Treatment for patients with cleft lip and palate requires long-term team care provided by related specialties, such as surgery, orthodontics, and speech-language therapy. In order to improve the treatment quality and work toward standardization of treatment, it is important to compare treatment outcomes scientifically and to understand the differences in treatment strategy through intercenter collaborative studies. Such studies are also advantageous for securing the number of cases to evaluate the effect of specific treatments. For these reasons, intercenter collaborative studies such as Eurocleft, Dutchcleft, Americleft, and Scandcleft have been performed since the 1980s around the world. In Japan, such studies commenced in the 2000s, and the Japancleft Committee was included in the Japanese Cleft Palate Association in 2009, and is continuing its activities.
The significance of intercenter collaborative research is not to rank institutions based on treatment outcomes, but to understand different treatment protocols, share information through scientifically evaluated treatment outcomes, and look for safe and reliable treatment strategies with less burden. This paper reviews the history of intercenter collaborative studies in the world and in Japan, focusing on dental arch relationships. Future prospects are also discussed.

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Microform cleft lip refers to a mild form of incomplete cleft lip. Since Brown’s report on this in 1964, there have been many reports on its diagnostic criteria and treatments. However, despite its history of more than half a century, there is still no consensus as to how far the lesion should be cut and how it should be left uncut in the operation for microform cleft lip. The usual surgical procedure in cases where reconstruction of Cupid’s bow becomes necessary is the Rotation and Advancement Method （R-A Method）. In our technique, the orbicularis oris muscle is dissected only when significant changes in the position of the muscle layer are required. However, at our hospital in the past 20 years, there was no case of full-thickness dissection of any orbicularis oris muscle. We assessed 10 cases in the past 20 years diagnosed as microform cleft lip according to Iwanami et al.’s diagnostic criteria. The cleft types of these cases were subdivided using Onizuka’s classification and Yuzuriha et al.’s classification. We analyzed the procedure of primary surgery, the presence or absence of secondary surgery, procedure of secondary surgery, and current symptoms. Postoperative results through facial photographs of the patients at their final visits were evaluated using Thomson’s evaluation criteria, with the following results. By Onizuka’s classification, there were 2 cases of Second Grade Second, and the remaining 8 cases were Second Grade Third. By Yuzuriha et al.’s classification, there were 3 cases of Minor-Form, 4 cases of Microform, and 3 cases of Mini-Microform. Incisions extending from the nostril floor to the entire length of the lips were performed in 7 cases, including 5 cases by the R-A Method. The remaining 3 patients underwent only partial incision without whole lip skin incision. In all cases, the deep muscularis was continuous and this continuity was preserved. Reconstruction of the orbicularis oris muscle was performed in 6 cases with dehiscence and thinning of the superficial muscularis, regardless of the extent of the incision. In the long-term follow-up, secondary surgery was performed in 4 cases, 6 times in total. Using Thomson’s assessment, all cases showed significant improvement post-operatively. Based on these results, it is our opinion that continuous muscularis does not require dissection of the full thickness of the orbicularis oris muscle. Furthermore, this surgical technique is considered less invasive.

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Purpose: Palatoplasty, a surgical procedure for soft palate repair, enables velopharyngeal closure but suppresses maxillary growth. Velar adhesion （VA） refers to the creation of an incision and suturing of the borderline of the oral and nasal mucosa of the soft palate, which reduces the width of the cleft during palatoplasty and facilitates less invasive surgery. In our department, we perform VA during cheiloplasty in patients with unilateral cleft lip and palate （UCLP） and pushback palatoplasty at the age of 1 year and 6 months; however, the effects of VA on maxillary growth remain unclear. In this study, we investigated the effects of VA on maxillary arch forms up to palatoplasty. Furthermore, we determined the duration of use of the feeding obturator and the effects of both on maxillary alveolar arch morphology.
Methods: The study included patients with UCLP who underwent pushback palatoplasty at the Saga University Hospital of Oral and Maxillofacial Surgery. We retrospectively recorded age at the time of cheiloplasty and palatoplasty and duration of post-VA feeding obturator use from medical records. Additionally, we measured the maxillary plaster model at 1 year and 6 months of age and confirmed the effects of VA on maxillary arch length, width, and symmetry, as well as alveolar cleft and palatal cleft width.
Results: We observed no intergroup difference in age at the time of cheiloplasty and palatoplasty. The mean length of feeding obturator use after cheiloplasty was 12.3 months in the VA （−） group and 5.8 months in the VA （+） group （＜50% of the duration in the VA ［−］ group）. VA did not significantly suppress the length and width of the dental arches. Palatoplasty effectively reduced the width of the alveolar cleft and achieved bilaterally symmetrical alveolar morphology in patients who did and did not undergo VA. The cleft width at the posterior end of the hard palate was significantly reduced to 6.02mm in the VA （+） group.
Conclusions: Our study highlights that VA effectively reduces the width of the cleft palate in patients who undergo palatoplasty and enables a less invasive procedure. VA did not inhibit maxillary growth, and we observed symmetrical maxillary alveolar arch morphology at the time of palatoplasty. Future studies are warranted to confirm the long-term effects on maxillary development and on language and occlusal function.

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Objective: Alveolar bone grafting （ABG） is a common effective therapy to improve the alveolar arch form and induce permanent tooth eruption in a patient with alveolar cleft. However, several studies have reported cases in which the grafted bone was absorbed earlier after surgery. We conducted the present study to investigate the outcomes of ABG in our hospital and to identify factors associated with a poor prognosis in order to improve the prognosis for further ABG.
Methods: Fifty-seven patients （65 clefts）, who underwent ABG in the Department of Oral and Maxillofacial Surgery, Dokkyo Medical University Hospital during the 13-year period from April 2008 to March 2020, were included in the present study. The survey items included cleft type, gender, age at grafting, distance of cleft, infection after grafting, wound rupture, lack of lateral incisors and canine tooth eruption in the cleft. The characteristics of the poor bone formation group （re-grafting group） were extracted and compared with those of the good bone formation group.
Result: Of the total of 65 clefts, 5 （7.7％） clefts, which included 4 cleft lip and palate and 1 cleft lip and alveolus, were the poor bone formation group. In the comparison between the good and poor bone formation groups, the incidence rates of wound rupture, and lack of lateral incisors in the cleft were significantly higher in the poor bone formation group. Furthermore, the mean distance of the cleft was significantly larger in the poor bone formation group.
Discussion: Orthodontists and oral surgeons should cooperate closely to obtain a good outcome of ABG. The operation should be performed at the recommended appropriate age （canine tooth eruption period）, and special care for wound rupture and postoperative infection control is important. Furthermore, it is important to conserve the lateral incisors in the cleft wherever possible and to avoid excessive expansion of the cleft.

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Purpose: As a characteristic of the maxillofacial morphology of patients with cleft lip and palate, anterior crossbite is often observed due to the lack of maxillary growth caused by postoperative scar tissues. This study investigated the maxillofacial morphologies of patients with skeletal mandibular prognathism accompanied by unilateral cleft lip and palate, where surgical orthodontic treatment was applicable.
Methods: Subjects included patients with unilateral cleft lip and palate treated at the Orthodontics Department of Tokyo Dental University Chiba Dental Medical Center. Twenty patients who underwent surgical orthodontic treatment were selected as the surgery group, and 27 patients who underwent orthodontic treatment alone as the orthodontic group. Cephalometric analysis was performed using lateral roentgenographic cephalograms. A comparison between the two groups at the first visit and the time of re-diagnosis was performed, and also changes between the first and re-diagnosis visits were compared.
Results: At the first visit, there was no significant difference in the maxillary anteroposterior relationship between the two groups. Compared to the orthodontic group, the surgery group had a shorter anterior cranial base, more anterior positioning of the mental region, and a higher gonial angle. At the time of re-diagnosis, the mandibular ramus and body of the mandible in the surgery group were significantly longer and larger. Significant differences were observed in the Wits appraisal, ANB angle, and angle of convexity items. The surgery group had a more significant anteroposterior positional discrepancy of the maxilla and mandible than the orthodontic group. Significant differences were observed in the amount of growth for the SNB angle and N-perpendicular to Pog, and the mandible was positioned more anteriorly. Incisor overjet showed a significant difference at the time of the first visit, the time of re-diagnosis, and between the first and re-diagnosis visits.
Conclusion: For patients with unilateral cleft lip and palate, the maxillofacial characteristics for which surgical orthodontic treatment was selected included subjects who were not affected by the anteroposterior position of the maxilla, had high gonial angles and short anterior cranial base. Surgery was indicated in patients where the mandible, which was in an anterior position at the initial examination, developed over time, causing an anteroposterior positional discrepancy between the maxilla, making the incisor overjet significantly negative. This study suggested the necessity of observing mandibular growth.

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To understand the actual conditions of the use of orthodontic anchor screws （OASs） in patients with cleft lip and/or palate （CLP） at the Department of Orthodontics and Speech Therapy for Craniofacial Anomalies in Tohoku University Hospital, we conducted a clinico-statistical survey of the use of OASs in CLP patients treated with edgewise appliances during the seven-year period from April 2014 to March 2021, and compared the results with the conditions in non-cleft （non-CLP） patients.
1. The numbers of CLP patients and non-CLP patients surveyed were 62 （1：1 male-to-female ratio） and 53 （1：2.5 male-to-female ratio）, respectively.
2. The distribution of cleft types of CLP patients was as follows: cleft lip: 6.5％, cleft lip and alveolus: 27.4％, cleft lip and palate: 43.5％, cleft palate: 22.6％. Types of malocclusion of CLP patients included crossbite, crowding and maxillary protrusion in order of number. Types of malocclusion of non-CLP patients included maxillary protrusion, crossbite, and congenitally missing teeth in order of number.
3. The mean ages of placement were 17.1 years in CLP patients and 19.2 years in non-CLP patients. CLP patients were significantly younger than non-CLP patients.
4. The maxillary buccal posterior region was the most common site of placement: 51.7％ in CLP patients and 40.6％ in non-CLP patients. The mandibular buccal posterior region was the next most common.
5. The total number of OASs used in CLP patients was 176, of which 143 OASs were successful and 33 OASs failed, resulting in an overall success rate of 81.3％. The total number of OASs used in non-CLP patients was 155, of which 124 OASs were successful and 31 OASs failed, resulting in an overall success rate of 80.0％. There was no significant difference in the success rate between CLP patients and non-CLP patients.
6. There was no significant difference in the success rates among placement sites, age, gender, diameter of OAS, or length of OAS in both CLP patients and non-CLP patients. There was no significant difference in these success rates between CLP patients and non-CLP patients either.

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This study analyzed 1,446 patients with primary cleft lip and palate, or both, who visited our specialized outpatient department during the 40-year period since 1981. The results were as follows.
1. Among patients attending the outpatient department, 1,446 primary cases of cleft lip and/or palate were identified.
2. Of the 1,446 patients, 483 had cleft lip （33.4％）, 551 had cleft lip and palate （38.1％）, and 412 had cleft palate （28.5％）.
3. There were 748 males and 698 females, with a male-to-female ratio of 1.07：1.
4. Between the ages of 0 and 20 years, the most common age of the first visit to the outpatient department was less than 1 month old, with 939 patients （65.0％）.
5. The average birth weight of patients was 2,936.2g and there were 527 （37.0％） patients in the 2,500–2,999g range, the highest percentage.
6. A total of 1,130 patients （78.2％） were living in Kagoshima Prefecture, and 316 patients （21.8％） were living in another prefecture.
7. Patients were most frequently introduced by obstetricians, followed by pediatricians, and perinatal and maternity centers.
8. A total of 134 patients （9.3％） had a congenital anomaly.
9. The number of visits for prenatal counseling, which started in 2006, totaled 276, and has increased since 2011. Prenatal counseling was provided to reduce the emotional burden on the family.
10. Cleft lip and cleft palate was the most common cleft type in the survey period. The proportion of male patients was greater than that of female patients in periods Ⅰ, Ⅲ, and Ⅳ. The proportion of female patients was higher than that of male patients in period Ⅱ. In period Ⅰ, less than 50％ of patients visited our specialized outpatient department for the first time before 1 month old.
In periods Ⅱ, Ⅲ, and Ⅳ, about 70％ of the patients visited the outpatient department before 1 month old. The percentage of low birthweight infants weighing less than 2,500g was 10.4％ in period Ⅰ, 16.8％ in period Ⅱ, 21.4％ in period Ⅲ, and 12.4％ in period Ⅳ. In recent years, patients have increasingly been introduced by pediatricians, and perinatal and maternity centers. The rate of congenital anomaly complications in cleft palate was higher than in other cleft types.

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After primary repair, approximately 90％ of patients with cleft palate gain sufficient velopharyngeal function for verbal communication. However, the function gradually deteriorates as patients get older due to enlargement of the velopharyngeal space. Conventional secondary procedures such as pharyngeal flap are often regarded as too invasive, and there is an unmet need among these patients who experience slight inconvenience during communication due to insufficient velopharyngeal function. There are reports from abroad in which fat grafting is performed for these patients, and a systematic review found that patients with mild to moderate incompetency are good candidates for this procedure. At the National Center for Child Health and Development, in 2019 we started a prospective study to evaluate the safety and efficacy of the procedure; one patient has completed the treatment and evaluation so far. Fat grafting is thought to be safely feasible and may be a promising alternative for patients with mild to moderate velopharyngeal incompetence.

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Patients with cleft lip and palate often present with an anterior crossbite, molar crossbite, and sloping of the occlusal plane due to three-dimensional inferior growth of the maxillary bone. In the present case, a patient with cleft lip and palate with a narrowed maxillary dental arch was treated consistently in our clinic, resulting in a harmonious facial appearance and a good occlusal relationship.
The patient was a 6-year 1-month-old male with a left-sided cleft lip and palate. He had no skeletal problems and a narrowed maxillary dental arch, with an anterior crossbite and bilateral molar crossbite. Phase Ⅰ treatment included lateral expansion of the maxilla and cleft jaw bone grafting. Thereafter, growth was observed, but with anterior growth of the mandible, the patient was skeletal Class Ⅲ due to the posterior position of the maxilla and anterior position of the mandible at the age of 16 years 3 months. He exhibited a concave soft tissue facial profile with midfacial deficiency, and his lip was prognathic. Intraoral examination demonstrated a small overjet of －4.2mm, an overbite of 3.7mm, and a palatal transposition of the upper left lateral incisor. The midline of the upper and lower dentition was discordant. In addition, the length of the soft palate was short and there was dysfunction of nasopharyngeal closure. In the Phase Ⅱ treatment, the patient underwent upper and lower dentition alignment with a multi-bracket appliance, extraction of the maxillary left lateral incisor, and maxillary and mandibular osteotomies. The maxilla was moved anteriorly and the molars were moved upward by Le Fort Ⅰ osteotomy. The mandible was moved anteriorly using a sagittal split ramus osteotomy （SSRO）. The patient underwent postoperative orthodontic treatment to tighten the occlusion, genioplasty, lip and external nasal modification, and pharyngeal valvuloplasty. A good facial profile, occlusal status, and improvement of nasopharyngeal closure function were achieved.

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