Maxillary development of patients with cleft lip and palate tend to be low with various degree. Many trials and challenges have been performed to recover such deformities on maxillary dental arch. In this paper, I explain my view to many kinds of treatments from baby to adult stages regarding to cleft lip and palate.

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The Index of Orthognathic Functional Treatment Need （IOFTN） is an index used to assess the indication for surgical orthodontic treatment, and was conceptualized in the United Kingdom. IOFTN is categorized from Category 1 （none） to Category 5 （very great）, and each category is divided into several subcategories by various factors such as occlusal relationship and the presence or absence of functional difficulties. The aim of this study was to determine whether IOFTN is a useful index for Japanese patients. The subjects for this retrospective assessment were 128 patients with jaw deformities for whom orthognathic surgery was performed in our hospital （Niigata University Medical and Dental General Hospital） during the period from January 2015 to December 2017. The subjects included 37 males and 91 females （average age: 23±8years）. A combination of Le FortⅠ osteotomy and bilateral sagittal split osteotomy was used in 79 cases （61.7％）, a combination of multi-segmental Le Fort I type osteotomy and bilateral sagittal split osteotomy was used in 8 cases （6.3％）, bilateral sagittal split osteotomy was used in 36 cases （28.1％）, and other techniques were used in 5 cases （3.9％）. The ANB angle was measured to classify the skeletal pattern as follows: Class 1 （1≦ANB≦4）, Cla­ss 2 （ANB＞4）, and Class 3 （ANB＜1）. The most frequent skeletal pattern was Class 3 （82 cases: 64.1％）. 29 cases （22.7％） were Class 1 and 17 cases （13.3％） were Class 2.
The results showed that 118 patients （92.2％） were categorized as Category 4 or 5 with great need for surgical orthodontic treatment. No patient was categorized as Category 1 or 2. In conclusion, IOFTN might be an accurate indicator of treatment need for Japanese patients with jaw deformity requiring surgical orthodontic treatment.

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A questionnaire-based survey of the current status of treatment of jaw deformity was carried out before a consensus meeting for treatment in 2018. The survey consisted of questions concerning treatment planning, preoperative preparation, prophylactic antibiotics, ane­sthesia, transfusion, orthognathic surgery, posto­perative management, and complications. All 36 institutions ans­wered the web-based questionnaire, and the results of the survey were discussed in the consensus meeting. This study revealed the current status of treatment of jaw deformity in Japan. Because the study included only a small number of institutions, a more extensive survey is required to clarify the actual status of treatment of jaw deformity in Japan.

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Purpose: To perform a statistical analysis of orthognathic surgery performed at the Oral and Maxillofacial Surgery Department of Yamagata University Hospital between 1990 and 2017.
Methods: Sex, age, clinical diagnosis, surgical method, operation time, bleeding volume, and postoperative management of 583 patients were analyzed.
Results: There were 190 males and 393 females. The age at the time of surgery ranged from 5 to 73 years （average age 22.0 years）. Mandibular protrusion alone was the most frequent clinical diagnosis, accounting for 278 cases （47.7％）, followed by 99 cases of facial asymmetry with mandibular protrusion （17.0％）, and 45 cases of open bite with mandibular protrusion （7.7％）. A total of 384 cases （67.1％） of sagittal split ramus osteotomy （SSRO） and 140 cases （24.5％） of double-jaw surgery using SSRO and Le Fort Ⅰ osteotomy （LF Ⅰ） were performed. There were 20 cases （3.5％） of genioplasty （GEN） concomitant with SSRO. In recent years, double-jaw surgery has been the most frequent surgical procedure. The average surgical time and bleeding volume were 162.8min and 278.9ml in SSRO respectively, and 310.1min and 767.6ml in LF Ⅰ＋SSRO respectively, and both decreased over time. The number of days patients stayed in hospital was on a downward trend, with the shortest stay being 6 days, the longest 40 days, and the average 17.9 days. For occlusion management after surgery, no cases have been fixed with wire since 2010, and intermaxillary rubber traction was used in all cases. With regard to congenital diseases, 9 patients with cleft lip and palate, one with Apert syndrome, and one with Pfeiffer syndrome were treated.
Discussion: In spite of the increase in complicated surgical procedures in recent years, operating time, hospitalization time and bleeding volume have decreased. These trends may signify improvements in surgical techniques and perioperative management. Because almost all of our cases are referrals from other dental clinics, the constant trend in the number of surgeries indicates smooth cooperation with regional medical facilities.

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The relationship between the shape of the cranial vault and the position of the mandibular fossa is not clear. To clarify the relationship, three-dimensional analysis was performed using cases with mandibular protrusion but without facial asymmetry. Nineteen female patients with skeletal mandibular protrusion who had visited Meikai University Hospital were used in this study. The lateral deviation of mental spine was less than 4 mm in all cases. Genetic/congenital anomaly cases, endocrine disorders, or cases with severe trauma and TMD were excluded. Computed tomography （CT） images of the 19 cases were taken at the first visit. Three reference planes were defined in CT images. The horizontal reference plane was defined as the plane running through the right and left porion, and left orbitale. The mid-sagittal reference plane was defined as the plane running through the midpoint of the bilateral nasomaxillary suture and basion, and perpendicular to the horizontal reference plane. The frontal reference plane was defined as the plane running through the left porion, and perpendicular to the horizontal reference and mid-sagittal reference planes.
There was a significant negative correlation between the bilateral difference in the sagittal length of the cranial vaults and the bilateral difference in the sagittal position of the mandibular fossas. This implies that posteriorly located mandibular fossas are seen in cases with asymmetric cranial vaults having longer A-P length on the same sides. In contrast, there was no correlation between the bilateral difference in the vertical length of the cranial vaults and the bilateral difference in the vertical position of the mandibular fossas. Also, there was no correlation between the bilateral difference in the transverse length of the cranial vaults and the bilateral difference in the transverse position of the mandibular fossas. Interestingly, there was a significant negative correlation between the bilateral difference in the sagittal position of mandibular fossas and the bilateral difference of mandibular body lengths, suggesting that the mandibular body length compensated the A-P position of the mandibular fossa to prevent facial asymmetry.
The obtained findings indicate that the shape of the cranial vaults is related to the A-P position of mandibular fossas in patients with skeletal mandibular protrusion but without facial asymmetry. It is likely that the bilateral difference of the mandibular body lengths has a compensating effect on the bilateral A-P difference of the mandibular fossas in the present cases.

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Purpose：The purpose of this study was to consider the tongue pressure production during swallowing in patients with mandibular prognathism after orthognathic surgery.
Methods：The subjects were 10 female patients with mandibular prognathism after orthognathic surgery（age range, 18y6m–25y10m; mean age: 22.6 years; after surgery）, 10 female volunteers with normal occlusion （age range, 20y0m–24y2m; mean age: 21.7 years; normal occlusion）, and 10 female patients with mandibular prognathism（age range, 16y3m–22y7m; mean age: 20.2 years; mandibular prognathism patients）. The tongue pressure in five parts at the time of swallowing 4 ml of tasteless and odorless jelly was measured after attaching sensor sheets on the palate of each subject. Features of tongue pressure waveforms, the time series of tongue pressure production, the duration of tongue pressure, and the maximum tongue pressure value were evaluated.
Results：The tongue pressure waveforms showed a similar tendency between the after-surgery patients and the normal-occlusion patients. The tongue pressure waveform rose at each measurement location and peaked at 200–400ms. It then gradually declined and disappeared. The incidence of a double-peak tongue pressure waveform was more frequent in the mandibular-prognathism patients.
Although the time series of tongue pressure production was the same for the three groups, the maximum tongue pressure value at all channels was lower in the after-surgery group and the mandibular-prognathism patients than in the normal-occlusion patients.
Conclusions：The tongue pressure waveform was due to changes of their morphological characteristics after orthognathic surgery. But the maximum tongue pressure value at each location was lower compared with patients with normal occlusion. These results suggest that, in patients with mandibular prognathism after surgery, the tongue as a whole may remain in a lower position during swallowing.

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A total of 1,337 patients underwent orthognathic surgery and evaluation for dentofacial deformity during the past 27 years from April 1991 to March 2018, in the Department of Oral and Maxillofacial Surgery, Fukuoka Dental College Medical and Dental Hospital.
The results were as follows:
1．The average number of orthodontic surgery cases was 49.5±14.4.
2．The patients were 351 males and 986 females, and the ratio of males to females was about 1 : 2.8.
3．Maxillary retrognathism＋Mandibular prognathism was the most clinical diagnosis with 282 cases（21.2％）, followed by mandibular prognathism with 217（16.2％）, and facial asymmetry with 150（11.2％）.
4．The average age of the patients was 25.1±1.5 years old（range : 14-65）, and has been rising gradually.
5．Le Fort I osteotomy（L1）＋Sagittal split ramus osteotomy（SSRO）was performed for most cases（702 cases. 52.5％）.
6．The average operation time and amount of bleeding in L1＋SSRO were 241.5±55.8 minutes and 552.1±247.1ml, respectively. Those in SSRO were 157.5±35.0 minutes and 159.9±84.2ml, respectively.
7．The duration of intermaxillary fixation is almost 5 days in recent years.
8．Hospitalization period was 27.3±2.6 days by the end of fiscal 2003. The time taken to provide a critical path, that has been 18.2±1.5 days for L1＋SSRO cases and 16.4±1.3 days for SSRO cases.
9．475 patients came from our orthodontic clinics and 655 were referred from other clinics.

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Surgical correction for skeletal maxillary protrusion is frequently associated with various risks, such as relapse and progressive condylar resorption （PCR）. In addition, affected patients with a deformity of the condylar head have increased risk of these complications. We report a case of skeletal maxillary protrusion associated with hypoplasia of the bilateral mandibular condyles, in which a favorable outcome was attained by utilizing a combination of Le Fort I osteotomy and anterior segmental maxillary osteotomy procedures along with planned mandibular autorotation.
A 26-year-old woman visited the Department of Orthodontic Dentistry at our hospital with complaints of maxillary protrusion and anterior open bite. The patient was diagnosed with hypoplasia of the bilateral mandibular condyles and maxillary protrusion associated with an open bite of the anterior teeth by several radiographic and orthodontic examinations, and was referred to our department for surgical correction. Preoperative orthodontic treatment was initially performed for 1 year 8 months, after which she underwent orthognathic surgery. The operation was two segmental Le Fort I osteotomy （a combination of Le Fort I and anterior segmental maxillary osteotomy）, along with mandibular autorotation. At more than 2 years after surgery, the patient expressed satisfaction with changes in facial appearance and stable occlusion also remained.
Accordingly, we consider that these surgical procedures may be effective for patients with maxillary protrusion associated with hypoplasia of the bilateral mandibular condyles.

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Long-term loss and caries of molars cause the collapse of occlusion. Loss of vertical occlusal stop complicates dental and skeletal problems and may make orthodontic treatment difficult. We report a case of facial asymmetry with contradictory lateral inclination between the upper occlusal plane and the inferior border of the mandibular body caused by occlusal collapse in the molars. The treatment outcome including stable occlusion and proper facial appearance was obtained after orthognathic treatment.
A female aged 24 years and 3 months visited our hospital because of anterior teeth crowding and open bite. The mandible was deviated to the right in the frontal view. Her profile was straight-type but excessive lower height was noted in the lateral view. As intraoral findings, Class Ⅲ molar relation, −1.0mm of overjet, and −3.0mm of overbite were seen. Missing and crown collapse of the lower left molars caused the reduced occlusal vertical dimension. Skeletal evaluation by cephalometric analysis showed forward and downward projection of the mandible. The mandibular anterior teeth were retroclined. The collapse of the molars caused the facial asymmetry with the maxillary occlusal plane inclined to the lower left and mandibular body inclined to the lower right, as shown in P-A cephalometric analysis.
The treatment plan was to perform maxillomandibular surgical orthodontic treatment with extraction of the maxillary right central incisor and first premolar, maxillary left first molar, and mandibular right first molar. In presurgical orthodontic treatment, the occlusal stop was to be obtained by the mesial movement of the molars. The inclined maxillary occlusal plane and the mandibular body were corrected by the bite-raising of the lower left molar section and extrusion of both upper and lower right molars. Orthognathic surgery was performed to improve the anterior-posterior, vertical, and horizontal skeletal discrepancy.
In this case, the lateral inclination between the upper occlusal plane and the inferior border of the mandibular body were contradictory due to the loss of occlusal stop in the molars, resulting in the complicated facial asymmetry vertically and horizontally. By planning appropriate treatment, the occlusion and facial appearance were greatly improved.

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Orthognathic surgery is thought to have a great impact on aesthetic appearance and psychology, and there are also cases where mental illness appears after surgery. Anorexia nervosa is a mental disorder characterized by persistent caloric intake restriction and a strong fear of weight gain and becoming obese; treatments include behavioral therapy. We report on the safe perioperative management without worsening of anorexia nervosa successfully treated by behavioral therapy with orthognathic surgery.
The case was a 32-year-old female. A clinical diagnosis of skeletal mandibular prognathism as a chief complaint was made; we aimed to improve her occlusal position, and so decided to perform surgical orthodontic treatment. There was a history of cleft palate, anorexia nervosa, binge-eating/purging, and attention-deficit/hyperactivity disorder. All treatment in a behavioral therapy program for psychosomatic medicine of another hospital was interrupted, and the body weight dropped to 20kg one year before the jaw corrective surgery. Aiming to increase weight for surgery a few months before surgery, she was hospitalized in another department of psychosomatic medicine. When her weight increased to 35kg and meals of up to 1,600kcal/day could be eaten, it was judged that surgery was possible. Body weight at the time of hospitalization was 34.5kg, and on the day after hospitalization, bilateral sagittal split ramus osteotomy was performed under general anesthesia, and postoperative sedation was attempted with dexmedetomidine until the day after surgery. In addition, the bone fragment was fixed to a metal plate, and after arousal, only intermaxillary rubber towing was performed. During hospitalization, no restrictions were imposed on drinking of water and favorite foods except during the fasting and prohibition of drinking water due to general anesthesia, and they were consumed mainly when the patient was able to ingest. Nutrition started with a high nutrient fluid diet from the day after surgery. This was changed to whole porridge and soft meal on the second postoperative day, and she was able to ingest the whole amount at discharge. The weight at the time of discharge was 36.7kg, and overeating or self-induced vomiting was not observed during hospitalization.
It was thought that close cooperation with psychosomatic physicians before surgery, and perioperative management for behavioral therapy led to good results.

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Orthognathic surgery is performed to establish functional occlusion and to make esthetic improvements. The most common surgical procedures are Le FortⅠosteotomy and sagittal split ramus osteotomy（SSRO）. Generally, their postoperative course is uneventful. In many facilities in Japan, the plates are removed approximately one to two years after osteotomy. We report a case of refixed non-unioned maxilla caused by a fractured plate, 15 months after a Le FortⅠosteotomy, which has not been reported previously.
A 43-year-old man visited our hospital with a chief complaint of concave profile and malocclusion. Subsequently he underwent Le FortⅠosteotomy and SSRO. Facial findings were symmetric from the frontal view and a concave profile from the lateral view. Intraoral findings revealed an overjet of−8 mm and an overbite of＋5 mm, showing ClassⅢmolarization. Cephalometric analysis revealed ANB:−13.4°, U1 to SN: 108.1°, L1 to mandible: 69.0°, FMA: 19.0° and gonial angle: 121.3°. He was diagnosed as SkeletalⅢand Dental ClassⅢwith a low mandible and short face. Intraoperatively, the maxillary segments were rigidly fixed by 5 titanium plates in the piriformis margin and zygomatic buttress after the maxilla advanced 5 mm. They were not filled with an autogenous bone graft after the Le FortⅠosteotomy because we confirmed immobilization of the maxilla. The patient was satisfied with the results of the operation. The postoperative course has been uneventful since then. However, mobility of the maxilla was found 15 months after the Le FortⅠosteotomy. We diagnosed this as a non-unioned maxilla, and performed surgery to refix the non-unioned maxilla. One of the titanium plates in the piriformis margin on the right side had completely fractured, and the other titanium plates had become loose. Therefore, the fractured plate and another plate were replaced by new ones. In addition, a bone graft harvested from the mandibular ramus was placed with screws in the gap between the maxillary segments. At present, the postoperative course has been uneventful without complications to date. We need to take into account the possibility of plate fractures for patients with short faces, due to the overload coming from the occlusal force and the necessity of a larger movement

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