Purpose: To minimize the deteriorative effect of palatal surgery on maxillary growth, intensive debates concerning treatment protocols have long focused on the timing and procedure of cleft palate surgery. Combining the concepts of early two-stage regimens and Furlow’s palatoplasty, we have developed an early two-stage protocol （ETS）, which consists of soft palate closure at 12 months of age with modified Furlow’s palatoplasty and hard palate closure at 18 months of age for children with complete unilateral cleft lip and palate. We have already reported on the long-term outcomes of this treatment protocol. In this paper, we summarize them and discuss the usefulness of this treatment in terms of craniofacial growth compared with the conventional pushback palatoplasty （PB）.
Material and methods: The subjects enrolled in the present article had non-syndromic complete unilateral cleft lip and palate, and were being consecutively treated at the Department of Oral and Maxillofacial Surgery, Osaka Women’s and Children’s Hospital. Dental model analysis was conducted at the age of 4 years on 72 children （32 of the ETS group, 40 of the PB group）, and cephalometric analysis was performed on 68 male children （37 of the ETS group, 31 of the PB group） at the ages of 10 and 15 years.
Results: At 4 years of age, the anteroposterior and transversal distances 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-olds’ index, good dental arch relations were found in 48.2％ of the ETS group and in 8.0％ of the PB group. In the cephalometric analysis, the ETS group showed a significantly larger maxillary length and a shorter mandibular body, resulting in a greater A-N-B value, compared with the PB group. The ETS group also showed a shorter posterior vertical maxillary length than the PB group.
Conclusions: The long-term results showed that the early two-stage palatoplasty protocol using modified Furlow’s palatoplasty for patients with unilateral complete cleft lip and palate is advantageous regarding the maxillomandibular relationship compared with pushback palatoplasty.

View full abstract

Objective: In patients with unilateral cleft lip and palate, scar tissue produced by palatoplasty causes maxillary dental arch constriction, palatal area decrease, and tooth rotation. Two-stage palatoplasty reportedly results in better maxillary bone development than one-stage palatoplasty; however, few studies have reported the effects of different surgical techniques on tooth axis and dental arch morphology. We report the effects of different surgical techniques on the morphology of the palate, tooth axis, and dental arch.
Methods: Patients with unilateral complete cleft lip and palate who presented to the Department of Orthodontics, Chiba Dental Center, Tokyo Dental College, were categorized into one-stage palatoplasty （one-stage） and two-stage palatoplasty （two-stage） groups. A plaster model of the maxillary dentition at the time of initial examination was reconstructed using a 3D dental image created with a 3D scanner, and measurements were taken using 3D measurement software.
Results: Compared with the one-stage group, the two-stage group showed no significant difference in dental arch width. Furthermore, no significant difference was observed in the arch width in the two-stage group. The palatal height diameter was less in the first molar region. The palatal cross-sectional area was greater between the deciduous canines but smaller between the first molars in the two-stage group. The palatal surface area was greater between the deciduous canines. In both surgical methods, the central incisor of the affected side showed mesiolingual rotation. In the one-stage group, the first molar of the affected side showed mesiolingual rotation, and in both the one- and two-stage groups, the central incisor of the affected side showed distal tipping. The anterior segmental angle of the affected side was significantly greater and the posterior segmental angle was significantly smaller in both surgical methods; however, no significant difference was observed between the surgical methods.
Discussion: In the two-stage group, the maxillary arch length was significantly greater in all regions, suggesting that the suppression of the anterior–posterior development of the maxillary arch and palate was less. In both surgical techniques, anterior constriction of the dental arch due to rotation of the lesser segment into the alveolar cleft was observed, suggesting that the difference in rotation of the small segment did not depend on the surgical technique.

View full abstract

Cleft patients in the Oral and Maxillofacial Surgery Clinic of Niigata University Medical and Dental Hospital have been treated according to our two-stage palatoplasty regimen. In our surgical method, soft palate surgery is performed at 1.5 years of age, after which an interim obturator is used, then the hard palate closure surgery is delayed until 4 years of age. In our unit, whereas facial growth might be improved, speech development in early childhood might be impaired to a greater or lesser extent, which is classified into three different groups. We evaluated speech outcome and maxillary morphology including the residual cleft after the soft palate surgery on each group of 16 patients to investigate speech management in late hard palate closure. As a result, backed articulation seems to be significantly related with the posterior edge of the residual cleft after soft palate closure. In order to correctly interpret the incidence of speech deficiencies, it is essential to obtain adequate information about speech management in early childhood.

View full abstract

A statistical investigation was carried out on patients with cleft lip and/or palate in the Maxillofacial Unit, Oita Oka Hospital during the 15-year period from February 2005 to December 2019. The following results were obtained:
1. The total number of primary and secondary patients was 282 （143 males and 139 females）.
2. One hundred and forty-seven patients （52％） were residents of Oita City.
3. The median age of primary patients at the first visit was 13 days for primary cases and 107 months for secondary cases.
4. There were 29 patients with cleft lip （10％）, 55 patients with cleft lip and alveolus （20％）, 135 patients with cleft lip and palate （49％）, 52 patients with cleft palate （18％） and 8 patients with submucous cleft palate （3％）.
5. The largest proportion of primary patients was referred from some obstetric clinics.
6. The total number of prenatal counseling cases was 11, which started in 2013, and the number of cases of postnatal rounds in obstetric clinics was 33, which started in 2008.
7. Most secondary patients were referred with the purpose of surgical operations related to cleft lip and/or palate.
8. The most performed operation was secondary lip repair in 95 cases for cleft lip and/or palate.

View full abstract

The 2019 Coronavirus pandemic （COVID-19） has had a serious impact on speech therapy. As the virus can be transmitted by droplet infection, seeing clients on an outpatient basis was suspended for several months and even after face-to-face therapy was resumed, it is required to wear a mask or face-shield and to keep physical distance. It is quite difficult to perform articulation therapy without seeing or showing intraoral articulatory movement. This paper reports our experience with implementing telepractice using electropalatography （EPG）.
The subjects were four school-aged children with speech sound disorders due to cleft palate. Two of them were introduced to telepractice before COVID-19, because they could not see a speech therapist frequently as they lived in remote areas. For the other two subjects, telepractice was introduced after COVID-19. A portable EPG training unit （PTU: Articulate Assistant Ltd., Edinburgh） or a tablet type EPG （STARS: Asahi Roentgen Ltd., Kyoto） was lent out for home practice. Through the use of EPG, it was possible to monitor the child’s tongue-palate contact patterns remotely and also to show the typical patterns as an example. Telepractice was performed once a week for 30 minutes. After 10 to 30 sessions, their speech sound disorders were resolved and speech intelligibility was improved.
The combined use of EPG and telepractice seems to bring wider access to speech therapy for patients with speech sound disorders who have little opportunity to receive speech therapy for various reasons.

View full abstract

It is desirable to use bone substitutes during secondary alveolar bone grafting in patients with cleft lip and palate. One of the main advantages of these grafts is the avoidance of a second surgical site for autogenous bone harvesting.
This report presents the case of a 13-year-old boy with cleft lip and palate of the left side. The patient underwent secondary alveolar bone grafting at the age of 7 years and 10 months. Octacalcium phosphate collagen composite （OCPCol）, a bone substitute material developed at Tohoku University, was placed in the alveolar cleft prior to the eruption of the permanent canines. Three years after surgery （age, 10 years and 10 months）, the permanent canines erupted spontaneously through the alveolar bone. Bone formation at the cleft site was facilitated by the eruption of the canines and adequate bone volume was observed.
Orthodontic treatment was initiated to align the maxillary dentition. The alveolar bone bridge was maintained and no bone resorption was seen at the cleft site after the eruption of canines. An increase in the vertical growth of the maxilla was observed 5 years after surgery.
In this case, the surgical outcomes were similar to autogenous bone grafts with regard to bone stability and postoperative occlusal management. The results of this report demonstrate that OCPCol may be a viable alternative in patients with cleft lip and palate.

View full abstract