9/22/2015

Classificationofcleftlipandpalate:AnIndianperspective:KaroonAgrawal,JournalofCleftLipPalateandCraniofacialAnomalies

REVIEWARTICLE
Year:2014|Volume:1|Issue:2|Page:7884

Classificationofcleftlipandpalate:AnIndianperspective
KaroonAgrawal
Director Professor and Head, Department of Burns, Plastic and Maxillofacial Surgery, Safdarjung Hospital and VMMC, New Delhi,
India
CorrespondenceAddress:
KaroonAgrawal
T23,FirstFloor,GreenParkMain,NewDelhi110016
India

Abstract
Classificationoftheclefthasevolvedoveracentury.Manydescriptive,diagrammatic,andcodingsystemshavebeen
proposedtobeused.However,thereareonlyfewwhichhavestoodthetestoftime.OneofthemisIndianclassification.
Indianclassificationofcleftlip(CL)andpalateproposedin1975isapopularclassificationinIndiapresently.Thereare
numerouscombinationsofcleftdeformities,andwefoundthatsomeofthemcouldnotbeclassifiedappropriatelywith
theoriginalclassification.Thecleftsareclassifiedinthreegroups:CLasGroup1,cleftpalateasGroup2andGroup3
for combined CL, alveolus and palate in continuity. Originally right, left, midline, and alveolus were abbreviated. To
maketheclassificationwholesome,theoriginalclassificationhasbeenrevisitedandpresentedwithadditionalfeatures.
Thebasicclassificationinthreegroupsremainsasoriginal.Additionalabbreviationshavebeenaddedtoclassifythe
specialsituations.Partial,submucosal,SimonartSQsband,protrudingpremaxilla,andmicroformhavebeenaddedto
thelistofabbreviations.Thisclassificationhasbeenusedforover30yearsbytheauthorinover4000cleftpatients.We
finditsimpletouse,versatileenoughtoclassifyalmostallpossiblecleftcombinations,easyforcommunicationduring
discussionandconvenienttowriteasdiagnosisinpatientsSQfiles.Easycomputerarchivingandefficientretrievalof
thedataarethespecialfeaturesofthisclassification.

Howtocitethisarticle:
AgrawalK.Classificationofcleftlipandpalate:AnIndianperspective.JCleftLipPalateCraniofacAnomal20141:78
84

HowtocitethisURL:
AgrawalK.Classificationofcleftlipandpalate:AnIndianperspective.JCleftLipPalateCraniofacAnomal[serial
online]2014[cited2015Sep22]1:7884
Availablefrom:http://www.jclpca.org/text.asp?2014/1/2/78/137894

FullText
http://www.jclpca.org/printarticle.asp?issn=23482125year=2014volume=1issue=2spage=78epage=84aulast=Agrawal

1/6

9/22/2015

Classificationofcleftlipandpalate:AnIndianperspective:KaroonAgrawal,JournalofCleftLipPalateandCraniofacialAnomalies

Introduction

Cleftlipandpalate(CLP)iscommonandinterestingcraniofacialanomalyinplasticandreconstructivesurgery.CLP
hasmanyvariationsandcombinations.Thismakesitdifficulttoexpresscorrectly.Todescribeagroupofanomalies,
classificationsystemorgradingsystemserveasaneffectivetoolofcommunication.Goodclassificationsystemallows
us to organize a large amount of data into a comprehensive system and simplifies treatment planning and record
keeping.ThiswasrealizedbyDavisandRitchiein1922andpresentedthefirstclassificationofCLP.[1]Sincethen
manycleftsurgeonshavepresentedvariousclassificationsbasedonanatomy,morphologyandembryology.Thereare
many based on diagrammatic representation. In this article, attempt has been made to trace the chronological
development of classification systems. Balakrishnan, [2] presented Indian classification in 1975. This still remains a
popularcleftclassificationsysteminIndia.
TheIndianclassificationhasnotbeenpublishedintheformatinwhichitisbeingusedpresently.Thepublishedarticle
emphasizes that clefts could occur at nine sites and this could be coded for ease of computerization, in the format
prevalentthen.[2]Wehaveencounteredmanychildrenwithcleft,whichcouldnotberightlyplacedinthisdescriptive
classification.Hence,theoriginalclassificationhasbeenmodifiedandpresentedwithadditionalfeatures.

EvolutionofCleftClassifications

DavisandRitchiepresentedthefirstclassificationforcongenitalCLP.Thealveolarprocessformedthefoundationfor
groupings: Group I Prealveolar, Group II Postalveolar, Group III Unilateral alveolar cleft and Group IV Bilateral
alveolarcleft.Theysuggestedthattheterm"harelip"shouldbediscarded.[1]Thiswasneitherananatomicalnoran
embryologicalclassification.AroundthesametimeBrophy(19211923)classifiedthecleftsin16distinctmorphological
forms.[3]However,thiswasconsideredtoodifficultandimpractical.
Veau'sclassificationinfourgroupswasalsofarfromanatomicalandisnotinusetoday.Cleftlip(CL),CLwithalveolus,
midlinecleftsandmanymorewerenotincludedinVeau'sclassification.[4]KernahanandStarkdesignatedtheincisive
foramenasthedividingpointbetweenprimaryandsecondarypalates.Thiscorrectlydescribedthedeformity.[5]
VilarSanchoclassifiedandcodedthembasedonGreeknomenclature.Lipwasrepresentedby"K"(keilos),alveolusby
"G"(gnato),hardpalateby"U"(urano)andsoftpalateby"S"(stafilos).Completecleftwasrepresentedincapitalsand
partialinsmallletters."2"wasusedtorepresentbilateral,"d"indicatedright,"l"indicatedleft,an"I"indicatedincomplete
and"o"indicatedoperated.BeinginGreek,itcouldnotbeadaptedbytherestoftheworld.Italsocouldnotclassify
many of the clefts. [6] Harkins et al. were appointed by American cleft palate association (ACPA) to design a
classificationofCLP.TheyproposedaclassificationinsixgroupsbasedontheconceptofKernahanandStark.This
includedrarecleftsalongwiththeusualclefts.Harkinsetal.dividedthegroupsfurtherbasedontheextentandsides.
[7]Thismadetheclassificationquiteelaborateanddifficulttorememberforanaveragecleftsurgeon.Hence,itdidnot
becomepopular.
Dahldividedthecleftsinfourgroups:CL,cleftpalate(CP),andunilateralCLPandbilateralCLP.[8]Spinamodifiedthe
ACPAclassificationwithincisiveforamenasareferencepoint.Cleftsweredividedintofourgroups:GroupIPreincisive
foramenclefts,GroupIITransincisiveforamenclefts,GroupIIIPostincisiveforamencleftsandGroupIVRarefacial
clefts. Each group had unilateral, bilateral and median each was further subdivided into total and partial. This was
adaptedbytheInternationalSocietyforPlasticandReconstructiveSurgery.[9]Sandhamaddedtype5as"othertypes
ofclefts"overDahl'sproposedclassification.[10]Alltheseclassificationsaredescriptiveandnotconvenientforroutine
communication.Itisdifficulttoarchiveincomputerandhencedataretrievalalsomaynotbeeasy.
Kernahanproposed"Y"classificationinnineboxeswithnasopalatineforamenasthecentralpoint.[11]Itwasfurther
modifiedbyElsahy,Millard,Friedmanetal.,Smithetal.andmanymore.[12],[13],[14],[15]ThemodifiedKernahan's"Y"
classificationrepresentsthecleftdeformityexactlyasitexistsandisveryversatile.Thishasunquestionableutilityforthe
clinicians. [16] This classification is a diagrammatic or symbolic representation of the cleft deformity and used for
http://www.jclpca.org/printarticle.asp?issn=23482125year=2014volume=1issue=2spage=78epage=84aulast=Agrawal

2/6

9/22/2015

Classificationofcleftlipandpalate:AnIndianperspective:KaroonAgrawal,JournalofCleftLipPalateandCraniofacialAnomalies

documentation or charting very effectively. It cannot be used for writing the diagnosis in the case file, for verbal
communicationordescriptioninthetextformatnorcanitbeusedforcomputerarchiving.Inthetruesense,itisnota
classification.ItisasymbolicrepresentationofthevariouscleftdeformitiesasKernahanhimselfstated.[17]
TherehavebeenmanyattemptstocodethevarioustypesofCLP.McCabeusedelectronicdataprocessingsystemfor
punchingcards.[18]SantiagocodedtheCLPformachinerecording,[19]Schwartzetal.introducedanRPLsystemfor
numerical coding with 03 numbers to simplify the representation of the clefts, [20] OrtizPosadas et al. developed
mathematicalexpressioninnumericalscoresreflectingcomplexityofclefts,[21]CastillaandOriolipresentedECLAMC
systemfornumeralcoding,[22]Liuetal.publishedfivedigitnumericalrecordingsystemforCLP[23]andmanymore.
However, these methods of classification or coding systems did not gain popularity because of its complexity and
difficultyinremembering.
Kriens,1989proposedLAHSHAL,anabbreviateddocumentationsystem.Lip(L),alveolus(A),hardpalate(H),andsoft
palate(S)wereusedtoformLAHSHAL.[24]Later,itwasmodifiedtoLAHSALontherecommendationofRoyalCollege
ofSurgeonsUKin2005.[25]ThiswasasimplifiedversionofKernahan's"Y"classificationandhadsimilarshortcomings
andlimitations.
AclockdiagramforCLPwasintroducedbyRossellPerry,todescribethepathologybasedontheseverityofdistortion
ofnose,lip,andpalate.Thesurgicaltreatmenthasbeendescribedbasedonthisclassification.Theauthorclaimsto
haveobservedtherelationshipwiththeseverityandtheoutcome.[26]Mostofthecleftsurgeonsmaynotagreewiththis
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 pathoembryological events resulting in various sub
phenotypesofcommonoralclefts.PatientswithinthethreecategoriesCL/alveolus(CL/A),CL/Aandpalate,andCP
weredividedintothreesubgroups:Fusiondefects,differentiationdefects,andfusionanddifferentiationdefects.This
classificationprovidesnewcleftsubgroupsthatmaybeusedforclinicalandfundamentalresearch.[27]However,this
classificationhaslittleroleinclinicalpractice.

IndianClassificationanditsModification

TheoriginalIndianclassificationandbriefnotationsaspublishedbyBalakrishnanaregivenin[Table1].Usingthese
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. [2]
Whileusingtheclassificationanddilemmaover"/"sign,wereplaceditwith"+"signasitwasmoreappropriatesignto
expressthecombination.Inoriginalclassificationsystemcompletenessofthecleftisnotspecified.Tomarkthepartial
cleft"P"notationwasevolved.Ifthereisnospecificnotation,itisconsideredascompletecleft.Thereafter"S"wasadded
torepresent"submucosal"cleft.AbbreviationsforSimonart'sband,protrudingpremaxilla(Pmax),andmicroform,"sb,"
"Pmax"and"micro"respectivelywereaddedovertheyears[Table1].Theabbreviationpartofthisclassificationhasfour
parts.Groupisabbreviatedas"Gp"inthefirstpart.Otherpartsarewelldepicteddiagrammatically[Figure1].{Figure1}
{Table1}
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],
[Figure2],[Figure3],[Figure4],[Figure5]and[Figure6].{Figure2}{Figure3}{Figure4}{Figure5}{Figure6}{Table2}

ClinicalExperience

Balakrishnan'sIndianclassificationhasbeenusedbyusinmorethan4000cleftpatientsoveraperiodof30years.With
the addition of more abbreviations, it has become more versatile. It is now possible to classify almost all the
combinationsofthecleftsencountered,anditcanberepresentedbyabriefnotation.Onaroughestimate,morethan
1000cleftsurgeonsinIndiaareusingthisclassificationfordecadesasatestamenttoitsvalidity.
http://www.jclpca.org/printarticle.asp?issn=23482125year=2014volume=1issue=2spage=78epage=84aulast=Agrawal

3/6

9/22/2015

Classificationofcleftlipandpalate:AnIndianperspective:KaroonAgrawal,JournalofCleftLipPalateandCraniofacialAnomalies

Thisclassificationistaughttoourresidentsduring1stmonthoftheirtraining.Theauthorhaspersonallytaughttomore
than40residentsoverpast30years.Allofthemareabletousethisclassificationveryeffectively,withashortlearning
curvethough.

Discussion

The Indian classification has anatomical and embryological basis. This is more logical version of original Davis and
Ritchie (1922) [1] and Dahl classifications. [8] Incisive foramen is the demarcation between primary and secondary
palate.AnycleftanteriortoincisiveforamenisGroup1andcleftbehindincisiveforamenislabeledasGroup2(Gp2).
When it is involving incisive foramen, both primary, and secondary palate will be cleft. Hence, it has been rightly
groupedasGroup3.
Clinicallytoo,thisclassificationisquiterelevant.Allelementsoftheprimarypalate,thatis,lip,alveolus,anteriorpalate
andnosearerepairedtogetherasasingleentity.Theelementsofthesecondarypalate,thatis.,hardandsoftpalate
anduvulaarerepairedtogether,hencegroupedtogetherasGp2.
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
severecausingfunctionalaswellasestheticconcerns.Thiswaythegroupinghasbeendoneinincreasingorderof
severityfrom1to3.Thisorderisfollowedinveryfewclassificationsystems.[8],[9]Manyclassificationsdidnotfollow
thisorderofincreasingclinicaldeformity,[4],[16]stillsomeofthemwereusedextensively[Table3].{Table3}
Popularityofaclassificationsystemandmanyclinicalpracticesdependupontheteachers,howtheyteach,preach,and
practice. Most of the students are clones of their teachers. Veau had a great following and his trainees have rightly
passedonthelegacytotheirnextgenerations.Hence,theclassificationdesignedbyVeaubecamepopularandisstill
inuseinafewcenters,thoughtechnicallyitisnotsound,isincomplete,doesnothaveanembryologicalbasisandis
notrelevantsurgically.Indianclassificationhassurvivedoverthepast40years.Thisispopularinspiteofnotfindinga
place in textbooks or websites. It has survived because Balakrishnan's trainees passed on the baton to the next
generationeffectively.Simultaneouslybecauseitisembryologicallyandclinicallysound.
There are many cleft coding systems or schematic representation of clefts in literature. [17],[18],[19],[20],[21],[22],[23],
[24],[25],[26],[27]Thesearestandalonecodingsystems.Theyaredifficulttocommunicateorwriteinthepatientrecords.
However,theyareusefulfordocumentation,computerization,andarchiving.TheIndianclassificationscoresoverall
theseclassificationsbecauseitisdescriptiveandalsohasanabbreviationform.Theseabbreviationscanbeusedfor
codingofclefts[Table1]and[Table2],[Figure7].Thisistheonlyclassificationwhichincorporatesbothinthesame
system.{Figure7}
ThisIndianclassificationissimple,easytocommunicate,easytowriteinabbreviatedformat,anditisalsopossibleto
code it. It is very convenient for data retrieval from the computer archive. The abbreviated form of classification is
especiallyusefulforshortcommunicationandcodingofthepatients'records.
Thiscontributiontotheliteratureisessentialformakingthisclassificationavailabletothecleftsurgeonsalloverthe
world. The new generation residents are not aware of this full classification. Because of the lack of availability in
literature,theytendtocommitmistakes.Hence,itispertinenttopresentitinajournalwithawidereadership.

Acknowledgments

TheauthordedicatesthispublicationtolateProf.C.Balakrishnan,thefatherofmodernplasticsurgeryinIndiaandthe
teacherofteachers.Theauthorthankstheresidentsandnewgenerationcleftsurgeonswhomotivated,ratherforced
me to write this manuscript. Thanks are due to Dr. Aparna Agrawal, Director Professor of Medicine for editing and
correctionofEnglishtranscript.

References

http://www.jclpca.org/printarticle.asp?issn=23482125year=2014volume=1issue=2spage=78epage=84aulast=Agrawal

4/6

9/22/2015

Classificationofcleftlipandpalate:AnIndianperspective:KaroonAgrawal,JournalofCleftLipPalateandCraniofacialAnomalies

References
1

DavisJS,RitchieHP.Classificationofcongenitalcleftsofthelipandpalate.JAMA192279:13237.

2
3

BalakrishnanC.Indianclassificationofcleftlipandpalate.IndianJPlastSurg19758:234.
BrophyTW.Cleftpalateandharelipprocedures.IntJOrthodOralSurg19217:31930.

VeauV.DivisionPalantine.Paris:MassonetCie1931.

Kernahan DA, Stark RB. A new classification for cleft lip and cleft palate. Plast Reconstr Surg Transplant Bull
195822:43541.

VilarSanchoB.Aproposednewinternationalclassificationofcongenitalcleftlipandcleftpalate.PlastReconstr
SurgTransplantBull196230:2636.
HarkinsCS,BerlinA,HardingRL,LongacreJJ,SnodgrasseRM.Aclassificationofcleftlipandcleftpalate.Plast
ReconstrSurgTransplantBull196229:319.

7
8

DahlE.Craniofacialmorphologyincongenitalcleftsofthelipandpalate.Anxraycephalometricstudyofyoung
adultmales.ActaOdontolScand197028Suppl57:11+.

SpinaV.Aproposedmodificationfortheclassificationofcleftlipandcleftpalate.CleftPalateJ197310:2512.

10
11

SandhamA.Classificationofcleftingdeformity.EarlyHumDev198512:815.
KernahanDA.ThestripedYAsymbolicclassificationforcleftlipandpalate.PlastReconstrSurg197147:469
70.

12

ElsahyNI.ThemodifiedstripedYAsystematicclassificationforcleftlipandpalate.CleftPalateJ197310:247
50.

13

MillardDRJr.CleftCraft.Vol.I.Boston:Little,BrownandCompany1977.p.4155.

14

Friedman HI, Sayetta RB, Coston GN, Hussey JR. Symbolic representation of cleft lip and palate. Cleft Palate
CraniofacJ199128:2529.

15

Smith AW, Khoo AK, Jackson IT. A modification of the Kernahan "Y" classification in cleft lip and palate
deformities.PlastReconstrSurg1998102:18427.
Berlin AJ. Classification of cleft lip and palate and related craniofacial disorders. In: Bzock KR, editor.

16

CommunicativeDisordersRelatedtoCleftLipandPalate.2nd ed.Boston:Little,BrownandCompany1979.p.
20.
17
18

KernahanDA.Oncleftlipandpalateclassification.PlastReconstrSurg197351:578.
McCabePA.Acodingprocedureforclassificationofcleftlipandcleftpalate.CleftPalateJ19663:38391.

19

SantiagoA.Classificationofcleftlipandpalateformachinerecordcoding.CleftPalateJ19696:4349.

20

Schwartz S, Kapala JT, Rajchgot H, Roberts GL. Accurate and systematic numerical recording system for the
identificationofvarioustypesoflipandmaxillaryclefts(RPLsystem).CleftPalateCraniofacJ199330:3302.

21

OrtizPosadasMR,VegaAlvaradoL,MayaBeharJ.Anewapproachtoclassifycleftlipandpalate.CleftPalate
CraniofacJ200138:54550.
CastillaEE,OrioliIM.ECLAMC:TheLatinAmericancollaborativestudyofcongenitalmalformations.Community
Genet20047:7694.

22
23

LiuQ,YangML,LiZJ,BaiXF,WangXK,LuL,etal.Asimpleandpreciseclassificationforcleftlipandpalate:A
fivedigitnumericalrecordingsystem.CleftPalateCraniofacJ200744:4658.

24

Kriens O. Lahshal: A concise documentation system for cleft lip, alvolus and palate diagnoses. In: Kriens O,
editor.WhatisCleftLipandPalate?AMultidisciplinaryUpdateWorkshop,Bremen1987.Stuttgart:Thieme1989.
HodgkinsonPD,BrownS,DuncanD,GrantC,McNaughtonA,ThomasP,etal.Managementofchildrenwithcleft
lipandpalate:Areviewdescribingtheapplicationofmultidisciplinaryteamworkinginthisconditionbasedupon
theexperiencesofaregionalcleftlipandpalatecentreintheUnitedKingdom.MaternMedRev200516:1127.

25

26
27

RossellPerry P. New diagram for cleft lip and palate description: The clock diagram. Cleft Palate Craniofac J
200946:30513.
Luijsterburg AJ, Rozendaal AM, VermeijKeers C. Classifying common oral clefts: A new approach after
descriptiveregistration.CleftPalateCraniofacJ201451:38191.

Tuesday,September22,2015
http://www.jclpca.org/printarticle.asp?issn=23482125year=2014volume=1issue=2spage=78epage=84aulast=Agrawal

5/6

9/22/2015

Classificationofcleftlipandpalate:AnIndianperspective:KaroonAgrawal,JournalofCleftLipPalateandCraniofacialAnomalies

SiteMap|Home|ContactUs|Feedback|CopyrightandDisclaimer

http://www.jclpca.org/printarticle.asp?issn=23482125year=2014volume=1issue=2spage=78epage=84aulast=Agrawal

6/6