It is important to acquire the velopharyngeal closure function (VPF) for speech management after palatoplasty in patients with cleft palate. This paper focuses on the acquisition of velopharyngeal closure function and introduces the operation of two flap palatoplasty. In addition, the solution was examined with the analysis of the postoperative poor progress cases.

Since 1983, our department has adopted the two-stage palatoplasty as Zürich system (veloplasty is performed by the Perko’s method at 18 months, and the hard palate closure is performed by vomer flap at 5 years and half). After that, the veloplasty was changed to the modified Furlow’s method from 1996 with the aim of improving the velopharyngeal competence. We investigated the surgical timing for early normal articulation without affecting maxillary growth, and are currently undergoing hard palate closure at 4 years. As the result of changing the procedure of the veloplasty from the Perko’s method to the modified Furlow’s method, the rate of velopharyngeal insufficiency decreased at the age of 5 years with the modified Furlow’s method. In addition, as the result of advancing the operation timing of hard palate closure from 5 years and half to 4 years, the velopharyngeal competence at 5 years of age increased and the palatalized articulation decreased. In this way, it was thought that establishing and systematizing a management system and treatment policy that would allow a general oral surgeon to obtain certain results would be one of the ways to improve the cleft palate speech outcome.

We have been applying an early two-stage palatoplasty as our standard treatment protocol for patients with cleft lip and palate. This protocol was advocated by Nishio et al. and consists of hard palate closure at 1.5 years of age following soft palate plasty with Furlow double opposing Z-plasty conducted at 1 year of age. The aim of the protocol is to obtain good palatal development without retreating the favorable postoperative speech outcome that had been obtained by the conventional one-stage pushback palatoplasty we had previously implemented. In the present article, we firstly report speech outcomes following the early two-stage protocol, and compare the results with those obtained after pushback palatoplasty. Then, we describe surgical approaches that we incorporate recent years to obtain better speech results.

　We retrospectively investigated speech outcomes of 267 children with non-syndromic unilateral cleft lip and palate (UCLP) who were born between 1990 and 2005 and received consecutive treatments in our department. Of the subjects, 152 underwent the early two-stage palatoplasty (ETS group), and 115 underwent one-stage pushback palatoplasty (PB group). Assessments concerning velopharyngeal function and articulation errors were made by an experienced speech therapist in our department. Results were stratified by the same speech therapist based on the cleft palate language test (for clinical language) published by Japanese association of communication disorders. Regarding velopharyngeal function at 4 years of age, 85.5% (130/152 cases) of the ETS group was assessed normal, 9.2% (14/152 cases) was mild velopharyngeal insufficiency (mild VPI), 5.3% (8/152 cases) was moderate VPI. No cases of VPI were found. In the PB group, 90.4% (104/115 cases) was found normal, 5.2% (6/115 cases) was mild VPI, 3.5% (4/115 cases) was moderate VPI, and 0.9% (1/115 cases) was VPI. No statistically significant difference was observed. The incidences of articulation errors at 4 years of age in the ETS group and in the PB group were 25.0% (38 cases), and 33.9% (39 cases), respectively, indicating no significant difference.

　Based on the results, we are currently introducing multiple procedures in primary palatoplasty for even better speech outcome. Attention is paid to three major points; 1. radical dissection of the cleft muscle from the aponeurosis of the tensor veli palatini muscle, 2. control of velopharyngeal space by using the donor site of the vomer flap, and 3. usage of buccal myomucosal flap for cases with wide cleft.

Oral tuberculosis is rare. We report a case of a patient with oral tuberculosis in the lower gingiva. The patient was an 83-year-old woman with no previous history of tuberculosis. Her chief complaint was a refractory ulcer of the mandibular gingiva expanding over a period of 11 months. The surface of the ulcer was granular, without induration, and part of the mandibular bone was exposed. CT showed a slightly enhanced area coinciding with the ulcer. T-spot blood test was positive. Tuberculosis was suspected, and she was referred to the Department of Infectious Diseases. Chest CT did not indicate pulmonary tuberculosis, but an acidophilic bacterium test returned positive for both Ziehl-Neelsen staining by direct smear examination and culture inspection. In addition, Mycobacterium tuberculosis was identified through PCR. She was diagnosed with tuberculosis, and treatment using rifampicin, isoniazid, and ethambutol was started. A gingival biopsy was performed after sputum examinations returned negative three times. Pathologically, the granuloma was composed of caseous necrosis surrounded by Langhans giant cells, epithelioid cells and infiltration of lymphocytes, which lead to a final diagnosis of oral tuberculosis. The ulcer healed after two months of chemotherapy. Medication was continued for one year, and there was no recurrence.

Desmoid-type fibromatosis is a soft tissue tumor formed by fibroblast proliferation that tends to infiltrate surrounding tissue but does not give rise to metastases. The stomatognathic area of the mandible is considered to be a relatively common site. Most of the previous reports are of advanced cases, and onset occurs mainly in young patients. There are many reports on treatment methods, including surgery, pharmacotherapy, and radiotherapy, so it can be difficult to decide on a treatment method. For the purpose of formulating a medical treatment for desmoid-type fibromatosis, the first edition of the guidelines for the treatment of extra-abdominal desmoid-type fibromatosis was published in Japan 2019. We report a case of desmoid-type fibromatosis arising in the masseter muscle of a 64-year-old man. His chief complaint was trismus. At initial presentation, a palpable small tumor was discovered in the left cheek. T2-weighted MRI showed a hyperintense area of about 10 mm in the left masseter muscle. Cytology ruled out malignancy, so an excisional biopsy was performed. The tumor was found in the masseter muscle. The tumor was about 15 mm and was diagnosed as desmoid-type fibromatosis by histopathological examination. We found no previous report of a tumor localized to the masseter muscle in an extensive search of the literature from the past 12 years. This case was considered to be a case of early treatment for the onset of illness at an advanced age. Two years after surgery, no recurrence has been observed.