Objective: To evaluate the efficacy of the early two-stage palatoplasty regimen (ETS) advocated by Nishio et al. in 1997, in this paper we report speech results at 4 years of age on children treated by this method.
Materials and Method: Thirty complete unilateral cleft lip and palate (CUCLP) treated by ETS were examined (ETS group). ETS consists of velar closure using the modified Furlow technique at 12 months of age and hard palate closure at 18 months of age. We compared the speech results of the ETS group with those of 41 patients treated by the one-stage pushback method at 12 months of age (PB group).
Results: 1. The ETS group tend ed to be later in acquiring oral function and producing consonants than the PB group. The beginning ages of sucking, blowing and producing labial consonants were significantly delayed in the ETS group. This procrastination in the ETS group might have resulted from the residual cleft in the hard palate being left open until 18months of age.
2. At 4 ye ars of age both surgical techniques resulted in good speech in the majority of patients. Velopharyngeal competency was competent in 93.3% of the ETS group and 95.1% of the PB group.76.7% of patients in the ETS group and 63.4% in the PB group acquired normal articulation. Six patients (20.2%) in the ETS group and 12 patients (29.3%) in the PB group had palatalized articulation. The kind of these palatalized consonants was dento-alveolar consonants in the ETS group. In the PB group, we recognized dento-alveolar consonants and postalveolar consonants. This difference in the kind of palatalized consonants between the ETS group and PB group might be a reflection of the better growth of upper dental arch in the ETS group.
Conclusion: This report revealed that the speech results of the ETS group at 4 years of age were better than those of the PB group.

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Objective: This study evaluated maxillary arch morphology of children with complete unilateral cleft lip and palate (CUCLP) treated with the early two-stage palatoplasty (ETS) described by Nishio et al. which has been practiced in Osaka Medical Center and Research Institute for Maternal and Child Health since 1997.
Material and methods: The subjects were 72 children who had CUCLP without associated malformations. Thirty cases were treated with ETS (ETS group). ETS consists of velar closure with the modified Furlow procedure at 12 months of age and hard palate closure at 18months of age. In 42 cases push-back (Wardill-Killner) palatoplasty was performed at 12months of age (PB group). Primary lip repair was carried out at 3 months of age with the modified Millard technique. Besides, we added cross sectional data from 66 non-cleft children as a control group (Cont group). Dental casts of these three groups were measured and compared at the age of 3,12,18 months and 2,3,4 years in the ETS and Cont group, and at 3,12 months and 4 years in the PB group.
Results: At 4 years of age the size and form of maxillary arch in the ETS group showed significantly better growth in both anterior-posterior length and transversal width than in the PB group, but smaller than in the Cont group. The rate of increase of the anterior-posterior length of major segment in the ETS group between 12 months and 4 years of age was better than that of the Cont group. This result implied that patients treated in the ETS group gained catch-up growth with non-cleft children in the anterior-posterior length of the maxillary arch. When we compared the change of transversal width between the ETS and Cont groups, the growth rate of the inter-canine width in ETS decreased from 18 months to 2 years of age (for 6 months after the hard palate closure), whereas Cont showed rapid growth in the inter-canine width during the same period.
Conclusion: This study showed that the early two-stage palatoplasty inhibited the growth of the maxillary arch in CUCLP patients less than the one-stage push-back procedure performed at 12 months of age.

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Secondary bone grafting was performed on 229 patients with cleft lip and/or cleft palate including 289 alveolar cleft sites from August 1986 to December 1998. Among them,188patients including 233 alveolar clefts which were grafted with autogenous iliac cancellous bone and with sufficient records were studied based on the primary data of the patients and the prognosis of bone grafts. We divided the patients into three groups according to age and eruption situation of the tooth adjacent to the alveolar cleft:
Group 1: Before eruption of canine or lateral incisor on th e cleft site
Group 2: After eruption of canine or lateral incisor of those under 18 years old
Group 3: Over 18 years old (including 18)The results were as follows.
1. Soft tissue coverage consisted of local mucoperiosteal flap in 137 patients, buccal rotation flap in 10 patients, and tongue flap in 41 patients.
2. The overall success rate of bone bridg e formation was 93.6% (218/233). By group, the success rate was 98% (49/50) in group 1,97.1% (67/69) in group 2, and 89.5% (102/114) in group 3. These results showed no statistical significance between the success rate of bone bridge formation and the group division (p=0.025).
3. On assessment of marginal bone leve l, the overall rate of score 1 (over 75% of full root length of teeth adjacent to the cleft) was 32.1% (74/233). By group, the rate of score 1 was 62.0% (31/50) in group 1,31.9% (22/69) in group 2, and 18.4% (21/114) in group 3. These results showed statistical significance between the rate of score 1 and the group division (p<0.001). The rate of score 1 and 2 (over 50%) was 60.1% (140/233) in total. By group, the rate of score 1 and 2 was 84.0% (42/50) in group 1,58.0% (40/69) in group 2, and 52.6%(60/114) in group 3. These results showed statistical significance between the rate of score 1and 2 and the group division (p<0.001).

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An experimental animal model with malformation in the maxillofacial region is needed for basic research on the mechanism of maxillofacial growth of patients with congenital malformations. These animals with malformation are also necessary for research on the effects of orthognathic treatment in these patients. Neonates with a malformation in the maxillofacial region induced by teratogenic agents or produced by genetic methods usually supervene other serious anomalies, and therefore are rarely alive after birth. This experiment was performed to develop a new method of making an experimental animal model with congenital malformation in the naso-labial region, which could be bred after birth.
The fetuses of ICR mice on the 14th day of gestation were exposed from the uterus being enveloped by the amnion. The naso-labial region of the mouse fetuses was irradiated through the amniotic wall by an argon laser without leakage for any amniotic fluid. The fetuses which received laser surgery were delivered by Caesarean section on the 18th day of gestation, and after birth, they were raised by a foster-mother. At birth,54.6% of the fetuses which had undergone the operation were alive and 55.4% of the living neonates showed morphological asymmetry in the naso-labial region. These mice neonates could be brought up for more than 3 months, and differences in the form and size between the irradiated side and non-irradiated side of the naso-maxillary region became apparent as the whole body growth progressed.
These results revealed that the fetal surgery by using an argon laser might be a useful procedure for developing the experimental animal model with cranio-facial deformities.

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In this paper we present the result of presurgical orthopedic treatment for patients with cleft lip and palate in Kanagawa Children's Medical Center. Eighteen infants with complete unilateral cleft lip and palate were included in this study.
In these patients, we used a passive acrylic plate mimicking the normal palate form with adhesive paste or slim adhesive tapes fixed from the hook to the cheeks.
The average age at insertion of the plate was 17 days of life, and average age at removal of the plate was 204 days of life. Feeding was significantly improved after wearing the plate, approximately equivalent to the Hotz plate.
The cleft defect was reduced significantly, and the position of the margin on both segments improved vertically. The cleft in the alveolus changed from 10.8 mm to 1.5 mm on average. The cleft in the palate changed from 13.0 mm to 8.5 mm on average. The width of the alveolar arch slightly increased, and these values were larger than the average of noncleft contemporaries.
In our procedure, the cleft defect reduced significantly without maxillary collapse.

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One of the problems in secondary revision of the nose is the relapse of nasal morphology after surgery. We attempted to clarify the relapse of nasal morphology after secondary revision of the nose in unilateral cleft lip (UCL) patients.
The subjects were 23 UCL patients who underwent secondary revision of the nose in our clinic.
The average relapse ratio of naso-labial angle (NLA), height of nasal tip (Prn (x)), and alinasal width (Width) was 29.2%,29.2%, and 25.4% respectively. The amount of relapse from 1 month to 3 months postoperatively was largest, and then the degree of relapse from months to 6 months postoperatively decreased. After 9 months postoperatively, nose morphology was almost stable. According to the degree of morphological change of nose by operation, subjects were divided into two groups; large group, and small group. No significant differences were found between relapse of the large group and small group in measured NLA, Prn (x), and width at 1 year postoperatively. These results suggest that the relapse of nose morphology after secondary revision of the nose was about 30% whether morphological change of nose by operation is large or small.

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Mothers who have babies with cleft palates seldom succeed in breast-feeding and feel difficulties feeding even using bottle feeders. This study surveyed feeding experiences, and how mothers managed to feed their babies, in order to offer better assistance in feeding. Questionnaire sheets were handed to 200 mothers whose babies attended the author's clinic, and 161 mothers answered.
The results were:
1) About 39% of the mothers first saw and held their babies on the day of birth, but about 20% of the mothers did not meet their babies until more than 5 days after birth.
2) About 64% of the mothers had received instructions on feeding methods d uring pregnancy. After childbirth,70% of the mothers received instructions on the care of their breasts and bottle feeders, but only 50% of the mothers received instructions on how to hold their babies and the posture of the babies.
3) Information about the Hotz plate was provided to only 16% of the mothers. About 70%of the mothers whose babies wore Hotz plates felt that feeding their babies was easier.
4) Almost all of the mothers wanted to breast-feed directly, but few succeed ed. Many mothers wanted to try breast-feeding, if it was technically possible.
5) The most frequent methods of feeding were bottle feed er with milk, bottle feeder with breast milk, breast feeding, N-G tube, and spoon feeding respectively. The mothers' own contrivances for feeding their babies were: 1) feeding posture and methods,2) various kinds of bottle feeders and teats, and so on.
6) Difficulties concerning feeding their babies were: 1) discharging of milk from nose and/or mouth,2) taking a longer time to feed,3) feeling stress when feeding their babies, and so on.
7) About 59% of the mothers had advisers when they felt difficulties feeding their babie s, with nurses being the most frequent advisers. Unfortunately about 40% of the mothers had no adviser at all. The mothers felt that the information concerning bottle feeders and feeding methods was useful, and wanted to have more information about how other mothers fed their babies. It was found that mothers who had babies with cleft palates encountered many troubles with feeding and tried many contrivances. In order to improve the feeding methods, much more attention should be paid by the medical staff engaged in cleft palate practice.

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This paper reports the application of alveolar bone grafting for a 23-year-old woman with right unilateral cleft lip and palate who had unoperated hard palate and alveolus. Preoperative intraoral view revealed a large oronasal fistula at the hard palate 13mm in width and 32 mm in length. Alveolar bone grafting was carried out in the usual fashion. The mucoperiosteum on the medial and lateral side of the cleft was elevated and separated into the nasal and oral side from the labial alveolar bone surface to the end of the palatal cleft. The nasal side mucoperiosteal flaps were sutured to form a nasal side closure. The enlarged and bulbous inferior turbinate was partially reduced to facilitate the nasal side closure. The oral side closure was also made in the same manner. Particulate cancellous bone harvested from the anterior iliac crest was densely packed into the palatal and alveolar bony defect. The postoperative course was uneventful. Intraoral findings two years after the surgery showed complete closure of the hard palate and alveolus. Periapical radiograph and CT showed adequate bone formation around the hard palate and alveolar area. These results suggest that alveolar bone grafting is a considerably useful surgical intervention not only for the repair of alveolar bony defects but also the closure of large oronasal fistulas situated in the hard palate.

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Oronasal fistulas after palatoplasty are commonly closed at the secondary bone grafting in patients with alveolar cleft. Sometimes oronasal fistulas might cause problems in speech and/or intake of food. Oronasal fistulas therefore should be closed in those cases by using a fistula closure appliance until the secondary bone grafting. The conventional palatal appliance consists of an acrylic resin plate and wire clasp. However, such a plate appliance has the discomfort of leakage of food and insufficient stability. Further, patients suffer mental anguish about wearing the plate appliance. Therefore we developed a new type of obturator by using a self-curing viscoelastic resin for patients with problematic oronasal fistula. This obturator is easily fabricated and suitable for the form of the oronasal fistula. Here we report the method of fabricating the new type of obturator and its clinical application.

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An international group of speech pathologists discussed the universal reporting parameters for the speech of individuals with cleft palate at the NIDCD workshop. The course and the tentative agreement are reported.

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[in Japanese]

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