An epidemiological study of cleft lip/palate deals with prevalence, cause, treatment protocol, and assessment of the treatment results. In the present report, I focus on the prevalence and assessment of treatment.
I. Prevalence of cleft lip/palate
Cleft lip/palate is the most common congenital external malformation. The prevalence is approximately 0.18% in Japan, but it varies with race and country. Some reports have suggested that the prevalence is on the decline. However, the Miyagi study of congenital external malformation from 1973 to 1992 showed no evidence of a decline or rise of the prevalence. Therefore, it would appear that the prevalence has been static in recent decades. Furthermore, Miyagi study showed an obvious decline in births with cleft lip/palate in conceivable conjunction with the decline in birth rate.
2. Assessment of treatment
The treatment results are largely affected by the three surgeries: cheiloplasty, palatoplasty, and alveolar bone grafting. In particular, cheiloplasty and palatoplasty distinctly affect the treatment results. Thus, the assessments of these two surgeries are important. In Japan, a large variety of surgical protocols in terms of timing, method, and combination are adopted. Recently, the Japan Cleft Project consisting of six universities initiated a study including the assessment of surgical protocol.
The most important point of assessment is classification of cleft type. As a record before primary surgery, I recommend taking photographs of the nose and cleft condition of maxilla. A study model of the maxilla is not recommended, because the impression procedure is difficult in hospital without a dentist. Although the morphological order of the cleft ranges very greatly, the classification is very simple. Prevalent classifications of cleft type do not describe the cleft condition accurately. To overcome this, not a description of prevalent classifications of cleft type alone, but a photographic record is essential as previously noted. As the first timing of taking cephalograms, five years old is recommended. Short-term assessment of cheiloplaty and palatoplasty in terms of skeletal pattern, occlusion, speech, and velopharyngeal closure is conducted at this time using cephalograms, study models, oral photographs, and so forth. In addition to the assessment of two primary surgery, these materials serve as a baseline for further treatment of occlusion throughout the growing stage.
Finally, the epidemiological study will lead to advances in the treatment of cleft lip/palate, which will enhance the quality of life of cleft patients throughout long-term treatment.

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[in Japanese]

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Oral problems such as discrepancy between upper and lower jaws, jaw cleft with the defects of tooth, alveolar bone and maxillary bone, fistula to the nasal cavity, shallow palate with scar, and malocclusion can be seen in cleft lip and palate patients. In the prosthodontic treatment for these patients, prevention against relapse of maxillary bone and dentition set up by surgical and orthodontic treatment must be considered, which is a special factor different from ordinary prosthodontic treatment. However, most of the problems can be relieved or improved by recent developments in surgical and orthodontic treatment and through a well-managed team approach. Consequently, prosthodontic treatment has become more simple with minimal intervention for the anterior teeth. Thus, a fixed bridge can be applied for most of the patients and the number of abutment teeth is decreasing. This makes daily oral hygiene control by the patients easier and more efficient, leads to a long-term good condition and raises the QOL of the patients.
On the other hand, sufficient and long-term observation of the posterior teeth out of the prosthodontic treatment is scarcely done. Full consideration of the relapse of the posterior teeth is required.

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We have performed two-stage closure of the cleft palate in 12 cases with complete unilateral cleft lip and palate. After the soft palate cleft was closed at an average age of 21 months, a speech plate was placed on the remaining cleft of the hard palate. The remaining hard palate and alveolar cleft was closed with local mucoperiosteal flaps at 11 years of age. Autogenous bone was grafted to the alveolar cleft at the same time. We evaluated the speech plates, maxillary growth at six years of age, alveolar bone height followed by bone grafting, and speech outcome in all cases.
It was possible to place speech plates from about 2 years old for the closure of the hard palate and alveolar cleft. The maxillary growth from this treatment was much better than that achieved with the mucoperiosteal push-back method. Ten (83%) cases showed satisfactory bone height levels after bone grafting. Velopharyngeal insufficiency and lateralization were found in one and six cases, respectively. The total period of treatment for speech disturbance averaged one year and nine months.

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Many patients with cleft lip and palate showed feeding and speech disturbance, lip scar after primary reconstruction, and growth retardation of maxilla. Treatment of cleft lip and palate should be managed by interdisciplinary approaches, which include plastic and reconstructive surgery, pediatrics, orthodontics, oral surgery, speech therapy, and so torth. Orthodontics play various roles in feeding with palatal plate mimicking the normal palate just after birth, orthopedic treatment during the growing stage, and comprehensive orthodontic treatment at permanent dentition. Furthermore, presurgical orthopedic and/or orthodontic treatments were performed prior to lip closure and alveolar bone graft. The aim of these presurgical orthopedic and/or orthodontic treatments is averaging of presurgical status, which may minimize the risk of surgical procedure. To support the adaptation of the patients to the community, further review should be carried out through a multicenter study and discussion among the staff treating the patients with cleft lip and palate.

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The five categories rating based on dental models has been used in many assessments of dental arch relationships in patients with unilateral cleft lip and palate (UCLP). This study was performed using the 5-Year-Old Index in the Department of Oral-Maxillofacial Surgery, Dentistry and Orthodontics, The University of Tokyo Hospital (UTH). In this study, the usefulness of the index was examined and dental arch relationships in deciduous dentition in patients with UCLP were evaluated. An evaluation of speech was also carried out.
Dental models in late deciduous dentition of 31 patients with complete UCLP were used in this study. The average age was 6 years 0 month and primary surgeries were performed in 13 hospitals. The modified Millard's method with small triangular flap was used for lip closure and the pushback operation was performed for palate closure in 22 patients (M-P group). Eight out of 22 patients were treated in UTH (UTH group). Intra- and inter-examiner agreements were evaluated using the weighted kappa statistics. Speech evaluation was performed on 25 out of 31 patients using clinical records.
Intra- and inter-examiner agreements were high indicating good reliability. The average score was 3.23 in all 31 patients, and 3.36 and 3.00 in the M-P group and in the UTH group respectively. Good dental arch relationships (Group 1 and 2) were found in 16.1% of all patients, in 13.6% of the M-P group and in 37.5% of the UTH group. Poor relationships (Group 4 and 5) were found in 32.3% of all patients, in 36.4% of the M-P group and in 25.0% of the UTH group. Articulation disorder was found in 36.0% of all patients, in 26.3% of the M-P group and in 12.5% of the UTH group. Velopharyngeal insufficiency was found in 4.0% of all patients but was not found in both the M-P and UTH groups.
The 5-Year-Old Index seemed to be a reliable method for the evaluation of dental arch relationships in patients with UCLP. Average dental arch relationships revealed in this study were slightly better than those of our previous studies using the Goslon Yardstick. On the other hand, when compared with other reports from foreign institutions, the proportion of patients with poor dental arch relationship was larger. However, facial appearance, speech ability and racial difference should be taken into consideration when interpreting the results of this study.

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Fifteen years have passed since the Cleft Palate Team at Niigata University Dental Hospital, which is currently named the Dental Section of Niigata University Medical and Dental Hospital, was established in February 1991. This team has conduted various activities such as the registration of patients, management of interdisciplinary examinations and conferences, compilation of common examination booklets, holding of seminars for patients' mothers and instruction in facial make-up for patients.
The purpose of this study was to investigate and evaluate these activities in order to plan the future roles of the team.
One thousand and forty-three patients were registered as of June 2006. The numbers of primary and secondary cases were 764 and 279 respectively. The number of patients registered yearly was 45 on average from 1993 to 2005. Sixty-three cases were discussed at the clinical conferences.
The classes for patients' mothers have been held three times per year and 23 times in total. Thirty-two patients have been taught how to apply make-up since April 2001. All the patients hoped to learn how to apply make-up at the hospital. Almost all the patients have reported feeling comfortable after applying facial make-up, suggesting that the training in facial make-up at the hospital is useful.
Initially, the cleft palate team focused on unifying the system for treating cleft palate patients in the hospital and notifying doctors and medical staff of it. However, our main activities have extended to giving mental support to the patients and their families since 2000. In the future, it will be necessary to extend the mental support activities in Niigata Prefecture and Hokuriku region beyond the limits of the University Hospital.

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To identify the effect of a Hotz plate on the occurrence of palatalized articulation, we investigated the relationship between a Hotz plate and the occurrence of palatalized articulation. Furthermore, characteristics of palatal morphology relating to palatalized articulation were analyzed three-dimensionally.
The frequency of palatalized articulation was assessed in 142 patients with unilateral complete cleft lip and palate (UCLP) who underwent palatoplasty and speech assessment at 4 years of age. Threedimensional (3D) analysis of palatal morphology was performed in 32 UCLP patients, who had dental casts of the maxilla taken at about 4 years of age. Patients were divided into four groups: NH (-) group, showing normal articulation without a Hotz plate; PH (-) group, showing palatalized articulation without a Hotz plate; NH (+) group, showing normal articulation with a Hotz plate; and PH (+) group, showing palatalized articulation with a Hotz plate. The numbers in each group were 10,5,10, and 7, respectively. All dental casts were measured using a non-contact 3D laser scanner SURFLASER, and the 3D data were analyzed using the software 3D-Rugle. The landmarks were identified on the 3D images, then measurements on the horizontal, frontal, and sagittal planes were obtained and compared among the groups. The results were as follows.
1. Palatalized articulation was observed in 16 (29.1%) of 55 patients without a Hotz plate, whereas it was observed in 12 (13.8%) of 87 patients with a Hotz plate. There was a significant difference between the two groups.
2. In 15 patients treated without a Hotz plate, morphological characteristics of the palate, including narrowness in the posterior region, asymmetry and shallowness in the anterior region, were recognized. These characteristics were more remarkable in the PH (-) group (5 patients) than in the NH (-) group (10 patients). These abnormal morphologies of the palate were considered to account for the palatalized articulation.
3. In 17 patients treated with a Hotz plate, there were no significant differences in palatal morphologies between the NH (+) group (10 patients) and the PH (+) group (7 patients).
4. In the 12 patients with palatalized articulation, these morphological characteristics that were observed in the PH (-) group (5 patients) were not remarkable in the PH (+) group (7 patients).
5. The above findings suggest that the Hotz plate improves abnormal palatal morphologies and may decrease the occurrence of palatalized articulation.

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Objective: To compare deciduous dental arch relationships of patients with complete unilateral cleft lip and palate (UCLP) divided into two groups with differing primary protocols.
Design: Retrospective study of treatment outcomes using blinded evaluation of dental study casts.
Patients: 64 (two-stage group: 35, PB group: 29) consecutively treated 4-year-old patients with complete, nonsyndromic UCLP.
Interventions: In bolth groups, passive presurgical orthopedics were used until 12 months and primary lip repair was completed at 3 months of age. In the two-stage group regimen, velar closure was completed with the modified Furlow procedure at 12 months of age and hard palate closure at 18 months of age with the Veau technique. In the PB group regimen, one-stage push back palatoplasty was completed at 12 months of age. Every operation was completed by one surgeon.
Main outcome measure: Averaged ratings and score distributions of dental casts using the 5-Year-Old Index by three assessors were calculated. The 5-Year-Old Index is a clinical tool that allows categorization of the dental arch relationships of deciduous dentition in patients with UCLP into five groups (group 1: exellent, group 2: good, group 3: fair, group 4: poor, group 5: very poor). The weighted Kappa analysis was used to compare intra- and interexaminer reliability.
Results: Intra- and interexaminer reliability tests showed good or excellent reliability. The mean score of the two-stage group was significantly better than that of the PB group. Most of the half numbers in the two-stage group were distributed in group 1 or group 2.
Conclusions: The early two-stage palatoplasty regimen is less harmful to the maxillo-facial growth than the one-stage push back procedure at 12 months of age.

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The present study investigated the current incidence of cleft lip and/or palate using a questionnaire at the maternity hospitals in Oita Prefecture from 1994 to 2003.
1. A total of 81649 newborn infants were examined, and 147 had cleft lip and/or palate (0.180%).
2. Among those 147 infants with cleft lip and/or palate,37 had cleft lip,77 had cleft lip and palate, and 29 had cleft palate. Of the 30 infants with cleft lip,28 were unilateral and 2 were bilateral clefts. Of the 57 infants with cleft lip and palate,46 were unilateral and 11 were bilateral.
3. As for the sex, there were 15 males and 22 females among infants with cleft lip,39 males and 38 females among infants with cleft lip and palate, and 16 males and 13 females with cleft lip.
4. Period of gestation: 133 infants were delivered in normal term, and 10 infants in preterm.
5.110 infants were born by natural childbirth,24 infants by cesarean section, and 6 infants by vacuum extraction.
6. Associations of malformation were recognized in 28 out of the 147 infants (19.6%) including light weight at birth, chromosome aberration, and defects of the heart.19.6% of all cleft lip and/or palate infants had complications at birth, especially cleft palate patients.

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In this paper we present the results of rapid maxillary expansion after secondary alveolar bone graft for 10 patients with cleft lip, alveolus and palate. Six patients with bilateral cleft lip and four patients with unilateral cleft lip were included in this study.
The average age at bone grafting was 8 years and 7 months. The average age at maxillary expansion was 11 years and 1 month.
Splitting of the intermaxillary suture was observed in all cases, included in five patients with incomplete splitting. In two cases with bilateral cleft lip in whom the premaxilla was set back by surgical operation, incomplete splitting of the intermaxillary suture was observed. In a unilateral case that had asymmetry collapsed maxilla, expansion of suture splitting leading to the symmetrical form was observed.
Secondary bone grafting and subsequent maxillary expansion with suture splitting is the recommended treatment for cleft lip and palate patients who have a collapsed maxilla.

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We conducted maxillary distraction using mini plate fixation of the maxilla after application of the rigid external distraction system (RED system). Mini plate fixation after upper jaw distraction was used to avoid a relapse change after maxillary displacement on a patient with right unilateral cleft lip, alveola and palate. The reason for performing plate fixation was to remove the distraction device and avoid a change after maxilla displacement. In addition, we ligatured the full-size arch wire and dental arch in a mass, keeping minimum tooth movement. We examined the distance not only of maxillary bone displacement but also of tooth movement against maxillary bone. The patient was a boy 16 years and three months old at the time of the maxillary distraction operation, and he received alveolar bone grafting before maxillary distraction. We conducted the distraction osteogenesis on a high transverse (Le Fort I) maxillary osteotomy after having fixed an attraction hook. Initial distraction rate was 2 mm, and distraction was continued at a rate of 1 mm/day for 9 days until the desired amount of maxillary movement had been achieved. We performed the maxillary plate fixation 8 days after distraction. To compare between pre-distraction and posttreatment, the study used cephalometric radiograph tracings. The distraction length at maxillary point A was 9.1 mm anterior and 5.7 mm downward by the time we had achieved the desired distraction length. After 1 month, point A was 2.9 mm posterior and 5.7 mm upward. However,9 months later, point A had not changed. Tooth movement against maxillary bone was 1.2 mm for extrusion from pre-distraction to post-distraction. The displacement was 1.4 mm labial and 1.0 mm intrusion since the end of distraction one month later.1.5 mm extrusion was found at post-treatment, and the large change was not considered to be due to the effect of plate fixation.

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