The purpose of the present study is to clarify the effect of two-stage palatal closure by our own technique based on Perko's technique, to maxillary growth in comparison with that of the ordinary palatal pushback operation in patients with complete unilateral cleft lip and palate. After lip repair by Tennison's method at age 5 months, one group of 14 patients (Group I) received an ordinary palatal pushback operation at age 20 months. Another group of 16 patients (Group II) received the two-stage palatal closure in which the primary veloplasty, was performed at age 20 months, with the dissection of supraperiosteal mucosal flaps from the posterior half of the hard palate and with simultaneous posterior transposition and muscle union in the soft palate. Then, the hard palate closure was performed at age 6 years. The children were studied at age 5 months (stage A; prior to lip repair), at age 20 months (stage B; prior to primary palatoplasty), at age 4 years (stage C), and at age 6 years (stage D; 2 months after the hard palate closure in Group II).
A longitudinal and three dimensional maxillary growth was monitored by the measureme n t of the maxillofacial cast models obtained from each of the patients. Non-cleft subjects (Control group) were also classified into four stages to match the cleft groups by age and body weight.
Results obtained were as follows;
1. Though the morphological feature in the cleft groups was remarkable at stage A, the difference was mainly because of the segmental displacements and there was no significant difference in the forward and the downward growth of the maxilla between the cleft groups and the control group. The remarkab le inhibition in the forward and the downward growth of the maxilla especially occurred at th e anterior alveolar region after lip repair in both of the cleft groups at stage B.
2. The maxillary growth difference between the cleft groups of I and II became distinctive after the primary palatoplasty. The inhibition in the forward and the downward growth which occurred after the lip rapair was able to be compensated in the Group II by the catch-up growth in the subsequent stages whi ch resulted in no significant difference compared to the control group at stage D. However, this didn't occur in Group I.
3. The remaining cleft of the hard palate after the primary veloplasty in Group II showed narrowing in its size along with the growth of the palatal shelves.
4. The multivariate analysis on the dental occlusion between the cleft groups of I and II at stage D showed that the difference in occlusion was notable in the incisor relation as shown in the trends of edge-to -edge in Group II and of the crossbite in the Group I.

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The rapid maxillary expansion method for adult patients or for those who have nearly completed their maxillary development is often unsuccessful due to rigidity of facial skeleton and closure of some sutures. In paticular, as patients in comparatively higher age with postoperative cleft lip and palate show different closure-pattern of suture from the normal, and have scar tissue around the maxilla, application of the rapid maxillary expansion is extremely hard. Recently, an osteotomy to make rapid maxillary expansion easier, namely, the surgical orthodontic expansion method has been used frequently. However, very few reports of dynamic investigations of this method are available.
Thus, the author prepared the frontal s ection models though the first molar and the first premolar as well as the horizontal section model through the base of maxillary arch from the adult human dried skull, and made a series of analyses on principal strain, principal stress and displacement at every part of the facial skeleton on lateral expansion by finite element method before and after various steps of the osteotomy. The following findings were obtained.
1. From distributions of the maximum and minimum principal strains, and the maximum and minimum principal stresses before surgery on those three twcr-dimensional models, the principal resistance against lateral expansion was found to be at the bony palate, alveolar process, inner part of maxilla arou n d the zygomaticomaxillary suture and pterygomaxillary suture area.
2. After the first step osteotomy of the frontal section model on the first molar (Le Fort I osteotomy), the principal strain disappeared from any parts except the bony palate and lingual side of the tooth crow n. However, the principal stress was not changed much from the preoperative state. After the secon d step of osteotomy (splitting of midpalatal suture), neither principal strain nor principal stress was noted at a ny parts.
3. Distributions of the principal strain and principal stress after the first step osteotomy of the frontal section model though the first premolar (Le Fort I osteotomy) did not show much difference fro m the preoperative state. However, after the second step of osteotomy (splitting of midpalatal suture) none o f the principal strain and principal stress was noted at all.
4. After the first step osteotomy of the horizontal section model through the base of maxillary arch (splitting of midpalatal suture), the principal strain reduced markedly at the bony palate, while the principal stress disappeared from any parts except the anterior part of incisive foramen, the posteri o r part of anterior wall in maxilla and the posterior wall in maxilla. After the second step of os t eotomy (separation of pterygomaxillary suture), the range of distributions of the principal strains and principal stresses reduced remarkably.
5. Displacement at every part of the facial skeleton before and after the first step osteotomy on the three two-dimensional models was fairly similar, but after the second step osteotomy, changes of the direct i o n of displacement as well as increase of the volume of lateral and forward displacement were noted.
6. In the surgical orthodontic expansion method, Le Fort I osteotomy and splitting of midpalatal suture are essential. To apply this method, it is necessary to have sufficient knowledge of displacement at every part of the facial skeleton after each step of osteotomy.

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We are maintaining mice of CL/Fr strain with spontaneous cleft lip and palate in an attempt to investigate genetic and fetal environmental influences on the development of teratogenicity we report in this paper our findings on the spontaneous incidence of such deformity in mice of the same strain which were cultured in our laboratory. We confirmed vaginal embolus of mother animals used for experiments on the next day of mating which was designated as a zero pregnant day. Since secondary palate was closed around the 15th embryonic day in mice of CL/Fr strain, mother animals were sacrificed by vertebral dearticulation on the 18th embryonic day before fetuses were removed by cesarotomy for observation. As a result, the mean feties implantation rate was confirmed to be 7.68 heads out of 22 heads used for experiments, with 7.23survived fetuses on the average, whose 25.8 % had cleft lip and/or palate. When classified by the cleft type, cleft lip was observed in 13 (31.7 %) heads, cleft lip and palate in 27 (65.9 %) and cleft palate in one (2.4 %).

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The purpose of this study is to develop a quantitative technique for analyzing distorted sounds acoustically associated with Japanese Lateral Misarticulation (JLM), often observed in cleft palate speech.
Six cleft palate patients with nearly normal dental arch and sufficiant velopharyngeal function, three patients with functional articulation disorders, and twenty-four normal subjects ranged three group by age served for this study.
Target syllables were /∫i/, /t∫i/, /ki/ and /çi/. For /∫i/, /t∫i/ are often observed in JLM and /∫i/, /t∫i/ of JLM are clinically confused with /çi/, /ki/.
In the first experiment using s ound spectrograph, we found the large frequency level over about 4kHz on the section patterns of consonants of normal /∫i/, /t∫i/, while consonants of JLM /∫i/, /t∫i/ showed an almost smooth spectral level along frequency axis.
A microcomputer(NEC PC-9801E) was used to quantitatively analyze these spectral chracteristics of consonants.
The procedure of our analysis technique was as follows.
First, consonant segments of the speech signal wer e detected and processed to obtain spectral envelope (SE) by cepstrum method. Secondly, SE level was normalyzed at 60 dB and lastly the difference between average of the SE of low subband and that of high subband was calculated. (SES: Spectral Envelope Score)
The speech sounds were evaluated by SES and SES obviously distinguished JLM /∫i/, /t∫i/, from normal /∫i/, /t∫i/, SES of JLM /∫i/, /t∫i/ were almost equal to those of normal /çi/, /ki/ compared with normal /∫i/, /t∫i/.
It was suggested that SES effectively evaluated JLM /∫i/, /t∫i/ quantitatively.

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A new surgical technique of velopharyngeal sphincteroplasty is described and the results in 4 patients with persistent nasal leakage after velopharyngeal flap operation are presented.
Improvement in nasal leakage was found in 3 patients.
This method may be useful for the correction o f palato-pharyngeal incompetence.

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The present study was designed to investigate nasal diseases in patients with cleft palate. One hundred and one patients with cleft palate were studied. Anterior rhinoscopy was performed in all cases and radiographic examination, rhinomanometry, olfactory test, endoscopic examination of the olfactry mucous membrane were performed when needed. Besides, to clarify the relationship between nasal diseases and middle ear disease, we performed otoscopy, audiometry and impedance audiometry. The following results were obtained.
(1) Cleft lip and palate patients were highly associated with deviation of the nasal septum and hypertrophy of the inferior turbinate.
(2) The rate of sinusitis in cleft palate patients was high. It was considered that sinusitis is one of the causes of middle ear disease.
(3) There were no correlations between the rate of sinusitis and the type of clefts or existence of the deviation of the nasal septum.
(4) Nasal resistance in cleft palate patients was heightened by sinusitis, deviation of the nasal septum and hypertrophy of the inferior turbinate.
(5) Olfactory acuity was disturebed slightly in cleft palate patients. The main cause of this disturbance was the obstruction of rima olfactoria by sinusitis.

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Otological and endoscopical study of 192 cleft palate patients was carried out. The results were as follows:
1. Otitis media with effusion was most common (123 ears 32%), followed by chronic otitis media, retraction pocket, cholesteatoma, adhesive otitis media, and middle or inner ear anomaly. In general, in c i dence of ear diseases in this study was 44.5 %.
2. A variety of abnormal movements were seen in pharyngeal orifices of the Eustachian tube. They were classified into two groups. One has tubal opening during swallowing, phonation or mouth opening a s in yawning, which indicated low incidence of middle ear disease, while the other without tubal openin g indicated comparatively high incidence of disease, especially OME.
3. In repaired cleft population, patients with submucous cleft had lower incidence of middle ear disease than those with other cleft types. In submucous cleft population, those with repaired cleft had lower incidence of middle ear disease than those with unrepaired cleft.
4. There was no significant correlation between side of cleft and side of middle ear diseases in unilateral complete cleft lip and palate.
5. Tere was almost no correlation between pharyngeal flap and middle ear diseases.
6. Endoscopical findings of epipharyngeal contamination shows close relation to middle ear diseases.

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Based on the clinical observation of sucking from the aspect of expression in cleft palate feeding, we have invented a new type nipple. The nipple is designed as flat and hard on the top, hemispherical and soft on the bottom, and with crosscut opening for better adaptation to the palatal anatomy and for better tongue touches for encouraging the practice of feeding skills. The aim of the present study is to clarify the physical properties of the nipple in comparison with those of conventinal nipples on the market.
The results from the clinical experiment on the expression pressure (du r i n g non-nutritive sucking)revealed that the pressure in cleft palate infants showed very low level with 28.5 mmHg (± 9.6) compared to 109.1 mmHg (± 20.9) in normal infants. The laboratory test on the compression-strain of the nipple showed that the nipple required lesser loads by 20-60 g than the conventional nipples when the strains were above the 5 mm level. The test on the liquid flow through the crosscut opening under the suction of -1,000 mmH₂O showed that (a) the flowout amount of liquid increased in accordance with the increase of the strain of nipple and (b) the flowout amount of liquid of the nipple with crosscut opening showed more by 50-100 ml/min than the conventional nipples with crosscut opening. These results suggested that the nipple with our feature may be more effective than the conventional ones for clinical use in infants with poor sucking ability.

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The purpose of the present study is to clarify the clinical state of impediments in cleft palate feeding and to test the clinical effect of the new nipple for cleft palate feeding.
Clinical findings on the feeding difficulties at the first visit of patients, the feeding conditions (i. e., intake volume, feeding times, required time for feeding and the body weight gain) before and after the use of the nipple were studied on the subjects with complete cleft of the lip and palate. The period for observation was about 3 months including the time of first visit, and 1 week,1 month,2 months,3 months after the use of the nipple.
The results obtained were as follows,
1. Impediments of feeding difficulty were the ulcer formation on the nasal membrane due to the penetration of the conventional round nipple into the cleft gap (5 cases), combined use of tube feeding with conventional nipple (7 cases), prolonged feeding time (3 cases) and drop feeding with the use of bulb syringe (11cases).
2. The mean intake volume and the total time spent for feeding per day were 424 ml and 215 min at the time of first visit. However, these showed remarkable changes 1 week after the use of the nipple such as increased intake amount (574 ml/day) and decreased time (146 min/day). The mean intake volume at 3months later showed 845 ml/day which was within the normal standard range (800-900 ml/day).
3. The body weight increased through the observation periods, and 3 months later, it came very close to the normal standard. These results suggest that the use of the nipple may contribute to stimulation o f selfdemand feeding and the physical development of complete cleft lip and palate patients.

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Pharyngeal flap operation has been used widely for repair of velophayngeal incompetency. We have advocated "Palatal Pull Upward Method" in unilateral and bilateral cleft palate repair. The purpose of this palatal pull upward method is to shorten the vertical distance of the velopharyngeal space at rest position. Thus, this operation functionally coincides with the direction of the levator muscle constriction. We applied this cocept to velopharyngeal insufficiency.
operation method
1) Both palatal mucoperiosteal flaps are sufficiently freed to reach the posterior pharyngeal wall.
2) A vertical incision is made from just below the adenoid mass at the level of the atlas on the posterior pharyngeal wall.
3) The incision is deepend to the whitish prevertebral fascia and only the left side is elevated.
4) The right nasal mucosal flap is guided into the left posterior pharyngeal wall pocket and attached with mattress sutures.
5) After the left nasal mucosa is sutured to the opposite nasal mucusa, the levator muscles on each side are sutured together to construct a muscle sling.
Lateral X-ray film and nasopharyn geal fiberscopic findings show satisfactory results. We have used this method and had good speech results in all 20 cases. Compared with conventional operations, this method is very simple and the direction of the levator muscle movement coincides with the position of orifice when the velum is pulled upward.

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Statistical analysis was carried out on 60 patients with cleft lip and/or palate in our orthodontic clinic during the last nine years.
Results obtained were as follows:
1. The majority of the patients were in TIC stage of Hellman's developmental stages of occlusion.
2. For the distribution of various cleft type, UCLP was observed in 52 % of the patients, and BCLP in 30 %, CL in 17 %, CP in 1.7 %. Left side cleft was predominant in UCLP patients.
3. Mesio-distal interrelationship of upper and lower first molars was Angle Class III in 40 % of the patients, and Class II in 27 % of them. Mandibular protrusion was observed in 70 % of the patients, and c r ossbite in 82 %, anterior crowding in 42 %, mandibular overclosure in 33 %, and open bite in 8.3 %.
4. For anomalies of the number of teeth, supernumerary teeth were lower in frequency while congenital missing teeth were found in 48 patients (80 %). In the case of maxillary lateral incisor missing, f requency in right and left lateral incisors missing was 33 % and 79 %, respectively, in UCLP-L patient s, and in UCLP-R patients, both sides were 57 %. No right-left difference in frequency of maxillary lateral inciso r missing was found in BCLP and CL patients (60-70 %).
5. For birth weight,13 % of the patients were immature infants (below 2500 g).
6. Initial lip repairs were performed during the age of 3-4 months in 73 % of the patients, the mean age was 3.4 months. Initial palatoplasties were performed during the age of 13-24 months in 87 % of the patien t s, the mean age was 20 months.
7. Eighty-two percent of the patients were eldest or second eldest in their families, and 68 % of the patients were the youngest children in their families. Two pairs of sisters with clefts were detected.

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