INTRODUCTION
Dentofacial deformities (DFD) are defined as severe skeletal changes associated
with alterations in dental occlusion1,2. These
deformities lead to modifications in the myofunctional system depending on the
type of disproportion. Such modifications include alterations in the functions
of chewing, swallowing, breathing, and speech, temporomandibular disorders
(TMD), alteration in the usual posture of the lips and tongue, and muscular
asymmetry3. The modifications in the
orofacial myofunctional system (OMS) are due to muscular responses, called
muscular adaptations, necessary for the functioning of the stomatognathic system
(SS)2,3.
Literature indicates that skeletal and occlusal alterations can be caused by
alterations in the OMS, and the latter could direct the bone growth of the
face4, bringing together speech
sciences and plastic surgery.
Orthognathic surgery (OS) is performed to correct maxillomandibular bone
disproportions and, consequently, provide a balance between the stomatognathic
functions and harmony between the anatomical structures5. Planning of this procedure is performed in conjunction
with the surgeon and orthodontist, and the contribution of the speech therapist
in this step is crucial, because this professional identifies the orofacial
myofunctional alterations present and allows the planning of a possible
rehabilitation program in order to provide greater stability in the surgical
results2.
The role of the therapist in the team responsible for patients with indication
for surgical procedures to reposition the bone bases is important, but it is
still a field that is being explored. The speech therapist who operates in the
area of OS contributes to a better neuromuscular reorganization after the
surgical procedure by correcting the form and reshaping the tissues, and seeking
a balance between the anatomic functions and the SS.
For these reasons, speech therapy services within the interdisciplinary team are
important to assist in the accomplishment of a proper prognosis and contribute
to the harmonious implementation of the SS2,5,6.
The speech therapist, when part of the OS interdisciplinary team, performs
important functions such as evaluation of the SS in the pre-operative and
post-operative periods. They can offer the patient and the team a comparison
between the evaluations at different moments, verifying the characteristics,
compensations and adaptations presented2.
Speech therapy before and after surgery is assessed according to the service and
in accordance with the specific characteristics of each patient2. The authors suggest that in each moment
of the intervention, the therapist plays an important role, beginning with the
preoperative phase and continuing to be involved till the postoperative
period.
Several studies have explained each phase of speech-language intervention,
detailing the aims of the therapy2,5. In the
preoperative phase, it is recommended that interventions be carried out in one
and three months prior to surgery, aiming to provide guidance and clarification
on the perception of the mechanisms and correct muscle patterns during the
conduct of the oral functions and rest. This moment of action is critical,
because this information will postoperatively contribute to the sensory impulses
to be sent to the central nervous system, and constitute a new proprioceptive
system5.
In the post-surgical period, the speech therapist can begin assessment
immediately after the surgery or within approximately 20 to 60 days after the
procedure, depending on the service rendered by the therapist and the time the
patient is discharged by the surgeon. The process can be divided in two phases:
immediate postoperative period (intermaxillary fixation and restriction) and the
therapy itself.
In the initial period, this professional should reiterate their guidance and
perform a preventive analysis to identify the structures of the SS that may lead
to instability in the postoperative period. After this phase, the therapy can be
initiated, during which the characteristics presented by the patient should be
evaluated for possible changes and/or adaptations in soft tissues, postural,
muscular and functional disorders. From this evaluation, the initiation of
muscular exercises, gradual reintroduction of feeding, sensitization work, and
others that are listed according to the needs of the patient may be carried
out2,5.
For speech-language therapy in OS, the patients must be dedicated and must
contribute towards achieving the proposed goals. With adequate performance and
automation of SS functions, speech therapy discharge can be determined, with
more spaced sessions eventually being required to enable the speech-language
pathologist to ensure that recurrence does not occur5.
OBJECTIVE
Given the above, the objective of this study was to identify the relationship
between speech therapy and OS in refereed publications.
METHOD
The precepts of the Cochrane Handbook were followed to establish the research
method7.
The location and selection of studies was conducted by a search of published
texts, without a specific time period, in the following databases:
PubMed SciELO, and BVS. In the PubMed database, the articles
selected were limited to studies conducted in humans, in English and
Portuguese, using the descriptors: “orthognathic surgery and clinical
protocols and speech therapy,” “orthognathic surgery and therapy and speech
therapy,” and “orthognathic surgery and therapeutics and speech
therapy.”
In the SciELO and BVS database the descriptors used were: “Cirurgia
ortognática e protocolos clínicos,” “Cirurgia ortognática e
terapia,” and “Cirurgia ortognática e
terapêutica,” and were limited to studies carried out in humans, in
Portuguese or English languages.
The text search in the databases was performed independently by the researchers,
aiming to minimize citation losses. The analysis of each of the citations
retrieved in the database was also performed independently by the researchers.
Initially, the analysis of the titles and abstracts of the citations was
performed, to identify the pertinence of their selection and inclusion in the
study. Citations in languages other than English and Portuguese were excluded,
as were repeated overlapping keywords. Also excluded were studies related to
literature reviews, letters to the editor and those that were not directly
linked to the topic.
In a second phase, the complete texts selected by researchers which were
effectively related to the research proposal were read in full. Publications
which could not be recovered in full through the CAPES Journal Portal and/or the
official site of the journal were also excluded.
All stages of the study were conducted independently by the researchers and, when
any discordance was identified, the final position was determined by consensus.
Figure 1 shows the article selection
strategy used in this study, while Chart 1 presents a summary of the reasons for study exclusion.
Figure 1 - Strategy for the selection of articles.
Figure 1 - Strategy for the selection of articles.
Chart 1 - Articles excluded according to the selection criteria
established.
| Articles excluded |
Nº |
| Review articles |
08 |
| Articles with non-primary themes |
170 |
| Articles without abstracts |
08 |
| Articles not freely available |
22 |
Chart 1 - Articles excluded according to the selection criteria
established.
The 15 articles selected were evaluated critically regarding the type of study,
objectives, number, and gender of participants, age, criteria and methods,
results and conclusions. In relation to the criteria and methods, we sought to
verify and describe the methodology employed in each one of the studied
articles, in order to analyze whether there was homogeneity among them. A
general description of the results and conclusions section was performed, as
presented by the articles.
RESULTS AND DISCUSSION
The overall results of the study are briefly described in Chart 2.
Chart 2 - Summary analysis of the articles.
| References |
Objectives |
Methods |
Results/Conclusions |
| Migliorucci et al., 20178 |
To propose a myofunctional therapy program for
individuals who underwent OS.
|
3 distinct stages: 1) Preparation of an initial
program from a literature review about the therapeutic process
after surgery; 2) Implementation of the initial program in 21
patients which resulted in a second version of the program; 3)
Content analysis by three speech therapists and new
modifications were carried out.
|
The program was developed based on 38 scientific
publications. After the suggestions of specialists, the final
version was composed of 12 sessions - Evaluation + 10 therapy
sessions once a week (myofunctional exercises, sensory
stimulation and functional training) + revaluation. It was
possible to develop a program of orofacial myofunctional therapy
for patients who underwent OS.
|
| Lima et al., 20152 |
To describe the case of a patient who underwent
OS and the speech accompaniment in the preoperative and
postoperative periods, as well as to evaluate the impact of the
dentofacial deformity on quality of life.
|
Case study of a patient with Class III
malocclusion. The evaluation was performed by means of the MBGR
Evaluation Protocol with scores. The speech intervention
occurred in the preoperative period (three months) and
postoperative beginning on the 20th postoperative day (for three
months). The impact of dentofacial deformity in the quality of
life of the patient was assessed by means of Oral Health
Impact Profile - reduced version.
|
Improvement in muscular mobility, reduced pain on
palpation, tonus balance, more efficient chewing, alternate
bilateral, appropriation of the swallowing pattern and adequacy
of speech production, and improvement in quality of life.
|
| Palomares, 20141 |
To evaluate the quality of life related to oral
and specific health of ortho- surgical patients taking into
consideration the following aspects: - esthetic self-perception
of patients; - clinical characteristics of malocclusions; -
gender, age, socioeconomic status.
|
A total of 254 patients were divided into four
groups, according to the stage of treatment: Initial
(pre-treatment), in orthodontic preparation for OS, in
post-surgical orthodontic finalization and containment (after
completion of treatment). They were interviewed in three major
centers of Rio de Janeiro. Quality of life was assessed by the
OHIP-14 and OQLQ questionnaires. The severity of malocclusion
and esthetic self-perception were assessed on the basis of the
Index of Orthodontic Treatment Need (IOTN) and the Dental
Esthetic Index (DAI).
|
The patients who completed all the steps of
orthosurgical treatment showed significant improvement in
specific quality of life relating to oral health, compared to
the other groups. The esthetic self-perception of the
containment groups and the post-surgical procedure was more
positive than in other groups. Clinical characteristics that can
be correlated with negative impacts on quality of life:
crowding, crossbite, open bite. Correlation between the OHIP-14
and OQLQ instruments was moderate, confirming that they assess
different aspects of oral health-related quality of life. OQLQ
demonstrates greater sensitivity in detecting changes in the
quality of life of ortho-surgical patients than OHIP-14.
|
| Alves e Silva et al., 20139 |
To compare the changes related to self-esteem and
satisfaction with the appearance between pre and postoperative
phases in patients submitted to OS and evaluate the quality of
life of these patients six months after the surgery.
|
A study was conducted on 15 patients, randomly
selected, with dentofacial deformities, who underwent OS in the
Oswaldo Cruz University Hospital of the University of
Pernambuco. The study had a follow-up period of six months, with
two stages: 1) Pre-operative (day of hospitalization):
application of a questionnaire to assess patients’ satisfaction
with their appearance and social relations; and 2) in the
post-operative period (six months after surgery), using
application Form I which evaluated the same variables of the pre
and the WHOQOL-bref.
|
The results showed that 13.3% of the patients had
improvement of esteem, especially in relation to the
satisfaction of appearance. Improvements were also observed in
social, professionals and family relations. With regard the
assessment of the quality of life, and in accordance with the
questionnaire of the World Health Organization, the lowest
average improvements corresponded to environmental control.
|
| Jakobsone et al., 201310 |
To analyze changes in facial profile of the soft
tissue after bimaxillary surgery of Class III correction, with
the objective of determining if a decrease or increase in the
height of the face affects the changes in profile, with an
emphasis in the anteroposterior direction.
|
Sample comprised 84 operated patients with Le
Fort I osteotomy + bilateral sagittal osteotomy with rigid
fixation. The surgery was performed in Oslo University Hospital,
Ullevaal, between 1990 and 2003. The patients were monitored
over 3 years - T1: one week before surgery; T2 one week after
surgery; T3, T4 and T5: 2, 6 and 12 months after surgery, and
T6: 3 years after surgery. Cephalometry of 81 patients (55 men
and 26 women were evaluated. The patients were divided into
three subgroups according to the change in the anterior facial
height during surgery (1 = no change group - less than 2 mm
shift in the in the anterior face height; 2 = decrease group -
decrease of 2 mm or more in the anterior face height; 3 =
increase group - increase of 2 mm or more in the anterior facial
height. Calculations of soft and hard tissue ratios were based
on long-term soft tissue response to surgical
repositioning.
|
The soft and hard tissues followed the same
pattern of changes in male and female patients, with the
exception of point B in soft tissues. The horizontal surgical
repositioning varied, depending on whether the anterior facial
height was increased or decreased. For the prominence of the
upper lip, the pattern of long-term change was the same
regardless of changes in facial height. In all groups, the
thickness of the upper lip decreased in both the short- and
long-terms, particularly in patients with surgical increase in
facial height. The inferior thickness of the lips increased in
the short term, but decreased during the follow-up period. There
were significant associations between tissues and the
corresponding changes in hard tissues, with the exception of
point A of the soft tissue and the upper lip, when the facial
height increased. The proportions were higher for mandibular
variables than for maxillary variables, particularly at point B
and pogonion when the height of the anterior face reduced. The
different changes in the patterns of soft tissue should be taken
into consideration during the planning of the degree to which
maxillary advances and mandibular recesses would be made.
|
| Rustemeyer & Martin, 201311 |
To evaluate the response of facial tissues in
patients with Class II and III facial pattern treated with
bimaxillary OS, evaluated cephalometrically and by 2-D
photogrammetry; To compare the capacity of the exams to predict
postoperative results.
|
28 patients who underwent bimaxillary surgery for
a correction of Class II, and 33 patients who underwent
bimaxillary surgery for the correction of Class III. The lateral
cephalogram and a lateral photogram were analyzed in two moments
- before the dental treatment and after 9 months of the
surgery.
|
No significant differences were found between men
and women, in the results of cephalometry or photogrammetry.
Angles of hard tissues changed significantly in the comparison
between the pre- and post-operative periods in Class II and
Class III surgical procedures. The pre- and post-operative
measures of soft tissues did not differ between the methods of
evaluation. This study revealed that cephalometry and 2-D
photogrammetry provide additional information to improve the
accuracy in predicting changes in the tissues in orthosurgical
surgery, especially in skeletal Class II patients.
|
| Chen et al., 201212 |
To assess changes in facial profile after
osteotomy in the vertical branch to correct mandibular
prognathism.
|
30 patients (20 females and 10 males, with an
average age of 20.7 years) who needed surgical correction for
mandibular prognathism were treated at the Kaohsiung Medical
University Hospital from January 1993 to December 1998. The
average time of follow-up of these patients was 27.2 months (12
and 102 months). To evaluate the changes in the profile after
surgery, two periods of cephalometry registration –
pre-operative T1 and T2 were done one year after the surgical
procedure, in which markings were performed, and the same were
compared.
|
Significant horizontal changes were observed in
relation to T1 and T2. The mean horizontal retreat of the
pogonion point (Pog) was 11.7 mm. The ratio of the retreat of
the lower labial (Li) / lower incisor (Li), labiomental (Si) /
B-point, and soft tissue (PogS) / pogonion points were 0.98,
0.99 and 0.95, respectively. No differences were identified in
relation to sex. A satisfactory treatment plan for people with
mandibular prognathism not only corrects malocclusion but also
considers facial improvement.
|
| Bergamo et al., 201113 |
To present the treatment of skeletal malocclusion
Class III with transversal alteration and facial asymmetry,
whose magnitude required orthodontic and surgical
treatment.
|
A male patient with 15:1 years, was brought into
the orthodontic clinic of Ribeirão Preto School of Dentistry,
USP, with the main complaint of occlusal changes. Facial
analysis indicated sharp facial asymmetry, slightly concave
facial bones, maxillary hypoplasia, increase of the lower third
of the face, Class III, narrow maxilla, posterior open bite,
deviation of mean line of maxilla to the right.
|
At the end of the treatment functional occlusion,
overjet, overbite and adequate intercuspation were observed.
Mandibular prognathism and facial asymmetry were eliminated. In
the case presented, the ortho-surgical treatment was well
indicated, promoting adequate masticatory function and adequate
facial esthetics.
|
| Gornic et al., 201114 |
To evaluate and quantify, through cephalometry,
changes caused in the airways due to the OS involving mandibular
setback.
|
17 patients submitted to ortho-surgical treatment
for Class III correction were selected. Among the patients
evaluated, 14 underwent combined OS of maxillary advancement and
mandibular indentation; while in the others, mandibular setback
was performed alone. Pre-operative cephalometric profile
radiographs were evaluated, up to 7 months before surgery, and
immediate post-operative radiographs, up to one week after
surgery.
|
The mean setback of the mandible was 7.32 mm
after the surgery. The impact on the airspace was evidenced by
an average reduction of 0.97 mm at the level of the oropharynx
and 3.41 mm at the level of the hypopharynx as the initial mean
diameter of these spaces was 16.88 mm and 13.05 mm,
respectively. This reduction was statistically significant only
in the region of the hypopharynx (p =
0.025).
|
Chart 2 - Summary analysis of the articles.
Based on the objectives, the studies were grouped into four categories, namely:
1) speech-therapy group (STG) = studies addressing speech and/or direct therapy
intervention2,8; 2) changes group (CG) = studies that
reported esthetic and functional changes in hard and soft tissue1,6,9-16; 3)
techniques group (TG) = studies that describe specific tests and/or methods to
verify changes in hard and soft tissues17,18 and 4)
others group (OG) = studies that did not fit the objectives of the previous
groups19 (Figure 2).
Figure 2 - Grouping of studies grouped based on their aims.
Figure 2 - Grouping of studies grouped based on their aims.
Regarding types of studies, majority were found to be longitudinal descriptive
studies (46.5%)5,8-11,13,16, followed by
cross-sectional descriptive studies (26.5%)1,16,18,19 and case
reports (20%)2,13,15. Only one study was a theoretical descriptive type
(7%)8.
Figures 3 and 4 detail the mean ages in each group, as well as the more prevalent
sex in the studies. It should be noted that some studies did not perform such
classifications, therefore the data were not presented in the charts.
Figure 3 - Mean age of the study participants.
Figure 3 - Mean age of the study participants.
Figure 4 - General classification based on the sex of the study
participants.
Figure 4 - General classification based on the sex of the study
participants.
In general, adult individuals with completed craniofacial growths were
considered. The literature recommended that indication for OS should be
determined after the completion of craniofacial growth, considering available
orthodontic and surgical resources, in order to correct maxillary and/or
mandibular deformities. This is because orthodontic treatment alone is unlikely
to correct the deformities20.
Women underwent OS significantly more often than men in selected studies. This
finding is comparable to those of previous studies that claim that more women
OS21, in general because women have
greater concerns about their health and esthetics, and seek treatment more
frequently22.
Analysis of the articles based on the methodology used and according to the
groups stipulated in the study indicates that in the STG, one study2 is a case report, and another article8 is a theoretical descriptive study that
describes the elaboration of a speech therapy program for patients undergoing OS
and the process of their content validation. In the CG, most articles used
longitudinal descriptive studies6,9-12,14, and in the
majority of the papers, the study was conducted in the university hospitals in
the country and/or abroad or in reference to national hospitals. In this group,
two other articles13,15 were case reports.
In the TG, a study that used a longitudinal descriptive approach was carried out
in the United Kingdom while another using a cross-sectional study design did not
specify the location of study. In the OG, a longitudinal descriptive study that
took place in a medical school in the state of São Paulo was identified.
In general, majority of the studies were performed in university hospitals.
Literature indicates that these institutions must integrate research, teaching,
and care, and this premise is noted in the official definition of a university
hospital, which was published on the MEC website, one of the governing bodies
and maintainers of university hospitals in Brazil23. This finding may be related to the principles of Brazilian
university hospitals, as stated in the literature23, which explains that the main hospitals in the world are
recognized not only as centers of education and care, but, above all, as
knowledge centers.
With respect to the results and conclusions of the studies, the researchers found
improvement in quality of life, in the functions of the stomatognathic system,
and mobility and tonus of the muscles in the STG, which may be confirmed by
means of standardized clinical protocols2.
In one study8, the researchers managed to
develop and validate the content of a speech program that contains evaluation,
therapy (involving orofacial myofunctional exercises, sensory stimulation and
functional training) and reevaluation.
In the CG, the researchers’ findings in general were: 1) increased confidence
after completion of OS, mainly in relation to satisfaction of appearance; 2)
improvements in social, professional and family relations; 3) significant
reduction in facial height due to mandibular repositioning; 4) decrease in the
thickness of the upper lip, both in the short- and long-terms, particularly in
patients with surgical increase in facial height; 5) an increase in the
thickness of the lower lip in the short-term, although it decreased in the
follow-up. Furthermore, several studies reported no significant differences in
changes between soft or hard tissues between males and females, schooling and
family income; changes in the marker points of soft tissue when pre- and
post-surgical results were compared, as well as improvements in facial
esthetics.
In the GT group, researchers17 showed no
statistically significant differences between two methods of superposition,
namely, Voxel-based registration and 3-D evaluation. However, surface-based
registration displayed high variability in mean distances between the
corresponding surfaces compared to the Voxel registration, especially in soft
tissues. Within each method, there was a significant difference between the
overlays of the hard and soft tissue models. Researchers18 reported that the proposed method significantly aided in
diagnosis, prognosis, teaching parameters for facial analysis in orthodontics
and OS, and in patient guidance and patient follow-up.
The TG is related to CG for this analysis, since the researchers used several
techniques and/or exams to verify the anatomical changes in hard and soft
tissues, and esthetic and functional changes in their studies. Such techniques
include tomographic imaging, surface electromyography (EMG) examination,
pressure measurement system exam, gypsum models, facial analysis, periapical
radiography, 2-D photogrammetry and, most commonly, cephalometry.
Thus, both groups deal with examinations and/or objective procedures which sought
to evaluate the changes in soft and hard tissues in the pre- and post-operative
periods to evaluate masticatory function, and to compare and verify changes,
stability and relapse. Based on the literature, we can state that the
examinations and procedures used in these two groups are important to enable
speech therapists, orthodontists and oral and maxillofacial surgeons use the
required parameters to perform a proper diagnosis, pre- and post-surgical
evaluations and treatment. These data need to be precisely documented to ensure
the best possible outcome for each patient24.
CONCLUSION
The objective of this review was to identify the relationship between speech
therapy and OS. During the literature search, little information was found on
direct speech therapy intervention, and most of the studies were directed to
esthetic and functional changes in the hard and soft tissue of patients who
underwent OS. Some studies addressed specific methods and/or exams to verify
soft and hard tissue changes in the facial profile of patients who underwent OS
and one study detailed the profile of individuals who underwent treatment for
dentofacial deformity and apnea-hypopnea syndrome.
COLLABORATIONS
|
MFNS
|
Analysis and/or interpretation of data; conception and design of the
study; completion of surgeries and/or experiments; writing the
manuscript or critical review of its contents.
|
|
LDMT
|
Analysis and/or interpretation of data; aprovação final do
manuscrito; conception and design of the study; completion of
surgeries and/or experiments; writing the manuscript or critical
review of its contents.
|
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1. Faculdade de Ceilândia, Universidade de
Brasília, Ceilândia, DF, Brazil.
Corresponding author: Laura Davison Mangilli
Toni, Faculdade de Ceilândia, Centro Metropolitano, Conjunto A, Lote
1 - Brasília, DF, Brazil. Zip Code 72220-900. E-mail:
davisonmangilli@yahoo.com.br
Article received: January 30, 2018.
Article accepted: September 5, 2018.
Conflicts of interest: none.
