Assessment of velopharyngeal closure function (VPF) is most important in planning speech therapy for patients with cleft palate, however, the level of VPF after palatoplasty does not necessarily concur with the consistent results of the speech condition. In this study, the VPF of patients with cleft palate was evaluated for three speech conditions: blowing, phonating consonant and vowels. Furthermore, the characteristics of velopharyngeal incompetence (VPI) and the response to speech therapy were discussed.
Materials The subjects were 42 patients who had received palatoplasty at the average age of 22 months and speech therapy in the Department of Oral and Maxillofacial Surgery, Kyushu University Hospital. Their cleft types were unilateral cleft lip and palate in 19 patients, bilateral cleft lip and palate in 11 submucous cleft palate in 7 and isolated cleft palate in 5.
Methods Their outcomes of speech treatment were evaluated at 4 to 6 years of age. The VPF values were classified into four groups according to the nasal air leakage in the mirror test in three speech conditions. Group one (G1) showed good VPF in all the speech conditions, group two (G2) showed VPI only when phonating vowels, group three (G3) showed VPI when phonating both consonants and vowels, and group four (G4) showed VPI in all the speech conditions. The VPF was compared among the four groups regarding the blowing ratio, nasalance score by the Nasometertest, and both velopharyngeal morphology and movement of the soft palate from cephalometric analysis.
Results Twenty-three patients were classified as Gl,6 as G2,7 as G3, and 6 as G4. Cephalometric analysis revealed that the soft palate was long and showed good mobility in Gl. In G2, the mobility of the soft palate was poor. In G3, the soft palate was short but the mobility was good. In G4, the soft palate was short and the mobility was poor.
Conclusion Evaluating the velopharyngeal closure function under various speech conditions is useful for comprehending the symptoms and planning treatment. Our guidance of speech therapy for postoperative VPI using the mirror test is that G2, which is characterized as poor movement of the soft palate, needs facilitation of mobility; G3 with a short palate needs prosthodontic treatment, if necessary, followed by surgical approaches to lengthen the soft palate, and G4 with poor mobility of the short soft palate needs secondary palatoplasty.

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Objectives: The purpose of this study was to investigate the effects of the timing of secondary bone grafting on the growth and development of dentofacial complex in patients with complete unilateral cleft lip and palate (UCLP).
Design: Retrospective lateral cephalometric study.
Interventions: Thirty patients received similar primary surgical procedures by the same surgeon and the similar first phase orthodontic treatment. These patients were divided into two groups according to their age at secondary bone grafting: 23 patients at a mean age of 9.6 years (early group) and 7 at a mean age of 12.2 years (late group).
Methods: Lateral cephalometric radiographs of all subjects were obtained at two different times: at the age of 7 or 8 years (prior to bone grafting) and at the age of 15 or 16 years (more than one year after bone grafting). Twenty-eight measurement items on the sagittal and vertical growth of viscerocranium were compared between the early and late groups by the unpaired t-test.
Results and discussion: Vertical maxillary growth was inhibited significantly in the early group in comparison with the late group; however, there was no significant difference in sagittal maxillary growth between the two groups. This suggests that sagittal anterior maxillary growth is almost completed before the age of 10 years, but the alveolar process is still growing vertically after the age of 10 years.

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Cleft lip and/or palate patients of our department for the past 17 years since its establishment (January 1989) were analyzed statistically.
The results were as follows:
1. The total number of primary cases was 501.
2. They consisted of 146 (29.4%) cleft lips,200 (40.3%) cleft lip and palates, and 150 (30.2%) cleft palates.
3. Cleft lip and cleft palate were more frequent in males and cleft palate in females.
4. The laterality in CL and CLP cases was unilateral in 77.8% and bilateral in 22.2%. Left laterality (1.8 1) was observed in unilateral cases.
5. Among the patients,488 patients (97.4%) were residents of Okinawa prefecture.
6. As for gestational age, full term birth accounted for 88.0%.
7. The incidence of low-weight babies (less than 2,500g) amounted to 16.2% of the patients, which was higher than in normal cases.
8. The mean age of mothers at delivery was similar to that of the normal group.
9. As for the childbirth state, natural childbirth was often found.
10. Associated congenital anomalies were found in 18.4% of all cases, and they were more frequently found in cleft palate patients.

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The purpose of the present study was to investigate the distribution of age and cleft types on 3,293 patients with cleft lip and/or palate who visited the Orthodontic Clinic in the Dental Hospital at Tokyo Medical and Dental University during 1971-2005. In addition, the cases of surgical intervention related to orthodontic treatment were surveyed. Results were as follows:
1) The most common age group of the patients registered at the first visit was 6-9, which accounted for 52.7% of all patients. The frequency of adult patients (18 years old and up) has been increasing recently.
2) The most common age group of the patients with whom orthodontic treatment was commenced during 1971-1991 was 9-11, which accounted for 47.1% of all patients. On the other hand, during 1992-2005, patients aged 8-10 accounted for 40.5%. The frequency of adult patients (18 years old and up) has been increasing recently.
3) The distribution by cleft type was 18.1% with cleft lip (unilateral,15.6%; bilateral,2.5%),62.7% with cleft lip and palate (unilateral,46.1%; bilateral,16.6%), and 18.9% with cleft palate.
4) The overall ratio of male to female was 1.2: 1, and that in each cleft type was 1: 1 in cleft lip,1.6: 1 in cleft lip and palate, and 1: 1.8 in cleft palate.
5) Concerning the surgical intervention related to orthodontic treatment, mandibular osteotomy was introduced in 1980, two-jaw surgery in 1984, secondary bone grafting in 1986, and segmental osteotomy in 1994. The RED system was applied to maxillary distraction osteogenesis in 1999, and after that, the Zurich system and dento-alveolar distraction were introduced. The total number of surgical interventions was 796.

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A clinico-statistical investigation was carried out with cleft lip and/or palate patients in the Department of Orthodontics, Tokushima University Hospital, during the 12 years from April 1994 to March 2006.
1. The number of cleft lip and/or palate patients was 201, accounting for 7.4% of all orthodontic patients during the 12 years. The patients were 110 males and 91 females with a male to female ratio of 1: 0.83.
2. The peak age of the first visit was 0 years (41.4%) and 7-9 years old (21.4%). As for Hellman's dental developmental stage, the percentages of stage I and MB patients were 54.2% and 15.4%, respectively.
3. The distribution of cleft type was as follows: cleft lip and palate 60.2%, cleft lip and alveolus 21.4%, cleft palate 14.9%, and cleft lip 3.0%. The unilateral cleft lip was more frequently seen on the left side than on the right side, and in males than in females. Cleft palate was more abundant in females than in males.
4. As for the resident distribution, patients from the Shikoku area were 96.0%, breaking down into 71.1% from Tokushima prefecture and 16.9% from Kagawa prefecture.
5.68.6% of patients were referred from other departments in Tokushima University Hospital.
6. By classification of crossbite, cases of type 4 (anterior crossbite) were most frequent, being 39.6%.

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We describe a case whose permanent canine underwent surgical exposure and was aligned into grafted bone actively with orthodontic treatment after bone grafting, and the occlusion has been stable for a long period of time. A male patient had a complete unilateral cleft lip/palate, and fresh autogenous cancellous bone and marrow harvested from iliac bone were grafted to the alveolar cleft at 8 years 2 months of age.
The width of the cleft was 7 mm on the alveolar side, and 17mm on the wide nasal side at the point of the bone grafting operation.
Although the exchange of erupting permanent teeth had been observed after bone grafting, the canine in the left maxilla was found to be perpendicular to the root of the adjacent central incisor on panoramic radiographs. Problems with canine eruption were suspected. So surgical exposure of the impacting canine was prformed two years and eight months after bone grafting.
We considered that this surgical exposure was done on the following grounds: the dislocation of canine-tooth germ had taken place because of wide cleft on the nasal side, and the direction of the canine root formation depended on the existence of maxillary bone, so the root axis was decided. From the literature, as the root axis did not change after bone grafting, the direction of canine eruption might be limited. In this case the canine was guided into grafted bone at the alveolar cleft with orthodontic treatment after surgical exposure. Permanent occlusion was completed at 15 years 6 months of age.
More than 18 years after the bone grafting, the occlusion remains stable. The axis of the canine remains controlled without relapse.
Our experience with this case suggested that alveolar bone grafts provide places where cleftadjacent canines erupt and align, and thus help to acquire stable occlusion.

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We report a case of Wolf-Hirschhorn syndrome with cleft palate.
A 2-month-old girl with Wolf-Hirschhorn syndrome was referred to our department because of poor sucking and cleft palate. She had a characteristic facial appearance, congenital hypotonia, growth and psychomotor retardation. Although a palatal plate was applied for feeding problems, there was no improvement of her intake and management of nourishment by gastric feeding tube continued.
At the age of 2 years 2 months, palatoplasty was performed by the push-back method under general anaesthesia. The postoperative course of the patient has been favorable and her feeding difficulties improved after surgery.

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