a. Modern western concerns about the possible influences of cleft palate surgery on maxillary growth began with Graber's 1949 paper.
b. Animal studies on various problems related to cleft palate surgery and postsurgical maxillary growth were listed and reviewed, with emphasis on those conducted in the laboratories of the author and colleagues at the University of Iowa. It was noted that the number of animal studies on this topic, worldwide, is relatively small and that the best concentration of current efforts appears to be in Nijmegen.
c. Lists of questions and factors were suggested for consideration by new investigators of cleft palate surgery and maxillary growth problems.

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New concept on the configuration with cleft lips, and the personal opinion of their repair, are reported based on the author's clinical experience of four hundred and thirty two infant cases.
1. The DEGREE of cleft lip.
CLEFT DEGREEs, which are expressed by the percentage of the cleft width, at the level of the vermilion and of the nasal floor, to the height of the mid-face, are from 0 to around 50 respectively. The critical value between complete and incomplete of the cleft is about 23.
A fine operative allowance might be performed in proportion to the degrees of the cleft.
2. The TYPE of cleft lip.
The cleft lips are regarded as a complex malformation, composed of nasal floor cleft, labial cleft, and alveolar cleft. NASAL, LABIAL, ALVEOLAR, and MIXED type are clssified, according to the predominance of locality of the cleft in this series.
The choice of operative procedure is determined by the type of cleft.
3. The FORM of cleft lip.
The INTERMEDIATE form of the cleft lip, of which laterality of the cleft are essentially bilateral are found frequentlty, in so-called unilateral group of cleft lip.
To create the symmetrical nose is rather easy, however, to make the proportional lip is difficult and should be planned carefully, in intermediate form of cleft lip.
4. The DEVIATION of tissues.
It is important to realize that the tissues of the cleft lip are deviated in various directions, horizontally in the lip, vertically in the nose, and saggitally in the alveolus.
The distorted tissues must be corrected against each tissue deviation. Specifically, to bridge the mucosal flap at the cleft alveolar edges saggitally is an essential step to obtain rational spontaneous correction of the deviated maxillae.
5. The DEFICIENCY of tissues.
The tissue deficiency in the mid-facial longitudinal region, nasal root∼ columella∼ prolabium∼ premaxilla, are defective in many cases of this series, even though they are not so severe as in DeMayer's IV-or V -group.
Various methods of tissue supplement are necessary in the adolescent age for their repair. The lipswitch graft, especially in Lambda type by the author's method, is specially efficient to afford the natural look for these deficient lips.

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The purpose of this- study was to reveal the structural characteristics of nasomaxillary complex (NMC) in unilateral cleft lip and palate patients. The cleft groups consisted of 24 unilateral cleft lip and palate subjects (UCLP),24 unilateral cleft lip subjects (UCL) and 24 isolated cleft palate subjects (ICP), while the control group consisted of 25 non-cleft subjects. All subjects were between 8 and 12 years old. The initial P-A and L-R cephalograms were used to describe morphological features. In addition,3 DCT films of 4 patients with UCLP were used to analyse deformities of NMC in threedimension.
The results were as follows:
1. At frontal view of the UCLP group, particular patterns of deviation were recognized. The central part of the nasal septum was deviated towards the cleft side, and the lowest point of nasal septum and the apex of an upper incisor were deviated towards the normal side. The width of maxilla on the normal side and on the cleft side were not different. The dental arch width was smaller on the cleft side than that on the normal side.
2. Regarding the causes of NMC deviation, deviation of the nasal septum was caused by the presence of anterior and posterior cleft and palatoplasty. Deviation of the upper incisor apex from the normal side and inclination of central incisors towards the cleft side were caused by the presence of anterior cleft. Constriction of the dental arch width, and shortness of the posterior upper facial height and midfacial depth were caused by palatoplasty. The lingual tipping of upper incisors was caused by lip repair and patatoplasty.
3. Maxillofacial deformities in UCLP were limited to the NMC area. In the major segment, the anterior portion was deviated toward the normal side and the alveolar process of anterior teeth was inclined lingually. In minor segment, the anterior portion was rotated to the inside, and the entire alveolar process was inclined toward the palatal side.
4. The curvature of the nasal septum was suggested to indicate the potential of maxillary growth.

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The purpose of this study was to evaluate the relationship between craniofacial patterns and cleft of alveolus and palate. Twenty-one posteroanterior cephalograms of unilateral cleft lip, alveolus and palate patients over Hellman dental age III C were studied. The line running through the Lo (latero orbitale) bilaterally was indicated by the horizontal line, and the midline was perpendicular line to the horizontal line through the center of the CG (crista gali). The lateral deviation of the mandible; inclination of the plane running through the apex of the upper lateral posterior alveolar process bilaterally, occlusal plane and mandibular plane; distance from horizontal line and midline to the apex of the upper lateral posterior alveolar process occlusal plane; and mandibular plane were measured, and statistical analysis was performed.
The following results were obtained
1. The mandible tended to deviate to the cleft side.
2. There were significantly positive relationships between mandible deviation and inclination of the plane running through the apex of upper lateral posterior alveolar process, occlusal plane and mandibular plane.
3. There were no relationshisps between mandible deviation and distance from the midline to both lateral alveolar apex of upper molar and Go (Gonion).
4. There were significantly negative relationships between mandible deviation and distance from the horizontal line to the buccal apex of the upper molar, occlusal plane and Go.
The result of this study suggested that deficiency of growth in the maxilla on the cleft side significantly alters the deviation of the mandible.
Therefore, it is important to recognize an appropriate mandibular position and control the vertical dimension of the occlussal plane.

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One of the important aims of secondary bone grafting in cleft patients is to provide a more ideal dental arch form orthodontically without any prosthesis. The purpose of this study was to determine the optimum time for secondary bone grafting from the view point of orthodontic dental rehabilitation.
The relationship between the time for operation and the effects of subsequent orthodontic treatment on the alignment of the teeth adjacent to the cleft and the gap of the dental arch was investigated in 26 unilateral cleft lip and palate cases. In all cases, the canines were aligned to the adjacent central incisor on the cleft side.
The results demonstrated that better prognosis is achieved if the bone graft is performed before the age of 11 years, before canine eruption, or the developmental stage of about one half the root length in the canine adjacent to the cleft. And this study also suggests two important points concerning the surgical procedure to obtain better prognosis:
1) to make wide graft bed.
2) to fill the graft bed completely with particulate marrow and cancellous bone.

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A statistical survey was carried out on patients with cleft lip and/or palate hospitalized in our department between Apr.1978 and Mar.1993 the following results were obtained.
1. The number of patients having cleft lip and/or palate in the last 15 years was 1,480 (811 males and 669 females). It accounted for 20.9 % of all orthodontic patients, and a ratio of male to female was 1: 0.82.
2. The mean age of patients at the initial visit was 7.6 years (S. D. =4.3). Patients between 5 and 9 years old were the majority, under 4 years old was 31.5 % of all cases.
3. According to the Hellman dental developmental stage before treatment, patients at stage IIIA was 35.9 %, IIIB was 32.1 %, IIA was 5.5 % and TIC was 10.2 %.
4. According to type of cleft, CLP (complete cleft lip and palate) was 71.0 % (UCLP (R) 18.1 %, UCLP (L) 34.8 %, BCLP 18.1 %), CL (cleft lip and/or palate) was 15.5 %, and CP (isolated cleft palate) was 13.5 %.
5. As for appearance of clefted side in UCLP and UCL, a ratio of right to left was 1: 1.9 and 1: 1.7, respectively.
6. More males had CLP more females, but more females had CL and CP.
7. Alveolar arch form of UCLP (Pruzansky and Aduss) was investigated in the deciduous dentition group and mixed in the permanent dentition group. In the deciduous dentition group the overlap type was 23.2 %, butt-joint type was 65.9 %, and free type was 11.0 %, and in the permanent dentition group 23.8 %,67.8 %, and 8.4 % respectively.
8. Type of total crossbite (type ARL) was most frequent (42.3 %), and then type with no crossbite (type N) was 15.0 %. Type ARL was nearly 50 % in CLP and type N was more than 50 % in CL.
9. After introduction of health insurance (1982) and moving Osaka Uniyersity Hospital to the new institution (1983), the number of patients with cleft lip and/or palate and ratio to all orthodontic patients increased.

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