- The SMILE program can help clients with nasality caused by low tongue posture or restricted frenulum—as long as VPI is not the underlying cause.
- Sufficient tongue mobility is required to execute the program. If a severe tongue tie is present, surgery may be needed first.
- The critical diagnostic distinction is VPI vs. frenulum-related low tongue posture—each requires a different treatment pathway.
- SMILE is now part of the broader MYOSolutions™ program targeting the 4 MYO Domains: Airway, Swallowing, Structure, and Speech.
- The Clinical Implications for Tongue Thrust & Lisps course teaches the full SMILE protocol.
Reader Question
From the Community
“I would like to know if your SMILE program would help someone who is not a tongue thruster but has other abnormalities like a restricted tongue movement because of extra frenulum material, a malformed tongue, and a cleft (somewhat repaired). In other words, I already know that programs can reach a variety of patients. Mine is an adult with not only all of the above problems but has just had teeth implants top and bottom. Her tongue and its relation to the teeth, and cleft (nasality) are her problems. I listened to a recording of her voice before implants and it sounded somewhat more clear but not substantially.”
Therapist Answer
Answered by Robyn Merkel-Walsh, MA, CCC-SLP, COM®️
Thank you for your question. If this client does NOT have VPI (velopharyngeal insufficiency) and the nasality is the result of the tongue tip being poorly elevated, then YES. I have treated multiple clients with nasality issues because the tongue was low or the tip was anchored due to restricted frenum.
What is very important is that the client has the mobility to execute the program. If there is a severe tongue tie, surgery may be needed prior to implementation.
Thanks for your interest.
About the SMILE Program
The SMILE (SysteMatic Intervention for Lingual Elevation) program, created by Robyn Merkel-Walsh, is an orofacial myofunctional therapy protocol that targets the root cause of persistent articulation errors—including lisps, interdentalized productions of t-d-l-n, and distortions of sh-ch-r—which is often a tongue thrust disorder or low tongue resting posture. The program combines oral placement, swallowing, and articulation therapies.
The SMILE program is now part of the broader MYOSolutions™ program, which targets the Merkel-Walsh 4 MYO Domains™: Airway, Swallowing, Structure, and Speech. For clinicians wanting to learn the program in a course setting, the Clinical Implications for Tongue Thrust & Lisps course teaches the SMILE protocol in detail.
When Can SMILE Help—and When Is Surgery Needed First?
Robyn’s answer highlights a critical clinical decision point: the SMILE program requires sufficient tongue mobility to execute the exercises. When restricted tongue movement is caused by a tight frenulum (tongue tie), the clinician must assess whether the client has enough functional range to participate in the program. If the restriction is severe, a surgical release (frenectomy or frenuloplasty) may be needed before or during the therapeutic process.
The key diagnostic question is whether the nasality is caused by VPI (a structural/functional deficit of the velopharyngeal mechanism) or by low tongue posture due to a restricted frenulum. If it’s the latter, lingual elevation therapy through the SMILE program can address both the nasality and the associated articulation errors. For more on the evidence base for oral placement approaches, see TalkTools’ overview of the OPT vs. NSOME debate.