The major problem of orthodontic treatment in patients with cleft lip and palate, exists in the imbalance of the relationship between the upper and lower jaws due to underdevelopment of the maxilla. To accelerate forward growth of the maxilla, the maxillary protraction appliance has been used in cleft lip and palate patients, generally in the mixed dentition period. However, the results of treatment vary between different patients and between patients of different ages. Recently, it has been recommended in some reports to perform maxillary protraction in the deciduous dentition period because of the greater potential of growth. The present study concerns eleven female patients with unilateral cleft lip and palate, treated with the maxillary protraction appliance with chincap at our clinic. Their treatment started at the deciduous dentition stage. The purpose was to investigate the treatment effect within the first year. The results were as follows:
1. Normal overjet was obtained in most patients within the first year of treatment.
2. Disharmony of jaw relationship was improved in all patients with the mean increment of 3.48 °at ANB angle.
3. The mean effect in anterior displacement of the maxilla was 2.4 mm. Half of the patients revealed a marked change exceeding 3 mm, while two cases of the remaining patients revealed less than 1 mm.
4. Maxillary protraction beginning in the deciduous dentition period was considered to be m ore effective than that beginning in the mixed dentition stage, however, limitations might still exist in patients with the lowest growth potential.

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Speech appliances are available for correction of hypernasality or nasal emission that is caused by velopharyngeal incompetence following primary palatoplasty. When a speech appliance is in place, patients, who are accustomed to wearing a speech appliance, can exhibit adequate velopharyngeal function during production of pressure consonants or blowing. That is, it is likely that velopharyngeal function can be regulated in relation to changes in oral air pressure accompanied by production of obstruent sounds or blowing so as not to avoid nasal emission or hypernasal speech.
The purpose of this study was to clarify the physiologic basis underlying an effect of a speech ap pliance placed to improve velopharyngeal function. Six patients with repaired cleft palate were employed as subjects. The subjects were accustomed to wearing a speech appliance. Three out of six subjects routinely wore a bulb attached palatal lift prosthesis (Bulb-PLP) and the others a palatal lift prosthesis (PLP) for the correction of velopharyngeal incompetence. Electromyographic signals of the levator veli palatini muscle and peak oral air pressure were monitored during three levels of blowing pressure (soft, medium and hard blowing) when a speech appliance was in place and removed. For subjects routinely wearing a Bulb-PLP, levator activity was not correlated with changes in oral air pressure when a Bulb-PLP was removed. However, when a Bulb-PLP was in place, levator activity changed in relation to oral air pressure during blowing and the activity was identified to be smaller than that observed during soft and medium blowing in the condition that a Bulb-PLP was removed. For subjects routinely wearing a PLP, levator activity changed in relation to oral air pressure whether a PLP was in place or not. However, when a PLP was in place, levator activity was significantly smaller than that observed in the condition that a PLP was removed.
Standard deviation of levator activity was smaller in the condition of a speech appliance in place than that in the condition that a speech appliance was removed irrespective of a type of a speech appliance. The results possibly imply that differential activity of the levator muscle, which is generated by placement of a speech appliance, might be a reserve to enable velopharyngeal function to close adequately in relation to changes in oral air pressure with context so as not to allow air to escape into the nasal cavity, and smaller deviation of levator activity is possible to imply that levator muscle activity can be adequately regulated to respond to target tasks.

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Abstract: A 78-year-old woman with unoperated cleft palate and open nasality is presented. Placement of a new denture equipped with pharyngeal section and pharyngeal bulb showed remarkable improvement of velopharyngeal function and in the articulation test as follows:
1) Examination of oral air flow volume, time flow, and peak flow rate during blowing with a new denture showed increases of 50%, 25%, and 63% respectively compared to those data with/without old denture.
2) Fiberscopic examination showed complete velopharyngeal closure during /K/ phonation with a new denture which did not with old denture.
3) Articulation test with a new d enture showed remarkable improvement of 58%, which revealed very close to acceptable level, from 29% with old denture.
The authors recommend the choice of prosthetic improvement equipped with a speech appliance for the patient with unoperated cleft palate, when she/he is elderly.

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One of the most important purposes of secondary alveolar cleft bone grafting is to allow for the closure of the cleft defect and provide a normal dental arch form orthodontically without any prosthesis. To obtain better arch form around the grafted bone area, making wide graft bed and filling the graft bed completely with cancellous bone tips are two major significant surgical procedures.
However, surgeons sometimes encounter the cases having enlarged and bulbous inferior turbinate of the cleft side, which interrupts making a wide graft bed.
In such cases, the inferior turbinate to make a wide graft bed can be reduced. Inferior turbinate can be reduced by scissors inserted from the nostril while maintaining the nasal mucosa opening; this is followed by water tight nasal side closure.
Application of this method enables not only making the nasal floor flat and deep but also making a satisfactory bone bridge for orthodontic tooth movement. Complication related to reducing inferior turbinate is minimal.
In conclusion, reducing inferior turbinate is considered to a very useful procedure for the patients who have enlarged and bulbous inferior turbinate of the cleft side.

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Secondary bone grafting to the alveolar cleft of patients with cleft lip and palate is now a widely accepted surgical procedure. This paper describes the placement of an osseointegrated implant at the site of a bone graft in an adult with unilateral cleft lip and palate.
The patient was a 19-year-old female with right unilateral cleft lip and palate. At the time of referral for surgery, the patient was found to have several residual clefting problems, including an oronasal fistula, an alveolar bony defect, and open space of the dental arch in the left central and lateral incisor areas. To close the oronasal fistula and reconstruct the alveolar ridge, iliac cancellous bone was grafted to the alveolar cleft. The postoperative course was uneventful, and 5 months after the bone graft, a self-tapping Brdnemark implant (length,13mm, diameter 3.75mm) was placed in the grafted bone. Four months after placement, the fixture was uncovered and a fixed prosthesis was set. The use of an alveolar bone graft with an osseointegrated implant enabled not only closure of the oronasal fistula but also full occlusal rehabilitation, without employing a conventional fixed bridge or a partial prosthesis. In conclusion, the method presented in this paper was considered to be very useful for the occlusion of residual alveolar clefts in adult patients with cleft lip and palate.

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Statistical investigation was carried out on 161 patients with cleft lip and/or palate in the Department of Orthodontics, Tokushima University Dental Hospital from April 1984 to March 1994. The following findings were obtained:
1. The percentage of cleft lip an d / or palate patients was 6.9% of all orthodontic patients during 10 years. The ratio of male patients was a little larger than that of the female's.
2. The peak age groups of the patients at first visit were under 3 years old group and 10-13years old group. I A and III B was most frequent in Hellman's dental developmental stage.
3. From the stand point of geographic distribution,94.4% of the patients were from the Shikoku area and 35.4% of the referred patients were from the Department of Plastic Surgery of Tokushima University.
4. Of malocclusion from the aspect of first molar relationships, Class II patients were most frequent, being 41.3%. From the terminal plane of the second deciduous molar, distal step type were most frequent, being 45.9%.
5. The distributio n of cleft type was as follows: cleft lip 6.8%, cleft lip and palate 89.4%, cleft palate 3.1%, median cleft 0.6%. The left side cleft was most frequent in unilateral cleft lip and/or palate, and there were more female patients than the male patients having cleft lip and cleft palate, while more male patients than female patients having cleft lip and palate.
6. The type of incidence of maxillary alveolar arch was as follows:
1) In unilateral cleft lip and/or palate patients, the butt-joint contact type was most frequent, being 69.9%.
2) In bilateral cleft lip and/or palate patients, the protrusion of pre-maxilla type was most frequent, being 53.6%.
7. In classification of crossbite, case of type 2 (total crossbite) were most frequent, being 44.8%.
8. The congenitally missing teeth were found in 66% of all patients. The upper lateral i ncisor on the cleft side was most frequent.

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