|Year : 2014 | Volume
| Issue : 2 | Page : 78-84
Classification of cleft lip and palate: An Indian perspective
Director Professor and Head, Department of Burns, Plastic and Maxillofacial Surgery, Safdarjung Hospital and VMMC, New Delhi, India
|Date of Web Publication||2-Aug-2014|
Dr. Karoon Agrawal
T-23, First Floor, Green Park Main, New Delhi - 110 016
Source of Support: None, Conflict of Interest: None
Classification of the cleft has evolved over a century. Many descriptive, diagrammatic, and coding systems have been proposed to be used. However, there are only few which have stood the test of time. One of them is Indian classification. Indian classification of cleft lip (CL) and palate proposed in 1975 is a popular classification in India presently. There are numerous combinations of cleft deformities, and we found that some of them could not be classified appropriately with the original classification. The clefts are classified in three groups: CL as Group 1, cleft palate as Group 2 and Group 3 for combined CL, alveolus and palate in continuity. Originally right, left, midline, and alveolus were abbreviated. To make the classification wholesome, the original classification has been revisited and presented with additional features. The basic classification in three groups remains as original. Additional abbreviations have been added to classify the special situations. Partial, submucosal, Simonart's band, protruding premaxilla, and microform have been added to the list of abbreviations. This classification has been used for over 30 years by the author in over 4000 cleft patients. We find it simple to use, versatile enough to classify almost all possible cleft combinations, easy for communication during discussion and convenient to write as diagnosis in patients' files. Easy computer archiving and efficient retrieval of the data are the special features of this classification.
Keywords: Archiving, classification, cleft lip, cleft palate, coding, Indian, nomenclature, terminology
|How to cite this article:|
Agrawal K. Classification of cleft lip and palate: An Indian perspective. J Cleft Lip Palate Craniofac Anomal 2014;1:78-84
| Introduction|| |
Cleft lip and palate (CLP) is common and interesting craniofacial anomaly in plastic and reconstructive surgery. CLP has many variations and combinations. This makes it difficult to express correctly. To describe a group of anomalies, classification system or grading system serve as an effective tool of communication. Good classification system allows us to organize a large amount of data into a comprehensive system and simplifies treatment planning and record keeping. This was realized by Davis and Ritchie in 1922 and presented the first classification of CLP.  Since then many cleft surgeons have presented various classifications based on anatomy, morphology and embryology. There are many based on diagrammatic representation. In this article, attempt has been made to trace the chronological development of classification systems. Balakrishnan,  presented Indian classification in 1975. This still remains a popular cleft classification system in India.
The Indian classification has not been published in the format in which it is being used presently. The published article emphasizes that clefts could occur at nine sites and this could be coded for ease of computerization, in the format prevalent then.  We have encountered many children with cleft, which could not be rightly placed in this descriptive classification. Hence, the original classification has been modified and presented with additional features.
| Evolution of Cleft Classifications|| |
Davis and Ritchie presented the first classification for congenital CLP. The alveolar process formed the foundation for groupings: Group I - Prealveolar, Group II - Postalveolar, Group III - Unilateral alveolar cleft and Group IV - Bilateral alveolar cleft. They suggested that the term "hare lip" should be discarded.  This was neither an anatomical nor an embryological classification. Around the same time Brophy (1921-1923) classified the clefts in 16 distinct morphological forms.  However, this was considered too difficult and impractical.
Veau's classification in four groups was also far from anatomical and is not in use today. Cleft lip (CL), CL with alveolus, midline clefts and many more were not included in Veau's classification.  Kernahan and Stark designated the incisive foramen as the dividing point between primary and secondary palates. This correctly described the deformity. 
Vilar-Sancho classified and coded them based on Greek nomenclature. Lip was represented by "K" (keilos), alveolus by "G" (gnato), hard palate by "U" (urano) and soft palate by "S" (stafilos). Complete cleft was represented in capitals and partial in small letters. "2" was used to represent bilateral, "d" indicated right, "l" indicated left, an "I" indicated incomplete and "o" indicated operated. Being in Greek, it could not be adapted by the rest of the world. It also could not classify many of the clefts.  Harkins et al. were appointed by American cleft palate association (ACPA) to design a classification of CLP. They proposed a classification in six groups based on the concept of Kernahan and Stark. This included rare clefts along with the usual clefts. Harkins et al. divided the groups further based on the extent and sides.  This made the classification quite elaborate and difficult to remember for an average cleft surgeon. Hence, it did not become popular.
Dahl divided the clefts in four groups: CL, cleft palate (CP), and unilateral CLP and bilateral CLP.  Spina modified the ACPA classification with incisive foramen as a reference point. Clefts were divided into four groups: Group I - Preincisive foramen clefts, Group II - Transincisive foramen clefts, Group III - Postincisive foramen clefts and Group IV - Rare facial clefts. Each group had unilateral, bilateral and median; each was further subdivided into total and partial. This was adapted by the International Society for Plastic and Reconstructive Surgery.  Sandham added type 5 as "other types of clefts" over Dahl's proposed classification.  All these classifications are descriptive and not convenient for routine communication. It is difficult to archive in computer and hence data retrieval also may not be easy.
Kernahan proposed "Y" classification in nine boxes with nasopalatine foramen as the central point.  It was further modified by Elsahy, Millard, Friedman et al., Smith et al. and many more. ,,, The modified Kernahan's "Y" classification represents the cleft deformity exactly as it exists and is very versatile. This has unquestionable utility for the clinicians.  This classification is a diagrammatic or symbolic representation of the cleft deformity and used for documentation or charting very effectively. It cannot be used for writing the diagnosis in the case file, for verbal communication or description in the text format nor can it be used for computer archiving. In the true sense, it is not a classification. It is a symbolic representation of the various cleft deformities as Kernahan himself stated. 
There have been many attempts to code the various types of CLP. McCabe used electronic data processing system for punching cards.  Santiago coded the CLP for machine recording,  Schwartz et al. introduced an RPL system for numerical coding with 0-3 numbers to simplify the representation of the clefts,  Ortiz-Posadas et al. developed mathematical expression in numerical scores reflecting complexity of clefts,  Castilla and Orioli presented ECLAMC system for numeral coding,  Liu et al. published five-digit numerical recording system for CLP  and many more. However, these methods of classification or coding systems did not gain popularity because of its complexity and difficulty in remembering.
Kriens, 1989 proposed LAHSHAL, an abbreviated documentation system. Lip (L), alveolus (A), hard palate (H), and soft palate (S) were used to form LAHSHAL.  Later, it was modified to LAHSAL on the recommendation of Royal College of Surgeons UK in 2005.  This was a simplified version of Kernahan's "Y" classification and had similar shortcomings and limitations.
A clock diagram for CLP was introduced by Rossell-Perry, to describe the pathology based on the severity of distortion of nose, lip, and palate. The surgical treatment has been described based on this classification. The author claims to have observed the relationship with the severity and the outcome.  Most of the cleft surgeons may not agree with this observation.
A classification based on the (patho-)embryology of the primary and secondary palates has been presented by Luijsterburg et al. in 2014. The classification is based on the patho-embryological events resulting in various sub-phenotypes of common oral clefts. Patients within the three categories CL/alveolus (CL/A), CL/A and palate, and CP were divided into three subgroups: Fusion defects, differentiation defects, and fusion and differentiation defects. This classification provides new cleft subgroups that may be used for clinical and fundamental research.  However, this classification has little role in clinical practice.
| Indian Classification and its Modification|| |
The original Indian classification and brief notations as published by Balakrishnan are given in [Table 1]. Using these groups and brief notations, he described 12 types of possible cleft deformities. Sixteen possible intergroup combinations in a series of over 1000 cleft patients have been described. He used "/" to describe combinations.  While using the classification and dilemma over "/" sign, we replaced it with "+" sign as it was more appropriate sign to express the combination. In original classification system completeness of the cleft is not specified. To mark the partial cleft "P" notation was evolved. If there is no specific notation, it is considered as complete cleft. Thereafter "S" was added to represent "submucosal" cleft. Abbreviations for Simonart's band, protruding premaxilla (Pmax), and microform, "sb," "Pmax" and "micro" respectively were added over the years [Table 1]. The abbreviation part of this classification has four parts. Group is abbreviated as "Gp" in the first part. Other parts are well-depicted diagrammatically [Figure 1].
|Figure 1: (a and b) Front and intraoral picture of a patient with right sided partial cleft lip with cleft of soft palate. This has been coded as Gp 1PR + Gp 2P.|
Click here to view
|Table 1: Indian classification as presented by Prof. Balakrishnan (1975)|
Click here to view
Clefts occur in innumerable combinations. It is not possible to enlist all the combinations. However, some of the common clefts along with their short forms based on modified Indian classification are given in [Table 2], [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5] and [Figure 6].
|Figure 2: (a and b) Front and intraoral picture of a patient with bilateral complete cleft of lip with complete cleft of hard and soft palate up to incisive foramen. The abbreviated code is Gp 1R + L + Gp 2.|
Click here to view
|Figure 3: (a and b) Front and intraoral photographs of a child with bilateral cleft lip and alveolus with protruding Premaxilla. This is coded as Gp 1A R + L Pmax.|
Click here to view
|Figure 4: Photograph of a child with complete cleft lip on right side with cleft lip, alveolus and palate on left side with Simonart's band on left side. This has been classifi ed as Gp 1R + Gp 3L sb.|
Click here to view
|Figure 5: Photograph of a child with complete cleft lip on right side with cleft lip, alveolus and palate on left side. This will be classifi ed as Gp 1R + Gp 3L.|
Click here to view
|Figure 6: Intraoral picture of a child with bilateral complete cleft lip, alveolus and palate with protruding Premaxilla. This is coded as Gp 3 R + L Pmax.|
Click here to view
| Clinical Experience|| |
Balakrishnan's Indian classification has been used by us in more than 4000 cleft patients over a period of 30 years. With the addition of more abbreviations, it has become more versatile. It is now possible to classify almost all the combinations of the clefts encountered, and it can be represented by a brief notation. On a rough estimate, more than 1000 cleft surgeons in India are using this classification for decades as a testament to its validity.
This classification is taught to our residents during 1 st month of their training. The author has personally taught to more than 40 residents over past 30 years. All of them are able to use this classification very effectively, with a short learning curve though.
| Discussion|| |
The Indian classification has anatomical and embryological basis. This is more logical version of original Davis and Ritchie (1922)  and Dahl classifications.  Incisive foramen is the demarcation between primary and secondary palate. Any cleft anterior to incisive foramen is Group 1 and cleft behind incisive foramen is labeled as Group 2 (Gp 2). When it is involving incisive foramen, both primary, and secondary palate will be cleft. Hence, it has been rightly grouped as Group 3.
Clinically too, this classification is quite relevant. All elements of the primary palate, that is, lip, alveolus, anterior palate and nose are repaired together as a single entity. The elements of the secondary palate, that is., hard and soft palate and uvula are repaired together, hence grouped together as Gp 2.
This grouping system follows the clinical severity of the cleft. CL is considered simple as it causes mainly esthetic deformity, CP results in functional problems considered more severe, and when both are cleft, it is considered most severe causing functional as well as esthetic concerns. This way the grouping has been done in increasing order of severity from 1 to 3. This order is followed in very few classification systems. , Many classifications did not follow this order of increasing clinical deformity, , still some of them were used extensively [Table 3].
|Table 3: Comparison of different cleft classifications in the literature|
Click here to view
Popularity of a classification system and many clinical practices depend upon the teachers, how they teach, preach, and practice. Most of the students are clones of their teachers. Veau had a great following and his trainees have rightly passed on the legacy to their next generations. Hence, the classification designed by Veau became popular and is still in use in a few centers, though technically it is not sound, is incomplete, does not have an embryological basis and is not relevant surgically. Indian classification has survived over the past 40 years. This is popular in spite of not finding a place in textbooks or websites. It has survived because Balakrishnan's trainees passed on the baton to the next generation effectively. Simultaneously because it is embryologically and clinically sound.
There are many cleft coding systems or schematic representation of clefts in literature. ,,,,,,,,,, These are standalone coding systems. They are difficult to communicate or write in the patient records. However, they are useful for documentation, computerization, and archiving. The Indian classification scores over all these classifications because it is descriptive and also has an abbreviation form. These abbreviations can be used for coding of clefts [Table 1] and [Table 2], [Figure 7]. This is the only classification which incorporates both in the same system.
This Indian classification is simple, easy to communicate, easy to write in abbreviated format, and it is also possible to code it. It is very convenient for data retrieval from the computer archive. The abbreviated form of classification is especially useful for short communication and coding of the patients' records.
This contribution to the literature is essential for making this classification available to the cleft surgeons all over the world. The new generation residents are not aware of this full classification. Because of the lack of availability in literature, they tend to commit mistakes. Hence, it is pertinent to present it in a journal with a wide readership.
| Acknowledgments|| |
The author dedicates this publication to late Prof. C. Balakrishnan, the father of modern plastic surgery in India and the teacher of teachers. The author thanks the residents and new generation cleft surgeons who motivated, rather forced me to write this manuscript. Thanks are due to Dr. Aparna Agrawal, Director Professor of Medicine for editing and correction of English transcript.
| References|| |
|1.||Davis JS, Ritchie HP. Classification of congenital clefts of the lip and palate. JAMA 1922;79:1323-7. |
|2.||Balakrishnan C. Indian classification of cleft lip and palate. Indian J Plast Surg 1975;8:23-4. |
|3.||Brophy TW. Cleft palate and harelip procedures. Int J Orthod Oral Surg 1921;7:319-30. |
|4.||Veau V. Division Palantine. Paris: Masson et Cie; 1931. |
|5.||Kernahan DA, Stark RB. A new classification for cleft lip and cleft palate. Plast Reconstr Surg Transplant Bull 1958;22:435-41. |
|6.||Vilar-Sancho B. A proposed new international classification of congenital cleft lip and cleft palate. Plast Reconstr Surg Transplant Bull 1962;30:263-6. |
|7.||Harkins CS, Berlin A, Harding RL, Longacre JJ, Snodgrasse RM. A classification of cleft lip and cleft palate. Plast Reconstr Surg Transplant Bull 1962;29:31-9. |
|8.||Dahl E. Craniofacial morphology in congenital clefts of the lip and palate. An x-ray cephalometric study of young adult males. Acta Odontol Scand 1970;28 Suppl 57:11+. |
|9.||Spina V. A proposed modification for the classification of cleft lip and cleft palate. Cleft Palate J 1973;10:251-2. |
|10.||Sandham A. Classification of clefting deformity. Early Hum Dev 1985;12:81-5. |
|11.||Kernahan DA. The striped Y - A symbolic classification for cleft lip and palate. Plast Reconstr Surg 1971;47:469-70. |
|12.||Elsahy NI. The modified striped Y - A systematic classification for cleft lip and palate. Cleft Palate J 1973;10:247-50. |
|13.||Millard DR Jr. Cleft Craft. Vol. I. Boston: Little, Brown and Company; 1977. p. 41-55. |
|14.||Friedman HI, Sayetta RB, Coston GN, Hussey JR. Symbolic representation of cleft lip and palate. Cleft Palate Craniofac J 1991;28:252-9. |
|15.||Smith AW, Khoo AK, Jackson IT. A modification of the Kernahan "Y" classification in cleft lip and palate deformities. Plast Reconstr Surg 1998;102:1842-7. |
|16.||Berlin AJ. Classification of cleft lip and palate and related craniofacial disorders. In: Bzock KR, editor. Communicative Disorders Related to Cleft Lip and Palate. 2 nd ed. Boston: Little, Brown and Company; 1979. p. 20. |
|17.||Kernahan DA. On cleft lip and palate classification. Plast Reconstr Surg 1973;51:578. |
|18.||McCabe PA. A coding procedure for classification of cleft lip and cleft palate. Cleft Palate J 1966;3:383-91. |
|19.||Santiago A. Classification of cleft lip and palate for machine record coding. Cleft Palate J 1969;6:434-9. |
|20.||Schwartz S, Kapala JT, Rajchgot H, Roberts GL. Accurate and systematic numerical recording system for the identification of various types of lip and maxillary clefts (RPL system). Cleft Palate Craniofac J 1993;30:330-2. |
|21.||Ortiz-Posadas MR, Vega-Alvarado L, Maya-Behar J. A new approach to classify cleft lip and palate. Cleft Palate Craniofac J 2001;38:545-50. |
|22.||Castilla EE, Orioli IM. ECLAMC: The Latin-American collaborative study of congenital malformations. Community Genet 2004;7:76-94. |
|23.||Liu Q, Yang ML, Li ZJ, Bai XF, Wang XK, Lu L, et al. A simple and precise classification for cleft lip and palate: A five-digit numerical recording system. Cleft Palate Craniofac J 2007;44:465-8. |
|24.||Kriens O. Lahshal: A concise documentation system for cleft lip, alvolus and palate diagnoses. In: Kriens O, editor. What is Cleft Lip and Palate? A Multidisciplinary Update Workshop, Bremen 1987. Stuttgart: Thieme; 1989. |
|25.||Hodgkinson PD, Brown S, Duncan D, Grant C, McNaughton A, Thomas P, et al. Management of children with cleft lip and palate: A review describing the application of multidisciplinary team working in this condition based upon the experiences of a regional cleft lip and palate centre in the United Kingdom. Matern Med Rev 2005;16:11-27. |
|26.||Rossell-Perry P. New diagram for cleft lip and palate description: The clock diagram. Cleft Palate Craniofac J 2009;46:305-13. |
|27.||Luijsterburg AJ, Rozendaal AM, Vermeij-Keers C. Classifying common oral clefts: A new approach after descriptive registration. Cleft Palate Craniofac J 2014;51:381-91. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3]