Myofunctional Therapy

Myofunctional therapy involves creating awareness and exercises to restore normal rest posture and patterns of the oral and facial muscles during chewing, swallowing, speech and breathing.

Exercises are introduced sequentially with a therapist at each visit and repetitive practice is done at home to reinforce new habits, and build strength, coordination and endurance of the tongue and other upper airway muscles.

It is almost like having a personal trainer for mouth gymnastics. Your therapist will continually introduce new challenges and keep you moving forward to reach new goals.

The end goals of myotherapy include habit elimination e.g., thumbsucking, restoring closed mouth nasal breathing and tongue to palate suction at rest, plus proper muscle patterns during chewing, swallowing, speech and breathing.

Often myofunctional disorders or problems in the way that the muscles of the mouth and face work and their origins early in life.

They may be related to tongue tie, which restricts normal tongue mobility. Other big root issues are allergies and mouth breathing.

Good latch during breastfeeding is key to coordinating suck, swallow and nasal breathing. It best helps the tongue and other muscles develop for optimal chewing, swallowing, speech, palate development and breathing.

When there are deviations from this including poor latch and poor tongue suction, or the introduction of dummies and bottle feeding, it alters the way that the muscles balance and work.

Another common contributor is lack of stimulation of the jaw muscles for example in premature infants who miss a critical period of suck and swallowing in utero, or are fed by nasogastric tube, or children who have overly processed diets that don’t require much chewing.

When the tongue is sufficiently toned to suction and seal to the roof of the mouth at rest, it is impossible to breathe through your mouth. Mechanically, it is most likely that the mouth will be closed and air can pass more smoothly from the nose down the upper airway.

Tongue to palate contact involves greater tongue tone which will allow the tongue to perform its function as an upper airway dilator muscle, to keep the upper airway open during sleep.

When the tongue is sitting low or there is a tongue tie, the back of the tongue becomes disused and flaccid. It is more likely to fall back into the airway during sleep, causing disturbed sleep.

In children, good resting tongue posture will provide the proper stimulus for the jaws to grow wider and more forward in the face.

There are many health benefits associated with nasal breathing.

The nose is a specially designed for filtering, warming and humidifying the air before it enters our lungs.

In addition, when we breathe through our nose, nitrous nitrous oxide is released in our paranasal sinuses. This this is a has antimicrobial properties which helps to sterilise the air that we breathe. It is also a potent vasodilator, which means that it improves blood flow and oxygenation throughout the body.

When the mouth is open, the air is not probably prepared before it enters your lungs. There is an increased rate of colds and other airway infections and allergies.

With dry mouth, there is also increased risk of dental problems such as bad breath, decay and inflammation of the gums.

Nasal breathing is key for optimal sleep. When the mouth is open, the airway is less toned and stable, and we are more likely to snore or have a collapse of the airway during sleep. This can lead to a fragmented and non-restorative sleep, which can affect mood, memory, concentration, behaviour, learning and work performance.

In children, nasal breathing is critical for optimal development of facial structures.

With chronic mouth breathing, there are changes in the way the muscles posture. The jaw becomes slack, the lips do not seal together, and the tongue sits low in the mouth. These changes can contribute to other functional disorders, including issues with chewing, swallowing and speech.

These changes in muscle posture tend to promote vertical facial development. This contrasts with forward development which is linked to more optimal airway development into adulthood.

Sometimes mouth breathing can be a habit even when there is a clear nasal passage.

Other times there can be persistent mouth breathing after interventions to open up the nasal airway. This may include surgery such as removal of adenoids and tonsils, or orthodontic expansion of the palate or nasal floor.

This is related to the long-term postural changes in the muscles that can occur with chronic disuse of the nose. The jaw becomes slack, the lips do not seal, the tongue sits low rather than lightly suctioned to the palate. Interventions to improve the nasal passages do not automatically lead to the reversal of these muscle deficits.

As long as the nasal passages are clear, myofunctional therapy is a critical intervention to address these muscular deficits.

Myofunctional therapy helps establish nasal breathing with good tongue to palate seal and the lips closed at rest. This is key for smoother airflow and breathing.

It also helps improve the coordination and tone of the tongue and other upper airway muscles so they can better prevent the upper airway from collapsing during sleep. Myofunctional therapy is a proven adjunct to other options to reduce snoring and obstructive sleep apnoea in both children and adults.

It is most promising in children because good muscle function provides the proper stimulus for the jaws to grow wide and forward. This is associated with better nasal passages, tongue space and greater support for our collapsible upper airway or throat.

Myofunctional therapy and restoring normal closed mouth breathing and tongue to palate suction is key for developing good airways and slowing the progression of problems for children into adulthood.

Evidence suggests that thumb sucking may play an important role in neurotransmission. The tip of our tongue is normally supposed to sit in the roof of our mouth called the “N-Spot.”

This spot is full of sensory receptors. When stimulated, it sends signals to the brain to release important neurotransmitters such as dopamine and serotonin which help us feel calm, balanced, and serve many other functions.

Thumb sucking is thought to be a compensation to provide this sensory input. It is my observation that children who present with thumb sucking will have an underlying tongue tie or airway issue that makes it more natural for their tongue to sit low and not serve this function.

When a child is ready to give up thumb sucking, myofunctional therapy can help to break the habit within 24 hours, often despite no success with trial of many other solutions.

The key is to use lots of barriers and reminders and replace the habit by teaching the tongue the proper spot to rest in the roof of the mouth.

After the habit has been eliminated, further therapy is aimed to reverse the dysfunctions that have occurred with chronic thumb sucking. These can include poor lip seal, open mouth posture, reverse swallowing, and lowered tongue posture.

This is especially important in young children to optimise facial and jaw development.

When the tongue has been restricted even prior to birth, there are often patterns of compensation and dysfunction.

Tongue tie release can be likened to removing a cast that has been there since birth. It is not expected that automatically the tongue will know how to move properly.

Myofunctional therapy is about training these new patterns and strengthening and coordinating the tongue and other muscles to allow the best functional outcomes following the release. This includes achieving good tongue to palate suction for improved breathing and sleep where possible.

When myofunctional therapy is not performed and the tongue is not able to coordinate itself to move whilst healing, there is increased risk of scarring and reattachment.

Early interceptive orthodontics with palate expanders can help restore normal structure of the palate. This can offer stable long-term improvements in the width of the nasal floor.

However, if the underlying muscle imbalances that result in poor palate development are not addressed, the teeth positions are unstable and tend to relapse back to the position where they were. This is sometimes called the “equilibrium zone” where the inward pressures of the lips and cheeks are balanced by the expansive forces of the tongue.

Key to long stability of results and optimal breathing for children is eliminating sucking habits, restoring tongue to palate suction, closed mouth nasal breathing and reducing activity of the lips and cheeks during swallowing.

In many cases, the aim is to complete myofunctional therapy within 8-12 visits. It depends on each individual’s age, compliance, self-awareness, progress and the level of dysfunction initially present.

The optimal time frame between appointments to be two weeks for at least the first couple of months, but Dr Lim will often work with what suits your schedule and lifestyle.

As you become more familiar with the desired patterns and achieve greater control strength and control, appointments may be more spread out.

Even after active therapy, we suggest that people continue to do exercises at home on a regular basis to reinforce new habits and check in with us over the next 12 months. This is how long it can take for new habits to become permanent.

It is our experience that when children have had prolonged therapy without any progress, myofunctional therapy can be an important missing link.

For instance, in Brazil every speech pathologist is trained in recognising and addressing myofunctional disorders during their university training.

This is relevant because children with open mouth breathing are more likely to have speech disorders. Chronic mouth breathing is associated with an open mouth low tongue posture and reduced tongue strength. This is associated with lisps and other misarticulations.

Myofunctional therapists will also assess for tongue tie which can also restrict tongue mobility and promote low resting tongue posture.

Teaching the tongue to rest properly in the roof of the mouth and exercises to coordinate the tongue can be helpful. This may include addressing root causes of mouth breathing and tongue tie release to facilitate therapy.

It is not uncommon for parents to report that speech becomes clearer following myofunctional therapy and often no further specialised speech therapy is required.

One of the most common reasons that adults present to our practice for tongue-tie assessment is chronic neck tension and headaches.

This often has some connection to decades of compensating for restricted tongue mobility by recruiting muscles of the neck to elevate the tongue.

Over time, this can be associated with the development of trigger points, or tight bands of highly sensitive connective tissue called fascia that develop in those neck muscles. When stimulated, these can trigger referred pain into the head region. Patients may describe them as tension or migraine headaches.

If strain of the muscles of the neck is seen during tongue elevation, and patients perceive that their headaches seem to be related to their neck tension, this could indicate they may be a suitable candidate for myofunctional therapy and tongue tie release to allow the tongue to move more freely.

In carefully selected cases, there will be a reduction in neck and shoulder tension and headaches.

It is best to have an in-person assessment and consultation to assess your likely response.

A dental open bite is often related to incorrect tongue posture.

Rather than the tongue sitting high the roof of the mouth, the tongue is sitting forward to pressing against the area where the front teeth sit.

This can be accompanied by tongue thrust swallowing, where the tongue pokes forward against the region of the front teeth during swallowing. This constant force from the tongue prevents the open bite from closing.

Orthodontic treatment using braces can close this open bite. However, if the aberrant tongue is not addressed, the bite will tend to open again.

The open bite is recognised by orthodontists as one of the most difficult are and unstable situations to manage in orthodontics.

Myofunctional therapy to address poor tongue posture and the poor swallow is important for long term stability.

Dr Lim commonly uses a couple of different appliances as adjuncts to help promote and achieve the goals of myofunctional therapy.

The first is called Myomunchee. This appliance is used to help practice and promote lip seal and chewing and swallowing with the mouth closed. It also disengages all the muscles of the lips and face and retains a more normal adult swallow. These appliances are typically used a couple of times a day to promote and reinforce these muscle patterns.

The second appliance is called a habit corrector and can be made by companies like Healthy Start or Myobrace. These postural appliances help lift the tongue up to rest up on the roof of the mouth and encourage lip seal, nasal breathing and proper swallowing without engaging the facial muscles.

These appliances are generally used for longer periods of the day during quiet times such as watching TV, reading a book or doing homework and are sometimes introduced during sleep for children.

Before proceeding with therapy, you do need an appointment in-house. This is so Dr Lim has the opportunity to take a closer look inside the mouth and at the way the tongue and other muscles work. She wants to identify in advance any potential obstacles such as small mouth, nasal obstruction, or tongue tie that will limit progress with therapy.

If you are from a regional area, we offer initial consults via Zoom to review your situation and determine whether it is worth coming to Perth for full assessment and records.

After the initial appointment, online therapy may become an option. Many patients, especially ultimately see value (particularly in keeping children engaged) and choose to continue attending their appointments in person.