1. How to become an expert at cleft lip and palate surgery?
For many years, I have been thinking and learning about mastering cleft lip and palate surgery. I considered the following items to help improve my own attitude towards the surgery: cleft technique, Als longa vita brevis, sharp surgeon’s sensibilities and surgical instruments, strong preference for particular surgical approaches, surgeon’s modest attitude and adequate surgical results, and one case from birth to maturity.
2. Summary of two-stage palatoplasty by Perko’s technique
Since 1983, we have performed a two-stage palatoplasty by Perko’s technique for patients with complete cleft palate （cleft types: UCLP and BCLP）. The first stage of the procedure is performed at 18 months of age and consists of closing the soft palate with myomucosal flaps. The second stage is then performed at 4 years 6 months, when the hard palate is closed with mucoperiosteal flaps.
In general, Perko’s two-stage palatoplasty, followed by speech therapy, resulted in good velopharyngeal function on nasometry. Furthermore, videofluoroscopy showed markedly improved velopharyngeal closure, and articulatory movements and normal articulation on listener judgments. Additionally, the group that received Perko’s two-stage palatoplasty showed a deeper and larger palate, better occlusion, and lower frequency of alveolar collapse than the one-stage group.
The long-term follow-up of 193 cases showed that only 8 cases （4％） required pharyngeal flap surgery and 5 cases （2.6％） required a Le Fort I osteotomy.
Raising the soft palate myomucosal flap is technically sensitive. This article describes my recommended surgical steps to successfully elevate the myomucosal flaps and push back the entire soft palate including its muscular sling.
This paper describes the author’s experience of treating cleft lip and palate and 40-year personal history as a plastic surgeon. The author has come to the conclusion that cleft lip and palate should be treated by a team of multidisciplinary members who are specialized at least in surgery, speech, and orthodontics.
In the team of Fujita-Health University, the author has been responsible for lip repair, and through experience has learned the following:
1）Although the first lip surgery is the best opportunity to get the best result, it may sometimes leave an unsatisfactory result.
2）Cutting off too much tissue may make it impossible to repair or perform any surgery at a later date.
3）The scar tissue resulting from the surgery may disturb the growth of the tissue.
4）Without scar, the change and growth over time often progress in a more desirable direction.
5）It is beneficial for all patients to attain an average result by all team members rather than having an outstanding result by only one skilled surgeon.
6）Clear demonstration of the surgical procedure helps improve the skills of the team members.
7）Follow-up of surgical results and improvement of surgical procedures based on meticulous reviews should be continued.
The Department of Oral and Maxillofacial Surgery at Niigata University Medical and Dental Hospital （“our department”） has been treating cleft lip and palate with a team approach and consistent management system since its establishment in 1974. We have been using the two-stage palatoplasty with Hotz plate （“two-stage method”） since 1983. The surgical protocol has been changed twice in the past in order to improve speech outcomes. Although we have reported the improvement of treatment results based on speech evaluation and morphological analysis of the maxillary dentition model, we have not examined the results from the perspective of occlusion. In this study, we evaluated the occlusal relationship using the 5-year-olds’ index, and examined the validity of the two surgical protocol revisions.
In this study, 97 patients with unilateral cleft lip and palate treated at our department were included. The 97 cases were classified according to the technique used for repairing the soft palate and the timing of hard palate closure:
（1） Group P＋5: 23 patients who received soft palate closure by the Perko method at 1.5 years of age and hard palate closure with Vomer flap surgery at 5.5 years of age between 1996 and 2009,
（2） Group F＋5: 49 patients who received soft palate closure by the modified Furlow method at 1.5 years of age for repair of the soft palate and hard palate closure with Vomer flap at 5.5 years of age between 1996 and 2009, and
（3） Group F＋4: 25 patients who received soft palate closure by the modified Furlow method at 1.5 years of age and hard palate closure with Vomer flap at 4 years of age between 2010 and 2017.
The results of the occlusion evaluation using the 5-year-olds’ index were as follows: 2.65 （P＋5 group）, 2.77 （F＋5 group）, and 2.80 （F＋4 group）, and there were no significant differences among the groups by the t-test.
These results indicate that the change in surgical protocol at our department has helped improve the therapeutic results of the two-stage method with Hotz plate, since a good occlusal relationship was maintained among the groups, which is known to be a characteristic of the two-stage method, in addition to the reported improvement in speech outcomes.
This research was planned by the Academic Survey Committee and was carried out with the cooperation of the members of the Japanese Cleft Palate Association （JCPA）. Nine hundred and sixty-five cases in 2019 were enrolled from 49 cooperating facilities belonging to the JCPA. Nine clinical characteristics of patients were investigated and the results were as follows:
1）Types: Cleft Lip （CL）: 110 cases （11.4％）, Cleft Lip and Alveolus （CLA）: 206 cases （21.3％）, Cleft Lip, Alveolus and Palate （CLAP）: 388 cases （40.2％）, Cleft Palate （CP）: 193 cases （20.0％）, Submucous Cleft Palate （SMCP）: 52 cases （5.4％）, Others （cases with mid-cleft, CL＋SMCP, and so on）: 16 cases （1.7％）.
2）Affected side: Left: 368 cases （52.2％）, right: 183 cases （26.0％）, bilateral: 160 cases （22.7％）. There are fewer bilateral cases in the CL type, but many in the CLAP type in comparison with others.
3）Gender: Female: 432 cases （44.8％）, male: 533 cases （55.2％）. In most types, males are affected more than females. However, in the CP type females are affected more than males.
4）Body weight at birth: The average body weight of SMCP is lower than that of other types.
5）Prenatal diagnosis: About 50％ of the patients with cleft lip are diagnosed prenatally.
6）Age of parents: The father’s age is slightly higher than the mother’s age in all types.
7）Frequency of consanguinity: There is about 6-8％ of consanguinity in each type.
8）Concurrent diseases （some cases have several concurrent diseases）.
9）Syndrome/Chromosomal abnormalities: CP and SMCP have a relatively higher ratio.
The chi-squared test shows statistical differences （p＜0.05） among cleft types in the affected side, gender, body weight, concurrent diseases, and syndrome/chromosomal abnormalities.
We obtained many valuable results from a relatively large number of Japanese patients with cleft lip and/or palate in one year.
In patients with severe maxillary hypoplasia with cleft lip and palate, maxillary distraction osteogenesis using the Rigid External Distraction （RED） system, an external maxillary distractor, has been applied; however, there is still little knowledge about long-term retention. Here we report the 8-year follow-up of an adult unilateral cleft lip and palate case with maxillary deficiency and reversed occlusion, who underwent both maxillary distraction using the RED system and sagittal split ramus osteotomy （SSRO）. The patient was a 31-year 2-month-old male with a chief complaint of masticatory dysfunction and esthetic disorder. He exhibited a concave soft tissue facial profile with severe midfacial deficiency. Intra-oral examination demonstrated total cross-bite and Angle Class Ⅲ malocclusion and missing upper right second premolar. Cephalometric analysis showed skeletal Class Ⅲ due to deficient maxilla and mandibular prognathism. At the age of 32 and 9 months, Le Fort 1 osteotomy was carried out and the maxilla was distracted using the RED system. After pre-surgical orthodontic treatment for 1 year and 6 months, SSRO was performed. Forward movement of the maxilla using the RED system resulted in a change of SNA from 71.7° to 81.0°, which improved the midfacial deficiency. Furthermore, by mandibular set-back, ANB changed from −19.1° to −1.5° and the overjet increased from −26.0mm to 3.0mm. As a result, acceptable occlusion and facial profile were obtained. Six years after starting retention, SNA decreased by 0.7° （7.5％）, A-McNamara decreased by 0.4mm （4.0％）, Ptm-A/PP decreased by 2.0mm （17.0％）, and the mandible showed slight clockwise rotation without significant change in occlusion and facial profile, so long-term stability of the bone was obtained. These results provide new insights on the long-term retention of maxillary distraction with the RED system, which is useful for determining the protocol for surgical maxillary advancement.
Unilateral cleft lip and palate causes problems with the development of the maxilla and dentition. We treated a patient with unilateral cleft lip and palate from childhood to adulthood whose treatment ended favorably and who was stable in the long term. When treating unilateral cleft lip and palate, the characteristics of this condition that should be considered were examined by looking at the treatment of a longitudinal case.
The patient was a female with left cleft lip and palate. Lip plasty was performed at 3 months old, palatoplasty was performed at 1 year and 6 months by the pushback method, and management by orthodontics began at 5 years and 0 months old. The deciduous dentition showed inferior maxillary growth, and the mandible showed an anterior position presenting skeletal mandibular protrusion. Severe anterior and lateral stenosis of the maxillary dentition was observed, and the entire dentition was crossbite. The position of the tongue was always low. The first phase of treatment used a maxillary anterior traction device and lingual arch to promote maxillary anterior growth and to improve the anterior dental occlusion, and training for dysarthria in conjunction with oral myofunctional therapy was used to obtain normal tongue position. In the second phase of treatment, at the age of 14 years and 10 months, oral myofunctional therapy in conjunction with the multi-bracket method was used to obtain normal occlusion and maxillary lateral expansion. At 17 years and 9 months, active treatment was ended and retention began. Six years and 9 months after active treatment ended, there was a decrease in overjet and overbite, and there was little regression, so oral myofunctional therapy was performed again. At the current time of 10 years and 1 month after the end of active treatment, no skeletal changes were observed, the occlusion has almost stabilized, and her condition remains favorable.
Looking back on this case, it is necessary to make a comprehensive judgment of various issues that differ from non-cleft patients, such as the technique of palatoplasty, the timing of the start of maxillary anterior traction, the timing of the start of orthodontic treatment, the treatment plan, the degree of achievement of goals, and long-term stability in order to formulate a treatment plan. We report here several important points to consider in orthodontic treatment for patients with cleft lip and palate.