Voice Therapy

Peter Varley BDSc, FDSRCS, DFHom(Dent.) and Angela Caine LRAM, AGSM. (profile)

There is a significant relationship between TMD and voice dysfunction. Many of the ligaments and muscles responsible for voice production are also responsible for the forces which move the jaw. It is unlikely that most dentists have considered the voice to be within the realm of dental treatment. It is even more unlikely that someone who sings out of tune or suffers recurring voice loss would consult a dentist.

It is important that dentists understand the connections between voice and musculo-skeletal dysfunction. They should recognise dentally related voice problems and when undertaking dental procedures not interfere with the patient's vocal skills. A treatment plan that considers voice function may provide the means to access what every clinician aims to work with - the patient's own self-righting mechanism.

Within dental practice the voice can be used as:

• A diagnostic tool for balanced posture.
• A tool to prevent orthodontic regression.
• A developmental tool for posture.
• A developmental tool for growth of the dentition.

It is generally believed that some people are born with a 'good' voice; that the 'good' voice is coincidental and if you have one you are able to sing. Good voices, like varicose veins, are thought to run in families. The voice can only be used in assessment and diagnosis by stepping away from this concept.

Muscle spasm in the supra hyoid system can limit vocal pitch and interfere with articulation and resonance, resulting in a seriously 'out of tune' voice. Similarly in a pelvic distortion as defined by chiropractors, compensatory muscle spasm can be expected in the sterno-cleido-mastoid and the supra hyoid systems.

This voice will only improve when the dental and skeletal clinicians discover a combined order of treatment which releases the spasm in both the supra hyoids and the psoas/iliac systems.

Every person possesses the physical means to talk and sing. It is not because the organ of phonation is missing that people cannot sing, but that the natural inborn facility is being obstructed or interfered with. Potential for sophisticated articulation of language and pitch, in speech and singing, is responsible for all significant modifications to the head and neck over the last 500,000 years.

The vocal model you are invited to consider as a diagnostic tool is based on the biomechanics of all functions of the larynx, acknowledging that its primary function is to breathe.

The primary functions of the larynx are:

• Breathing (inspiration and expiration).
• Swallowing.
• Effort closure (bracing in physical strength).
• Phonation (singing and speech).

Breathing, swallowing and physical strength are already part of an assessment and diagnosis of musculoskeletal efficiency. The following issues appear regularly on introductory questionnaires for patients, 'is the patient a mouth breather or a nose breather?' and 'is there a natural swallow, or a deviate swallow?' Applied Kinesiology is used to test the strength of different muscular pathways by resisting force. This indirectly tests the efficiency of effort closure. If three out of four laryngeal functions affect and are affected by musculoskeletal dysfunction, it would appear illogical that the fourth function is independent of it.

Facial Muscles

Breathing, speech, singing, chewing and swallowing all move the face, but the primary function of the face musculature is nose breathing. If the face and tongue muscles are developed with this priority of nose breathing, then facial muscle balance will also develop naturally for speech, chewing, swallowing and facial expression and as a result of this, beauty.

Tongue Posture

Tongue posture is central to both nose breathing and facial balance. There are two basic postures of the tongue:

• Suspended against the back of the hard palate.
• Lying in the floor of the mouth against the lower teeth.

These two basic postures of the tongue divide the facial muscles into two groups. Group A facial muscles are associated with a backward position of the tongue against the hard palate and nasal breathing. Group B facial muscles are associated with a forward positioning of the tongue in the floor of the mouth and the chewing of food.

Group A facial muscles radiate from the centre of the face.

Group B act in the vertical plane to chew. They originate in bone and insert into bone and they have more bulk and less delicacy than group A.

The Extrinsic Frame

The extrinsic muscles of the larynx function as a co-ordinated system of strap muscles. The extrinsic frame supports and stabilises the hyoid bone, and through it, acts to balance and co-ordinate any movement of the vocal tract which is in opposition to movement of the mandible and of the head and neck. The extrinsic frame is connected to bony attachments on the mandible, the scapula, the sternum and the cranium. An active pathway can be traced from the vocal fold to these bony attachments.

The Alexander Technique

Evidence for the influence of the extrinsic frame on voice function comes from a variety of disciplines. In 1932 F. M. Alexander discovered that the relationship of his head and neck affected his voice. He went on to improve his voice and his whole quality of life by attending to the balance of the head at the atlanto-occipital joint and from that developed the Alexander Technique. He probably made the first connection between skeletal structure and laryngeal function. Sonninen⁴ and Zenker and Zenker proposed that '..the strap muscles (the extrinsic frame of the larynx) also assist in regulating the tension in the vocal folds.'

Stammering

Further connections between structure and voice did not appear again until Caine et al examined 36 stammerers and found that they all had severe structural problems. Any successful treatment plan for stammering must include assessment for structural correction as well as help with changes of attitude and self image. If a stammer is observed the dentist can assume there will be particular problems of skeletal misalignment and function.

Structural Dysfunction

Fonder,⁷ Rocabado,⁸ Gelb and Selye are just some of the distinguished clinicians who have linked structural dysfunction with collapse of the posture of the cervical vertebrae and the concomitant problems of forward head posture, forward shoulder posture, collapsed tongue and facial muscle function.

Voice function can be affected by dysfunction in any of the structures which provide attachment for the extrinsic laryngeal frame such as:

• Malocclusion of the teeth.
• Lack of molar support.
• Tongue thrust.
• Temporo-mandibular joint dysfunction.
• Cranial torque.

If the voice is used as a diagnostic tool, potential pathological systems affecting laryngeal function can be diagnosed and maintained in a healthy state by preventive clinical treatment. These systems include:

• Temporo-mandibular joint function.
• Cranial torque.
• Postural balance.
• Breathing.
• Swallowing.
• Eustachian tube evacuation.
• Facial function.
• Tongue posture.
• Co-ordination.
• Potential voice skills.

The Voice in Assessment

Dentistry is generally considered to be mechanical and devoid of self expression. Singing on the other hand, is seen as a means of self expression and nothing to do with mechanics! You must get your patient to sing using whatever guile you may and if necessary enlisting the help of other members of your staff.

When the patient does sing it is easy to see the following problems if they exist:

• The tongue flat in the mouth for 'EE' and 'EH' vowels'.
• The cheeks shaping the vowels 'OO" and 'OH'.
• Tongue and jaw functioning together.
• Priority for facial muscle group B.
• A deviating mandible.
• Limited excursion of the mandible.
• Postural instability.

You can easily hear the following problems:

• Sharp intakes of breath.
• A shrill high pitched voice.
• Articulation problems - a stammer, hesitation, difficulty with some sounds.

Balance Board

A balance board exposes our natural ability to cope with being upright in a situation which changes moment by moment. When the patient combines balancing with reading a poem or singing, this moment by moment co-ordination exposes any inefficiency of the extrinsic frame.

The Voice as a Tool to Reprogramme Muscles

Reprogramming would involve singing and reciting while using body balls, therabands and balance boards to introduce rhythm and stretch into the body and into the whole vocal/respiratory tract. The tongue can be repositioned by reading and singing in dialect and foreign languages and by learning to understand, recognise and use facial muscle group A. All this can be made fun as well as giving the patient a measure of control in the treatment.

Voice and Body Exercises

Cain has developed a programme of exercises for voice and body to correct tongue thrust. A natural tongue position is one in which sufficient permanent tone is maintained on the styloglossus muscle to allow all vowels to be articulated in the pharynx and nose breathing to be maintained as a fundamental system. Mouth breathing should always be a supplementary system.

Many dentists and orthodontists only class a tongue protruding between the teeth as 'tongue thrust'. A tongue which is not striking the maxilla with its total width or which articulates generally forward of the alveolar ridge will allow relapse of good functional orthodontic work.

The patient is given exercises which use the voice and body together, maybe using equipment such as a body ball or a balance board. This encourages the patient to take responsibility for bringing about his or her own share of musculoskeletal correction and opens a dialogue with the clinician for reporting and discussing progress.

Conclusion

Parents need to be made aware of the connections between voice, posture and developing dentition. They can then encourage activities in which the voice and body act together to develop good tongue posture, an expansive palate and a dentition that naturally occludes. They also need to be made aware of the importance of singing throughout school life, and especially singing with the tongue suspended where it can spring backwards as well as forwards. Nose breathing efficiency and facial muscle balance will then be encouraged.

A balanced tongue that articulates against a fully developed palate, which it has shaped for such a purpose, between the ages of two to six, facilitates efficient nose breathing and good vocal mechanics for life, if the musculoskeletal system maintains its symmetry.

We must come to accept that the mandible is undergoing a change in function. It is no longer designed for chewing, but to support a system of sophisticated, articulated speech. Speech has, during the last 500,000 years, superseded chewing. Simpson states, 'Language has become far more than a means of communication in man. It is also one of the principal means of thought, memory, problem solving and other mental activities'.

Crelin states that, 'Ultimately, articulate speech led to a complicated spoken and written language, abstract thought, the fifth symphony and the theory of relativity'. If this view of evolutionary progress is acceptable it would indicate that any orthodontic treatment should take account of the long term effects on the voice.

The value of a beautiful smile is somewhat lost if the voice or TMJ are affected through the early extraction of teeth for overcrowding. On the other hand, if a system as powerful as the voice, exists within the musculoskeletal structure of the head and neck, it seems sensible to access that power for development, corrective treatment and subsequent stability of that structure.

1. Amorino S, Taddey J J. Temporo-mandibular Disorders and the Singing Voice. The National Association of Singing Teachers Journal 1993; 50(1): 3-14.
2. Garliner D. Myofunctional Therapy in Dental Practice, 3rd ed. Florida: Coral Gables, 1974.
3. Alexander F M. The Use of the Self, 1988 ed. London: Victor Gollanz, 1932.
4. Sonninen A. The External Frame Function in the Control of Pitch in the Human Voice. Ann NY Acad of Sci 1968; 155: 68-90.
5. Zenker W, Zenker A. Über die Regelung der Stimmlippenanspannung durch von Aussem Eingreifende Mechanismen (On the Regulation of the Vocal Folds through the Extrinsic Suspension Mechanism). Folia Phoniatrica 1960; 12: 1-36.
6. Caine A, Cardew E, Stimson N. Structural Predispositions in the Etiology of Stammering. Proc IFA World Congress on Fluency Disorders. Munich, August 1994.
7. Fonder A C. Dental Distress Syndrome. Rock Falls, Illinois: Medical-Dental Arts, 1990.
8. Rocabado M, Annette Z. Musculoskeletal Approach to Maxillofacial Pain. Philadelphia: Lippincott, 1991.
9. Gelb H. Clinical Management of Head Neck and TMJ Pain and Dysfunction, 2nd ed. Philadelphia: W B Saunders & Co, 1985.
10. Selye H. Stress without Distress. New York: Lippincott, 1974.
11. Caine A. Lost Your Tongue: A Voice and Body  Exercise Programme with Audio Tapes to Reposition the Tongue. Southampton: The Voice Workshop, 1993.
12. Simpson G G. The biological nature of man. In Washburne S L, Jaye P C (eds). Perspective on Human Evolution. New York: Rinehart and Winston, 1968.
13. Crelin E S. The Human Vocal Tract, Anatomy, Development and Evolution. Atlanta: Vantage Press, 1987.

Angela Caine LRAM, AGSM.

Angela studied opera at the Guildhall School of music. She began a research programme that has involved dentists, orthodontists, chiropractors and osteopaths considering the voice as a function that should not be ignored during sructural treatment.

Angela has lectured nationally on Voice Therapy and teaches Music and Alexander Technique at Southampton University. She is on the database for the Performing Arts Medicine Trust, which takes care of the problems of professional musicians. She is also a member of the Cranio Group, an organisation for the study of cranio-mandibular disorders. She works in Southampton with a chiropractor and a dentist treating voice problems through structural realignment.