Plastic surgery of the lip and columella was performed for a 116-day-old infant with a false complete median cleft of the upper lip. The columella was formed using a mucous skin flap taken from the red and white portions of the lip. For the lip, the labial mucosa and orbicularis oris muscle of the lateral lip were sutured in the midline the same as in a one-stage surgery for a bilateral lip cleft. For the philtrum, a full thickness skin graft with the subcutaneous vascular network preserved was performed from the front of the ear. As a result, a Cupid's bow could be formed, producing favorable results.

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Objective: The objective of this qualitative study is to examine how to treat cleft lip and palate in consideration of the feeling of patients, their mothers and families especially by understanding psychology and the therapeutic decision-making process of mothers at the end of Phase I orthodontic treatment.
Subjects and methods: We studied six mothers whose children with cleft lip and palate completed Phase I orthodontic treatment at the orthodontic department of A University. We measured their state anxiety and situation specific anxiety using the STAI psychological test and conducted semi-structured interviews, and obtained data by writing down the interview records word by word. The data was divided into contexts and categorized by analysis and understanding the meaning, and then integrated to obtain the central concepts as key themes and their structures.
Results: No subjects with strong anxiety tendencies were observed in judging the STAI for who should be excluded from this study. Seven key themes relating to psychology and the therapeutic decision-making of mothers were found in the data after the time of birth of children: embarrassment and shock, salvation through information, hopes and possibility of treatment, self-condemnation as a mother, hopes and anxiety of long-term treatment, parent-offspring conflict and persuasion for treatment, and trust in their doctor. In the therapeutic decision-making process, hopes and possibility of treatment, hopes and anxiety of long-term treatment, parent-offspring conflict and persuasion for treatment were running in circles. The structure of psychology showed the coexistence of self-condemnation as a mother and trust in their doctor.
Conclusion: We considered that self-condemnation as a mother is a wide-ranging issue including their child, treatment and pain, being deeply involved in their therapeutic decision-making, and being continuing indelibly with long-term treatment. We determined that trust in their doctor supports the decision-making of mothers in anxiety concerning long-term treatment and the mother-child relationship. We considered that these feelings consist of mutually correlated issues of the themes. As a new viewpoint for holistic medicine, it was suggested that the necessity of understanding these psychologies and the structure of decision-making of mothers and developing a continuous support system based on informed consent.

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A team approach treatment for cleft lip and/or palate has been performed in the Center for Advanced Oral Medicine, Hokkaido University Hospital since 1995. A clinical and statistical survey was carried out on patients with cleft and/or palate in our Center, during the 16 years from January 1995 until December 2010.
1. The total number of primary cases was 461. Out of the patients, 226 (49%) were referred from obstetrics and pediatrics, followed by 118 (25.6%) were from plastic surgery, and 80 (17.4%) from oral and maxillofacial surgery.
2. Distribution of the patients according to the cleft type was: cleft lip and/or alveolus(CL) in 51 (11.1%), cleft lip and palate(CLP) in 222 (48.2%), isolated cleft palate (CP) in 126 (27.3%), submucous cleft palate(SMCP) in 55 (11.9%), CL and SMCP in 7 (1.5%).
3. Mean initial visits were of CL at 10.8 weeks of age, CLP at 5.0 weeks, CP at 14.2 weeks, SMCP at 96.6 weeks, and CL and SMCP at 38.0 weeks.
4. A total of 451 (98%) were patients who live in Hokkaido prefecture. The geographic distribution of the patients resident was 54.7% from Ishikari subprefecture including Sapporo city, 10.4% from Iburi including Tomakomai city, 6.5% from Kushiro, 6.3% from Shiribeshi including Otaru city, and 22.1% from other subprefectures.
5. The type of CL and CLP in 280 cases was unilateral in 211 cases and bilateral in 69 cases, with a ratio of 3.1 : 1, and the laterality was the left side in 151 out of 211 and the right side in 60 out of 211, with a ratio of 2.5 : 1.
6. Associated congenital anomalies were found in 127 of all patients(27.5%), and they were more frequently in SMCP and CP: 26 out of 55 (47.3%) in SMCP, 57 of 126 (45.2%) in CP, 40 of 222(18.0%) in CLP, 4 of 51 (7.8%) in CLA.

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For the purpose of obtaining guidance of appropriate advice for parents of children with a cleft lip and/or palate, we conducted a questionnaire survey on cleft-related concerns using a procedure similar to the 1993 report by Miura, et al. Two hundred parents participated in the survey whose children were under the care of Showa University Cleft Palate Team. The children were aged between 0 and 12 years. Thirty seven children had a cleft lip (and alveolus), one hundred and twenty a cleft lip and palate, and forty three isolated cleft palate.
The parents were asked to select three items of most concern from thirty cleft-related items listed in the questionnaire and then were asked to ranking those selections from 1 to 3. In order to analyze the collected data, the 30 items were divided into the following 15 groups; sucking/feeding, development, surgery, speech, ear-nose disorders, malocclusion, appearance, social adaptation/personality, academic advancement/employment, marriage/birth, heredity, notification, X-ray studies, medical costs, and others. The results were as follows;
1. Among 15 groups, malocclusion was selected as the primary concern by 21% of the 200 parents, surgery by 18%, speech by 17%, and notification by 11.5%.
2. The parents showed a tendency to select those items related to care which is necessary for their own children now or in the future and their selections exhibited a strong association to the children's age and the type of cleft.
3. The concerns of the parents were the same when compared with the survey in 1993 which ranked the concerns from first to seventh. However a reduced tendency was evident in relation to heredity and an increased tendency in speech and notification.
4. Parents of children with cleft lip and/or palate are always considered to need advice not only about the treatment of each specialty from a professional in a cleft palate team but also about the overall treatment plan for their children. It is obvious that they require further improvement of cleft care as well as support from a psychosocial point of view.

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A clinical and statistical analysis was carried out on patients with cleft lip and/or palate at the Orthodontic Clinic, Niigata University Medical and Dental Hospital in the past 30 years (1979∼2008). The results obtained were as follows:
1. The patients consisted of 602 males (52.9%) and 537 females (47.1%).
2. Cleft morphology was classified as the following.
Cleft lip and palate (CLP): 51.5%, cleft palate (CP): 23.8%, cleft lip and alveolus (CLA): 19.1%, cleft lip (CL): 5.4% and others: 0.2%. As for the ratio of the cleft side, the left side in unilateral CLP, CLA and CL was higher than the right side. Male patients were more in CLP, CLA and CL than females, while female patients were more in CP.
3. The number of new outpatients was changing year by year in the past 30 years but no specific tendency was found.
4. The peak age of the first visit was 4 years and the majority of patients visited for their first time at the age of 4-6.
5. The majority of patients were referred from other dental departments in our hospital, and 92.5% of the patients were referred from the department of Oral and Maxillofacial Surgery.
6. The large majority of patients investigated lived in Niigata prefecture.
7. Most of the cleft lip and/or palate patients born between 1979 and 2001 in Niigata prefecture consulted our department.

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The purpose of this study was to investigate the influence of presurgical nasoalveolar molding (NAM) treatment for cleft palate patients and their family. A questionnaire survey regarding NAM treatment was performed involving 145 parents of children who underwent primary cheiloplasty after NAM treatment performed by the Showa University Cleft Lip and Palate Team between April 2004 and January 2008. Responses were obtained from 125 parents (response rate: 86.2%).
The results showed that the parents felt NAM was effective for cleft palate treatment and that NAM before cheiloplasty should be encouraged.

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Russell- Silver syndrome (RSS) is a syndrome characterized by intrauterine growth retardation, short stature without postnatal catch up growth, inverted triangular face with relative large head. Though orthodontic treatment may be performed for the malocclusion caused by growth disturbance and right - left asymmetry of viscerocranium, cleft palate is rarely complicated.
We report a case of RSS with cleft palate. The patient was 6-months girl at initial visit to our center, she was born at 39 weeks gestation in August 2007. At birth, her weight was 1,334 g, her height was 39 cm, Apgar score were 4/8. Because of extremely low birth weight, she was transported to the nearest municipal hospital in the following day. She had no problem in breathing and no abnormal findings were detected in the echocardiography. Though cleft palate was confirmed, suckling was possible. No abnormal findings were detected in head CT and MR imaging. She discharged in November, 2,315 g weighted. Though tube feeding was applied, weight gain was poor. She was referred to our center in February 2008, as it was thought that poor suckling was due to cleft palate. We made palatal plate and took a wait-and-see approach with pediatricians. From the appearance of growth delay, inverted triangular face with normal head circumference, asymmetry of the length of lower limb, RSS was suspected. We had cytogenetic analyses, epigenetic mutation of the H19-DMR on chromosome 11p was identified, diagnosis of RSS were confirmed with characteristic clinical features. Development delay was not obvious including speech, so we performed palatoplasty in September 2010, when she was 3 years and 1 month old, 6,365 g in weight. Mouth breadth was narrow, opening was limited, intubation was possible, but Dingman mouth gag was inapplicable. 20mm mouth opening was obtained by forced opening with utility mouth gag, she was operated while pulling and displacing her tongue. Postoperative complications were absent, speech therapy had started. The evolving of epigenetics elucidated the pathogenesis and the way for early diagnosis for RSS. In the treatment of RSS infants with cleft palate, it was thought to be important to respond in well considering for the pathogenesis.

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We report a case of a submucous cleft palate with floppy infant and chromosomal abnormality. The patient had nasal emission at milk intake and was brought to our clinic at ten months of age. There was no apparent external malformation except for submucous cleft palate and bifid uvula. A bone defect in the posterior midline of the bony palate was observed. Dyspnea was not observed, though general muscle strength was decreased. A diagnosis of floppy infant with psychomotor retardation was made in the pediatrics department of our hospital at eighteen months of age. Reciprocal translocation of the X chromosome and the 15th chromosome was confirmed by a chromosomal test.
Since we could not rule out the possibility of congenital myopathy considering her frequent febrile convulsions and because of the risk of respiratory insufficiency and malignant hyperthermia due to decreased muscle force, palatoplasty was postponed until three years and two months of age. Palatoplasty was performed by Furlow's method without serious complications related to general anesthesia. Functional recovery of the soft palate after surgery was not sufficient, though nasal emission decreased. It is necessary to evaluate functional recovery of the soft palate and the body by long-term follow-up.

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Cleft lip and palatal patients require treatment planning to decide the necessity and timing of orthodontic therapy, secondary bone grafting, orthognathic surgery and prosthodontic treatment for various problems of discrepancies between the upper and lower jaws, cleft jaw with tooth defects, alveolar bone and maxillary bone, and malocclusion. We report two cases with unilateral cleft lip and palate who were borderline cases between non-surgical and surgical treatment. In both cases, occlusion was improved by orthodontic therapy and prosthodontic treatment. Case 1 was a 5-year-old boy. The patient was diagnosed with a left-side cleft lip and palate and presented as follows: overjet, 0 mm; overbite, 0 mm; a narrow upper arch; and lateral crossbite. Orthodontic treatment was performed with an expansion appliance in the first stage and with a multi-bracket appliance at 13 years old. After orthodontic treatment, secondary bone grafting was performed at 19 years old and prosthodontic treatment was performed at 20 years old. As a result of the treatment steps, the patient's facial profile was improved and the occlusion was relatively stabilized. Case 2 was a 9-year-old boy. The patient was diagnosed with right-side cleft lip and palate and presented as follows: overjet, −5 mm; overbite, +1 mm; maxilla posteriorly located; and narrow maxillary dental arch. Orthodontic treatment was performed with an expansion appliance and orthopedic appliance in the first stage, and with a multi-bracket appliance at 13 years old. After orthodontic treatment, secondary bone grafting was performed at 24 years old and prosthodontic treatment was performed at 25 years old. As a result of the treatment steps, the patient's facial profile was improved and the occlusion was relatively stabilized.

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