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The British Journal of Developmental Disabilities

Vol. 53, Part 2, JULY 2007, No. 105, pp. 111-123

EFFECTS OF TWO TYPES OF

APPLIANCES ON OROFACIAL DYSFUNCTIONSOF DISABLED CHILDREN

Alev Alacam and Nalan Kolcuolu

*Alev Alacam, DDS, Ph. D.

Professor, Gazi University, Faculty of Dentistry, Department of Pedodontics,Ankara,06510,TurkeyTel:+90-312-2126220/288 Fax:+90-312-223 9226 e-mail: [email protected]

Nalan Kolcuolu, DDS, Ph. D.Research Assistant, Gazi University, Faculty of Dentistry, Department of Pedodontics,Ankara,06510,Turkey

* For Correspondence

Introduction

The importance of preventive therapiesin disabled patients have been understood

in dentistry also as in every step of theirmedical therapies. Oral-health educationof the family and the child, motivationand preventive applications starting fromearly ages, will probably solve most of theoro-dental health problems of this specialgroup. Otherwise, periodontal problems,missing teeth due to caries, malocclusionsand orofacial muscle dysfunctions of the

patients will make the treatment morecomplicated.

Orofacial dysfunctions mostly seen inDown syndrome (DS) or Cerebral palsy(CP) cases create a social problem for chil-dren besides their physical problems. How-ever these dysfunctions are not accepted

This study was presented in the 18th Congress of International Association for Disabilityand Oral Health, Gteborg, Sweden, August 23-26 2006.

as a serious or primary health problem bymost physcians. The extra-oral appearancewith an open mouth called dull lookcauses negative effects on the physicologi-

cal development of children, affecting theirsocial acceptance. Habitual mouthbreath-ing, feeding disorders, lack of mastication,protrusion of the tongue, lip incompetence,drooling, swallowing and speech disor-ders are the problems most often seen inthis special group. Usually patients havemouthbreathing which causes upper re-spiratory system problems and xerostomiaresulting in periodontal destruction anddental loss. All these problems need early

stage orofacial muscle treatment.It is known that lack of lip closure is not

abnormal in children under 3 years of ageand normal tongue posture developmenttakes place at approximately 4 years of


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TABLE I

Criteria for clinical examination of orofacial muscle dysfunctions (Oreland et al., 1989)

Swallowing:normal, infantile, special feeding (have swallowing

reflex), style feeding (impaired or no swallowing reflex)

Chewing:0 stroke; < 3 strokes; 3 < strokes < 5; 5 < strokes < 10;> 10 strokes; not cooperating

Mouthbreathing (habitual): yes, no, undeterminable

Lip seal:competent, incompetent, undeterminable

Tongue posture:normal, interdental, various

Drooling:yes, no, undeterminable

TABLE II

Pretreatment examination results of orofacial functions

Swallowing

normal 20 children

infantile 30 children

special feeding 27 children have swallowing reflex (semi-solid foods)

style feeding 3 children

impaired or no swallowing reflex (liquids only)

Chewing

16 children 0 strokes

32 children 3 < strokes < 5

2 children 5 < strokes < 1

41 children had chewing problems (eg. mashing on palate)

Mouth Breathing

nose breathing 29 children

mouth breathing 21 children

Lip Seal

incompetent 43 children

competent 7 children

Tongue Posture

interdental 34 children

extra-oral 8 children normal 8 children

Drooling

All the patients had drooling in various degrees


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the form of a pacifier with a rolling pearlpart (PICTURE 1). Castillo-Morales pala-tal plate was applied to 23 children whorefused to use a Dr.Hinz oral-screen (PIC-TURE 2). Castillo-Morales palatal plates

were prepared at the laboratory from indi-vidual impressions. A therapeutic buttonstimulator with an external diameter of 7-8mm and height of 4-8 mm was mounted onthe palatal surface of each plate. In somecases, dental retainers were used forsupport; otherwise, plates were preparedlike overdentures. If there was an incoor-dination of the appliance, the palatal platerenewed. Patients were motivated to use

the appliances continuously for an hourper application. A total of 3-4 hours a daywas recommended.

Parents recorded the daily usage time ofthe appliances and the improvements that

they observed in childrens orofacial dys-functions (chewing and feeding problems,drooling, lip seal, and tongue posture).

Patients were controlled clinically at 3-month intervals, for 12 months. At the endof 12 months, children stopped using theappliances and were evaluated for relapsefor an additional 3 months. Treatment of8 children had to be interrupted becauseof change of address, lack of compliance

PICTURE 1

Dr. Hinz oral-screen

PICTURE 2

Castillo-Morales palatal plate


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80%

33%

64%

9%

and loss of follow-up because of distance.Ultimately, 42 children were evaluated atthe end of the original 12-month treatmentperiod, while 36 were evaluated at the endof 3-month additional relapse period.

Statistical analysis of the treatment re-sults according to usage time and type ofappliance was evaluated with a sign test.The differences between the two appli-ances according to orofacial functional de-velopment effectiveness were determinedwith a proportion for difference-normalapproximation test.

Results

Daily usage times of the appliancesaccording to appliance type are given inTABLE III.

The results of the effects of the appli-ances on swallowing are presented in FIG-URE 1, chewing (FIGURE 2), tongue pos-ture and lip seal (FIGURE 3), and drooling(FIGURE 4).

The data revealed that Castillo-Moralespalatal plates were significantly more effi-cient (p < 0.05) at improving swallowing

TABLE III

Daily usage times of the appliances

Daily usage times Dr. Hinz Castillo-Morales

< 1 hour 7 4

1-2 hours 11 4

2-3 hours 3 8

3-4 hours 6 7

FIGURE 1

Effects of therapy on swallowing

0%

20%

40%

60%

80%

100%

25%

14%

Style feeding tospecial feeding

Special feeding tonormal

Infantile to normalswallowing

Castillo-Morales appliances

Dr. Hinz appliances

Pe

rcentofchildren


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90%

71%

FIGURE 2

Effects of therapy on chewing

0%

20%

40%

60%

80%

100%

80%

33%

Transfer tochewing

Increasing inchewing stroke


Dr. Hinz appliances

Percentofchildren

FIGURE 3

Effects of therapy on tongue posture and lip seal

0%

20%

40%

60%

80%

100%

100%

Tongue transfer

to interdentalposition


Dr. Hinz appliances

Percentofchildren

75%

69%

Tongue transfer to

intra-oral position

83%

77%

Lip seal

development

53%

33%

Lip seal

competency


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after 2-3 hours and 3-4 hours usage times.However the number of chewing strokeswas not affected by the appliance typeused (p < 0.05).

The effects on tongue posture was im-

portant for the Castillo Morales palatal plate(p0.05).

For lip seal competency, 1-2 hours and2-3 hours usage of the appliances did notresult in a statistically significant differ-ence. Usage of Dr. Hinz oral-screen for 3-4hours was effective after 3 months (p


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PICTURE 3Pre-treatment and post-treatment appearance of a 2 year old child with Down syndrome who

used a Castillo-Morales appliance

PICTURE 4

Pre-treatment and post-treatment appearance of a 4 year old child with Down syndrome who

used a Castillo-Morales appliance


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PICTURE 5

Pre-treatment and post-treatment appearance of a 5 year old child with cerebral palsy who used

a Dr. Hinz appliance

PICTURE 6

Pre-treatment and post-treatment appearance of a 3 year old child with cerebral palsy who used

a Dr. Hinz appliance


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DS (Castillo-Morales et al., 1982; Chapmanet al., 1983; Hoyer and Limbrock, 1990;Limbrock et al., 1990a; Schuster and Giese,2001; Backman et al., 2003; Carlsted et al.,2003). On the other hand, the oral screen

appliances were suggested as good alter-natives for lip exercises also. Between thefour commercially available types of Dr.Hinz oral screen appliances, the pearl-oralscreen which is in the form of a pacifierwith a rolling pearl part, was selected forthis study. The advantage of this applianceis that it is commercially available in twodimensions for primary and mixed denti-tion. The manufacturer stated that the roll-ing pearl improved the tongue position at

rest, controlled drooling and prevented theposition and strength of the lips. (Dr. HinzDental). Also, it is concluded that 3 -8 yearsof age is ideal to begin the therapy with Dr.Hinz oral screen (Hinz, 1986).

The children attending a lasting phys-iotherapy programme for orofacial stimula-tion in their institutions with an age range

between 3 -7 years were randomly selectedfor this study. All the children who par-

ticipated the study were guided to use aDr. Hinz oral-screen for a 2 week periodinitially, but 23 children out of 50 refusedit and were transferred to use the Castillo-Morales palatal plate. It became apparentthat the physiological development of handcoordination of the older children was adisadvantage for the pacifier form of Dr.Hinz oral-screen usage since older childreneasily removed the appliance and it becameharder to control the usage time. The ad-

vantage of the Castillo-Morales palatal platewas that it is an individual appliance that isharder to remove and the children showed

better compliance, contrary to the findingsof Castillo-Morales et al. (1982) who statedthat in children above the age of 4 years ofage the treatment would be unsuccessful

because of rejection of the plate.Most of the studies on orofacial regula-

tion therapies demonstrated that the bestresults have followed very early interven-tion between 6 months and 4 years of ageand stressed a dual concept of physiothera-peutic exercises for the oral region besides

a stimulator plate. It is known that activefacial muscular activity is evident in normalprenatal development and orofacial influ-ence starts with thumb-sucking at four tofive months before birth. However, thishabit seldom develops even after birth inDown syndrome cases (Carr, 1970; Fischer-Brandies et al., 1986). It is because of thisthat most of the studies on Castillo-Moralesorofacial regulation therapy were startedat a young age in children with Down syn-

drome (Limbrock et al., 1990a,1991; Carlstedet al., 2003; Backmann et al., 2003; Hunn,2000). On the other hand, Gerek and iy-iltepe (2005) successfully treated 7 chil-dren with cerebral palsy, at ages between8-17, with Castillo-Morales palatal plateswhereas Limbrock et al., (1991) stated thatthere was no effect of age on results of thetreatment in their Down syndrome studygroup of children aged 0-6. In our study

31 children had CP and the others had DSand MMR. Altough the wide age range be-tween 3-7 years did not affect the results,the importance of mental age in diagnosisand treatment planning rather than chron-ological age, must not be neglected.

The results of the study showed bothof the appliances had similar improving ef-fects on most of the parameters of orofacialdysfunctions at different time periods. TheCastillo-Morales palatal plate was found

significantly to be effective for only swal-lowing, lip seal and drooling parametersat 3-4 hours usage time at the end of a 12month period. So the importance of dailyusage times of the appliances rather thanthe appliance type became the most impor-tant criteria for success in the evaluation atthe end of the study. Gerek and iyiltepe(2005) had followed a different schedule


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starting with a 1 hour on, 10 minute off for6 hours regime when awake at first week,2 hours on, 10 min off for 8 hours in thesecond week, 4 hours on, 10 min off for 8hours at the third week and all day when

awake for 10-12 weeks. However there isthe risk that the child may become accus-tomed to the appliances for all day usagefor such a long time. On the other hand,the instructed usage time of at least onehour twice a day, by Carlsted et al. (2003)was thought to be in limits for success ac-cording to our results. Limbrock et al.(1991)preferred a schedule starting with onehour each day and quickly progressing toone hour three or four times a day whichwas similar to our study protocol. At theend of a 3 month relapse period withoutusing the appliances, 44.6% of the childrenremained stable while 41.6% who used theappliances more than 2 hours had contin-ued development in orofacial functions inthis study. These results were in correla-tion with the study of Korbmacher et al.(2004) who stated that improved orofacialappearance resulting from the early treat-

ment had remained stable after 12 yearswhereas initially slight improvements re-sulted in only slight improvements or un-changed findings in the longer term. Theregression in orofacial functions of childrenwho used the appliances less than 2 hourssupported the idea of Hoyer and Limbrock(1990) who suggested that relapse wouldhave happened if the usage of the appli-ance was neglected for a period of time inthe early stages of the treatment.

The most impressive results of thisstudy were the improvement in the feed-ing style and the development of facialexpression. Positive effects of therapy onswallowing and the increase in the numberof chewing strokes were found to directlyinfluence feeding types. 80 % of childrenin Castillo-Morales group were transferredfrom special to normal feeding and 90 %

of the same group increased their chewingstroke number. The ability to advance frommashing the food on palate to a more nor-mal feeding was very pleasing for the fami-lies of the children. On the other hand,

development of facial expression is closelyconnected with the total (motor, cogni-tive and social) development of the childand it is known that children with Downsyndrome have a slower than normal mo-tor development during the first 2 years,related to general hypotonia including theorofacial muscles (Carr, 1970; Limbrock etal., 1990a, Limbrock et al., 1991, Limbrock etal., 1993; Carlsted et al., 1996). Pre-treatmentand post-treatment photographs and videoregistrations of all of the children that par-ticipated in the study showed a significantdifference in orofacial development on a12 month follow-up period. However thelack of a control group limited our abilityto evaluate the effect of the appliances in-dependently from normal development. Insuch functional therapies, the lack of a con-trol group raises the same ethical problemsas dismissing the control group from treat-

ment. According to our results, it is thoughtthat the children who used their appliancesless than 1 hour could be controls in futurestudies.

The results of the study showed vastimprovement in the quality of the chil-drens orofacial functions, instilled happi-ness in their families and made their livesmore enjoyable in this respect. It is clearthat supporting the physiothearpy pro-grammes with a regularly applied prosth-

odentical appliance for a sufficiently longlasting treatment period (at least 3-4 hrs/day for one year) will achieve the desiredpermanent results in addition to a consci-entious and wishful family.


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Conclusions

Both appliances had positive effects onthe development of oral functions.

Appliance effectiveness was directly

related to the length of daily usage pe-riod.

There was no improvement in oral

functions in children who used theappliances less than an hour in bothgroups.

The Castillo-Morales palatal plate wasmore effective in the swallowing, lipseal and drooling parameters, with 3-4hours of daily use throughout the 12-month evaluation period.

Relapse evaluations showed that theusage time was effective on the func-tional regression whereas 44.6% of thepatients showed stability in their ac-quired functions in this study.

Summary

Habitual mouth-breathing, feedingdisorders, lack of mastication, protrusionof the tongue, lip incompetence, droolingas well as swallowing and speech disor-ders are the problems most often seen indisabled children with orofacial muscledysfunction. The aim of this study wasto improve these functional problems byusing either the Castillo-Morales palatalplate or the Dr. Hinz oral screen and eval-uate their effects on this special group.

Thirty one children with cerebral palsy,6 children with Down syndrome and 13children with mental motor retardation,at ages between 3-7, participated to thisstudy. The Dr.Hinz oral screen and Castillo-Morales palatal plate were used by thechildren for 12 months. Photographs andvideo images were taken at the beginningand at the end of the study. The changes in

oral functions were recorded on standard-ized forms by the parents and the doctor.At the end of the therapy period, relapsewas evaluated without the appliances for3 months more.

Statistical analysis of oral functions werecalculated using the 'sign test' and 'propor-tion for difference'. Both of the applianceswere observed to efficiently aid the devel-opment of oral functions. However patientswho used the appliances 3-4 hrs/day were

found to have a more favorable outcomethan patients using the appliances for 1-2hrs/day. Also the Castillo-Morales palatalplate was found to be more effective andeasily accepted in this study group. Relapse

results showed that in 44. 6 % of the chil-dren there was stability in the acquiredoral functions. 13. 8 % of the children whoused the appliances less than 2 hours in thestudy period showed a regression in theiracquired oral functions.

In this study, both of the applianceswere found to have a positive role on theimprovement of orofacial dysfunctionswhich affects the social acceptence of this

special group negatively. Conscientiousnessof the family and daily usage times werefound important factors on the success.

References

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with Down Syndrome: Oral developmentand morphology after use of palatal platesbetween 6 -18 months of age. InternationalJournal of Paediatric Dentistry, 13, 327-335.

Carlsted, K., Henningsson, G. and Dahllf, G.(2003).A four-year longitudinal study ofpalatal plate therapy in children with Downsyndrome: effects on oral motor function,articulation and communication preferences.

Acta Odontologica Scandinavica, 61, 39-46.


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Carlsted, K., Dahllf, G., Nilsson, B. AndModer, T. (2006).Effect of a palatal platetherapy in children with Down syndrome.

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Carr, J. (1970).Mental and motor developmentin young mongol children.Journal of MentalDefficiency and Research, 14, 205-220.

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