We have presented our basic concept of the surgical management of the cleft palate patients during the period from birth to preschool age.
The purpose of this studyis to arise the role of operater on the cleft palate repair and the related problems.
Here, we have discussed the following three problems by focusing on the cleft palate repair.
1. How to operate the cleft palate to have satisfactory speech.
2. Necessity to check up on dental caries and ear drum.
3. Consideration for dento-alveolar and maxillary growth.
In order to maintain the satisfactory speech function and the maxillary dental arch growth, we have been utilizing a palatal mini-mucosal flap method in cleft palate repair.
This method made it possible to maintain not only satisfactory speech function but also proper growth of maxillay dental arch length.
In this study, we have demo nstrated our surgical method of lengthening of the soft palate and obtaining the mobile palate.
In order to support the postoperative management of dental and ear problems, it is also neccesary to cheek-up the dental caries and the ear drum during the physical examination at the out patient department.
Among the factors of detrimental influence in maxillary growth follwing cleft palate repair, we have close-up the effect of wound contraction and scar contracture along the incision line. It is our opinion that the wound contraction in the sture line of the hard palate may cause narrowing of the maxillary dental arch width during early postoperative period and then was fixed by scar contracture.
On the other hand, the maxillary dental arch length was not obviously influ enced by the wound contraction and showed the progression on the development.
The protection of scar contaction at the site of pterygomaxillary junction may lead to the growth of maxillary dental arch length in proper way.
Avoiding the scar contracture at the sit e of pterygomaxillacy junction seems to be necessary to consider in cleft palate repair.
The operator also seem s to have the role of a promoter to support the total management of the cleft palate patients in this period.

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A Primary goal in the cleft palate surgery has been to develop surgical methods for doing more early surgical repairs without interfering with involved tissues potential for continueing normal growth and function. Most cleft palate surgeries entail leaving areas of denuded bone on lateral aspects of the hard palate and evidence from animal experimentations confirmed that contraction is an early link in a causal chain of events which results in diminished postsurgical maxillary growth. The strategies to promote a more favorable growth result are to find a surgical design which minimize the adverse effects of postsurgical contraction and to find appropriate surgical timing for the least damage to growth. Thus, we are now analizing results from animal trials of a newly designed, ridge flap, modification for palatoplasties. The design was based on observations that wounds which involved alveolar ridge mucosa contracted less than those which were entirely on the hard palate, and that teeth tend to drift toward healing wounds both before and after eruption. Thus, the ridge flap design involves lateral incision for pedicle flaps instead of medial aspects of alveolar ridge during the time when primary molars are still beneath the mucoperiosteum. Results thus far indicate that maxillary growth in width is significantly better, in the beagle model, than when clefts are closed with more traditional palatoplasty models.
Similar studies using beagle s, where we are testing hypothesis that surgically induced maxillary growth inhibition will be less are also presented.
Parts of this hork were supported by USPHS Research Grants DE 00853 and DE 05837, NIDR, Bethesda, MD.

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The role of the speech-language pathologist as an active member of the multidisciplinary cleft palate team was reviewed. Professional services for communication problems of cleft palate children younger than school-age are classified into two categories, management and treatment. Communication management includes periodic evaluation of the child's developmental processes of communicative abilities and preventive intervention to treat communication problems. Treatment means speech training mainly for the child's phonetic aspects of oral communication skills.
Based on our postsurgical follow-up data of 785 young cleft palate children, we presented several clinical issues in articulation, velopharyngeal closure function, and hearing. (1) Articulatory issues: In our data,61 % of the cleft lip and palate children and 74 % of the isolated cleft palate children acquired normal articulation at the age of 6 without any training intervention after palatoplasty which was performed between 12 and 18 months of age. Temporary abnormal articulation was observed in 24 % and 16 % in each group. We need more data to elucidate several issues: (1)Relation between articulatory results and cleft types, (2)Reasons explaining the appearance of temporary abnormal articulation, (3)Age at which articulation training for abnormal articulation should be started in children whose prognosis for natural improvement is poor, (4)Age at which the postsurgical follow program can be stopped, (2) Assessment of VP closure function: Our age-related assessment protocol was presented and three typical patients whose VP closures were compensated for by adenoidal masses were discussed. These experiences suggested important clinical issues: (1)Development of efficient evaluative protocol for young children, (2)Necessity for more data on adenoidal contributions to VP closure based on followup observation. (3) Audiological care: I emphasized audiological interests by each cleft palate care team member. Two successful case reports were presented, in which early wearing of hearing aids enhanced communicative capabilities. Our criterion of hearing aid recommendation is bilateral hearing levels of more than 30dB which persist for at least 6 months in spite of medical treatment. Although numerous studies on the interaction between mild hearing loss and language development have not produced any definitive conclusions, the positive recommendation of hearing aid use is clinically desirable to prevent or minimize the child's communicative problems.

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Orthodontic problems peculiar to the cleft palate patients, as pointed out so often, could be summarized collectively as follows; the gnathic deformity of the maxilla due to the lack of growth, maxillary segmental collapses, morphological as well as positional abnormalities of the individual teeth and the mandible. These dental irregularities are almost due to lingual bending of the alveolar bone more than the growth retardation, the condition of which is responsitive to the orthodontic treatment to a considerable extent. The position of the mandible, also, with the difference in size between individuals, seems to have an indirect influence from the maxilla through muscular function. To the contrary, the maxillary complex is deficient in itself, playing a leading role in all accompanying cleft disturbances. Accordingly, the most critical point in the orthodontic treatment is whether it is possible to accelerate the maxillary growth to its full potential. With regard to this important concern, maxillary expansion has ever been tried with a hope that it might give favorable effects on maxillary growth not only laterally but also in a forward direction. To be regretful, it has been nullified scientifically with abundant evidence that the orthodontic treatment would affect very little or nearly nothing. Relieved to indicate the effect of maxillary protraction introduced in the early 80's it must not be exaggerated only for the Japanese who are characterized with flat faces deficient in growth in depth with our arms spread out.
Then, it is quite natural for orthodontists to be obliged to focuss their efforts on growth control of the mandible by a lengthy application of chin cup to adjust it to the retarded maxilla. However, now this orthodontic approach has been criticized by many orthodontists because of an evaluation weighing with an excessive loading for the patient and his/her family to the treatment result which could be earned exclusively by a incomparably prolonged period of treatment for no less than ten years. As a matter of course it tends to procrastinate its start with more possibility of maxillofacial surgery for advancement of the maxilla.
It is absolutely tr ue that present surgical management of cleft children has various unfavorable effects on their maxillary growth more or less. The controversy could be summed up to two points practically; one is surgical method, and the other is timing. Moreover, particular is the trade-off in nature between speech and growth. It is thought like a seesaw. Most surgeons would agree to put more importance on improvement in speech in compliance with a speech therapist. Under these circumstances it is hard for orthodontists to expect to have their cleft patients' jaw grow well.

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Teeth and dentition play an important part in growth of jaw and face and development of chewing, speech and language in the childhood.
In the growing children with cleft lip a nd palate, presence of cleft undergoes an undesirable influence to the growth of dentition, jaw and face and to make matters worse functional disorders in chewing and speech. To get these normal function, first of all teeth should be kept soundly and the dentition and occlusion should be improved normally.
Children with cleft lip and palate are more susceptible to dental caries than healthy children because of anomalies of their palate and dentition, so oral health management are required to those children to keep teeth soundly.
Oral heal th management for cleft lip and palate children should be started at neonatal period. As it is, to start it at this stage is not so easy, so it should be begun as soon as lip operation is over, or immediately after operation of palate at the latest. Pedodontist should instruct to parents the function of teeth, relation to diet and dental caries and oral hygiene rightly, after that a recall schedule should be developed.

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It has been described that many cleft palate patients have middle ear disease. We have experienced many cleft palate outpatients sufferring from exudative otitis media (otitis media with effusion). Studies have shown that middle ear disease inhibits the growth of temporal bone air cells. In the present study, we investigated the relationship between exudative otitis media in cleft palate patients and the growth of temporal bone air cells.
Methods and Subjects: The area of tempor al bone air cells was determined using X-ray films (Schüller projection) by the rectangular area measurement method.67 cleft palate patients aged between 3 and 15 year (mean: 8.0 years) were enrolled in the study.38 normal children aged between 4and 15 years (mean: 7.3 years) served as controls.
Results: The cases without exudative otitis media did not show any difference in the growth of temporal bone air cells, regardless of the presence or absence of cleft palate. However, they were significantly different from the cases of exudative otitis media. Furthemore, there was a significant difference between the normal cases and the cleft palate cases.

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The purpose of this study is to elucidate the changes of velopharyngeal function in mandibular protrusion patients with cleft lip and palate following Le Fort I maxillary advancement.
Cineradiographic examination was carried out before and 4 and 10 months after surgery. The movements of oropharyngeal structures during swallowing and phonation and the swallowing transit time were analyzed.
The evaluation of their speech was done before and 10 months after surgery.
The results were as follows
1. The soft palate m ovement was reduced after surgery.
2. The time point of start of swallowing at after surgery was behind that at before surgery.
3. Articulation disorder did not occurred after surgery.
From this study, it was suggested that Le Fore I maxillary advancement for mandibular protrusion patients with cleft lip and palate bring in changes on a mode of velopharyngeal function after surgery.

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The birth incidences of cleft lip and cleft palate in the populations of China and Japan were compared on the basis of the reported data in both countries. They were absolutely the same; 0.182 % in both reports of the monitoring of the incidence of congenital malformations at birth in China and the joint investigation by researchers of 12 universities in Japan. The distrubution ratios of the subtypes of cleft were significantly different between China and Japan; cleft lip 30.5%,29.8 %, cleft lip and palate 61.4 %,48.9 %, cleft palate 8.2 %,21.3 %. The birth incidences of cleft lip and cleft palate were significantly variable in each district of both countries.

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Epidemiological and genetic studies were carried out on Japanese and Chinese patients with cleft lip and/or cleft palate (CL/P). The Japanese consisted of 974 propositi who were operated on in the University Dental Hospital Attached to the Faculty of Dentistry, Kyushu University, between 1973 and 1984, plus 7,427 members of the propositi's families. The Chinese consisted of 1,055 propositi who were operated on in the Affiliated Ninth People's Hospital, School of Stomatology, Shanghai Second Medical University, and who had been born before 1980, plus 19,939 members of the propositi's families. The cleft types investigated were cleft lip (CL), cleft lip with cleft palate (CLP), cleft lip with or without cleft palate (CL(P) CL+ CLP), and isolated cleft palate (CP). All types of cleft involving the lip and/or palate were designated as CL/P. The results oatained were as follows:
1) Concerning the type incidence, the Japanese had significantly lower incidence of CL than than the Chinese, while the Japanese had significantly higher incidence of CLP than the Chinese. However, the Japanese and Chinese had almost the same incidence of CL (P) and CP.
2) Concerning the sex difference in the incidence of each type, the in cidence among males was significantly higher than among females for all types with the exception of CP. The percentage of males with CL/P was significantly lower among the Japanese than among the Chinese.
3) Concerning the frequencies of consanguineous marriage in each type, th ere was no significant difference between the Japanese and the Chinese.
4) Concerning the incidence of CL (P) or CP among siblings of propositi where both parents were normal, the Japanese and Chinese had almost the same rate of incidence. Concerning the incidences of CL(P) or CP among siblings of propositi where either one parent or one or more siblings had cleft, the Japanese and Chinse both showed high values. There was some difference, but this was not significant because of the small numbers of cases.
5) The relation of incidence among sibl ings to population frequency suggested that CL (P) and CP were of a multifactorially determined thershold character rather than resulting from a major gene inheritance in both the Japnese and the Chinese.
6) The heritabilities of liability of C L/P for the Japanese were almost the same as those for the Chinese, namely, those of CL(P) for the Japanese and Chinese were 55 % and 53 %, respectively, while those of CL for the Japanese and Chinese were 63 % and 74 %, respectively.
The above results reveal that the Japanese and Chinese are similar to each other, although there are clear differences concerning type incidence and sex difference.

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A clinico-statistical investigation of 134 outpatients (1.3 % total outpatients) who visited our clinic to undergo a primary repair of cleft lip and/or cleft palate from 1985 to 1990 was carried out.
The following results were obtained:
1) Cleft morphology was classified to three categories: cleft lip (35.8%), cleft lip with palate (38.8%) and cleft palate alone (25.4%). All types of clefts were more frequently observed in females and the sex ratio of each cleft was 1: 1.4 for cleft lip,1 1.2 for cleft lip with palate, and 1: 2.4 for cleft palate, respectively. In both cases of cleft lip and cleft lip with palate, unilateral cleft on the left side was more predominant (58.3% for cleft lip,46.2% for cleft lip with palate) than other types of clefts.
2) The common congenital malformations associated with clefts were oral organs abnormalitie s or limbs abnormalities. The average incidence of cleft lip and/or cleft palate associated malformations was 13.4%, with the highest percentage 26.5% for cleft palate alone in the three types of cleft.
3) Incidence of artificial abortion for the patient mothers was 9.6%, which is about 1.7 times control, but the rate of patient mothers experiences to have fetal or prenatal deaths (10.4%) was not significantly different from the control.
4) The recurrenc e of the similar diseases among the parents and siblings was higher in the cleft lip group (11.1%) than in the cleft palate alone (8.8%). However, when the recurrence was compared including uncles and aunts, the cleft palate alone showed higher values (20.6%) than the cleft lip group.
5) The early repair of cleft lip was performed since 1985, which resulted in the earlier visit of the patients to our clinic. In 1990, the operation for cleft lip was performed at 50.2 days after birth in average, and 76% cleft lip patients visited our clinic within the first two weeks after birth.

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