08-070%2E1g

New Diagram for Cleft Lip and Palate Description: The Clock Diagram

Percy Rossell-Perry, M.D.

Objectives: The current classification diagrams for cleft lip and palate aredescriptions of the components involved in the cleft, but they do not consider indetail the severity of distortion. We sought to establish a new diagram (theClock Diagram) for cleft lip and palate, which describes the pathology accordingto the severity of distortion of the nose, lip, and primary and secondary palate,and to apply this classification scheme toward treatment selection.

Methods: The method is based on surgical results obtained from 1043 cleft lipand palate patients operated by the author between 1996 and 2007, under theprotocol based on our classification. To further illustrate the classification anddiagram method, two types of clefts are described, using the proposed diagramand compared with Kernahan’s diagram.

Results: This new diagram describes the cleft’s severity using terminologyfrom our clinic’s classification of cleft severity. In comparison with Kernahan’sdiagram, the Clock Diagram more effectively demonstrates a cleft’s severity. Ihave observed a higher incidence of lip and palate revision in severe clefts.

Conclusions: The Outreach Program Lima Clock Diagram classifies theseverity of the cleft and affords an individualized description of cleftmorphology. I have observed a direct relation between cleft severity and thenumber of poor outcomes in our patients.

KEY WORDS: classification, cleft lip and palate, diagram, severity

A common question in cleft reconstruction is, Should we

use the same treatment for any kind of cleft lip and palate?

We do believe the answer is no because the morphology of

clefts varies. There is a need for a new classification and

diagram that will allow for the most complete cleft

description possible involving the four basic components

of the cleft: nose, lip, primary palate, and secondary palate.

The current classifications for cleft lip and palate are

descriptions of the components involved in the cleft, but

they do not consider the severity of its distortion and

diagrams. The Kernahan and Stark’s classification and

diagram is one of the most used around the world. This

diagram shows us which anatomic segment is involved but

not how severely it is affected (Kernahan and Stark, 1958).

During recent years, new classifications and diagrams

have been developed that provide more specific cleft

descriptions. Based on the striped Y diagram (Kernahan,

1971), other authors described some modifications, but they

did not develop a new diagram (Friedman et al., 1991;

Schwartz et al., 1993). Mortier and Martinot (1997)

developed a scale that included preoperative and postoper-

ative results. Its disadvantage is that it has been applied only

to unilateral clefts and does not consider the width of the

cleft. Smith et al. (1998) described a more comprehensive

classification, but this is based on Kernahan’s description,

which considers the clefts as complete or incomplete only.

Ortiz-Posadas et al. (2001) published a new classification

based on cleft severity that included a very good description

of the cleft deformity. However, their scheme is too extensive

and difficult to remember and did not include a new

diagram. In addition, the secondary palate is described in a

manner similar to traditional classifications.

All these approaches have attempted to characterize

many features of cleft lip and palate, but they consider the

patient’s anatomy in a limited form or represent a

classification that is difficult to remember and apply. In

addition, most of these new descriptions do not include a

new diagram. The severity of the cleft is one of the most

important elements to be considered in presurgical plan-

ning. The use of presurgical orthopedics and modifications

of traditional surgical techniques are examples of individ-

ualized management of the more severe forms of cleft lip.

This work illustrates the design of a new diagram for cleft

lip and palate that is based on the degree of severity of the

four basic cleft components: nose, lip, primary palate, and

secondary palate.

METHODS

The method used is based on surgical results obtained

from 1043 patients with cleft lip and palate who were

Dr. Rossell-Perry is Medical Director, Interplast Foundation Outreach

Surgical Center, Lima, Peru.

Presented at the 10th International Congress on Cleft Lip and Palate and

Related Craniofacial Anomalies, Durban, South Africa, September 2005.

Submitted August 2008; Accepted October 2008.

Address correspondence to: Percy Rossell-Perry, M.D., Schell Street 120,

Apartment 1503, Miraflores, Lima, Peru. E-mail [email protected].

DOI: 10.1597/08-070.1

305

operated by the author, under the protocol guided by our

classification system (Tables 1, 2, and 3), from 1996 to 2007

(Rossell, 2006).

In all cases, we performed a presurgical estimation of the

measurements (Table 3). I used the Millard technique and a

modification (Reichert-Millard technique) for unilateral

cleft lip repair, a modified Mulliken technique for bilateral

cleft lip repair, and the Bardach technique for cleft palate

repair (Millard, 1990; Rossell, 2008).

To further illustrate the classification and diagram

method, two cases with different clefts are described using

the proposed diagram and are compared with others. For

cleft lip and palate description, I use the four basic

components: nose, lip, primary palate, and secondary

palate.

Nose

Changes in nasal components affect mainly the cartilage

structures. One of the most important affected components

of the nose is the lower lateral cartilage. This cartilage will

be displaced in three directions in relation to cleft severity,

so we can see three types of nasal deformity in a cleft lip.

In relation to other components such as the septum and

the maxilla, the amount of bony deficiency of the maxilla in

particular largely determines the displacement of the nose,

especially vertically and posteriorly. The deformity of

septum and maxilla affects not only nasal morphology

but also surgical outcomes.

Unilateral Cleft Lip (Fig. 1, above)

a) Mild: There is only horizontal displacement of the nose

on the cleft side.

b) Moderate: There is horizontal and vertical displace-

ment of the nose.

c) Severe: There is horizontal, vertical, and posterior

displacement of the nose.

Bilateral Cleft Lip (Fig. 2, above)

a) Mild: The columellar length is 2/3 to 1/3 of nasal height.

b) Moderate: The columellar length is up to 1/3 of nasal

height.

c) Severe: There is no visual evidence of the columella.

TABLE 1 Unilateral Cleft Lip Classification of Severity

Outreach Surgical Center, Lima, Peru

Type Nose Primary Palate Lip

A. Mild Mild Cleft less than 5 mm A1. Cupid’s bow less than 30 degrees

A2. Cupid’s bow between 30 and 60 degrees

A3. Cupid’s bow higher than 60 degrees

B. Moderate Moderate Cleft between 5 and 15 mm B1. Cupid’s bow less than 30 degrees

B2. Cupid’s bow between 30 and 60 degrees

B3. Cupid’s bow higher than 60 degrees

C. Severe Severe Cleft wider than 15 mm C1. Cupid’s bow less than 30 degrees

C2. Cupid’s bow between 30 and 60 degrees

C3. Cupid’s bow higher than 60 degrees

TABLE 2 Bilateral Cleft Lip Classification of Severity

Outreach Surgical Center Program, Lima, Peru

Type Nose Primary Palate Lip

A. Mild Columella 1/3 to 2/3 of nasal length Cleft less than 5 mm Prolabium 2/3 or more of lateral segment length

B. Moderate Columella up to 1/3 of nasal length Cleft between 5 and 15 mm Prolabium 1/3 to 2/3 of lateral segment length

C. Severe No nasal columella Cleft wider than 15 mm Prolabium 1/3 or less of lateral segment length

TABLE 3 Outreach Surgical Center Lima, Protocol

Outreach Surgical Center, Lima, Cleft Lip Protocol

Type Cleft Morphology Technique Time

Mild Microform Mulliken 3 months old

Unilateral complete or

incomplete

Reichert-Millard 3 months old

Bilateral complete or

incomplete

Mulliken modified 3 months old

Alveolar cleft Alveolar bone graft 6–8 years old

Moderate Unilateral complete cleft Reichert-Millard 3 months old

Bilateral complete cleft Mulliken modified 3 months old

Moderate nose deformity Primary rhinoplasty 3 months old

Moderate alveolar cleft Alveolar bone graft 6–8 years old

Severe Unilateral complete cleft Reichert-Millard 3 months old

Bilateral complete cleft Mulliken modified 3 months old

Severe nose deformity Primary rhinoplasty 3 months old

Severe alveolar cleft Alveolar bone graft 6–8 years old

Nasoalveolar molding or

lip adhesion

1–2 months old

Outreach Surgical Center Lima, Cleft Palate Protocol

Type Cleft Morphology Technique Time

Mild Incomplete form Soft palate repair

Index: less than 0.2 Minimal incision 1.5 years old

Two-flap palatoplasty 1.5 years old

Moderate Index: between 0.2 and 0.4 Two-flap palatoplasty 1.5 years old

Severe Index: greater than 0.4 Soft palate repair 6 months old

Delayed hard palate

repair

1.5 years old

Alveolar molding 1–2 months

old

306 Cleft Palate–Craniofacial Journal, May 2009, Vol. 46 No. 3

Lip

There is an absolute soft tissue deficiency in a cleft lip.

This involves all of the anatomic components: skin, muscle,

and mucosa.

Medial Segment

For unilateral cleft lips, I use the cupid’s bow rotation to

estimate the tissue deficiency in the lip component. Therefore,

high rotation of cupid’s bow leads to more tissue deficiency in

the medial lip component; whereas, with a low rotation of

cupid’s bow, less tissue deficiency is seen in the lip.

For bilateral cleft lips, I use the height of the prolabium

in relation to the height of the lateral lip segment.

I consider three degrees of severity for the lip component

in each type of cleft.

Unilateral Cleft Lip (Fig. 1, below)

a) Mild: Cupid’s bow rotation less than 30 degrees.

b) Moderate: Cupid’s bow rotation between 30 and 60 degrees.

c) Severe: Cupid’s bow rotation greater than 60 degrees.

Bilateral Cleft Lip (Fig. 2, below)

a) Mild: Prolabium height is 2/3 of lateral lip segment

height.

b) Moderate: Prolabium is between 2/3 and 1/3 of lateral

lip segment height.

c) Severe: Prolabium height is less than 1/3 of lateral lip

segment height.

Lateral Segment

The tissue deficiency observed is less common in the

lateral segment than in the medial segment. To estimate the

severity of this deficiency, I use the difference between cleftand noncleft sides for unilateral clefts and the difference

between both sides for bilateral clefts.

I compare the distance from the noncleft cupid’s bow

peak to the noncleft commissure and the distance measured

FIGURE 1 Above: Unilateral nasal component severity. Below: Unilateral lip component severity.

Rossell-Perry, NEW DIAGRAM FOR CLEFT LIP AND PALATE 307

from the point on the lateral segment where the white roll

ends to the commissure on that side for a unilateral cleft lip.

The difference between these two segments shows the

severity of the cleft in the lateral segment.

Unilateral and Bilateral Cleft Lip

a) Mild: Difference less than 5 mm.

b) Moderate: Difference between 5 and 10 mm.

c) Severe: Difference greater than 10 mm.

In incomplete forms, the presence or absence of

Simonart’s band is not relevant because this tissue is not

used in lip and nose reconstruction and should, in my

opinion, be removed. The presence of this band isrepresented in the primary palate component (see below)

by number 7 (0 to 5 mm) as a mild cleft deformity (0 mm).

Primary Palate

I use cleft width to determine a severity grade for

unilateral and bilateral clefts. In bilateral clefts, the type of

cleft is determined by the more severely affected side.

Unilateral and Bilateral Cleft Lip (Fig. 3)

a) Mild: Cleft width less than 5 mm.

b) Moderate: Cleft width between 5 and 15 mm.

c) Severe: Cleft width greater than 15 mm.

Secondary Palate

Evaluation of this component should be done before

palatoplasty is performed. The initial evaluation of cleft

palate width changes after lip repair because of the repaired

orbicularis oris muscle action.

Estimation of the cleft palate is done by comparing thecleft’s width (X) versus the width of both palatal segments

(Y1 + Y2) (Fig. 4). This distance has been taken at the

posterior border of the palatine bone between the hard and

soft palate, from the lateral mucosal and gingival union to

the posterior nasal spine.

X: Cleft width measured at hard palate posterior border level.

Y: Palatal segment diameter (right and left) measured at the

same level as X.

Ratio: X/Y1 + Y2

Under this estimation, the classification for the second-

ary palate component is as follows:

a) Mild: Ratio is less than 0.20.

FIGURE 2 Above: Bilateral nasal component severity. Below: Bilateral lip component severity.


b) Moderate: Ratio is between 0.20 and 0.40.

c) Severe: Ratio is greater than 0.40.

THE CLOCK DIAGRAM

This is a circle divided into four areas, one for each cleft

component. Each area is subdivided into three segments,

which represent the three degrees of severity: mild,

moderate, and severe (Fig. 5).

I assign the clock numbers (1 to 12) to each degree of

severity of the four components as follows:

a) Right superior quadrant (nasal deformity).

Degrees: Mild (1), Moderate (2), Severe (3).

b) Right inferior quadrant (medial segment lip and

prolabium deformity).


(The lateral segment lip deficiency is less common thanthe medial segment deformity, so I include its

description in the cleft code—see below.)

c) Left inferior quadrant (primary palate severity).


(For bilateral clefts, I describe both sides in the

diagram.)

d) Left superior quadrant (secondary palate severity).


The Cleft Code

The cleft consists of four numbers, one from each cleft

component described on the cleft diagram. These four digit

FIGURE 3 Unilateral and bilateral primary palate component severity.

FIGURE 4 Secondary palate component severity.


codes are simple to obtain from the clock diagram and

provide an accurate description of the severity of the cleft

deformity.

The sign (*) beside the second number (lip component)

indicates that the lateral segment is too short (Fig. 6). In

bilateral cases, the left side is represented beside the second

number (lip component) (Fig. 7).

RESULTS

The numbers of patients and the types of clefts are shown

in Tables 4 and 5. I use two different cleft types to illustrate

the classification and diagram method and the differences

with Kernahan’s diagram.

Type 1: Unilateral Cleft Lip (Fig. 6)

Two complete unilateral cleft lips are illustrated.

Kernahan’s diagram for these clefts is the same, even

though the clefts differ in severity.

Using the clock diagram and severity classification, we

have a different description for each cleft, in accordance

with differences in anatomy. Each one has a different code,

which is easy to remember also (Fig. 6). Description of the

cleft’s width and degree of lip tissue deficiency is not

addressed on Kernahan’s diagram. The cleft on the right

side has a short lateral segment, and this condition is

represented on the cleft code with the sign (*) beside the

second number (lip component).

Type 2: Bilateral Cleft Lip (Fig. 7)

Two complete bilateral cleft lips are illustrated. Kerna-

han’s diagram for these clefts again is the same. The clock

diagram shows a different description for each cleft that

provides important information for cleft lip and palate

FIGURE 5 The clock diagram.

FIGURE 6 Comparison of Kernahan’s method and clock diagram for unilateral cleft lip cases.


management (Fig. 7). Finally, to simplify and encourage

use of the system, a quick ‘‘cheat sheet’’ can be made for the

surgeon by placing the severity tables at the bottom of the

page that contains the clock diagram (Fig. 8).

DISCUSSION

This new diagram offers an estimation of cleft severity

based on our clinic’s cleft severity classification and better

describes individual cleft deformity in comparison with

Kernahan’s diagram. The code in Kernahan’s method and

in others is binary: The anomaly is described as either

present or absent. The degree of severity of a cleft is not

taken into consideration. The use of the same diagram and

code for each anomaly suggests that all components are

equally important.

In our method, evaluation of each feature is not binary;

three degrees are available for each cleft component,

providing more detailed information with respect to cleft

anatomy. This system is easy to remember and apply, and

this feature represents the most important difference from

other well-described classifications such as Mortier’s and

Ortiz-Posadas’s. In addition, there is no correlation

between these classifications and the authors’ management

protocols.

This severity classification and the clock diagram are

related to our management protocol. Severe forms require

presurgical treatment to obtain better results and fewer

complications. I have observed a higher incidence of lip and

palate revision in severe clefts, as have other authors

(Henkel, 1998). In my patients, 66.6% of all cases that need

major secondary revision are severe forms of unilateral and

FIGURE 7 Comparison of Kernahan’s method and clock diagram for bilateral cleft lip cases.

TABLE 4 Number of Patients and Type of Cleft

Type of Cleft n %

Unilateral cleft lip 460 44.1

Bilateral cleft lip 125 11.9

Complete cleft palate 388 37.2

Incomplete cleft palate 77 7.4

TABLE 5 Unilateral and Bilateral Types of Cleft

Type of Unilateral Cleft n %

Mild 192 41.73

Moderate 181 39.35

Severe 87 18.91

Total 460 100

Type of Bilateral Cleft

Mild 24 19.2

Moderate 36 28.8

Severe 65 52

Total 125 100

Type of Cleft Palate

Mild 50 10.91

Moderate 252 55.02

Severe 156 34.06

Total 458 100


bilateral cleft lip. In addition, severe forms of cleft palatehave a higher incidence of postoperative fistula (73% of

fistulas) and of velopharyngeal incompetence (49.52% of

VPI cases).

Finally, I must acknowledge that this system has some

shortcomings, such as the absence of lateral segment

description on the clock diagram and of other components

such as the nasal septum and maxilla. This deficiency

should be improved in the future.

CONCLUSIONS

A diagram was developed to characterize clefts according

to their severity. Traditional methods that have been

developed involve diverse cleft characteristics but arelimited in their description or are too cumbersome for

application. In addition, there is no correlation between

these classifications and management protocols.

Using our diagram, it is possible to incorporate elements

that are not considered in other approaches and to describeall possible clefts. Our method describes unilateral and

bilateral cleft lips and palates, assessing the severity of each

of the four cleft components. As such, this method provides

a very valuable tool for the evaluation of progress in

patient rehabilitation. This severity-based classification and

clock diagram are directly related to the management

protocol used in our clinic (Table 3).

Acknowledgments. I would like to thank Dr. Bill Schneider for his

assistance with native English speaker manuscript revision.

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