F S, A P: Abio Coppa Lessio Irino
F S, A P: Abio Coppa Lessio Irino
F S, A P: Abio Coppa Lessio Irino
ABSTRACT
Introduction: Dysfunctional swallowing has been addressed by specialists of different extraction for over a quarter of a
century: several publications describe the usefulness of myofunctional therapy and the negative effects of swallowing disorders at
various functional domain such as: orthodontics, speech production, oto-rhino-laryngological, pediatric growth and development.
Materials and methods: A total of 384 subjects in adolescence (198 males and 186 females, mean age 13.3 years, SD 2.1
years) underwent a stabilometric and postural examination, in order to identify the postural characteristics of the patient with
dysfunctional swallowing. All participants completed the protocol assessment that included a dental occlusion evaluation and a
swallowing function test with Payne technique. The aim of the present observational study is to verify the relationship between
swallowing and posture in a population of adolescents and to describe the postural characteristics of the subjects with dysfunctional
swallowing.
Results: The results suggest a significant correlation between tongue position and body posture. This observational study
allowed to define a specific nosography to describe the types of postural imbalance in individuals with dysfunctional deglutition,
called Glosso-Postural Syndrome.
Conclusion: Despite numerous publications where a relationship between lingual dysfunction and body posture is affirmed,
the terms of this relationship and the types of postural imbalance were not accurately described. We therefore consider it appropriate
to define a specific nosography to describe the types of postural imbalance in individuals with dysfunctional deglutition. We called
this nosographic entity Glosso-Postural Syndrome. The most important traits of type I and type II glosso-postural syndrome are
described.
Keywords: Dysfunctional swallowing, postural imbalance, glosso-postural syndrome, myofunctional therapy, malocclusion,
temporomandibular disorders.
DOI: 10.19193/0393-6384_2019_4_296
Fig. 1: Reduced palatal width, marked class III with a ten- Fig. 4: The tongue is a wonderful example of the intimate
dency to reverse bite by a low tongue posture pressuring and mutual interrelationship between structure and fun-
on the lower incisors. ction.
The age-old controversies whether or not the
orofacial muscles affect the teeth, or rather the teeth
affect the muscular function, can be settle by making
a differential diagnosis through muscle tests, study
of swallowing mechanics and examination of the oc-
clusion(27, 28). The relationship between lingual dys-
function and postural problems has been explored
often as well(1, 2, 29, 6, 30, 31, 32, 33, 34, 8, 9, 35, 36, 37).
For some authoritative authors the relationship
between lingual dysfunction and postural alteration
Fig. 2: clinical case of malocclusion and disfunctional
is considered obvious:
swallowing.
"The balance of stomatognathic muscu-
These aspects lead back to the relationship be-
lo-aponeurotic chain is incorporated into the uni-
tween structure and function, which in the opinion
versal muscular body. In swallowing disorders the
of this author cannot be considered a simple linear
tip of the tongue can orient and push against the up-
cause-effect relationship, but rather a complex circu-
per or lower teeth or between them. It is obvious that
lar relationship within a non-linear dynamic system
these thrusts will lead to alterations of the spatial
(Figure 4).
arrangement of the teeth and jaw bones, because the
Is there a relationship between body posture and tongue posture? 1899
balance of forces of the splanchnic conformers will appropriate specifications that describe the site, na-
be broken, and this will have negative reflections on ture, character or cause of the disorders, such as:
the global body posture"(1). anxiety-depression syndrome, Irritable Bowel Syn-
For other authors, even in this case orthodon- drome, Vertiginous syndrome, Pre-Menstrual Syn-
tists, this relationship was confirmed by the daily drome (PMS) and others.
exercise of one's profession: This set of signs and symptoms form an entity
“In the daily exercise of my profession, eval- recognizable by their constant reciprocal association
uating for years each patient from an orthodontic, or by often having a common cause and in the Glos-
gnathological, postural, functional point of view, so-Postural syndrome, both these aspects are recog-
I realized that in all cases of lingual dysfunction, nized.
whatever the cause, by resuming the tongue a more At the postural, osteopathic and musculoskele-
physiological position (pointing upwards in the di- tal levels, the clinical signs that distinguish the Glos-
rection of the retro-incisional papilla, and back of so-Postural syndrome are those specified in the fol-
the tongue on the palate), an immediate change in lowing sections. In addition to these clinical signs,
the best was obtained of the whole postural attitude, we can find a considerable number of symptoms and
starting from the head, down the vertebral column, signs associated with other levels: orthodontic, oc-
up to the pelvis and feet"(32). clusal, gnathological, otorhinolaryngological (oral
Despite numerous publications where a rela- breathing, adenotonsillary hypertrophy, recurrent
tionship between lingual dysfunction and body pos- otitis etc.), speech and swallowing, ophthalmologi-
ture is affirmed, the terms of this relationship and cal, pediatric, or pertinent to the internist(9).
the types of postural imbalance were not accurately
described. General considerations on the relationship
For this reason, a total of 384 subjects in ado- between posture and tongue functions
lescence (198 males and 186 females, mean age 13.3 Each individual develops a model of swallow-
years, SD 2.1 years) underwent a stabilometric and ing that constitutes an engram resulting from the
postural examination, in order to identify the pos- phylogenetic, ontogenetic, and environmental infor-
tural characteristics of the patient with dysfunctional mation received. The deglutitory pattern can both
swallowing. All participants completed the protocol stimulate and inhibit stomatognathic functions. In
assessment that included a dental occlusion eval- dysfunctional swallowing the tip of the tongue has a
uation and a swallowing function test with Payne low and anteriorized position, and instead of point-
technique. The aim of the present observational ing upwards in the direction of the back area of the
study is to verify the relationship between swallow- retro-incisional papilla (also called the Spot), it can
ing and posture in a population of adolescents and to push against the upper or lower teeth, or interpose
describe the postural characteristics of the subjects between them.
with dysfunctional swallowing. The results suggest This lower and anteriorized position by the
a significant correlation between tongue position and tongue, by virtue of abnormal thrusts during the
body posture. This observational study allowed to swallowing that are repeated above twelve hundred
define a specific nosography to describe the types of times a day, can cause alterations of the spatial ar-
postural imbalance in individuals with dysfunctional rangement of the teeth and the maxillary bones and
deglutition. We called this nosographic entity Glos- have negative reflections on the general posture of
so-Postural Syndrome(38). the individual.
Just as the occlusion and balance of the stoma-
Why choosing the term "syndrome"? tognathic system can be considered as woven with
In medical language the term syndrome in- the general postural equilibrium, so the lingual func-
dicates a set of signs, symptoms, functional or bi- tions are intertwined with the body equilibrium as a
ochemical alterations, more or less characteristic, whole.
however, without a precise reference to its causes Professional experience suggests that the
and to the etiopathogenetic mechanism (develop- tongue is a wonderful example of the intimate and
ment of an abnormal or atypical condition).There- mutual interrelationship between structure and func-
fore, a syndrome can be the expression of a specific tion (Fig.4). The posture and morphology of the
disease or of diseases having completely different body as a whole also represent the outcome of this
origins. The term syndrome is mostly followed by mutual relationship, at the buccal level, between the
1900 Fabio Scoppa, Alessio Pirino
and dural core-link, which, at the osteopathic lev- A lingual chain is defined as the muscle-fascial
el, represent aspects of primary importance. At the structures connecting the tongue to the whole organ-
cranial level, in dysfunctional deglutition, the har- ism, on a functional level(48, 49, 50).
monizing function performed by the tongue on the
cranio-sacral rhythm and to promote cranial motility Swallowing and posture: neurophysiological
is diminished. In physiological conditions, this oc- and energetic aspects
curs through the traction operated on the base of the To better understand the role of swallowing at
skull by the contraction of the styloglossus muscle the level of the whole body it is necessary to recall,
(flexion of the posterior sphere), and by the pressure albeit briefly, some neurophysiological and ener-
exerted by the tip of the tongue on the retro-incisal getic aspects. The pressure of the tongue on the ret-
papilla (a sort of "pumping” of the sella turcica of ro-incisal spot during physiological deglutition has
the sphenoid, which houses the pituitary gland). important neurophysiological implications, as docu-
By being inserted at the root of the tongue and mented in the scientific literature. Of particular rel-
the styloid process of the temporal bone, during the evance is the study that highlighted the presence of
correct swallowing, the styloglossus pulls the base as many as five types of exteroceptors in the square
of the tongue up and back, compressing the tongue centimeter of the palate corresponding to the lingual
against the palate with a direct action on the cranial spot(51).
base and the maxillary complex. In addition, other scholars documented that
During correct swallowing, the contraction the elevation of the tongue activates a greater to-
strain of the styloglossus on the posterior cranial tal volume of the cerebral cortex than swallowing,
sphere allows a physiological cranial mobility and with significantly greater activation in the cingulate
harmonizes the cranio-sacral relations through the gyrus, supplementary motor area, pre-central and
dural pathway. post-central gyre, pre-motor cortex, putamen and
At the same time, the tip of the tongue press- thalamus(52).
es against the anterior palate, transmitting a force, From this data we can surmise how important
through the vomer, to the rostrum of the sphenoid. it is, at a neurophysiological level, the movement of
This weak force, nevertheless, allows a slight mobi- elevation of the tongue to stimulate the lingual spot,
lization of the sphenoid, of great importance to acti- and how much information coming from this area
vate the spheno-basilar synchondrosis and promote a can influence the central regulation mechanisms of
physiological rhythmic cranial impulse(43, 44, 45,46). muscle tone and posture.
At the functional level, by virtue of the pre- So far it seems that we have not considered
dominantly transversal arrangement of its fibers, the enough the fundamental role of information coming
tongue can be considered a diaphragm that connects from this area in the mechanisms of central postural
the anterior and posterior muscle chains(47). regulation.
The physiological deglutition and the correct To understand how incorrect swallowing can
posture of the tongue favor a good balance of the produce important postural and functional abnor-
muscular tone of these chains. In the absence of this malities, it is also necessary to mention the energetic
balance, or when it’s perturbed, the sucking of the and psycho-emotional aspect.
thumb can be interpreted as an attempt by the child The retro-incisal papilla is a formidable energy
to rebalance the posterior cervical tensions and to point, to the point that patients with atypical deglu-
stimulate the cranial rhythmic impulse. tition are also energetically very deficient. Applied
The tongue is a diaphragmatic structure, akin to kinesiology allows an easily verification of this con-
the diaphragm, the pelvis or the upper thoracic egress, dition.
which can assume a compensatory and balancing role The tongue connects the Conception Vessel
at a morphological and postural level, especially in Meridian with the Governing Vessel Meridian. The
adulthood. According to the classical principles of correct high position of the tongue, with the apex
osteopathy, the various body diaphragms must be in between the retro-incisal papilla and the first pala-
balance and in harmony, in their mutual relationship, tine ruga, guarantees an optimal energetic balance
to ensure a good postural setting. of the body.
Each physiological deglutition tends to re-har- Evidently this is also due to the quality of
monize the cranio-cervico-facial muscular tension bal- breathing. Physiology requires a high rest tongue
ance and therefore the body's overall postural balance. position on the retro-incisal spot. Just try to breathe
1902 Fabio Scoppa, Alessio Pirino
with your tongue resting high and with your tongue At a biomechanical level, this chain controls
resting low to appreciate the difference in quality the anterior gravity line described by Littlejohn,
of these two breathing modes. Breathing with the stretched between the pubic symphysis and the chin
tongue up facilitates an optimal cerebral oxygena- symphysis.
tion with consequent optimization of all the bodily The lingual chain represents a functional unit
functions. A low tongue position never guarantees at the motor and postural levels; anatomically, it
the same breathing quality, especially when it’s in- is made up of a very rich network of muscles and
volved in oral breathing. aponeurosis which underscores its importance at the
At the psycho-emotional level, the lingual chain postural level.
is the physiological chain of the primary, primordial
rhythm, already present from the thirteenth week of
intrauterine life. It is the chain of suction and var-
ious biological rhythms (cranial rhythmic impulse,
swallowing of amniotic fluid, swallowing of saliva,
etc.). It is located in the antero-medial region of the
body, par excellence the body’s region of affectivity
and orality(53, 48).
relationships between the hyo-glossus complex, and this anteriorization may also be present in subjects
this not only true for the afore mentioned fascial con- with a dental class III malocclusion. At the neuro-
catenation, but also for proprioceptive control issues. muscular level, this anterior projection of the scapu-
At the proprioceptive and postural levels, the lar plane can be considered the outcome of the pre-
hyoid bone was compared to a gyroscope in a guid- dominance of the antero-medial lingual chain with
ance system(50,4). respect to the other kinetic chains.
Being devoid of articulations with other bones In addition to the anterior scapulae, which in
(“floating” bone) and suspended "like a hammock” itself represents a significant postural problem, the
by various connective tissue, it can act as a gyro- type I glosso-postural syndromes are characterized
scope providing information to the brain about the by: increase of the physiological curves, abdominal
balance of the body, through the neuromuscular protrusion with transverse abdominal muscle defi-
spindles. The position of the hyoid, which should ciency, pelvic anteversion, pronation of the foot and
be strictly horizontal, is a reflection of the tensions valgus presentation of the back of the foot (Fig. 8).
of the muscles, of the aponeuroses and of the liga-
ments with which it is connected. A dislocation or a
restriction of mobility of the hyoid bone, both active
and passive, characterizes a tension of the fascial
and visceral scaffold of the individual. The so-called
tongue-mandible-hyoid system is a complex bio-
mechanical system with functional connections that
must be taken into account during clinical diagnosis
and treatment(54).
symphysis: in fact the chin symphysis moves for- • lower stabilizing muscles of the weaker scapu-
ward and the pubic symphysis shifts backward and lar girdle (large dentate muscle and lower trapezius);
downward. stronger upper stabilizing muscles (scalene muscles,
In this condition, the abdominal pressure is ex- levator scapulae, upper trapezius insertions);
erted on the abdominal muscle wall and the anterior • weak inter-scapular musculature and strong
ligaments of the pelvis (especially the Poupard liga- pectoral musculature;
ment), rather than on the bone structure of the pelvis, • weaker deep flexor muscles of the neck (long
which is posed in anteversion. flexor of the neck, long flexor of the head, omohyoid
Furthermore, an increasing dorsal kyphosis and thyrohyoid); stronger neck extensors muscles
leads to an increase in intra-abdominal pressure, so (cervical para-vertebral, superior trapezius and leva-
that the abdominal muscles tend to yield to reduce tor scapula).
the pressure. At the neuromuscular level, if the lower shoul-
This series of considerations helps us under- der fixators are weak, the upper fixators will become
standing why patients with type I glosso-postural overworked, shortened and restricted. The hyperac-
syndrome typically have a protruded and lax abdo- tivity of the pectorals involves anteriorization and a
men (Fig. 7A, B), with predisposition to abdominal rounding of the shoulders; the weakness of the deep
ptosis and inguinal hernia. neck flexors produces an increase in high cervical
In these conditions, the synergistic-antagonistic lordosis. Furthermore, there may be a shortening
relationship between the diaphragm and the abdom- of the upper portion of the nuchal ligament, which
inal transverse muscle is altered. It is easy to deter- tends to fix the high cervical spine in lordosis: on
mine a high thorax hypo-mobility and a modification the whole, the neck tends to appear "recessed" and
of the diaphragmatic kinetics, with predisposition to compressed (Fig. 7A).
respiratory dysfunctions. In addition to dysfunctional motor and postur-
In this postural context, the “Upper Crossed al patterns, this superior crossed imbalance can in-
Syndrome" and the “Lower Crossed Syndrome”(55, 56, fluence and alter respiratory function and ribs-dia-
57, 58, 59)
are frequently reported, which over time may phragm dynamics.
result in “Movement Impairment Syndromes”(60).
These crossed syndromes consist of a neuro- Lower Crossed Neuromuscular Imbalance
muscular imbalance: the mutual relationship between The lower crossed imbalance involves the fol-
synergistic and antagonistic muscles is permanently lowing muscle pairs (Fig. 9B):
altered, at the level of the cervico-scapulo-thoracic • weak gluteus minimus muscle with hyperac-
and lumbo-pelvic district. tive and tight hip flexor muscles;
The neurophysiological explanation of these • weak abdominal musculature with overactive
imbalances covers two levels: and tight lumbar para-vertebral musculature;
• at the level of Sherrington's reciprocal inner- • weak gluteus medius muscle with hyperactive
vation, whereby a hyperactive and tense muscle in- and tight quadratus lumborum and tensor fascia lata
hibits its antagonist; muscles.
• at the central control level, with an alteration This neuromuscular imbalance implies a real
of the motor and postural patterns: to a hyper-pro- "replacement" or switch of muscles in the motor pat-
grammed muscle chain, whose activation is massive terns, both in the static and in the dynamic function.
and the timing of activation is too early, corresponds a In order to produce the hip extension, the weak-
hypo-programmed antagonistic chain, whose activa- ness of the gluteal muscles is compensated by the
tion is modest and the timing of activation is delayed. hyper-programming of the lumbar and ischiocrural
The predominant tonic-postural muscles be- muscles. In order to provide a good lateral lombopel-
long to the first category, tending to develop tension, vic stabilization, the weakness of the gluteus medius
shortening, and contracture; in the second category, is compensated by the fascia lata and the quadratus
usually we find muscles with a strong phasic reac- lumborum. In the flexion of the trunk, the inefficien-
tion, which can easily develop into weakness and cy of the abdominal wall is compensated by a strong
hypotonia. and tight ileopsoas muscle.
At the postural level, the result of these neuro-
Upper Crossed Neuromuscular Imbalance muscular imbalances is the anteversion of the pelvis
This type of unbalance is characterized by (Fig. 9A): with an increase in lumbar lordosis; in this context,
Is there a relationship between body posture and tongue posture? 1905
the shortened and restricted ischio-crural muscles Conversely, in the type I glosso-postural syn-
can be considered as the expression of a compensa- drome, the tongue is more frequently interposed an-
tory mechanism to reduce or curb the tendency to the teriorly, between the teeth, with occipito-atlantoid
pelvic anteversion. extension.
In both cases, abnormal tongue behavior is
usually associated with lip incompetence (lack of lip
seal) and with a tendency to oral breathing.
As in the type I syndrome, in this case as well,
the abnormal thrust of the tongue in a low and an-
teriorized position tends to create forces that, at
the postural level, develop mainly on the sagittal
plane. On the other hand, the tendency towards a
vertebral axial self-straightening is missing, which
corresponds to a diminished body height as a
A B
whole.
Fig. 9: A: Upper Crossed Neuromuscular Imbalance. In both types, the posture of the patient with
B: Lower Crossed Neuromuscular Imbalance. glosso-postural syndrome highlights the lack of
the self-straightening reflex due to lacking of the
Type 2 glosso-postural syndrome thrust of the tongue on the retro-incisal spot.
Much less common than type I, the type II glos-
so-postural imbalance is characterized by an abnormal Conclusion
relationship between the skull and the trunk, which
remains during adulthood if not treated (Fig. 10). In conclusion, the two glosso-postural entities
described must not make us forget that postural
system is a non-linear dynamic system. Therefore,
in addition to incorrect swallowing and other fac-
tors that tend to disrupt the tonic-postural balance,
other varieties of postural imbalance may also oc-
cur, including those of a scoliotic type.
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