the patient and to recover a sound ensures psychological preparation by but early functionality to alleviate and informing the patient regarding what shorten the length of treatment. The to expect in terms of postoperative end of this phase is based on the con- effects: edemas, intermaxillary block- dition that the patient will continue to manage their treatment.

Respiration THE HOSPITALIZATION PHASE The first axis of intervention in kine- After months of preparation, the mo- siology is respiratory. Immediate post- ment of surgical intervention arrives. It operative bronchial obstruction can is generally anticipated although some require early intervention in the post- patients can experience a certain level anesthesia care unit (PACU) or hospital of anxiety. The surgery will radically room. Fortunately such cases are rare. modify the morphology of the face The surgeon or anesthesiologist then and mouth. This marks the end of the determines if the patients have a high preparatory work carried out by the or- risk of congestion (smokers…). In most thodontist and the kinesiologist. In this cases, the signs of respiratory distur- stage, we use new techniques with bance are rather linked to the sensa- new objectives. This period, which lasts tion of having a lack of air brought on 3 days on average, emphasizes prodigal by elastic blocking and nasal conges- care and provides useful information. tion when the maxillary osteotomy has The rehabilitation begins on a patient occurred. This phenomenon is better in who is bedridden, edematous (to some patients who breathe buccally. Nasal extent), and has partially transfixed mucositis and blood flow back into the muscles. The patient has intermaxillary naso-pharynx. Some patients because blocking caused by rubber bands on the of transfixion or inhibition limit their braces and brackets specially prepared swallowing of saliva. All together this by the orthodontist for surgery. In rare will create a viscous mass deep in the cases, this can be accomplished by mi- throat, which will burden the patient. niscrew anchorages. The dental arches Respiratory kinesiotherapy now con- are also blocked with a previously-made sists of achieving directed ventilation

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maneuvers, if necessary, that are asso- from one individual to another in terms ciated with bronchial drainage. In these of volume and the duration of reabsorp- cases, we can resort to a bronchial as- tion. Patients find themselves very piration or simply a buccal pumping. bloated quasi-systematically even if this Learning to wash the nose with saline is not the case. It is also important to solution progressively cleans the upper follow the instructions on regular eleva- airways; nose blowing is forbidden to tion and mobilization to enable drain- avoid the risk of bleeding and of subcu- age. Frequent and regular cryotherapy taneous emphysema. treatment promotes reabsorption and It is therefore vital to reinforce the antalgia. It is recommended that this instructions for resting position of the therapy be done regularly but it should tongue in the new buccal cavity. The not exceed 20 minutes so as to avoid proprioceptive benchmarks will change, expansion of the subjacent vasculari- the first reflex is often to place the ante- zation.27 The manoeuvers of manual rior part of the tongue toward the back lymphatic drainage (MLD)21, associated of the teeth and to raise the retrobasilin- with early enlisting of the platysma fa- gual portion which will decrease res- cial muscles facilitate reabsorption7,37. piratory flow. Relaxing the base of the Therefore, the patient is asked to com- tongue frees the aerodigestive cross- municate verbally as early as possible. roads and gives a better sensation so Contracting the lips, tongue and cheek that the patient can swallow and com- can be very efficient to drain tissue. municate. Remounting the apex of the Furthermore, talking is psychologically tongue as soon as the intraoral sensa- stimulating, which ensures that the pa- tions are reawakened will permit the tient does not feel isolated and experi- exploration of the new morphology and ences a certain return to “normalcy.” the immediate integration of functional proprioception and reflexes. If the dys- Intermaxillary Blocking praxia is still present in the new layout, The third point concerns intermaxil- follow-up treatment will be longer and lary blocking. After initial radiography, more complex. If the reference points with the surgeon’s consent, we can are lost, it is better to start with a clean perform the intermaxillary blocking pro- slate. If the buccal opening is blocked, cedure (Fig. 10). It is a very important this important exercise can be simply step in the treatment, and it is very im- performed following verbal directions portant also or the patient as well. It ac- and without visual control. tually confirms the success of the pro- cedure so far. All restraints are removed and the patient can look at themselves Edema in the mirror, and the patient can see when the first movements have been The second objective of the treat- made. At this point, the first progres- ment is to fight against edema and sive exercises are incorporated into the pain. Facial edema as well as the for- recovery In the autorehabilitation phase mation of a hematoma are a natural re- that will take place at home, the follow- action to surgery (Fig. 9). Edemas vary ing are included: opening, propulsion,

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Figure 9 Edemas (a) and Hematomas (b) are significant postoperative side effects.

and separation, as well as removing the labial transfixion sutures. Many authors have expressed an interest in the early integration of a gentle and progressive rehabilitation.17,18,26,33,34 A new im- mobilizing technique is employed with two or three rubber bands which still allows the patient to move. No orthodontic correction needs to be induced to immobilize the patient. The objective is to integrate the new occlusion, to counteract “the muscle memory,” and muscle tension during consolidation. Figure 10 The greater the risk of pulsion or lingual Ablation of the postoperative interposition, the more the blocking of intermaxillary blocking. the anterior incisor-canine will be encouraged. nasal and buccal hygiene, in their management of the blockage, in their exercises, and in their alimentation. We will teach them the protocol for Therapeutic education progressive unblocking, how much and how long for, a protocol for rein- Finally, the last role of the kinesi- tegration of chewing via food; liquids ologist is to teach the patient. The then mixed and finally solids. Not for- patient can only leave the establish- getting of course, the autorehabilita- ment if they are self-sufficient in his tion protocol.

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Figure 11a, b, c Examples of intermaxillary blocking, 2 or 3 anterior rubber bands self-managed by the patient.

POSTOPERATIVE PHASE in case of problems. On this occa- sion, the quality of the occlusion on Once the ideal facial architecture has the splint is checked while following been restored by surgery, this period up on the progressive unblocking will last 6 months, but this depends on program, with the focus on eating. the finishing touches to be performed In terms of physical work; the lym- by the orthodontist. Rehabilitation aims phatic drainage of the face, the su- to: perficial alleviation of intraoral and – Monitor the postoperative follow- extraoral muscle tension, as well as up; cervicoscapular massages are per- – Contribute to antalgia; formed. These two last items are – Decrease the postoperative edema; detailed in a study presented later – Relax the muscle tension; on. After confirming the completed – Restore mobility; autorehabilitation tasks, other exer- – Reinforce and automatize preopera- cises are prescribed to improve mo- tive myofunctional activities; bility, tongue position, and muscle – Integrate morphological changes. relaxation. The prescribed exercises should be carried out three times per day. Any sign of excessive pain, The first postoperative infection, or discrepancy in relation to the occlusion could result in ear- consultation lier than expected contact with the The first consultation generally surgeon. The orthodontist should be takes place during the first week after contacted if problems should arise the patient’s return home. The main concerning, for example arcs, brack- goal is controlling any postoperative ets, and hooks. As a general rule, the side effects and being able to inter- orthodontic finishing touches will be act quickly with other professionals applied within 15 days to 3 weeks

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Figure 12 Asymmetric reabsorption of edema. Figure 13 Example of the correction of mandibular following surgery. During this period, kinematics with sensitive visual the patient, as well as their family, may feedback. still have a number of questions and kinematics of movement are recov- concerns, which must be addressed. ered by observing themselves in a These include issues related to the mirror, the patient’s index fingers edema (if it is still severe), which is pointing toward their temporoman- often asymmetrical in its reabsorption dibular articulators (Fig. 13) to find (Fig. 12), fatigue linked to surgical in- out as much information as possible vasion as well as the patient’s dietary about the new mobility in the face. needs/composition. The frequency of the visits now depends on the moni- tored clinical chart. It can be weekly, Facial Platysma muscles fortnightly, or every 3 weeks. The exercising of the platysma facial muscle is essential. This guarantees the maximum amount of reabsorption of hematoma and edema. Their Articular Mobility early stimulation allows the patient to show expressions on their new During treatment, the quality of face. It also contributes to removing mandibular mobility is reinforced to sensitive transfixions. In cases of sig- obtain (3 months later) a complete nificant buccal ventilation, the quick buccal opening of at least 40 mm, revival of the orbicularis oris and the permitting the patient to achieve nor- relaxation of the mentalis muscle mal daily functioning as well as the (associated with the automatization possibility of receiving future dental of naso-nasal ventilation) are crucial. care. The earlier mobility is achieved, Cases of labiomental synkinesis are the better it will be. It is recom- frequent, this labial competence is mended that the opening should be a crucial for achieving proper nasal ven- slightly greater than necessary given tilation. that after treatment stops, decreased It must be noted though that some stimulation will result in a closure of patients are nasal respirators with approximately 2–3 mm. The proper a labial open bite. The long-term

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stability of the new occlusal structure is linked to a functional labiolingual alternatingly unilateral. During early equilibrium15. integration procedures, the important masticatory constraints are currently under review in the hopes of encour- Mastication aging a faster, more efficient occlusal correction. The studies conducted by During treatment, the kinesiologist, Takahashi32 and de Valdés36 empha- specializing in oromaxillofacial reha- size the link between the efficiency bilitation, ensures the equilibrium of of the masticatory muscles and a the orofacial functions. The early inte- high lingual position. gration of intraoral proprioception after architectural changes is important. First of all, it integrates an adequate lingual resting position in the new buccal space. Whether the tongue is Physical therapy at rest or in use, it must not exert pressure on the dental arches nor must it Physical therapy is useful to liber- be interposed between them. During ate the tension of the masticatory musculoskeletal recovery, deglutition, musculature (Fig. 14). One can often ventilation, and phonation are then re- identify the masseter muscles and evaluated and automatized. One of medial and lateral pterygoid muscles the major functions that has not been this way. The temporal muscles are sufficiently explored in the literature important when regaining masticato- in the specific case is mastication. It ry function. Their tension often have a is, however, of primary importance unilateral preponderance. According because it stimulates contacts on to Jouvin16, if this tension persist for sites that were not in use before the too long, they will result in muscular operation. Faulty recovery of mas- fibrosis which will seriously limit the tication during the reintegration of buccal opening. Manual work also eating patterns while the patient is convalescing can lead to preferential unilateral mastication. This leads to an increased risk of homolateral muscle contractures, and of slowing down the correct positioning and the contralateral meshing of teeth. Makaremi and de Brondeau20 have observed the role of mastication in the correction of the occlusal quality. It is therefore important to be cautious about the kinds of foods ingested and occlusion, while ensuring that both sides are equally stimulated. Mastica- Figure 14 tion is rarely bilateral, it is more often Removing intraoral muscle tension.

J Dentofacial Anom Orthod 2016;19:203 15 TH. GOUZLAND, M. FOURNIER

allows the practitioner to act on the Specific Cases suboccipital and cervical muscle tension. Morphological modifications result in changes in tension on the Among the highlighted cases which suprahyoid and infrahyoid chains. The must focus on and require specific fibrosis may be submitted to excess care, we find traditional patients who tension that will have to be normal- were preoperative in class II and who ized to regain a balanced hyoglossal were in the habit of compensating es- function; the hyoidal muscle system thetically for years by lightly pushing has an anatomical link with cervical the mandible. There are also those in posture. Its position also affects the class III who have lingual function on ventilatory space. It is important to the buccal floor with the apex function- address it so as to maintain freedom ing in front of the maxillary dental arch. of movement. The works of LeBanc The assumptions, frequent in post- show a return of the hyoid bone to its operative though transitory, are more original position after some years. It or less present from one patient to is, therefore, important to try to stabi- the other and last a reasonably long- lize it especially if the reason for sur- time. These sensitive disorders when gery was the incidence of OSAHS. patients are regaining facial mobility and the mobility of expressions can lead to parasitic or compensatory Posture contractions of the platysma muscles or the incidence of parafunctions The link between posture and (Fig. 15). maxillofacial structures, although The use of transcutaneous electri- rarely documented, is frequently out- cal nerve stimulation (TENS) or elec- lined 1,6,24,28,30,37,38. We must, therefore, trotherapy can promote the return of be aware of bad posture during con- sensations. The presence of material valescence and the integration of a new craniofacial architecture within the general framework of the body. A prolonged nocturnal unilateral position can cause constraints that will have very serious repercussions for TMJs. Cephalic anteriorization, in- terscapular amyotrophy, or cervical muscle tension can affect the axes of mandibular function, risking TMD. Recent analyses conducted by Fau- lin et al.9 conclude that posture does not influence the appearance of TMD, however, it is not a static analysis, just a position in a specific situation and does not factor in the notion of Figure 15 movement and of postural dynamics. Parafunction appears after hypoesthesia.

16 Gouzland Th., Fournier M. The oromaxillofacial rehabilitation in orthodontic-surgical protocols THE OROMAXILLOFACIAL REHABILITATION IN ORTHODONTIC-SURGICAL PROTOCOLS

from osteosynthesis indicates the Ablation of osteosynthesis use of polarized electric currents as material well as vibratory systems. Intermaxillary blocking, despite During their recuperation, patients, progressive daily withdrawal, pro- especially the more active ones, ad- vides prolonged dental contact in- mit to feeling the effects from the os- formation, whereas the normal du- teotomy in their daily life. For some, ration of contact does not exceed once the edema is reabsorbed, touch- 25–30 minutes maximum for the ing the plates and titanium screws day. The patient becomes used to leads many to request the ablation this contact while integrating the or removal of the material. Accord- new occlusion into the body’s frame- ing to Mouton5, in 2006, they were work. A type of dental clamping can just isolated cases but at present the also be observed. The patient must request is becoming more and more fight against this parafunction that frequent. In most cases, this request is similar to centered bruxism, and is made 8–14 months after the oste- it generates masticatory muscle ten- otomies, which means that rehabilita- sion and causes pain. tion would usually be complete. The orthodontist now returns to The surgeon can request that the complete the corrections during the rehabilitator attend the preoperative 2–3 weeks postoperatively. Ablation consultation to ease muscle tension, of the daily splint, changing the arc or which will be progressively reinstated modifying the installed rubber bands after treatment ceases. It can also be can all generate reflex muscle ten- planned in postoperatively to reassess sion on a fully modified area. To im- the functions, relax residual contrac- prove the patient’s comfort as well tures, or even to develop a precise pro- as his compliance to treatment the tocol for autorehabilitation exercises orthodontic follow-up schedule must to be done by the patient over time. be maintained and muscle relaxation For example, a patient who presents strongly encouraged. a strong lingual interposition during Very often, mandibular excursion treatment and therefore presents a recovers with proper kinematic exer- serious risk of relapse. OSAHS symp- cises. However, the very important toms can require upkeep of the tonic- actions must not be forgotten but ity of the velar and retrobasilingual automatized, such as with mastica- muscles. The final goal being function- tion or phonation. This gives a natural al automatization. aspect. The same can be done with This post-ablation care structure a patient who, after lower-limb ortho- of the osteosynthesis plates is a lot pedic surgery, recovers his mobility less systematic and implemented on and all his force, but continues to a case-by-case basis, some patients limp because the movement was not may not need physical therapy nor fully reintegrated. myofunctional treatment at this stage.

J Dentofacial Anom Orthod 2016;19:203 17 TH. GOUZLAND, M. FOURNIER

THE PSYCHOLOGICAL COMPONENT

Throughout the treatment, the psy- For others, the effects were only felt chological care of the patient is of the some days later. utmost importance. It is, therefore, a Cutaneous pain relief, following long process requiring the psycholo- bone displacement, causes a some- gist’s involvement from start to fin- what significant esthetic change. The ish. The role of the rehabilitator is to patient must adapt to this new face maintain this motivation throughout. and create a new identity. Although This support allows us to follow the the result is always better, it is an ex- progress of the patient’s psychologi- ternal view and so the patient must cal state. still be able to recognize themselves In the preoperative period, apart in the mirror as well as be recog- from the breathlessness, patients nized by others. At first, the edema, may show signs of anxiety. Special- which can be serious, upsets the ists must answer all the patient’s patient and does not give a positive questions about treatment duration, impression of the new morphology. possible pain, edema, diet, the rubber Vanpoulle37 emphasizes that women bands, future physical appearance are more sensitive to this esthetic etc. To allay the worries of patients, difference as opposed to men. Fur- each person’s consultation must be thermore, a significant dysmorphia complementary and must go in one can bring about a great change that common direction. is more easily tolerated than a small In the postoperative period, a fre- displacement because in this case, quent sensation of oppression has the patient who was not happy with been described and this can be linked their old face, adopts the new one to a number of things: intermaxillary more readily. blocking, obstructed airways, com- The rapid reabsorption of edema, the pression due to edema, and a lack recovery of one’s facial expressions, of intraoral proprioception with the their opinions of themselves when tongue misplaced. The state of fa- looking in a mirror are all favorable tigue in which the patient finds them- factors. Possible delays in the recov- selves can also be contributory. Their ery of sensitivity can have a negative diet may be less rich and nocturnal effect. The kinesiologist must make discomfort can slow down recovery. the entire process psychologically ef- Some patients describe an almost fortless by optimizing the positive im- immediate aftermath to the surgery. pact of functional and esthetic results.

STUDY

In daily practice, we are very often the functional progression of the confronted with the phenomena of buccal opening as well as the pos- contractures or muscle tension. De- tural balance of the person who is in scribed by the patient and manually the process of reconstructing their identified by the rehabilitator, they body image. To try and clarify the cause pains and have an impact on importance and structure of these

18 Gouzland Th., Fournier M. The oromaxillofacial rehabilitation in orthodontic-surgical protocols THE OROMAXILLOFACIAL REHABILITATION IN ORTHODONTIC-SURGICAL PROTOCOLS

muscle phenomena, a study was scribed by Barette3, is abundant in pro- conducted. prioceptive receptors, has the role of The muscle groups studied are stabilization and the postural position- the masticatory muscles: masseter, ing of the head within the three planes temporalis, and lateral and medial of space, particularly to maintain the pterygoids. These powerful mandi- horizontality of sight. They are sensi- ble elevator muscles often suffer tive to palpation in cases of excessive from preoperative tension due to tension, causing pain in the upper dysmorphia or to lingual dysfunc- neck. The surface is composed of long- tion. After intervention, they have to er splenius and semispinalis muscles undergo morphological bone-based working in a chain24. The sternocleido- changes, intermaxillary blocking, mastoid, occipitalis, and scalene mus- pain, finishing touches and ortho- cles (often excluded when discussing dontic treatment. Their care is unani- contractures in favor of SCOM) have mously acknowledged by all authors the job of orienting the head in space. after orthognathic surgery.1,5,17,18,34,37 Then we find the muscles linked to Second, the study evaluated the the scapula, the upper trapezius mus- presence of cervical and suboccipi- cles, and the circumflex scapular ar- tal muscle tension as many of the tery . There is also a connection to the problems brought up by patients are face via the occiptofrontalis muscle. located in this region. The muscles The antagonistic muscles situated on concerned are deep and short, and the anterior side contribute not only to they extend from the occiput to the counterbalancing the ones preceding first cervical vertebra. There are four to ensure postural equilibrium of the per side, rectus capitis anterior, rec- head but they are directly linked with tus capitis lateralis, obliquus capitis the stomatognathic system when superior, and obliquus capitis infe- it comes to surgery. The surpahyoid rior, which is in contact with Arnold’s and infrahyoid muscular system is the nerve. A muscle contracture that is anatomical, postural link between the too severe will put tension on the mandible, the base of the skull, the nerve and provoke occipital neural- tongue and the torso, this is achieved gias. Sensations of this type have by way of relays on the hyoid bones, been briefly mentioned in some cas- which is how it earned the name pos- es. This suboccipital musculature de- tural “gyroscope“30 (Fig. 16).

J Dentofacial Anom Orthod 2016;19:203 19 TH. GOUZLAND, M. FOURNIER

Figure 16 Anatomical connection of the hyoglossal apparatus.

Sample the population in question without dis- The sample studied concerns pa- crimination according to sex or age. tients who underwent orthognathic surgery in the form of a maxillary or Method bimaxillary mandibular osteotomy. Genioplasties and maxillary disjunc- The patients making up the sample tions have been excluded, because were followed from their immediate they do not create sufficient structural postoperative rehabilitation to the modifications. The selected sample end of the treatment, over the course for the study contains 35 individuals of approximately 6 months. The crite- who were randomly selected among ria studied were:

20 Gouzland Th., Fournier M. The oromaxillofacial rehabilitation in orthodontic-surgical protocols THE OROMAXILLOFACIAL REHABILITATION IN ORTHODONTIC-SURGICAL PROTOCOLS

– Preoperative Angle’s class (without Results subdivisions) – History of muscle tension and neck pains Data collection shows that the mas- – The appearance of immediate con- ticatory system (MAS) is implicated in tractures (during hospitalization or 100% cases (Fig. 17) and most often upon the return home) unilaterally (83%). Experience shows – Later appearance of contractures that there is rarely a change in side – Tension localization on the mastica- during the recovery period, although tory muscles (MAS) in some cases it shifts. The CSO re- – Tension localization in the cervical gion is not systematically prone but and the suboccipital region (CSO). all the same it occurs in 74% cases. The division of the Angle’s classes Data collection was done in part by within the group did not allow us response to a questionnaire and also to draw any significant conclusions by the result of a palpatory analysis (Fig. 18). However, that would leave done during the consultations. The us to suppose that Class III patients parameters are subjective but were (60%) are less susceptible to CSO recorded by the same operator under than Class II (77%). the same conditions.

Figure 17 Appearance of muscle tension in the masticatory apparatus and the cervical and suboccipital musculature.

J Dentofacial Anom Orthod 2016;19:203 21 TH. GOUZLAND, M. FOURNIER

Figure 18 Report CSO muscles tension according to occlusal class.

The lateralization of the CSO corre- lated to identical MAS movements, in 11 out of 12 cases on the same side, Homolateral MAS

which suggests that there is a link Contralateral MAS between the two (Fig. 19). It would have been interesting in the cases of bilateral CSO to know if one side was significantly more contracted, to Figure 19 trace a parallel with the correspond- Lateralization of CSO muscle tension in ing masticatory side. relation to MAS. Of the seven patients having indicated preoperative symptoms, six experienced immediate postopera- Discussion tive pains. This implies that the fewer contrac- Although the results appear inter- tures patients have because of interesting and by professional practice vention, the more comfortable their we could track the correlation quite recovery will be. well but the sample size does not al- The final element that stands out is low us to draw any conclusions es- the onset of symptoms within days of pecially about the class II to class III the intervention (23 cases), which is proportion. The same can be said for almost twice the number shown in im- the type of orthognathic surgery be- mediate postoperative care (12 cases). cause no difference was observed. The preoperative position and the im- The preoperative analysis of the mor- portance of the intervention are not photype would be interesting to cor- the only factors. This implies a more relate to the lateralization of muscle mechanical factor during the removal tension. of the transfixion and functional stimu- Moreover, only the onset of symp- lation. toms has been indicated but not there

22 Gouzland Th., Fournier M. The oromaxillofacial rehabilitation in orthodontic-surgical protocols THE OROMAXILLOFACIAL REHABILITATION IN ORTHODONTIC-SURGICAL PROTOCOLS

is nothing about the resurgence over lateralization implies the existence the course of postoperative treat- of a correlation between the two. ment. The statements made by the The difference between the preop- patients refer to events such as the erative occlusal classes is not at all modification of the elastic forces, significant. The direct modification of stopping the splint, changing the arc, muscle tension on the anterior mus- or resuming work. The kinesiotherapy cles by surgery and the onset of pos- follow-up throughout treatment even terior cervical contractures suggest a if spaced out in time has proven to treatment impact beyond that of the be effective in managing this type of masticatory apparatus, via the mus- manifestation as well as for ensur- cle chains on the rest of the posture. ing better treatment compliance with Furthermore, Vaillant35 demonstrates shorter delays. the impact of cervical muscles on postural control. The significance of the results of the study confirms Synthesis the views tied to experience and the need to treat these muscular mani- Although the sample studied was festations for the improved comfort not very large (35 cases), the ten- of the patient and also to encourage dency for muscle tension to appear the postural integration of any facial is very clearly marked in the effects morphological modification surgery. of orthognathic surgery, especially on It seems worthwhile to conduct the the masticatory apparatus but also study on a larger sample and eventu- on the suboccipital musculature. The ally to include other criteria.

CONCLUSION

Surgico-orthodontic care special- results and limit the risk of relapse. ists, to restore functional and struc- The conclusions of the study con- tural equilibrium, will be faced with ducted on the onset of postopera- many anatomical, psychological, and tive muscle tension show that they functional disruptions. The kinesiolo- must not be neglected. This means gist, oromaxillofacial rehabilitation we need to have a more general vi- specialist, assists in preoperative sion of the patient and provide them treatment to ensure that the pa- with the best therapeutic solutions. tient benefits from optimal surgical All this can only happen with a mul- conditions. The kinesiologist works tidisciplinary team in which each on the musculoskeletal system and person plays a key role and the com- corrects orofacial dyspraxias. In bined efforts help to establish well- this way, they contribute to making coded protocols. postoperative recovery more comfortable for the patient and optimize Conflict of interest: The authors have recuperation. In the long term, the declared that they do not have any conflict rehabilitation will automatize the of interest.

J Dentofacial Anom Orthod 2016;19:203 23 TH. GOUZLAND, M. FOURNIER

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