When it is necessary to adopt a team approach for treating patients with cleft lip and/or palate, it is usually appropriate that the team members come from the same institution. However, as members are selected for their specialist knowledge for the treatment, it is sometimes difficult to gather all members from the same institution. This paper presents a new type of multidisciplinary team approach composed of specialists from different institutions. This special meeting is called the “Kobe Conference”.
This conference is held three times a year. The team specialists are plastic surgeons, orthodontists and speech-language pathologists. An interview is arranged and the examination includes flexible endoscopic and cephalometric observations. After this investigation, all members discuss the diagnosis and create a treatment plan. The aim is to enable each specialist to share the same information, in order to deepen the discussion and to enable the team to create a proper treatment plan. An additional benefit is that the younger, less experienced practitioners can study at clinics that specialize in cleft palate treatment.
A medical camp is also held by the same members once a year during the summer. This camp is good not only for the members of the conference to observe the communication skills and social abilities but also for the patients and caregivers to understand the diseases and treatments under stable psychological conditions.

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[Purpose] The team approach is essential for favorable outcomes in the management of patients with cleft lip and palate. In a large rural area in and around Nagano prefecture, an inter- and multi-disciplinary team approach organized with multiple institutions has been developed utilizing networking to treat cleft patients. This paper describes the steps and problems in developing our multi-institutional team after more than 10 years of practice.
[Methods] Patients were operated on in a central hospital at several year intervals. Some divisions, such as speech therapy, orthodontic treatment, and ear-nose-and -throat treatment, which require frequent visits, were decentralized and patients could receive treatment at local clinics. Several networking tools, including a small conference, annual local workshop, mailing list, pocketbook, and homepage, have been used for over ten years to maintain good connections among various specialists of the team.
[Results] 1067 patients with cleft lip and palate have been treated by our multi-institutional team. All patients could visit outpatient clinics within one hour to be treated by a speech pathologist, an orthodontic dentist or an ENT doctor. After over 10 years of working as a team using those networking tools, mutual understanding and common views could be established among team members. The small conference and pocketbook continue to be used. However, it took time and effort to maintain some networking tools. The local workshops were simplified. The mailing list was used under limited situations. The homepage of the team was only used to educate patients and their families.
[Conclusion] Simple networking tools are required for keeping good communication and confidence among members of the multi-institutional team. After establishing confidence, the multi-institutional team can assure patients of favorable and adequate medical care only with brief communications among members of the team.

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Our hospital provides comprehensive and consistent treatment in Okinawa Prefecture, with a center for cleft lip and palate established by our department in 2007. However, being located on the main island of Okinawa, it is difficult for the diagnosis/treatment system of the hospital to provide people living on remote islands with sufficient follow-up care following surgical and other procedures. The present study reports the consistent care services provided in the hospital, specific problems in collaboration with remote islands, including the Yae-yama area, and a survey regarding consistent treatment/collaboration while taking into account the duties and responsibility of a prefecture consisting of a large number of small islands. The following findings were obtained.
To reduce economic and psychological burdens on patients and their families living on remote islands and promote consistent medical care, it is essential to collaborate with general hospitals, dentists specializing in oral surgery, general dentists, and parents' associations, which support patients and families, as well as cleft lip and palate centers, which support health care professionals and institutions. It is also necessary to promptly establish a telemedicine system using digital communication networks. These systems are the key to promoting consistent health care on isolated islands.

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The Kyoto University cleft care team consists of members with the following specialities: plastic surgery, oral and maxillofacial surgery, speech therapy, clinical psychology, orthodontics, otolaryngology, pediatrics, anesthesiology, dentistry, nursing, and nutrition. Our team has established multidisciplinary care for individuals with clefts and related craniofacial anomalies. The patients come from a wide area including the Kinki district, the Hokuriku district, the Chugoku district and the Shikoku district. The number of newly visiting patients is about 70 and the number of operations is about 120 a year. We aim to establish a highly convenient medical care tailored to the diverse needs of patients in terms of living environment and psychological aspects, with accurate diagnosis and treatment and a medical care system based on a wealth of clinical data.
This paper presents the overall flow of operation of our institute using an example of a patient with unilateral cleft lip and palate, and gives an overview of our team. The details of various activities to establish systematic medical team care are also described.

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The Cleft Lip and Palate Centre of Fujita Health University Hospital was started in 1992, and it has been treating congenital anomalies of the jaw and face including cleft lip and palate.
A long period, various knowledge and good techniques are required for treating cleft lip and palate. With the team approach, it is important how the team is managed and operated. The styles of the medical treatment team can be considered as follows: (a) relay system, (b) conductor system, (c) coordinator system, (d) assembly system, etc.
The Fujita Health University Hospital Cleft Lip and Palate Centre currently uses (c) the coordinator system. More than 1600 patients have been treated so far. In future, it is necessary to create a more exact and efficient team system.

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We have developed a multidisciplinary approach to treat patients with cleft lip and palate over the last 30 years, cooperating mainly with the Clinics for Maxillo-Oral Disorders in the dental division. This cooperation has improved the outcomes of our palatoplasty and secondary alveolar bone grafting. However, we have had some problems, such as our medical and dental clinics were separated by a street, and we had little opportunity for comprehensive discussion with our speech therapists and otolaryngologists. To resolve these problems, we established the Tohoku University Hospital Cleft Palate Center that allowed us to integrate each clinic, i.e., plastic surgery, maxillo-oral disorders (dental division), speech therapy and pediatrics, on the same floor. The otolaryngology clinics for patients with cleft palate are held on the same day as the plastic surgery and dental clinics. In our Cleft Palate Center, we usually treat patients separately by division, but when we encounter a patient with problems, we gather at the clinic to discuss the case. The layout of the clinics allows us to easily interact with each other. In addition, we hold a comprehensive monthly meeting together with the plastic surgeons, dentists, speech therapists, otolaryngologists and nurses, which the pediatricians and obstetricians can also attend if necessary. Furthermore, we use the institution's intranet to share clinical information between the divisions. All these efforts help ensure our success, optimize treatments and make the patients happy.

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[Purpose] Determining the optimal timing and procedure of palatal surgery for children with cleft lip and palate has long caused major controversy. An early two-stage palatoplasty protocol has become a recent trend in an attempt to obtain preferable craniofacial growth without compromising adequate speech development. In this study, we examined whether the resulting craniofacial growth and speech outcome obtained by the early two-stage palatoplasty protocol are better than those obtained by the conventional one-stage push-back palatoplasty protocol.
[Materials and methods] Seventy-seven nonsyndromic children with UCLP were enrolled in this study. They were divided into two groups: 34 children, who were treated with early two-stage palatoplasty, in which soft palate closure was performed using a modified Furlow's procedure at 12 months of age and hard palate closure was performed at 18 months of age (ETS group), and 43 children, who underwent one-stage Wardill-Kilner push-back palatoplasty at 12 months of age (PB group). Dental cast model analysis for palatal morphology and dental arch relationships, cephalometric analysis for craniofacial growth and assessments of speech outcome were performed for each child at 4 and/or 8 years of age.
[Results] At 4 years of age, the anteroposterior and the transversal palatal distance of the ETS group were significantly longer than those of the PB group. In an assessment of the dental arch relationships using the 5-Year-Old Index, good dental arch relations (group 1 and 2) were found in 48.2% of the ETS group and in 8.0% of the PB group. In the cephalometric analysis, the children in both cleft groups revealed a great maxillomandibular retrognathism to the anterior cranial base, compared with the non-cleft group. The children in the ETS group showed a significantly larger maxillary length and favorable anteroposterior jaw relations compared with the PB group, although the maxillary plane was significantly more open in the ETS group due to less posterior vertical maxillary growth. No statistically significant differences were observed in the incidence of either velopharyngeal incompetence or articulation errors between the two groups at 8 years of age.
[Conclusions] The long-term results indicate that the early two-stage palatoplasty protocol for patients with complete unilateral cleft lip and palate is advantageous with regard to anterioposterior jaw relations compared with the one-stage push-back palatoplasty protocol without compromising speech outcomes as evaluated for all children at 4 and/or 8 years of age.

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The outcomes of alveolar bone grafting and orthognathic surgeries in patients with cleft lip and/or palate have become reliable in the last two decades. On the other hand, predictable and cost-effective treatments are required worldwide. In orthodontic treatment in The University of Tokyo Hospital, treatment with maxillary expansion followed by prosthodontic management used to be considered first, but recently, treatment with minimum maxillary expansion and minimum prosthodontic management is planned. A nasoalveolar molding plate (NAM) is used for the presurgical orthopedics and alveolar bone grafting is performed in deciduous dentition. The orthodontic treatment is usually commenced in the early mixed dentition using a lingual arch and a sectional arch as basic appliances. The maxillary protraction is often applied while paying attention to the fact that its long-term results are difficult to predict. In the permanent dentition, tooth alignment including maxillary second molars is performed using a multi-bracket appliance. In cases with very poor maxilla-mandibular relationship, orthognathic surgery is unavoidable, and it is recommended even in borderline cases. In patients with cleft palate, extraction of lateral incisors or premolars is often required and a space at the alveolar cleft is mostly closed by the medial movement of the canine. On the contrary, a lateral incisor is frequently aligned with or without crown restoration in patients with cleft lip and alveolus. The retention is continued as long as possible with a fixed lingual wire in the maxillary anterior teeth and a plate-type retainer. In cases with a residual space at the alveolar cleft, an adhesive bridge is often placed recently. The majority of these treatments will become unnecessary when the primary surgeries are improved and the palatal arch form and the maxilla-mandibular relationship become good. Such improvements are desired.

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The author has been engaged in the treatment of cleft palate as a speech-language-hearing therapist (ST), aiming to contribute to the following three areas: 1) the provision of team medicine; 2) accurate assessment and improved therapy techniques for velopharyngeal function; and 3) research on articulation therapy. This paper reports the author's approaches for cleft palate speech.
(1) A study was conducted to determine the time taken to acquire normal articulation in patients with cleft palate with and without cleft lip (following cleft palate). Velopharyngeal adequacy, which is indispensable for normal articulation, refers to the ability to raise the intraoral pressure necessary to articulate voiceless plosives, and the study examined the time taken to acquire the articulation of a voiceless bilabial plosive [p] that infants pronounce at an early stage. The results suggest that the time needed to acquire developmentally appropriate articulation as the ability to raise the intraoral pressure in the early stages of infancy may be 12 to 18 months in patients with cleft palate, and plosive [p] may be an index of such acquisition. Therefore, when speech training is necessary, it may be appropriate to initially evaluate this ability, and then to provide training based on the development of normal articulation.
(2) The treatment programs for velopharyngeal inadequacy in our hospital are shown in this paper, mainly with roentgen lateral cephalometry during phonation (cephalometry). Based on the velopharyngeal form ratio (s/p) of the velar length (s) per pharyngeal depth (p) and velar mobility, velopharyngeal closure and speech are comprehensively evaluated, and the treatment plan is determined by the doctor. In patients showing an s/p ratio of 1.1 or less, surgery is performed.
(3) Articulation training was provided to patients shown to have a fair or poor velar mobility on cephalography, and tests were periodically performed to examine the effects of such training. This paper introduces specialized therapy approaches performed by the ST, such as the use of palatal lift prostheses (PLP) and resonance tube therapy where tube-phonation exercise for voice disorder was a chance.

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Pierre Robin sequence (PRS) is a condition that presents with symptoms such as microgenia, glossoptosis, and respiratory disorder caused by upper airway obstruction, and is often associated with cleft palate.
Respiratory and feeding management is necessary immediately after birth, and there is often distress during perioperative management, speech and swallowing training.
We retrospectively examined 26 cases of PRS who attended our center from 2006 through 2010. The PRS cases were classified into three groups: non syndromic (ns) PRS or syndromic (s) PRS in relation to the presence of determined syndromes, and unique (u) PRS, with unidentified congenital anomalies. The following results were obtained.
1. There were 10 males and 16 females: 14 cases of ns PRS, 10 cases of s PRS, and 2 cases of u PRS.
2. The age at first visit varied from 1 to 291 days. The weights at birth were 2,932±447g in ns PRS, 2,850±571g in s PRS, 1,607±804g in u PRS. There was no significant difference between ns PRS and s PRS.
3. As for the management of respiratory and feeding disability, in stage I (from neonates to six months) , tracheal intubation was needed in 1 case and tube feeding in 10 cases for ns PRS, tracheostomy was needed in 3 cases and tube feeding in 8 cases for s PRS, and tracheal intubation and tube feeding was needed in 1 case for u PRS.
In stage II (from 1 year to 18 months; period considered the appropriate time for surgery) , no respiratory or feeding management was needed for ns PRS and u PRS. In contrast, for s PRS, tracheostomy was maintained in 3 cases and tube feeding was continued in 6 cases.
4. As for the palatoplasty, for ns PRS and u PRS, palatoplasty was performed at the age of 24.9±7.0 months and 40.5±4.9 months respectively, in all cases. On the other hand, in s PRS, palatoplasty was not necessary in 1 case, was performed in 1 case, was planned in 2 cases, and has not been performed in 6 cases.
Post-operative hemorrhage was encountered in an ns PRS case as a perioperative complication.

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There are few evaluation methods to judge the severity of articulation disorders in patients with cleft palate. Therefore, we investigated the correction ratio and backing score by articulation testing in order to assess the severity of articulation disorders.
1. Calculation of correction ratio in evaluation of articulation disorders
We included 67 patients (aged 4 to 18 years of age) with cleft palate who underwent palatoplasty. Then, we assessed the correction ratios in these patients by articulation testing and compared the correction ratios associated with different types of articulation disorders as well as the speech intelligibility during conversation in patients who underwent these procedures.
The correction ratios for glottal stop and mid-dorsum palatal stop were lower than those for other articulation disorders (p < 0.01, p < 0.05). In the speech understandability analyses, we classified the patients into five groups according to the intelligibility of their conversation. Group I, in which speech is always easy to understand, showed a high score (p < 0.01).
2. Evaluation of the backing score from the site of articulation
We included 13 patients (4 to 12 years of age) with cleft palate who had shown retraction of the site of articulation. Assessments were based on perceptual evaluation during utterance of /s/, /t/, /ts/ and /ɕ/. Then, the results were calculated as the backing score (0 to 12 points), which denotes the difference between normality and abnormality of the site of articulation. We observed high scores in the case of glottal stop and mid-dorsum palatal stop, which involve gaps retracting from the site of articulation.
Furthermore, we observed that the correcting ratio decreased when the backing score increased. There was a correlation between the correcting ratio and backing score (r = -0.8).
These results indicate that the correction ratio and backing score can provide information regarding the recovery process in articulation disorders and serve as objective indicators of articulation while providing feedback regarding the severity of the condition and the patient's intelligibility during speech therapy for articulation disorders.

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Several postoperative feeding protocols have been reported for use after cleft palate operation. Many surgeons recommend cup, syringe or tube feeding as it has been suggested that wound immobilization encourages good healing. As the special nipple used for cleft palate is usually long and large, it may cause wound perforation due to contact and pressure. In this study, we used a new device with a short tap, Kiss^® 2, a silicone rubber feeding device produced by Akiyoshi Iida, ICI Design Institute Inc. (Japan) for postoperative feeding immediately after surgery.
Subjects and methods: Twelve consecutive 1-year-old patients with nonsyndromic cleft palate undergoing two-flap palatoplasty by a single surgeon were selected. The subjects consisted of six with isolated cleft palate, five with unilateral cleft lip and palate, and one with bilateral cleft lip and palate. They were allowed to feed using Kiss^® 2 or a spoon or cup starting 1 day after surgery for cleft palate repair.
Results: Six of the twelve patients could drink milk by using Kiss^® 2. The remaining six patients preferred to use a spoon or cup; these patients had had insufficient practice in using Kiss^® 2 before the operation. There were no significant differences in the incidence rate of palatal fistula, intravenous fluid administration period, or duration of hospitalization between the patients that did and did not use Kiss^® 2.
Discussion: The cleft palate surgical wound has a risk of dehiscence caused by nipple pressure during feeding postoperatively. Kiss^® 2 has a short tap to prevent the nipple from coming into contact with the suture wounds. Even cleft palate babies with weak sucking force can feed on their own by holding the bottle with both hands, and can control the amount of outflow by varying the pressure of their lip against the silicone gum device.
Cleft palate patients may require preoperative familiarization with Kiss^® 2. Previous studies in the USA indicated very short hospitalization periods and no need for restricting feeding nipples, but further studies are required for confirmation.

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[Purpose] The authors studied whether confirming nasal emission during voiced blowing (VB) was useful for judging velopharyngeal closure function (VPF).
[Object] The subjects were 212 patients (98 male, 114 female) who underwent evaluations after palatoplasty from December 2010 to June 2012. The age at evaluation was 10 ± 4 years old and those with mental disabilities, the 22.11q deletion syndrome, hearing loss and remaining fistula were excluded. For these, we evaluated once to multiple times, and there were 363 cases in total. The rating system followed the cleft palate laboratory procedure of the Japanese Association of Communication Disorders and also the presence of nasal emission during VB.
[Results] (1) The number of cases in which nasal emission was not observed by both blowing and VB was 250 out of 363 cases, and the general judgment of VPF was normal in 207 cases, extremely slight VPI in 38, and slight VPI in five.
(2) Nasal emission was not seen in blowing but was seen in VB in 54 cases, and VPF was normal in 19 cases, extremely slight VPI in 28, and slight VPI in seven. There was a significant difference between group (1) and (2) by the chi-square test in the determination results of VPF.
(3) Nasal emission was seen only in blowing but not in VB in four cases, and every case showed extremely slight VPI.
(4) Nasal emission was observed both in blowing and in VB in 55 cases, extremely slight VPI in 40, slight VPI in nine, and VPI in six.
(5) In cases in which a successive change could be followed, nasal emission in VB seemed to be some kind of indication of later VPI.
[Discussion] It seems to be the mechanism of velopharyngeal closure function in VB was nearer to speech production, and it was thought that there was usefulness to supplement the VPF judgment of the case that nasal emission was not recognized in blowing. Furthermore, the possibility that it was the sign which turned worse was suggested when nasal emission was recognized in VB even if thought that VPF was good.

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The purpose of bone graft is to close alveolar cleft and fistula and to build good occlusion by guidance with natural tooth eruption of the lateral incisor (cuspid) or orthodontic treatment by continuity of the alveolar bone. However, the aspect of the absorption of the transplant bone after the art varied and examined the case not to achieve an original purpose for the purpose of checking progress after the bone graft that I appeared and enforced in our course at this time.
【Material and methods】 In 202cases that enforced bone graft, the last treatment (orthodontic or prosthetic treatment) for occlusion construction was finished, and data intended for enough 132 cases on the occasion of examination in that.
I evaluated 6-month bone bridging after treatment of bone graft using a classification of Enemark and examined a state of alveolar cleft and the last cure.
【Results】
1) I classified states of alveolar bone by Enemark classification. Level-1 was 55 alveolar cleft. Level-2 was 50 alveolar cleft. Level-3 was 23 alveolar cleft. Level-4 was 4 alveolar cleft. The classification that the guidance of the tooth is possible is Level-1 and Level-2. The total of level-1 and Level-2 was 105 cases (79.6%).
2) The case that the last cure after the bone graft treated follow-up until eruption of nature of the tooth or the guidance of the eruption of the tooth was 56 alveolar cleft. Lateral incisor was a birth defect, and the case that gave orthodontic treatment was 41 alveolar cleft. The case that did not need prosthetic treatment was 97 alveolar cleft (73.5%). The case that prosthetic treatment needed was 35 alveolar cleft (26.5%).
【Conclusion】The case that enforced bone graft before cuspid tooth eruption of 91.7% was Level-1 or Level-2, which was a good result.
In addition, 86.7% of alveolar cleft that performed bone graft before cuspid tooth eruption in that were good occlusion, and there is no need of prosthetic. It was thought that a good result appeared by ascertaining appropriate bone graft time.

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Forty-two unilateral cleft lip and palate patients who were managed under two-stage palatoplasty with Hotz's plate and Furlow's double-opposing Z-plasty (F group) for soft palate repair were evaluated in terms of speech function until 8 years of age. The results were also compared with those of unilateral cleft lip and palate patients who underwent Perko's Widmaier modification method (P group: 75 patients) for soft palate repair.
1. There was no significant difference between the F group and P group on velopharyngeal competence (VPC) at 8 years of age. The VPC of the F group was almost the same as that of one-stage platoplasty patients reported before.
2. The VPC of the F group was significantly improved between 4 years and 5 years of age. This was earlier than that of the P group, which improved after hard palate closure.
3. Normal articulation in the F group had developed better by 8 years of age than in the P group, because of fewer abnormal articulations and larger number of spontaneous normal development. However, the peak of achieving good VPC was after hard palate closure in both groups, and a majority gained normal articulation after finishing speech training by a speech therapist.
4. Recently, we perform the hard palate closure operation at around 4 years of age, in order to avoid the delayed development of speech function.
We must continue to evaluate the long-term effects for speech function and jaw growth after earlier hard palate closure.

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Maxillary retardation, high mandibular plane angle and lingual tipping of maxillary incisors have been reported as characteristics of the facial morphology of patients with cleft palate (CP). However, large variations from maxillary protrusion to mandibular protrusion are found clinically in individual patients. In this study, the facial morphology of patients with CP was examined before the patients underwent orthodontic treatment at The University of Tokyo Hospital.
Fifty Japanese patients with CP in Hellman's dental age II-IIIC (35 females, 15 males) were examined. Cleft type distribution was 28 with hard and soft palate cleft (HS), 11 with soft palate cleft (SP) and 11 with submucous cleft palate (SM). The mean age was 8.3 years old (range 5.9-11.9 years). Lateral cephalograms taken before orthodontic treatment were used, and SNA, SNB, ANB, mandibular plane angle (MPA), maxillary incisor inclination (U1-FH) and mandibular incisor inclination (FMIA) were measured and compared with the Japanese norms.
The average facial morphology of patients with CP showed maxillary retrusion, skeletal Class III and lingual inclination of both maxillary and mandibular incisors. However, differences from the norm were small. The facial morphology of individual patients showed large variations from severe maxillary protrusion to severe mandibular protrusion, and about 30% of patients showed maxillary protrusion (ANB > 6°). CP in this considerable proportion of patients might have been caused by the Robin sequence in which the primary cause of CP was a small mandible. Further studies by gathering more information about cleft and mandibular morphology before primary palate plasty are needed to clarify this point.

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In recent years, there has been an increased awareness of the need to incorporate assistance from heredity specialists to provide multidisciplinary team services for the treatment of cleft lip and palate. We conducted a semi-structured questionnaire survey involving 26 mothers of asymptomatic children with cleft lip and palate who visited the heredity clinic between October 2009 and December 2010 to examine the effects of outpatient services for cleft lip and palate, and consider future approaches.
The survey results showed that these mothers were concerned about various issues related to heredity such as the future of their children (children with cleft lip and palate, and their brothers/sisters-to-be), the rate of recurrence in subsequent pregnancy, causes of recurrence, and preventive methods. However, 70% of them had not managed to talk to medical professionals about these issues for such reasons as not knowing the right person to ask. They considered it desirable that such information be provided at early stages, during pregnancy and immediately after birth.
Regarding the effects of attendance at the heredity clinic, 24 mothers (92.3%) indicated that the outpatient services were “helpful” because it enabled them to: 1) obtain information on heredity (the recurrence rate and means of prevention); 2) obtain emotional support; 3) know where to ask for genetic information; and 4) organize information. The 24 mothers answered ‘yes’ when asked whether they would recommend and encourage others to visit the outpatient heredity clinic. In contrast, 2 mothers (7.7%) indicated that the outpatient services were “not helpful” because they could not obtain new information. This suggested the need to develop and implement appropriate means for heredity counseling and ongoing support.
Based on these findings, we revised our leaflet describing the primary medical condition of cleft lip and palate to include information on heredity counseling and where to find it. We are currently providing a verbal explanation of the services using the leaflet. Recognizing that heredity-related issues are a sensitive subject, we exchange information with heredity specialists when necessary. We pay attention to the facial expressions and utterances of children with cleft lip/palate and their families during treatment phases to provide appropriate services. There is an increasing demand for support that takes into consideration the lives of patients’ families. It is desirable to develop collaboration between heredity specialists and psychologists to facilitate a multidisciplinary team approach to improving support in relation to heredity.

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We report a case of bilateral cleft lip and palate, which is associated with absence of both premaxilla and maxillary bilateral central incisors, in an 8-year-old female who presented with reversed occlusion. Preoperative maxillary dental arch coordination was performed, followed by interdental distraction osteogenesis at the age of 10 years and 9 months, in order to narrow the gap of the defective alveolar bone. Subsequently, the premaxilla was reconstructed by bone grafting on the remaining defective section of the alveolar bone at the age of 11 years and 3 months. Le Fort I distraction osteogenesis was performed with preoperative orthodontic treatment at the age of 12 years and 9 months; however, anterior cross bite, projected lower lip, and large mobility of both maxillary lateral incisors occurred during postoperative orthodontic treatment. Consequently, the occlusion was reevaluated at the age of 14 years and 8 months and was adjusted by bilateral extraction of maxillary lateral incisors, bilateral medialization of maxillary canines, and bilateral transplantation of extracted mandibular first premolars to the mesial side of the maxillary first premolars. Finally, nose deformities were repaired using costochondral graft, and the facial profile was remarkably improved. Although the treatment took 9 years and 10 months, the occlusion has been stable for 2 years and 6 months since the completion of treatment.

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