Lip Closure Research Articles

Control of lip closure in stop consonant production

Studies applying mechanical perturbations to the lower lip and the jaw have shown a trade off between movements of perturbed and unperturbed articulators in making the lip closure for a bilabial stop. While this concept is attractive, evidence for such trading relationships in normal speech has remained elusive, partly due to methodological problems. This study examines the vertical positions of the upper and lower lip at closure for bilabial stops. An electromagnetic transduction system was used to track receivers on the upper and lower lips, and the lower incisors for transducing jaw movements. The speech material consisted of VCV sequences where the first vowel was /a/, the middle consonant /p,b/, and the second vowel /i,a/; stress occurred on the second vowel. Preliminary results from three subjects showed upper lip positions at closure to occur over a range of 0.3 cm; the range for lower lip positions was 0.5 cm. Examination of 40 tokens for each subject revealed a positive relationship between upper and lower lip positions at closure, with correlation coefficients ranging from 0.5 to 0.7. The results will be discussed in relation to theories of speech motor control. [Work supported by NIH.]

Palatal Changes after Lip Surgery in Different Types of Cleft Lip and Palate

This study concerns palatal development during 6 months following primary lip closure. The sample consisted of 75 children with different forms of cleft lip and palate and 51 noncleft children. The palate was measured at 3 months of age, just before lip surgery, after surgery at 6 months, and again at 9 months of age. The results showed that lip closure has a strong effect in the anterior alveolar region. This effect was restricted to 3 months after surgery. The changes in complete clefts were more explicit than in incomplete cleft forms. Furthermore, the data showed that arch depth reduction due to lip surgery was compensated for by continued anteroposterior palatal growth. Early orthopedics appeared to prevent major palatal collapse immediately after lip surgery. Finally simultaneous closure of the alveolar cleft at the nasal side resulted in continued reduction of anterior cleft width.

Cleft Lip Rhinoplasty

Cleft lip rhinoplasty may be performed as an endonasal or an open rhinoplasty procedure. It is helpful for the rhinoplasty surgeon to know the type of lip closure and the extent of nasal surgery performed at the time of primary lip repair. Current methods of primary lip repair attempt to create an esthetic lip scar and leave a minimal degree of nasal tip deformity to allow the child to avoid secondary lip and nasal tip surgery at the preschool age. Single cleft lip rhinoplasty has to deal more with asymmetry than double cleft lip rhinoplasty. The double cleft lip deformity has to deal with a true deficiency in the columella and the possible need for lip augmentation. Closure of the alveolar cleft and the cleft palate in both types of cleft lip and palate often creates scar tissue that retards maxillary growth and introduces the need for cephalometric analysis and possible orthognathic surgery.

Cleft Lip and Hemangioma: A Patient with Wolf-Hirschhorn Syndrome

A patient with Wolf-Hirschhorn syndrome had multiple congenital anomalies and a right cleft lip. Hemangioma involved the full thickness of the upper medial lip segment at the age of 2 months, which caused lip repair to be very difficult. The first attempt at adhesion cheiloplasty resulted in complete separation. The tumor did not respond to steroid treatment. A subsequent trial of lip repair with the assistance of a tension-relieving suture tied to the nasal septum was successful. This type of tension suture is helpful to prevent dehiscence when security of lip closure is questionable or cannot be achieved.

Dentofacial morphology in adolescent or early adult patients with cleft lip and palate after a treatment regimen that included vomer flap surgery and pushback palatal repair.

Dentofacial morphology was evaluated in 94 adolescent or early adult patients born with unilateral or bilateral cleft lip and palate. As well as lip closure, the primary treatment included vomer flap surgery and pushback palatal repair. Roentgencephalometric measurements as well as classification of the patients into different classes of dentofacial deformity indicated development of bimaxillary retrognathia with severe midfacial deficiency in about a quarter of the cases. Our results were similar to those reported by other teams who used similar surgical regimen.

Surgical treatment of mandibular prognathism in collaboration with orthodontic treatment in Korea

Mandibular prognathism is defined by John Hunter as follows: "The lower jaw projecting too far forward so that the foreteeth pass before those of the upper jaw, therefore disfigurement and malocclusion are two of the main facial characteristics." Other distinguishing features are the coexistence of class III malocclusion, incomplete closure of lip, deviation of the midline, and decrease of labiomental fold. Generally, the functional occlusal relationship and balanced facial harmony cannot be obtained by surgical or orthodontic treatment alone. Its success depends on careful conjoint, supplementary diagnostic, and treatment planning. As a cardinal principle the authors made the following combined surgical and orthodontic treatment plans: (1) Orthodontic treatment relocates and decompensates the malpositioned teeth (remove the masking effect of teeth) and, therefore, skeletal deformity is exposed maximally. (2) Surgical treatment eliminates the maximally exposed skeletal defect. Therefore, dramatic facial balance and functional occlusal relationship are obtained. Treatment planning includes the pre- and postoperative orthodontic treatment, lateral cephalometric prediction tracing (LCPT), and model surgery with dental cast. The authors made it easy with the use of an acrylic dental wafer to coordinate exact occlusal relationship after surgery. We treated mandibular prognathism by using Dautrey's modification of the sagittal split ramus osteotomy (SSRO) (10 cases) and intraoral vertical ramus osteotomy (IVRO) (5 cases) and sometimes additional genioplasty (2 cases). IVRO was used in those cases where (1) the amount of setback was more than 10 mm and (2) where there was a flat gonial angle.(ABSTRACT TRUNCATED AT 250 WORDS)

Functional primary closure of cleft lip

A technique of primary closure of the cleft lip is described. It is based on a complete understanding of the anatomy of the entire facial musculature such that it can be restored to normality and so encourage normal function and development.

Nasal airway, lip competence, and craniofacial morphology.

The aim of the present investigation was to demonstrate whether children selected by their open lip posture show differences in their nasal airway resistance and facial morphology compared to children with closed lip closure. Thirty-two children with poor lip competence were compared to a control group of 20 with secure mouth closure. Patients with poor lip competence showed a significantly higher ML-NSL angle and also ML-NL angle. Anterior rhinomanometry, as well as measurements of the pharyngeal space on lateral headfilms, displayed no significant differences between the two groups. The same material was also grouped cephalometrically into skeletal open and skeletal deep bite configurations. The mean value of the nasal airway passage was lower in the skeletal open group, but not at a significant level.

Muscle response to the oral-screen activator. An EMG study of the masseter, buccinator, and mentalis muscles.

The myofunctional changes that occur during orthodontic treatment with functional appliances constructed with vestibular screen elements, such as buccal shields and lip pads, have not been sufficiently investigated. The aim of this study was to examine electromyographically the response of the masseter, buccinator and mentalis muscles to the oral-screen activator (OSAC), which is a conventional activator constructed with buccal shields and lip pads. The material consisted of 10 children, with Angle Class II, division 1 malocclusion and narrow dental arches (mean age 10.7 years), treated at the Department of Orthodontics, School of Dentistry, Malmö, Sweden. The group had a mean overjet of 8.5 mm, and a mean ANB angle of 6 degrees. Six out of the 10 cases had incompetent lips at relaxed lip position. The construction bite of the OSAC was taken with the anterior teeth in edge-to-edge position. The recording procedure included the following positions: (a) postural position of the mandible with lips relaxed and lips closed; (b) clenching; (c) swallowing saliva; and (d) spatula exercise. EMG recordings were made after 1, 2, and 3 months of appliance treatment. Differences between means were tested with a two-way analysis of variance (ANOVA). The results showed that during postural position with lips closed there was a statistically significant increase in mentalis EMG with the oral-screen activator in place. The buccinator and masseter muscles showed no EMG activity during rest with or without the appliance in the mouth. During clenching we found no statistically significant difference in masseter EMG with or without the appliance in place. During swallowing saliva a statistically significant decrease was recorded in mentalis EMG with the oral-screen activator in the mouth, while buccinator activities remained the same with and without the appliance. The masseter activity, on the other hand, increased significantly with the activator in place. During spatula exercise mentalis and buccinator were highly activated. The conclusions drawn from this study are that the oral screen activator (OSAC) increased masseter activity during swallowing, but it remained unchanged during clenching. Lip pads increase mentalis activity during lip closure, but reduce mentalis hyperactivity during swallowing. The buccinator activity was insignificant and buccal shields did not change that activity. Spatula exercise stimulates both mentalis and buccinator activity.

Reliability of labial closure force measurements in normal subjects and patients with CNS disorders.

This study determined the reliability of maximal upper and lower lip closing forces measured using a strain-gauged cantilever beam assembly. An intraclass correlation approach was used to explicitly partition the "error free" between-subject variance and measurement error variance across repeated days (2) and across repeated trials (5). Ten healthy adults served as controls and 30 patients with diagnoses of multiple sclerosis, cerebrovascular accident, or Parkinson's disease served as subjects. The intraclass correlation analyses revealed generally high reliability (R greater than .90) for upper and lower lip force measurements, for various combinations of control and/or patient groups, and within each individual patient group. There was moderate correspondence between the quantitative measures of lip force and the clinical assessment of combined upper (r = .67) and lower lip closure force (r = .62) but low correspondence between the quantitative measures of lip force and the presence of motor speech deficit. The lower lip force of patients with Parkinson's disease (M = 3.1 N) on Day 1 was markedly reduced from that of all other patient groups and controls (M = 10.1 N). These results yield helpful information for the design of investigations of oral-motor weakness and for the quantitative assessment of an individual's clinical status.

Myofunctional therapy in patients with orofacial dysfunctions affecting speech.

Tongue thrusting, deviate swallowing, mouth breathing, orofacial muscle imbalance, deviate mandibular movement and malocclusion are the most important orofacial dysfunctions underlying disorders of articulation. Their development is linked to early bottle feeding and sucking habits. The phoniatrician is charged with the early detection of orofacial dysfunctions affecting speech. Early correction of habits and retraining by speech therapy are important preventive measures. Case histories, phoniatric and myofunctional diagnoses and dental/orthodontic findings were compiled for a total of 103 patients aged 3-30 years (11 +/- 4 years). Forty-five patients have completed a regimen of myofunctional therapy. For these patients highly significant improvements in lip strength, lip closure, breathing and tongue placement as well as in the swallowing pattern and orofacial muscle balance have been observed. Concomitantly, two thirds of the patients (66%) attained normal articulation. Speech defects were resistant to therapy in only 2 cases. In dental/orthodontic practice myofunctional therapy is used for retraining abnormal positions and functions of the orofacial muscles so as to create a normal occlusal relationship. The results of this study show that myofunctional therapy is highly instrumental also in phoniatrics as a special form of treatment for disorders of articulation.

Oral dysfunction in children with Downs' Syndrome: an evaluation of treatment effects by means of videoregistration

The objects of the study were: (1) to analyse lip and tongue function in 24 children with Down's Syndrome as compared to an untreated control group of 19 healthy children; (2) to evaluate treatment effects of stimulation plates of the type Castillo Morales, in children with Downs' Syndrome. The range of the observation period during treatment was 4-11 months. Video recordings of 5 minutes (300 seconds) duration served as a basis for stop watch registrations of tongue protrusion and open mouth habit. Before treatment, the duration of tongue protrusion in the Downs' Syndrome group amounted to approximately half of the registration time as compared to an average of only 6.4 seconds in the control group. The values for lip closure differed only slightly. Following the insertion of the stimulation plate, the duration of tongue protrusion, in general, dropped markedly. No improvement in mouth closure or lip posture could be observed. A normalization of tongue function without the plate inserted was achieved after 4-11 months of treatment in 12 out of the 24 children. Follow-up registrations, ranging from 5 to 20 months, could be obtained in 7 out of the 12 successfully treated children. The results appeared to be stable in five of these children.

Kinematic analysis of lip closure in stutterers' fluent speech : McClean M.D.; Kroll R.M.; Loftus N.S.J. SPEECH HEAR. RES. (1990) 33/4 (755–760)

Kinematic analysis of lip closure in stutterers' fluent speech : McClean M.D.; Kroll R.M.; Loftus N.S.J. SPEECH HEAR. RES. (1990) 33/4 (755–760)

Staging in Cleft Lip and Palate Habilitation

Treatment staging in cleft lip and cleft palate habilitation is a controversial and complex subject because of the number of variables involved. The time of surgical intervention, as well as the specific surgical technique, should have normal speech as well as optimal growth as realistic goals. A protocol for habilitation includes perinatal presurgical maxillary orthopedics. Lip adhesion is proposed for wide unilateral and asymmetrical bilateral cleft lips at approximately 6 weeks of age. Definitive lip closure is accomplished by the rotationadvancement technique at 3 months of age if lip adhesion is not required or 3 to 4 months after lip adhesion. The soft and hard palate clefts should be closed by 6 to 9 months for optimal speech. Closure of the dentoalveolar cleft is accomplished with a graft of autogenous iliac bone prior to the eruption of the permanent canine when the tooth root is one fourth to one half developed. Palatopharyngoplasty is considered after 3 to 4 years of age following speech therapy and thorough evaluation. Orthognathic surgery may be considered from adolescence to adulthood.

Sucking efficiency of early orthopaedic plate and teats in infants with cleft lip and palate

Intraoral negative pressure during bottle feeding with two kinds of teats (a regular Nuk and a cleft Nuk) was measured in 7 infants with cleft lip and palate, 8 infants with cleft palate, 2 infants with cleft lip, 4 infants with operated cleft lip and palate and 7 normal infants. Infants with cleft lip and palate or cleft palate were unable to generate negative pressure before cleft lip and palate closure. The presence or absence of an early orthopaedic plate did not make any difference. In infants with unoperated cleft lip and with operated cleft lip and palate, peak negative pressure during feeding differed little from that of normal infants.

Orthognathic Surgery in Cleft Patients Treated by Early Bone Grafting

For the past 25 years at Children's Memorial Hospital in Chicago a protocol has been followed for complete clefts that involves placement of an infant maxillary orthopedic appliance prior to lip closure, surgical closure of the lip, autogenous split-rib grafts to the alveolus to stabilize maxillary segments, and palatal closure, generally within the first year of life. The oldest 36 patients whose skeletal growth was for all practical purposes finished have been followed to determine the need for and type of orthognathic surgery. Of the total sample, 8 patients (22.2 percent) required some type of sagittal orthognathic surgery (1 patient in this group also required vertical maxillary alignment) and 2 patients required maxillary augmentation only in the form of an onlay graft. This report may serve as a baseline for others who wish to report on the incidence and type of orthognathic surgery in their cleft palate centers.

Kinematic Analysis of Lip Closure in Stutterers’ Fluent Speech

An analysis of lip and jaw motion was carried out in order to evaluate previous observations on the fluent speech of stutterers and to describe possible effects of speech therapy. A strain gauge system was used to transduce lip and jaw movements during fluent repetitions of "sapapple" in adult stutterers and nonstutterers. Fifteen movement parameters were measured on lip closure for the initial /p/ sound in a group of 10 normal speakers, 10 stutterers who had no recent speech therapy, and 8 stutterers who had been through an intensive speech therapy program involving modification of speech timing. The no-therapy group and nonstutterers did not differ significantly in terms of any movement parameter. Stutterers who had been through speech therapy showed significant increases in jaw movement duration and time to peak velocity of the upper lip, lower lip, and jaw. The expected timing pattern for lip and jaw velocity peaks on lip closure (UL-LL-J) was the most frequently occurring pattern, but deviations from this pattern were observed in both stutterers and nonstutterers. The occurrence of reversals was most prevalent in the therapy group, and it was associated with increases in jaw movement duration across subjects. It is suggested that for the type of movement studied here, anomalies in stutterers' fluent speech are likely to be the result of acquired adjustments rather than properties of the speech neuromotor system that underly dysfluency.

Improved Primary Surgical and Dental Treatment of Clefts

The improved combination of surgical and dental teamwork in the primary treatment of clefts presented here is consistent with principles. In fact, this is a staged design for correction of classic clefts of the lip and palate that, based on biological principles, facilitates the continuance of the failed embryonic "migrations" toward a normal end point. Positioning of the alveolar segments, dissection of mucoperiosteum out of the cleft, and union of mucoperiosteum across the alveolar and anterior hard palate cleft make it possible to create a periosteal tunnel across the bony gap and set up a condition conducive to bone formation and eventual tooth eruption in the cleft area. Lip closure by adhesion reduces the tension of the primary lip closure and allows gentle molding until solidification of the arch occurs. Thus a complete cleft has been rendered an incomplete cleft. With a balanced, stabilized maxillary platform, the definitive lip and nose corrections can be carried to completion early (by 2 to 4 years of age). These planned actions bypass a persistent cleft, fistulas, raw areas, malposition of alveolar segments, and probably the necessity for later bone grafting. The only question not totally answered is the effect of this approach on final growth. Although most reports seem to indicate that growth has and will proceed within normal limits, another 10 years of careful follow-up is indicated and, in fact, is in progress.

Kinematic analysis of lip closure in stutterers' fluent speech : McClean M.D., Kroll, R.M., and Loftus, N.S., University of Toronto, Toronto, Ontario. Journal of Speech and Hearing Disorders, (1990) 33, 755–760

Kinematic analysis of lip closure in stutterers' fluent speech : McClean M.D., Kroll, R.M., and Loftus, N.S., University of Toronto, Toronto, Ontario. Journal of Speech and Hearing Disorders, (1990) 33, 755–760

Computer simulation of a trumpet

In an effort to generate realistic trumpet mouthpiece pressure waveforms, a player-trumpet model was created that consisted of the player's lungs, the player's airway, the player's upper lip, and the trumpet. The player's lungs were modeled as a constant pressure source. The player's airway (from lungs to lips) was modeled as a resistance of 20 acoustic ω (cgs). The player's lip was modeled as a swinging-sliding door having 1 deg of rotational freedom and one degree of translational freedom. The trumpet was modeled in terms of its pressure response to a volume-flow impulse. Equations were solved iteratively to give (1) lip opening as a dynamic function of the forces and torques acting on the lip, (2) volume flow as a function of lip opening and the pressure difference across the lips, and (3) mouthpiece pressure as a convolution of volume flow with trumpet impulse response. Waveforms were calculated and displayed for the lip-opening area, the volume flow through the lips, and the pressure in the mouthpiece. The lip-opening area and mouthpiece pressure waveforms were realistic when compared to experimental waveforms in the literature. However, there are still too few experimental data to constrain the model in terms of lip closure time and total air flow on sustained notes. Simulation data will be presented and compared with experimental data. [The work to be reported was carried out while the author was on leave at IRCAM in Paris. René Caussé supplied player and trumpet data and Duanne Dudley supplied trumpet impulse data.]