Review Annals and Essences of

artilces Dentistry
doi:10.5368/aedj.2011.3.2.4.1

CLASSIFICATION OF CLEFT LIP AND CLEFT PALATE-A REVIEW

1 1
M S Rani Professor and Head, Department of Orthodontics
2 2
Nithya S Chickmagalur Graduate Student
1
Department of Orthodontics, V.S Dental College and Hospital ,V.V Puram, K.R Road, Bengaluru-4, Karnataka, India.
2
Harvard school Of Medicine

ABSTRACT

Classification for cleft lip and palate is important for both clinical research and epidemiological investigation. Classification of
the cleft lip and cleft palate plays an important role in diagnosis and planning the treatment. It involves the embryological
processes, the frontonasal and the right and left processes of the maxilla. The incisive foramen is a basic anatomic
landmark for classification of cleft l ip and palate. Davis and Ritchie’s classification was a fundamental classification, which is
followed by symbolic representation of Kernahan and their modifications. Newer approaches have also used mathematical
expressions to provide a complete description of the deformity including those which can be used for computerized data
analysis. This article is a review of the past and the most recent classifications, a bird's eye view on how
improvements/advancements in the field have led to a better understanding and representation of the various types of cleft
deformities.

KEY WORDS:. : Taxonomy, classification, cleft lip, cleft palate

INTRODUCTION

Taxonomies of cleft lip and palate deformities have seen a Veau 4 in 1931 put forth the classification of Cleft lip and
sea of changes, each with a different basis for cleft palate which was divided into four types as shown in
classification, ranging from anatomic and embryologic the Fig.2
considerations to the complexity of the deformity. Cleft
deformities exhibit variations that may bear on surgical Type-1: Cleft of the soft palate only; Type-2: Cleft of the
procedures and dental management. A fundamental hard and soft palate extending no further than the incisive
classification was put forth by Davis and Ritchie 1 in 1922 foramen, thus involving the secondary palate alone; Type-
which was used for years, despite its short comings. The 3: Complete unilateral cleft, extending from the uvula to
Kernahan and Stark’s2 classification and diagram is one of the incisive foramen in the midline, then deviating to one
the most used around the world. Newer approaches have side and usually extending through the alveolus at the
also used mathematical expressions to provide a position of the future lateral incisor tooth; Type-4:
complete description of the deformity including those Complete bilateral cleft, resembling type 3 with two clefts
which can be used for computerized data analysis. extending forward from the incisive foramen through the
This article is a review of the past and the most recent alveolus. When both clefts involve the alveolus, the small
classifications, a bird's eye view on how anterior element of the palate, commonly referred to as
improvements/advancements in the field have led to a the premaxilla, remains suspended from the nasal
better understanding and representation of the various septum.
types of cleft deformities.
In 1942 Fogh Anderson5 gave a very similar classification
First person to classify malformations of the face was based on embryological development , which is as
Forster3 in 1861, a Pathologist from Wurzburg (Germany) follows: Group 1 – clefts of the lip- unilateral or bilateral;
as shown in Fig.1. Davis and Ritchie1 in 1922 classified Group 2 – clefts of the lip and cleft palate (single or
the congenital clefts into three groups according to the double); Group 3 – clefts of the lip and palate upto the
position of the cleft in relation to the alveolar process. incisive foramina.
Group I: Pre-alveolar clefts, unilateral, median, or bilateral;
Group II: Post-alveolar clefts involving the soft palate only, In 1958 Kernahan and Stark2 recognized the need for a
the soft and hard palates, or a submucous cleft; Group III: classification based on embryology rather than
Alveolar clefts, unilateral, bilateral, or median.Their morphology. Primary palate comprised of premaxilla,
classification had many shortcomings such as, insufficient anterior septum, and lip. The roof of the mouth - from the
descriptions of cleft lip, cleft of the primary palate with incisive foramen or its vestige, the incisive papilla, to the
intact secondary palate and presence or absence of uvula - is termed the secondary palate. The incisive
alveolar involvement, and the incisive foramen. foramen is the dividing line between the primary and
secondary palates. Their classification was as follows:
Clefts of primary palate: Unilateral, Bilateral and median
Vol. - III Issue 2 Apr – jun 2011 1
Review Annals and Essences of
artilces
Clefts of Secondary palate: Unilateral, Bilateral and Dentistry
median vertical block of three pairs of rectangles representing
Clefts of primary and secondary palate: Unilateral, lip, alveolus, and hard palate standing on top of a
Bilateral and median triangle representing the soft palate. In 1987, Pfeifer
introduced another diagram that enables one not only
To this classification must be added the cleft of the to represent the cleft but also the surroundings of the
mesoderm of the palate, or submucous cleft, which may cleft malformation. Both diagrams are easy to use,
be camouflaged unless the uvula is cleft. but they did not consider the malformed nose and
Based on embryological principles used by Kernahan and Vomer.
Stark2 Harkins and associates6 (1962), presented a
classification of facial clefts. A modified version is as In 1971 Kernahan9 further modified this classification into
follows: a striped Y symbolic classification (Fig. 4). He has
represented the most severe and extensive form of cleft
I. Cleft of Primary Palate lip with cleft palate deformity as a ‘Y’. The incisive
foramen can be represented symbolically by a small circle
A. Cleft Lip with the dividing pointing between the primary and
(1) Unilateral: right, left (a) Extent: one-third, two-thirds, secondary palates. Each right and left limb is divided into
complete three portions representing respectively the lip, alveolus
(2) Bilateral: (a) Extent: one-third, two-thirds, complete and area between alveolus and incisive foramen. The
(3) Median (a) Extent: one-third, two-thirds, complete stem of the Y is similarly divided into three portions
(4) Prolabium: small, medium, large representing hard palate (7, 8) and soft palate (9). Each
(5) Congenital scar: right, left, median (a) Extent: one- individual can be diagrammatically represented by
third, two-thirds, complete stippling appropriate areas of clefting. In submucous cleft
B. Cleft of Alveolar Process of palate the appropriate section is cross hatched,
(1) Unilateral: right, left (a) Extent: one-third, two-thirds, Simonart's band can be represented by cross hatching the
complete anterior portion of the limb of the Y. By assigning numbers
(2) Bilateral: (a) Extent: one-third, two-thirds, complete to the striped Y segments, classification and retrieval of
(3) Median (a) Extent: one-third, two-thirds, complete information can be achieved with ease. Shortcomings of
(4) Submucous: right, left, median the Kernahan Striped Y system are as follows:
(5) Absent incisor tooth
2. Cleft of Palate 1. The degree of cleft is ambiguous
A. Soft Palate 2. Premaxillary protrusion and alveolar arch collapse
(1) Posteroanterior: one-third, two-thirds, complete cannot be depicted.
(2) Width - maximum (mm) 3. The palate is not divided into its hard and soft portions
(3) Palatal shortness: none, slight, moderate, marked for differential description in partial and complete
(4) Submucous cleft (a) Extent: one-third, two- clefts.
thirds, complete 4. Function is not illustrated along with structure, so there
B. Hard Palate is no indication of velopharyngeal incompetence.
(1) Posteroanterior (a) Extent: one-third, two-thirds, 5. The diagram lacks labeling for patient name, date and
complete stage in the course of the treatment.
(2) Width - maximum (mm) 6. Inadequate detail for recording cleft lips, especially
(3) Vomer attachment: right, left, absent asymmetric deformities in bilatera l cleft lip;
(4) Submucous cleft (a) Extent: one-third, two- 7. Inadequate detail for assessment of palatal deformities
thirds, complete associated with speech results and rates of fistula
3. Mandibular Process Clefts formation
A. Lip (a) Extent: one-third, two-thirds, complete 8. Potentially misread data that was hard to analyze by
B. Mandible (a) Extent: one-third, two-thirds, complete computer.
C. Lip Pits: Congenital lip sinuses
4. Naso-ocular: Extending from the narial region toward The classification was modified later by other
the medial canthal region. investigators, Elsahy10, Millard11, 12, Friedman et al13, 14 and
5. Oro-ocular: Extending from the angle of the mouth Smith et al15 in 1998. The description of the cleft
toward the palpebral fissure. deformities became more detailed. To overcome the short
6. Oro-aural: Extending from the angle of the mouth comings of Kernahan and to permit the recording of
toward the auricle. further details Elsahy10 (1973) modified Kernahan
Striped Y classification in the following ways:
In 1964 Pfeiffer introduced symbolic representation of
cleft lip and cleft palate7, 8, at the 2nd International 1. New triangles 1 and 5 atop the arms of the Y
Symposia on Cleft Lip and Palate in Hamburg as represent the right and left nostrils floors respectively
shown in the Fig.3. It is a pentagon that consists of a 2. Circle 13 between the arms of the Y represents the
premaxilla.

Vol. - III Issue 2 Apr – jun 2011 2

3.

Fig. 1 .Table XXV of Forster’s publication

Koch et al., British Journal of Oral and Maxillofacial Surgery (1995) 33, 51-58.

Fig.2. Veau’s Classification of cleft lip and palate

Whitaker et al., Cleft Palate Journal, July 1981, Vol.18 No.3, 161-76.

Figure: 3 Symbolic representation of Pfeiffer 1966 and 1987

British Journal of Oral and Maxillofacial Surgery (1995) 33, 51-58.

respectively
4. Squares 2 and 6 represent the right and left aspects 6. Squares 4 and 8 represent the prepalate (i.e. that
of the lip, respectively. portion of the premaxilla immediately anterior to the
5. Squares 3 and 7 represent the right and left alveoli, incisive foramen) on the right and left sides,
 respectively.
7. Squares 9 and 10 represent the hard palate proper (Fig.6), horizontal lines in these nose segments, of
(i.e. posterior to the incisive foramen) with both right density proportionate to the degree of nasal deformity, can
and left sides respectively. be used to mark it. Horizontal lines can also be employed
8. Square 11 represents the Velum, both right and left to show submucosal clefts. Stippling depicts over clefts.
sides.
9. Circle 12 below the stem of the Y represents the In 1979, the embryological classification was
posterior pharyngeal wall. integrated into the International Classification of
The numbering of the segments in the striped Y and Diseases (ICD) by the World Health Organization16
addition of the triangles and circles as described above in 1979. The sequence though, was not absolutely
are shown in Fig. 5. Elsahy gave further instructions for correct, it is as follows: 749.0 cleft palate; 749.1 cleft lip;
elaboration of his modified striped Y as follows: Protrusion 749.2 cleft lip and palate. In Chapter XVI I of WHO ICD
of maxilla can be shown by extending a line from circle 13, Version 200717, discusses about the congenital
by which the length represents its degree. Notching of the malformations, deformations and chromosomal
vermillion border or alveolar ridge can be indicated by a abnormalities (Q00-Q99) and Cleft lip and cleft palate
narrow band of stippling in the lower portion of segments (Q35-Q37). Q 35 Cleft palate includes fissure of palate,
2/6 or the upper portion of 3/7 respectively. Maxillary Palatoschisis and excludes cleft palate with cleft lip.
segment collapse can be depicted by shading or stippling Q35.1- cleft palate, Q35.3- cleft soft palate, Q35.5- cleft
segments ¾ or 7/8 for right and left sides respectively. hard palate with soft palate, Q35.7- cleft Uvula, Q35.9-
Displacement of palatal segments in complete cleft palate cleft palate unspecified. Q 36 Cleft lip includes
can be shown either by drawing double vertical lines on Cheiloschisis, congenital fissure of lip, hare lip, labium
the sides of segments 9 and 10 with right and left arrows leporinum and excludes cleft lip with cleft palate. Q 36.0
to indicate the direction of deflection or by drawing an X Cleft lip, bilateral, Q 36.0 Cleft lip, bilateral, Q 36.1 Cleft
over the appropriate right and /or left arrow on the lip, median, Q 36.0 Cleft lip, unilateral. Q37 includes cleft
diagram. Submucous clefting of the palate can be palate with cleft lip. Q 37.0 Cleft hard palate with bilateral
depicted by cross hatching. The competence of cleft lip, Q 37.1 Cleft hard palate with unilateral cleft lip, Q
velopharyngeal closure can be denoted by drawing a line 37.2 Cleft soft palate with bilateral cleft lip, Q 37.3 Cleft
between square 11 and circle12, the length of which soft palate with unilateral cleft lip, Q 37.4 Cleft hard and
represents closure adequacy from no line (= no closure) soft palate with bilateral cleft lip, Q 37.5 Cleft hard and soft
to full length connection(=complete closure) palate with unilateral cleft lip, Q 37.8 Unspecified cleft
palate with bilateral cleft lip and Q 37.9 Unspecified cleft
This classification has the following advantages over the palate with unilateral cleft lip.
original Striped Y:
1. It gives information about the degree of cleft lip. In 1991 Friedman et al 13, 14 proposed the modification
2. It indicates the presence or absence of collapse of the which combines the graphic and striped schemes of
alveolar arch Elsahy and Millard; further it incorporates various cleft
3. It describes the state of the hard and soft palate as a microforms and assigns severity scores to the anatomic
separate identity. and functional deformities. Instead of shading the blocks
4. It describes the position of the palatal segments in in the diagram to indicate the severity of the deformity a
complete cleft palate. number is placed in each diagrammatic segment to
5. It indicates the presence or absence of velopharyngeal represent, as shown in the Fig.7
closure, thus giving some idea of the patient’s speech.
6. It indicates the absence or presence of protruding Spina 18 in 1974 proposed a modification of
maxilla and the degree of protrusion. classification presented by the nomenclature committee of
7. It facilitates comparison between different patients and the American Cleft Palate association. The reference point
different stages in the same patient (preoperative and for the proposed classification is the incisive foramen.
post operative)
Group I: Pre-incisive foramen clefts (clefts lying anterior
to the incisive foramen), Clefts of the lip with or without an
alveolar cleft: A. Unilateral B. Bilateral C. Median
Group II: Trans-incisive foramen clefts (clefts of the lip,
alveolus, and palate).A. Unilateral. B. Bilateral.
Group III: Post-incisive foramen clefts and Group I: Rare
facial clefts.
Group IV: Rare Facial clefts
8.
Millard11,12, (1977) endorsed Elsahy’s revision of A completely new recording-system for the
Kernahan’s striped Y classification. He further modified it diagnosis of cleft lip and palate malformations is the
by adding inverted triangles atop the upright triangular LAHSHAL system that Kriens19 introduced in Bremen in
segments 1 and 5 to stand for the right and left aspects of 1985. He projects the first letter of the English terms
the nasal arch respectively. In his symbolic representation for Lip, Alveolus, Hard, and Soft Palate in one
 Fig. 4. The Kernahan striped Y classification of cleft lip and palate.
1 - Right lip; 2 - right alveolus; 3 - right premaxilla; 4- left lip;
5 -left alveolus; 6 -left premaxilla; 7 -hard palate; 8 - soft palate; 9 -submucous cleft.
Elsahy NI. Cleft Palate J. 1973;10:247–250

Fig.5. Symbolic representation of Elsahy Fig.6 .Symbolic representation of Millard

Elsahy NI. Cleft Palate J. 1973; 10:247–250 Cleft Palate J 1991; 28: 252.

Fig. 8. The Smith et al. (1998) modification of Kernahan’s striped Y classification.

1 complete cleft; a through d incomplete cleft from minor to lips with Simonart’s band;
2 alveolus; 3 primary palate; 4 cleft up to the palatine process of the maxillary bone;
5 cleft up to the palatine process of the palatine bone; 6 cleft soft palate; a submucous cleft.
Smith AWPlast Reconstr Surg. 1998;102: 1842–1847.
 Table 1. A Concise Description of the LAPAL

Side Right Middle Left

anatomic Lip Alveolus and Palate Alveolus and Lip
component Primary Primary palate
palate
Complete 4 4 4 4 4
Larger than half 3 3 3 3 3
Smaller than half 2 2 2 2 2
Subcutaneous or 1 1 1 1 1
Submucous
Intact 0 0 0 0 0
System for Classification of Cleft Lip and Palate
Qiang Liu et al., Craniofacial Journal, September 2007, Vol.44 No.5, 465-68.

Table-2 Modification of Tessier’s cleft classification system

David, J. David; Moore, M.H.; Cooter, R.D.; Cleft Palate Journal, July 1989, Vol. 26, No. 3, (163-185)

Table-3 Transverse view of Koch’s prearranged graphic.

Extent Shape
Grade 1 microform submucous 1
Grade 2 subtotal partly open/partly submucous 2
Grade 3 total open 3
I not affected region

Koch et al British Journal of Oral and Maxillofacial Surgery (1995) 33, 51-58.
Fig.7 . Data collection sheet and Symbolic representation of Friedman

Davison et al., British Journal of Plastic Surgery, 1998, 51, 281-284

line. A bilateral total cleft of Lip, Alveolus, Hard and
Soft Palate is recorded like this: ‘LAHSHAL’ and a The LAPAL system21 2007 consists of only five
left cleft of lip and alveolus is recorded as ‘...AL’ Arabic numerals that describe accurate anatomic
consequently reading like a roentgenograph. Total components and the extent of any cleft. Numerals are
clefts are documented in capitals while for subtotal ordered from the right side to the left side, corresponding
ones small letters were used. to what one sees when facing a patient. One numeral is
used for the palate posterior to the incisive foramen for the
following reasons: (1) Clefts in the posterior hard palate
The main disadvantage of the LAHSHAL system is
and soft palate are almost in the midline; (2) A bilateral
the inflexibility to describe a complex cleft
malformation. So, it cannot tell a submucous cleft from a cleft palate is not attached to the nasal septum; and (3)
microform. And it is impossible to record a cleft The soft palate has no relationship to the Vomer, although
region that is partly submucous and partly open. a unilateral cleft palate is fused with the nasal septum on
one side. The extent of cleft deformities (i.e., intact to
Smith et al 15 (1998) modified the Kerna han Y complete cleft) is represented by Arabic numerals 0 to 4 in
classification further, in an attempt to make up for the order to provide more detailed information, even though
shortcomings. The description of the cleft deformities some minor clefts such as a minor degree of cleft
became more detailed (Fig. 8). Incomplete cleft lip was alveolus, do not have a great bearing on management.
denoted as letters ‘‘a’’ to ‘‘d’’ for minor defects to lips with This procedure is consistent with clinical appearances and
Simonart’s band. A similarly detailed description also was helps explain the system. The simplicity and precision of
used to describe a secondary palatal deformity by the LAPAL system means it is understood easily and can
subdividing it into three segments: palatine process of the be used for computerized data analysis The LAPAL
maxillary bone, the palatine process of the palatine bone, system has universal application for clinical research and
and the soft palate. The letter ‘‘a’’ denotes a sub-mucous epidemiological investigation. Labelling according to
cleft. In addition, there is an indication of the cleft side of LAPAL system is presented in Table-1.
the secondary palate based on its relationship to the
Vomer. The Smith et al. (1998) modification is more Following are some examples of LAPAL system:
comprehensive than the Kernahan Y classification. Example-1: A complete cleft lip and palate on the left side
would be recorded as 00444
Example-2: A bilateral complete cleft lip with complete
However, due to simultaneous input of numbers and
cleft alveolus and palate on the left side and cleft alveolus
the lettering system used for sub grouping, it is
on the right side would be recorded as 43444;
cumbersome to gather data with the systems currently in
use. On the one hand, if the numerical values of the Example-3: A cleft soft palate and submucous cleft would
be recorded as 00200;
Kernahan classification were introduced into a
computerized system, as many as nine digits would be
Koch and Koch 22 in 1995 proposed a new extended
required to identify a complete bilateral cleft. The Smith et classification, LAHSN of cleft deformities. In addition to
al. (1998) modification adds details to the Y classification the lip, alveolus, hard palate, soft palate, they also
and can describe any kind of cleft deformity. At the same considered the Vomer and the micro forms in three
time, this modification adds complexi ty; recording symbols dimensions. The anatomical regions-lip, alveolus, hard
are mixed with numbers, alphabets, primes, virgules, and and soft palate, and nose (LAHSN) can be affected
even commas. The recording symbols are difficult to use single, or they can be affected in all combinations
for computerized data analysis. with each other. The severity of all single and
combined malformations of LAHSN depends on its
Using the Kernahan concept with modification, extent in sagittal, transverse and vertical directions,
Schwartz et al 20(1993) developed a three-digit numerical (Fig.9, Fig.10 and Fig.11) and it depends on whether
system RPL system to record the location and number they are submucous or open forms. For a better
of anatomic components involved in cleft deformities. The estimation of the severity, and for a description of the
right limb of the Kernahan Y classification (1, 2, and 3) is real extent of a cleft, we think, it is necessary to
represented by the first digit of this recording system (R). have a gradation for each cleft region. A classification
The base of the Y (7, 8, and 9) is represented by the considering this should have the same gradation for
second digit (P), and the left limb (4, 5, and 6) is identified each region and be applicable to all the various
by the third digit (L). Each digit is represented by the types of clefts. It must satisfy the clinical demands, be
numerals 1 to 3, consistent with the anatomic components reproducible, and be simple. Since the severity of a
involved in an anteroposterior direction. Any of the 63 cleft cleft malformation depends on its extent in transverse,
possibilities in the Kernahan classification can be vertical and sagittal direction and its shape-whether it
represented by three digits only, allowing immediate is an open or submucous form, this has to be
identification and computerized data analysis. However, considered when a cleft diagnosis is going to be
the RPL system is too simple to describe the incomplete recorded (Table-2).
and asymmetry of cleft deformities.
Fig.9 : Frontal view of Koch’s prearranged graphic. Fig.10. Sagittal view of Koch’s prearranged graphic
British Journal of Oral and Maxillofacial Surgery (1995) 33, 51-58

Fig.11 Transverse view of Koch’s prearranged graphic

British Journal of Oral and Maxillofacial Surgery (1995) 33, 51-58.

Fig.12.Tessier’s cleft classification system Cleft Palate Fig-13. The Clock Diagram
Journal, July 1989, Vol. 26, No. 3, (163-185) Percy Rossell-Perry (2009) Cleft Palate-Craniofacial
Journal: May 2009, Vol.46 No.3, pp. 305-313

Vol. - III Issue 2 Apr – jun 2011 90

 Table-4 Score assigned to the clefts in Primary Palate

Primary palate score

Normal 0
Microform 1
Incomplete1/3 3
Incomplete 2/3 6
Complete with contact of segments 12
M.R. Ortiz-Posadas et al., Cleft Palate–Craniofacial Journal, November 2001, Vol.38 No. 6, 545-50.

Table.5. Factor Corresponding to the Millimeters of Separation of the Segments

Separation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
in mms
Factor 1. 1. 1. 1. 1. 1. 1. 1. 1. 2. 2. 2. 2. 2. 2. 2. 2. 2. 2. 3.
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0
M.R. Ortiz-Posadas et al., Cleft Palate–Craniofacial Journal, November 2001, Vol.38 No. 6, 545-50.

Table. 6 . Score Assigned to Secondary Palate Clefts

Secondary Palate Score

Normal 0
Submucous without bifid uvula (soft palate) 1
Submucous with bifid uvula (soft palate) 4
Incomplete 1/3 central (soft palate only) 8
Incomplete 2/3 unilateral (soft palate 1 one palatal shelf) 13
Incomplete 2/3 bilateral (soft palate 1 both palatal shelves) 14
Complete grade I* unilateral 25
Incomplete 2/3 1 complete grade II† 27
Complete grade I bilateral 28
Complete grade II unilateral 34
Incomplete 2/3 1 complete grade II 36
Complete grade II bilateral 37
Complete grade III‡ unilateral 50
Incomplete 2/3 1 complete grade III 53
Complete grade III bilateral 55
M.R. Ortiz-Posadas et al., Cleft Palate–Craniofacial Journal, November 2001, Vol.38 No. 6, 545-50.

Table 7.Examples of the Score Assigned to Some Clefts in the Primary Palate

Description of Cleft
Left Side Right Side Score
Complete wcs (2 mm) — 14
Complete wcs (17 mm) — 32
Incomplete 2/3 Complete wcs (18 mm) 59
Complete wcs (19 mm) Complete wcs (4 mm) 77
Complete wcs (18 mm) Complete (18 mm) 100
M.R. Ortiz-Posadas et al., Cleft Palate–Craniofacial Journal, November
alveolus, hard and soft palate on the other hand have
In transverse direction the cleft malformation is to be considered.
very easy to localize and to record: left, or right
sided, or a bilateral malformation of the lip, alveolus, The sagittal direction extent (microform, subtotal or total)
hard palate and nose, and the medially located cleft of the malformation of lip, alveolus, hard and soft palate
malformation of the soft palate. is defined by adding the degree to the symbol
representing the affected region (without regard to the
In the vertical direction the two levels of the shape)
malformation-nose and Vomer on the one hand, lip,
Thus the classification is read as follows:
 bilateral total cleft of LAHS L3 A3 H3 S3 H3 A3 system uses the orbit as the frame of reference and the
L3 clefts are based around this axis A broad classification is
 Right side total LAHS L3 A3 H3 S3 - one proposed by Tessier (1976) utilizing a clockface
 Left side total cleft of lip -L3 analogy from 0 to 14 , Table-2. The point of reference for
 bilateral total cleft of lip and alveolus L3 A3 A3 L3 these clefts is the orbit with the clefts found in two different
hemispheres. Those of the lower lid region are facial,
 Bilateral total cleft of hard and soft palate -H3 S3
while those of the upper lid are cranial. Clefts 0 through 4
H3-
have extensions downward to involve the maxilla and fit
 Uvula bifida -Sl-
into the usual cleft lip and palate classifications. Their
 The formula is read like a roentgenograph: The superior extensions are the more severe major cranial
right side of the patient is written on the left side anomalies (Fig.12)
of the paper.
 The malformation of the outer nose and Vomer is M.R. Ortiz-Posadas, L. Vega-Alvarado, J. Maya-
documented in a second line above the recorded Behar25, proposed a new method, which allows for a
malformation of LAHS (without regard to the complete description of primary and secondary cleft
shape), for example: bilateral total cleft malformation palates, incorporating elements that are related to the
of the outer nose and Vomer N3 v3 v3 N3
palate, lip, and nose that will also reflect the complexity of
this problem. They developed a mathematical expression
A submucous cleft shows the same pathological to characterize clefts of the primary palate, including the
findings, except that it is covered with soft tissue. magnitude of palatal segment separation and the added
That means that the functional tissue layer (bone, complexity of bilateral clefts, yielding a numerical score
muscle or cartilage) is affected as well as in an open that reflects overall complexity of the cleft. Clefts of the
cleft form. These findings should be diagnosed and secondary palate are also considered in a separate score.
documented in the same manner. To be able to Using this method, it is possible to incorporate elements
record a submucous, open or a partly that are not considered in other approaches and to
submucous/partly open form of a cleft malformation, describe all possible clefts that may exist. In the case of
we use a second numeral following the degree of the cleft primary palate, along with the surgeon, they
sagittal extent: Submucous 1 ;Partly open/partly determined the necessary elements that to be considered
submucous 2; Open are:
Mortier et al 23 (1997) developed a dual scale, which
1. The complexity of unilateral complete clefts with contact
included two indicators: one corresponding to the severity
between the primary palate segments (cbs).
of the cleft (ISS, or initial severity score) and another
2. The separation, in millimeters, in the case of unilateral
related to the surgical result (PRS, or postoperative
complete clefts without contact between the primary
results score). This indicator considered seven features to
palate segments (wcbs).
describe the patient. A comparison of the ISS and PRS
3. The additional complexity associated with bilateral
allows for more objective judgment of the surgical result. clefts.
However, it has been applied only to unilateral incomplete
clefts of the primary palate.
Scores associated with the complexity of unilateral
24 ( complete clefts with cbs are shown in Table 4. Scores
Tessier 1976) formulated a classification system
range from 0 (normal primary palate) to 12 (complete cleft
based upon his extensive personal experience. This
of the primary palate with contact between the segments).
The degree of separation between the segments in
unilateral complete clefts with no cbs was used to
establish level of complexity. The relationship between the
magnitude of segment separation and complexity was
considered to be directly proportional (the greater the
separation, the greater the surgical complexity). As such,
a separation factor was assigned to each millimeter of
separation (Table 5). From a surgical and aesthetic-
functional perspective, the complexity of a bilateral cleft
and its repair exceeds the simple summed complexity of
the unilateral clefts that form the bilateral cleft. For that
reason, bilateral clefts were scored as 1.5 times the sum
of the unilateral cleft components. Therefore, in the case
of unilateral clefts wcbs, the value 12 (see Table 1),
corresponding to a complete cleft with contact between
the segments (cbs) is multiplied by the factor
corresponding to the millimeters of separation between
the segments. For example, a complete cleft wcbs (12
mm) has a score of 12 X 2.2 = 26 (rounded off to whole
5. This severity-based classification and clock diagram
numbers).
are directly related to the management protocol used
As an example of complexity score determination in the
in our clinic
case of a bilateral cleft–primary palate with this
methodology, consider a bilateral cleft–primary palate with
Limitation of their system is the absence of lateral
the following characteristics: a left incomplete cleft (one-
segment description on the clock diagram and of other
third) and a right complete cleft, with a 3-mm separation
components such as the nasal septum and maxilla.
between the segments.

To obtain the overall complexity score: CONCLUSION

Calculate the relevance of each unilateral cleft: Left
incomplete one-third = 3. Right complete wcbs (3 mm) =
The upper lip, premaxilla, and primary palate are
12 X 1.3 = 15.6. Sum unilateral cleft complexities: 3 + 15.6
formed by the merging of three structures: the frontonasal
= 18.6. process and the right and left processes of the maxilla.
Multiply the result by the bilateral cleft complexity factor
Any disturbance in the merging of the above processes
(1.5) i.e.18.6 X 1.5 = 27.9.
results in the formation of the clefts. The incisive foramen
is a basic anatomic landmark for classification of cleft lip
A method that fully describes clefts of the primary and
and palate. There are about one hundred combinations of
secondary palate, taking aesthetic and functional
the cleft lip and cleft palate. Proper diagnosis of this cleft
elements such as the features of the cleft itself and the
formation and its severity assessment helps in planning
deformity of the lip and nose into account, (see Table 6
and execution of the appropriate treatment. An attempt is
and 7), provides a very valuable tool for the evaluation of
made to review the various classifications of cleft lip and
progress in the patients’ rehabilitation. The advantages of
cleft palate. An ideal system must be easy to understand,
this utility may be seen in the work of Mortier et al 23
to document, to locate and to quantify the cleft lesion,
(1997), even though their approach is limited to
transcend language barriers, easily applicable to
incomplete cleft of the primary palate. Using the method
computerized data analysis, should be applicable for both
proposed here, all possible cleft forms and their severity
research and clinical applications.
can be characterized.
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