Center for Stomatognathic Dysfanction Osaka University Dental School The purpose of this study is to clarify the tri-dimensional maxillary growth according to the cleft types of the patients with cleft lip and/or palate. A total of 118 cases were divided into the following three experimental groups: the complete unilateral(UCLP), bilateral(BCLP) cleft lip and palate, and the cleft palate alone(CPO). The subjects belonging to each group were then assigned to three developmental stages ( i. e. stage 1; just prior to lip repair, stage 2; just prior to palatal closure stage 3; at 4 years of age ). The method of determining the maxillary growth, allowing interstage comparisons and intergroup comparisons, was the measurement analysis of the tri-dimensional maxillofacial models taken from the subjects. Ten non-cleft subjects were used as a control group at the final stage to identify dimensional growth inhibition of the cleft groups. The results obtained from this study were as follows:
The intergroup comparisons between the UCLP a nd the BCLP at stage 1 showed that the growth difference was notable in the anterior alveolar region as lateral segmentl displacement in the UCLP group, and was notable as protrusive incisal bone in the BCLP group. There was not much growth difference in the posterior alveolar region. The intergroup comparisons between the UCLP, the BCLP and CPO at stage 2 did not show any remarkable growth diffefences in any dimension. At stage 3, each of the three cleft groups showed growth in different directions. Remarkable forward growth inhibition of the UCLP, and remarkable downward growth inhibition of the BCLP were noted. This meant that the dimensional maxillary growth in both depth and in height did not co-ordinated with the forward and downward growth direction. The comparisons between the control and each of the cleft groups revealed the growth inhibition of the cleft groups, especially at the anterior alveolar region. The forward growth inhibition of the UCLP, the downward growth inhibition of BCLP, and both the forward and downward growth inhibition of the CPO were the characteristic findings.
These results suggested that the causes for the maxillary growth inhibition in patients with cleft lip and/01palate are not only in the alveolar segmental displacement, but also could be in the disharmonious skeletal composition of the nasomaxillary complex.

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Several investigators on their clinical and experimental studies have indicated that velar function might be effected by the tongue position. The present study was designed to analyse a neuro physiological relation between the tongue and velar movement.
An experimental model usin g anesthetized dog was established. The afferents of the glossopharyngeal nerve (IX) was exposed at the level of the cricothyroid cartilage. Twin platium wire electrodes were placed perorally into the levator veli palatini muscle of ipsilateral side. It was ascertained that a single stimulus generated by an electrical amplifier to the IXth afferent induced the levator reflex of an amplitude of 80-360μV with a latency of 16-28 m ec. That kind of stimulation did not elicite a swallowing reflex in th e series of the present experiment.
After the exp erimental model was provided, the lingual and hypoglossal nerves of the ipsilateral side were stimulated electrically to clarify an intricate function of those nerves to the levator contracture. The results were summarized as followings:
1) When conditionin g stimulus to the peripheral end of the dissected hypoglossal nerve 100-200m sec prio- toasingle stimulus to the IXth afferent, the levator reflex was inhibited.
2) The protrusion and retractor nerves were divided at the peripheral end of the hypoglossal nerve. The same inhibition to the reflex mentioned above was observed when a conditioning stimulus was given to the protrusion nerve. The finding of inhibition did not occur when a stimulus was given to the retractor nerve.
3) An inhibition of the reflex elicited by the protrusion nerve stimulation was eliminated when the lingual nerve was cut.
It is concluded that the levator reflex induced by the IXth afferent stimulation was controlled by the protrusion nerve of the hypoglossal nerve via the lingual nerve. In the control mechanism, the protrusion nerve seems to be an antagonist to the levator contracture.

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Simultaneous nasopharyngeal fiberscope (NPF) and cinefluoroscopic (Cine) recordings were taken to investigate- the followings using four normal individuals speaking typical Mid-West dialect of American English:
1) Stability of NPF positioning for recording procedures.
2) Reproducitivity of NPF positioning.
3) Reliability and validity of the pictures obtained from NPF (NPF view).
4) Temporal reliability of NPF views.
And 5) assessment of velopharyngeal movement with the data of NPF views.
The results indicate that 1) NPF in the velopharynx is highly stable during the examination; 2) a similar positioning of NPF on different occasions will be possible under the condition that the NPF tip maintains a constant dimension with the cranio-vertabral complex; 3) NPF provides highly consistent data about velar and lateral wall movement across different experimental occasions within subjects; 5) the levator veli palatini muscle appeares to be responsible for inward movement of the lateral pharyngeal wall at the level of the levator eminence; and 6) variability of velopharyngeal valving patterns is recognized across subjects.
As a result, it is confirmed that the NPF provides highly useful information for assessment of velopharyngeal closing mechanism in speech research and clinics.

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One of the important purposes of orthodontic treatment for the cleft lip and palate patients following cheiloplasty and palatoplasty is to expand the upper dental arch and improve the cross-bite. It is difficult in some cases, however, to achieve good results as we expected. In this study, the amount of cross-bite before and after expansion was measured on the dental casts using special gauges to evaluate limitation of the improvement of the cross-bite. The materials consisted of plaster models obtained from 37 unilateral and 18 bilateral cleft lip and palate. patients whose orthodontic treatment had started at the ages from 6 to 11 at the Orthodontic Departmen t, Osaka University Dental. School Hospital.
As the control, the longitudinal p laster models obtained from 20 non-cleft subjects were used. The age of the control group was matched with the cleft lip and palate group. The amount of cross-bite was measured at the areas of the central incisors, the cuspids and the first molars
The following results were obtained
1) The condition of cross-bite before expansion of upper dental arch: In UCLP group, the most severe cross-bite was found at the incisor area followed by the cuspid area and the first molar area. The amount of cross-bite on the cleft side was larger than the non-cleft side at each area. In BCLP group, almost the same amount of cross-bite was observed at each area as what was observed on the cleft side of UCLP group.
2) The condition of cross-bite after expansion of upper dental arch: In both of UCLP and BCLP groups, satisfactory improvement of cross-bite was achieved at the first molar area. However, in the areas of the central incisors and the cuspids, the cross-bite still remained in most cases in spite of the expansion as much as possible.
3) The change of the upper dental arch following expansion:
On the average, the change on the cleft side in UCLP group was larger than on the non-cleft side and also larger at the areas of the central incisors and the cusphds than the first molar area. At each area the larger change was observed in UCLP group than in BCLP group. In the individual cases, however, a lot of variations were found in the manner of expansion of the upper dental arch. The appliance for unilateral expansion is required to achieve expansion more effectively.

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The final goal of cleft palate surgery is to get normal speech and to avoid the impairment of maxillary growth and malposition of the teeth. In order to get normal speech, complete velopharyngeal function is essential. In this report, we examined velopharyngeal function, speech and relationship between them, under the careful selection of the material and method.
Material: The authors studied 49 children who had undergone pushback operation at age of 14 months to 19months, mean postoperative course was 5.4 years±0.9 s. d.. All the operations had been performed by one well trained operator. From this report we excluded the following cases; those with other congenital anomalies, with mental retardation, with serious hearing loss. Furthermore in this material, there was no such case which had undergone the secondary repair operation or speech therapy.
Method: For these selected cases, we examined velopharyngeal function and speech adequacy. Nasal air emission mesured by a mirror test, phonation of pressure consonant/p/, /b/and velopharyngeal closure in gagging are selected for velopharyngeal function test. Speech in conversation was examined by two examiners independently and assessed.
Results: In 92% of the patients, velopharyngeal closure in gagging was complete,82% had no nasal air emission,100 % could phonate the pressure consonant. As to the speech,60% was normal, but other 40% had some articulation disorders.
In conclusion, a natomical and functional closure of the cleft was improved sufficiently by the operation except for 40% of the patients whose articulation was slightly disordered. Though the spontaneous improvement may be expected in most of them in the following developmental course, the postoperative speech therapy seems to be necessary.

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It has been widely accepted that the malocclusion caused by a, cleft of the lip and/or palate involves so many complicated problems for oral habilitation that makes the orthodontic treatment difficult and time-consuming. The continuous montoring therapy which featured an incessant orthodontic intervention from the beginning of childhood through to the late adolescence of 18-20 years of age had been considered most effective approach until 1960s. In the regime the patient must from time to time visit all the members of the Cleft Palate Team as well as his general medical and dental practioners. These visits cause absenteeism from school and poor co-operation with wearing appliances and having them adjusted. To late the disadvantages are pointed out as follows;
1) Overtreatment leads to a breakdown of the orthodontist-patient relationship,
2) Frequent visits force psychological and economical burdens upon both the patient and his families.
3) Early treatment neither gurantees the better result nor reduces the need for later orthodontic treatment.
Hindsight suggests that treatment concentrated in the permanent dentition can induce better co-operation and resultant functional occlusion.
Then, the authors are proposing a new concept of four-stage orthodontic management which is coincided with the dentofacial growth and development of a cleft palate patient. Stage I: In the deciduous dentition (IIA-IIC in dental age) no routine treatment is basically carried out but the case with,
a) a severe anterior and/or posterior crossbite,
b) a protruded premaxilla with collapsed lateral segments, or
c) unfavorable dental problems for speech therapy.
Stage II: In the early mixed dentition (IIIA) treatment-focuses on correction of collapsed segments and alignment of the maxillary permanent incisors from the esthetic and psychological points of view.
Stage III: In the early permanent dentition (IIIC-IVA) corrective orthodontics by the full-banded or -bonded system plays the most important and indispensable part of all treatment.
Stage IV: In the late permanent dentition (IVC-VA) treatment includes final alignment of the teeth and pre- and post-surgical orthodontics.

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We carried out the clinicostastic study of patients who were first operated in the first Department of Oral Surgery, Faculty of Dentistry, Tokyo Medical and Dental University during a 3 year period from Oct.1st 1977 to Sep.30th 1980.
We exam ined 246 patients in terms of the following factors: distribution of cleft type, sex ratio, right-left differences, frequency in parents, siblings and other relatives and its associated anomalies. Further, comparing with the previous reports (1958 Kobayashi,1964 Ohashi), the characteristic was an increase of cleft palate patients (37.0%) and a decrease of cleft lip alveolus and palate patients (37.4%). In cleft lip patients and cleft lip and alveolus patients, the sex ratio has changed. With regard to the reason, the change in the number of patients that come to our hospital, and that of environmental factors of the person and so on, are considered. But in the future, it requires further examinations.
Associated anomalies of 53 cases were interviewed. Cleft palate was predominant. Cleft lip, cleft lip and alveolus, cleft lip, alveolus, and palate followed equally. Ankylo-glossia, abnormality of costae, mental retardation were comparatively and highly observed. We distinguised all cleft patients from familial occurrences and non-familial occurrences. The former cases had a high probability of associated anomalies.
Frequently, the patients with cleft palate had accompanying ankylo-glossia. Considering post -operative speech therapy, it is an important problem. Abnormality of costae were 11 cases (4.5%) and is predominant in females. Cost. X II defect were 10 cases, Cost. X III was only one case. Acompanying mental retardation was more frequent in cleft palate and cleft lip and palate. It is suggestive that, in several cases, speech retardation has an effect on the speech of cleft patients.

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The recognition and psychological status of parents regarding their children with cleftlip and palate were investigated by questionnaire.
The results wer e compared with those of our previous investigations of local community memberes in Nagoya district in Japan. (control group) Analyses of their responses reveal the followings:
1. The replies of the experimental group were identical with those of the control group.
2. The attitude of the control group toward this disease was rather indifferent.
3. The parents tend to ascribe the anomalies mainly to environmental facto rs, while the control group regarded them to be inheritent.
4. Prognostic anticipation were apparently different between the parent group and the control group. The control group were pessimistic about this probrem.
5. Both the parent and the control group though t that she pathology would offer some difficulties in getting married.
6. Both groups thought that oral surgery was the most effective theraputical department. Perhaps, this is an exceptional case in Nagoya district in Japan.
7. As for applications for the helth insura nce, P. R. activities should be carried out by administrative organization since most people have poor recognition.
8. Medically and administrally both groups re quire advancement of therapeutical institations, more public expenditure for the medical care and futher study for clarifying causes, etc.

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During about 3 years since June,1977 through January,1981,197 patients with cleft lip and/or palate were treated or under the continuous monitoring in the orthodontic clinic, Showa University Dental School. The number of those patients was nearly 20 percent of the-patients in our clinic.
This paper is a report of the statistical analysis of the patients with cleft lip and/or palate in ou r clinic, Findings are as follows:
1. UCLP(L) 31.5% UCL(L) 9.1 %
UCLP(R) 16.2% UCL(R) 6.6%
BCLP 20.3% BCL 4.6 %
CP 9.1%
2. Associated crossbite were found out in 73% of the total.
3. A half number of patients were classfied as Angle's Class III malocclusion.

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Clinico-statistical observation was carried out on 50 p atients with cleft palate in the department of the Oral Surgery, Nagoya First Red Cross Hospital during last 5 years from January 1,1976 to December 31,1980.
1. Referred cases were observed 74% of the 50 cases. Patients sent in by gynecologist were at the highest rate.
2.25 males and 25 females were observed. (male to female ratio of 1: 1). Cleft palate with cleft lip occurred more observed often in females.
3. Cleft palate with cleft lip, solitary cleft palate and secondary repair case of cleft palate accounted for 46%and 6% of the 50 cases.
4. The patient's age at the first vist was less than 3 months were 20 cases (40%).
5. Motheres' age at the time of delivery destributed from 25 years old to 30 years old in 23 cases (49%).
6.9 cases (19%) were associated with other anomalies.
7. Pushback procedure was used commonly for hard and soft cleft palate and Widmaier methode was used for solitary soft palate cleft.

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