Isn’t fascia the the supporting structure connecting the outer walls of a house to the roof? Although still a connection, fascia in the body is a thin casing of connective tissue that surrounds and holds every organ, blood vessel, nerve fiber, and muscle in place. This network of fibers connects from the tongue all the way down to the toes. Fascia is made up of a multitude of nerves that make it almost as sensitive as our skin.1 Like a freeway system, fascia connect all parts of the body and is responsible for an individual’s range of motion.1 Fascia is particularly relevant to oral health care when discussing the myofascial connection with head and neck abnormalities like tongue restrictions, forward head posture, neck pain, and temporomandibular disorder (TMD). When a patient presents with these conditions, it is important to consider what influence fascial release may have on all body systems, since this network of fibers doesn’t just effect the mouth or the toes independently.
Tethered Oral Tissues
The relationship between tongue posture and adequate craniofacial development, breathing, swallowing, and speech is becoming well understood within dentistry. When it comes to sleep disordered breathing, an inability of the tongue to reach the palate and rest fully into this space, places an individual at risk for the tongue collapsing into the pharynx and occluding the airway.2 Tongue mobility is influenced by the length and thickness of the lingual frenulum, anteriorly or posteriorly, and reaches from the ventral surface of the tongue to the floor of the mouth.3 When considering a release of this frenulum to allow for increased mobility of the tongue, treatment could include either a complete frenectomy or a partial frenotomy.2 What is the difference? Cutting into the thick fascia that was discussed previously. A partial frenotomy involves snipping the connective tissue with scissors, but often leaves the fascia untouched. Whereas a complete frenectomy typically utilizes a laser that allows a full release of the frenulum through the fascia.2 This difference of being able to cut through the fascia is critical when striving to achieve the full range of motion of the tongue. Myofunctional therapy is also an imperative component to treating tethered oral tissues and the tongue range of motion can be a limiting factor in treatment outcomes.2
Temporomandibular Disorder (TMD)
It is clear how fascia restricting the tongue can influence tongue mobility, but what about the effect on TMD? Second to arthritis, TMD is one of the most common musculoskeletal disorders that contribute to pain in the TMJ and masticatory muscle function.4 Oral health care professionals understand that TMDs are multifactorial in origin, such as trauma, hormonal influences, occlusal factors, and muscle hyperfunction.4 However, the underlying fascia connecting musculature could be a consideration as well. When the tongue cannot adequately reach the palate and is restricted in range of motion, the surrounding muscles connected from the hyoid bone strengthen as a compensation for the tongue, which can lead to feelings of tension under the jaw and chest. Additionally, when functioning, the tongue and jaw that support the hyoid bone can experience more disproportionate pulling or retraction.5 Parafunctional habits have also been linked to limited tongue mobility, as the tongue is typically responsible for a hormone release when it contacts the palate.6 If the tongue is unable to contact the palate and hormone release is not occurring, children often replace this with a habit such as teeth clenching, nail/lip/cheek biting, digit sucking, and object biting.7,8 Studies have shown that patients with TMD pain had increased frequency of these habits, due to the masticatory muscles becoming overused, which leads to increased muscle tension.4,9
In a recent study evaluating the effect of lingual frenuloplasty and orofacial myofunctional therapy (OMT) on singers and professional speakers with ankyloglossia, study participants reported symptoms such as, no longer feeling jaw tension or tightness, relaxation in shoulders, improved diaphragmatic breathing, reduced facial pain and tightness while singing, and feelings of fascial release through the neck down to the lower back after functional frenuloplasty treatment was completed.5 This research demonstrates not only the possible connection between tongue mobility and tension in head and neck muscles, but also shows what an impact fascial release can have on other body systems.
Posture
When I think of fascia constriction, I am reminded of a marionette. Strings pulling up on the head, arms, and feet control the movement. When fascia is restricted in certain areas, our bodies have the tendency to compensate and when talking about posture, this can have a significant influence. “During child growth or fetal development, the tongue could cause postural modifications, altering systemic tensions by fascial or trigeminal connections.”10 Thus far, we have seen what an impact restricting fascia can have on tongue mobility and TMD. If significant fascial restriction exists, tension on the head and neck muscles could have a significant influence on posture. In the study discussed earlier, one study participant identified improvements in her posture and no longer felt like she was being pulled forward after she underwent functional frenuloplasty.3
As mentioned previously, when tongue restriction is present, the body will compensate with musculature in other areas. The tongue resting low in the mouth forces the jaw down and back, which can put pressure on the pharynx. In the case of posture, forward head posture is often seen as a compensation to pull the jaw forward and open up the airway space.11 Other muscles in the body are recruited to achieve this postural change, such as increased effort of the sternocleidomastoid which forces the rib cage to elevate, thus compromising the function of the thorax and diaphragm.11 Another study evaluated mouth breathing and forward head posture on the respiratory biomechanics and exercise capacity in a group of 92 children. Of those 92 children, 32% presented with mouth breathing and 96% of those identified as mouth breathers, had forward head posture.11 Take the marionette analogy again; tension created on the head pulls up on the rest of the body down to the toes. Fascia restriction stemming from the tongue can have lasting impacts on forward head posture and body compensations as soon as a child begins walking if no intervention is done.
Conclusion
Addressing fascial constriction does not always involve surgical release, as there are myofascial release providers that manipulate stiff areas or trigger points through pressure. However, in the case of the aforementioned symptoms, the impact of fascia restriction through the frenulum can have a domino effect on other body systems. When a patient presents with these symptoms, it is important to consider how the fascia could be playing a role and what interventions could be made to address these concerns. Looking to the root causes of mouth breathing, bruxism, TMD, migraines, and postural changes is the foundation behind elevating the standard of care to complete oral systemic wellness and could have a lifelong impact on a patient’s health.
References
1. Muscle pain: It may actually be your fascia [Internet]. Johns Hopkins Medicine; 2024 [cited 27 March 2024]. Available from https://www.hopkinsmedicine.org/health/wellness-and-prevention/muscle-pain-it-may-actually-be-your-fascia#:~:text=What%20is%20fascia%3F,almost%20as%20sensitive%20as%20skin
2. Baxter R, Merkel-Walsh R, Baxter BS, et al. Functional improvements of speech, feeding, and sleep after lingual frenectomy tongue-tie release: A prospective cohort study. Clin Pediatr. 2020; 1-8.
3. Yoon AJ, Zaghi A, Ha S, et al. Ankyloglossia as a risk factor for maxillary hypoplasia and soft palate elongation: A function-morphological study. Orthod Craniofac Res. 2017;n.v: 1-8.
4. Kim SR, Chang M, Kim AH, et al. Effect of botulinum toxin on masticatory muscle pain in patients with temporomandibular disorders: A randomized, double-blind, placebo-controlled pilot study. Toxins. 2023;15: 1-12.
5. Summersgill I, Nguyen G, Gray C, et al. Muscle tension dysphonia in singers and professional speakers with ankyloglossia: Impact of treatment with lingual frenuloplasty and orofacial myofunctional therapy. International Journal of Orofacial Myology and Myofunctional Therapy. 2023; 49(1): 1-8.
6. Ferrante An, Ferrante A. Finger or thumb sucking. New interpretations and therapeutic implications. AAMS. 67(4): 285-297.
7. Cioffi I, Landino D, Donnarumma V, et al. Frequency of daytime tooth clenching episodes in individuals affected by masticatory muscle pain and pain-free controls during standardized ability tasks. Clin Oral Invest. 2017;21: 1139-1148.
8. Baeshen HA. Malocclusion trait and the parafunctional effect among young female school students. Saudi J Biol Sci. 2021;28: 1088-1092.
9. Mehdipour A, Aghaali M, Janatifar Z, et al. Prevalence of oral parafunctional habits in children and related factors: An observational cross-sectional study. Int J Clin Pedatr Dent. 2023;16(2): 308-311.
10. Bordoni B, Morabito B, Mitrano R, et al. The anatomical relationships of the tongue with the body system. Cureus. 2018;10(12): 1-7.
11. Okuro RT, Morcillo AM, Goncalves MA, et al. Mouth breathing and forward head posture: effects on respiratory biomechanics and exercise capacity in children. J Bras Pneumol. 2011;37(4):471-479.
