Extension and validation of the protocol of orofacial myofunctional assessment for individuals with cleft lip and palate

Graziani, Andréia Fernandes; Fukushiro, Ana Paula; Marchesan, Irene Queiroz; Berretin-Félix, Giédre; Genaro, Katia Flores

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Original Article • CoDAS 31 (1) • 2019 • https://doi.org/10.1590/2317-1782/20182018109 copy

Extension and validation of the protocol of orofacial myofunctional assessment for individuals with cleft lip and palate

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Purpose

To perform the expansion, validation of the content, criterion and construct of an orofacial myofunctional assessment protocol for individuals with cleft lip and palate; and to define evaluation parameters for the instrument use.

Methods

The expansion of the instrument was performed based on the MBGR protocol; the items, sub items and possibilities of answers of the amplified instrument were analyzed for their clarity by seven examiners for the content validation.. Assessment parameters were developed for the use of the instrument in order to minimize the subjectivity. Four examiners compared the aspects of the protocol to those of another instrument for the criterion validation, and the construct validation was performed comparing the results of pre and post orthognathic surgery treatment. The Content Validation Index and the Kappa, Spearman and Wilcoxon Correlation tests were applied for the validations.

Results

The mobility, tonicity and sensitivity aspects of the evaluation were added to the protocol and at content validation, 72% of the items were classified as very clear and 28% as clear. A manual with assessment parameters for all items and sub items of the protocol was constructed. The inter-examiner agreement was moderate. In the comparison of the protocols, for the validation of the criterion, a good relation among them was observed. For the validation of the construct the protocol was able to identify outcome after the treatment.

Conclusion

The protocol was expanded and considered validated in its entirety: content, criterion and construct, and evaluation parameters for its use were established.

Keywords
Cleft Palate; Validation Studies; Stomatognathic System; Speech, Language and Hearing Sciences; Evaluation

PROTIFI PROTOCOL ITEMS	AMIOFE PROTOCOL ITEMS
Lips: - habitual position	Lips: - lip postural condition
Tongue: - habitual position - width	Tongue: - tongue position - appearance- volume
Occlusion:- horizontal relation - vertical relation	Relation mandible/maxilla: - horizontal overjet - vertical relation
Hard Palate: - width - depth	Hard Palate: - width - depth
Lip Mobility: - closed bulging - closed retract	Lip Movements: - protrusion - retraction
Tongue Mobility: - bulging - retract - touch lips and commissures	Tongue Movements: - protrusion - retract - lift - lower - right lateral - left lateral
Breathing: - mode	Breathing: - mode

ASPECTS	ITEM	MODIFICATION/EXTENSION/EXCLUSION
Tongue	mucosa	replacement of the “marked” word by the word mark and addition of the word “orthodontic”
Palatine Tonsils	presence	replacement of the word “present” by the word “yes”
Teeth	n° of teeth	Written in full the “right” and “left” side of the quadrant
	oral health (teeth/gingiva)	replacement of the word “good” for “adequate” and the word “bad” for “inadequate”
	use of braces	addition of the word “orthodontic”
	Use of prosthesis	addition of sub items “partial” and “total”
Hard Palate	fistula	addition of sub items “present” and “absent”; replacement of the word “vestibular” for the word “oral vestibule”
Hard Palate	size	exclusion of the option: “small”, “medium” and “big”, and addition of the item for taking note of the measurement in millimeters
Soft Palate and Uvula	fistula	addition of sub items “present” and “absent”; replacement of the word “vestibular” for the word “oral vestibule”
	size	exclusion of the option: “small”, “medium” and “big”, and addition of the item for taking note of the measurement in millimeters
	Soft palate and uvula mobility	transfer of this item to mobility evidence
Pharynx	sidewalls	transfer of this item to mobility evidence; replacement of the options “good”, “regular”, “little” and “unobservable” for “adequate”, “altered” and “without movement”
Pharynx	rear wall	exclusion of the option “attempt”
Breathing	nasal flow	replacement of the terms “when arriving” and “after cleaning” for “pre-cleaning” and “post-cleaning”
Speech	resonance	addition of this item that involved the options “hypernasality” and “hyponasality”, displaced from other sub item, and addition of the option “balanced”
	speech language disorder	replacement of the words “speech language disorder” for the words “speech language alteration”
	Acoustic distortion and mouth opening	Exclusion of these items
	Functional adaptation	replacement of the word “interposition” for the words “lingual interdentalization”
	mandibular movement	replacement of the options “deviation to the right” and “deviation to the left” for the option “deviation” and of option “anteriorization” for “projection”
	saliva	addition of sub item “on the commissures”
Mobility	lips	addition of this item that involved the options: bulging, retract and snap
	tongue	addition of this item that involved the options: palate sucking, snap, vibrate, touch lips and commissures, in the incisive papilla, on the right and left cheek
	soft palate	addition of this item
	pharynx	addition of this item
Tonicity	lips	addition of this item
	cheeks	addition of this item
	tongue	addition of this item
	mentual	addition of this item
Sensibility	pain to the touch	addition of this item that involved the options: anterior temporal, superficial masseter, trapezium, sternocleidomastoid and ATM
Sensibility	tactile sensitivity	addition of this item that involved the options: mentual, lips, incisive papilla tongue and cheeks

ASPECTS	ITEM	VERY CLEAR	CLEAR
Lips	habitual position, aspect (superior/inferior), mucosa (internal/external), length	72%	28%
Cheeks	mucosa	86%	14%
Tongue	mucosa, width, height, habitual position, frenulum (extension/tongue fixing/ floor fixing)	72%	28%
Teeth	teething, n° of teeth, dental flaw, oral health (teeth/gingiva), use of braces, use of prostheses	86%	14%
Occlusion	horizontal relation, vertical relation, transversal relation	100%	-
Palatine Tonsil	presence, size	86%	14%
Hard Palate	aspect, bone carving, depth, width, fistula	72%	28%
Soft Palate and Uvula	aspect, extension, symmetry, fistula, uvula	72%	28%
Lips Mobility	bulging/ retract/ snap	72%	28%
Tongue Mobility	suck/ snap/ vibrate/ touch the apex at commissures/ lips	72%	28%
Soft Palate Mobility	“a” repeatedly	72%	28%
Pharynx Mobility	Lateral walls/ posterior walls	100%	-
Tonus	lips/ cheeks/ tongue/ mentual	100%	-
Sensibility	tactile (mentual, lips, incisive papilla , tongue and cheeks)	100%	-
Sensibility	Pain at touch (temporal, masseter, trapezium, sternocleidomastoid, ATM)	100%	-
Breathing	type/ mode/ possibility of nasal use/ nasal flow	86%	14%
Speech	resonance, compensatory disorder, mandatory disorder, speech language alteration, functional adaptation, speed, mandibular movement, lip movement, pneumo-phono-articulatory coordination, articulatory accuracy, intelligibility, saliva	86%	14%
Voice	pitch, loudness and type	86%	14%
Mirror Test	blow, “a”, “u”, “i”, [ f ], [ s ], [ ∫ ], plosive and fricative sentences	72%	28%

Analyzed aspects	Corresponding Items	E1XE2/E3/E4
LIPS	Habitual position	0.82 (almost perfect)
TONGUE	Habitual position	0.85 (almost perfect)
TONGUE	Width	0.82 (almost perfect)
OCCLUSION	Horizontal relation	0.81 (almost perfect)
OCCLUSION	Vertical relation	0.67 (substantial)
HARD PALATE	Width	0.82 (almost perfect)
HARD PALATE	Depth	0.81 (almost perfect)
LIP MOBILITY	Closed bulging	0.82 (almost perfect)
LIP MOBILITY	Closed retract	0.82 (almost perfect)
TONGUE MOBILITY	Retract	0.82 (almost perfect)
TONGUE MOBILITY	Touch the apex at commissures/ lips	0.85 (almost perfect)
BREATHING	Mode	0.85 (almost perfect)

Aspects	Corresponding Items	Correlation Coeficient (r)	VALUE p
LIPS	Habitual position	-0.70	< 0.001 ^* * p≤0.005
TONGUE	Habitual position	-0.72	< 0.001*
TONGUE	Width	-0.86	< 0.001*
OCCLUSION	Horizontal relation	-1.00	< 0.001*
OCCLUSION	Vertical relation	-0.81	< 0.001*
HARD PALATE	Width	-0.73	< 0.001*
HARD PALATE	Depth	-0.86	< 0.001*
LIP MOBILITY	Closed bulging	-0.89	< 0.001*
LIP MOBILITY	Closed retract	-0.88	< 0.001*
TONGUE MOBILITY	Retract	-1.00	< 0.001*
TONGUE MOBILITY	Touch the apex at commissures/ lips	-1.00	< 0.001*
BREATHING	Mode	-0.88	< 0.001*

Aspects	average	sd	p
Aspects	pre-post	pre-post	p
Lips	3.5 3.3	1.0-1.5	0.426
Cheeks	1.2-0.8	0.5-0.4	0.031 ^* * p≤0.005
Tongue	2.9-2.1	1.3-1.6	0.004*
Teeth	2.4-2.5	0.8-0.8	0.844
Occlusion	2.2-0.6	0.6-0.8	0.001*
Palatine Tonsils	0.0-0.2	0.0-0.7	1.000
Hard Palate	2.3-2.0	0.9-1.1	0.426
Soft Palate and Uvula	4.2-4.2	0.7-0.9	1.000
Mobility Lips/Tongue/Soft Palate	3.0-3.4	2.4-2.9	0.502
Tonus	2.9-2.8	1.3-2.1	0.850
Tactile Sensibility /Pain at Touch	0.8-1.3	1.2-2.2	0.465
Breathing	2.7-1.6	1.4-1.6	0.001*
Speech/Voice Analysis	4.9-4.1	1.5-1.9	0.031*
Velopharyngeal Function	16.9-15.7	5.3-6.7	0.313

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[1] Conflict of interests: nothing to declare.