Describing Cleft Lip and Palate Using a New Expression System

Rakesh Koul, M.D.S.

The wide spectrum of variations in the types of cleft lip and cleft palate has
made standardized and inclusive classification difficult. This article introduces
a new method for recording all types of cleft lip and cleft palate for data storage
and communication. The proposed Expression System incorporates the actual
words for the anatomical structures affected by clefts and can describe in a
quickly understood form, without the need to consult reference materials, the
location and extent of both typical and atypical clefts. The Expression System
overcomes several limitations of previous cleft registration methods, and its
simplicity and precision will benefit dental and medical specialists by furthering inter- and intradisciplinary communication.
KEY WORDS: anatomical nomenclature, classification cleft lip/cleft palate, symbolic classification

Classification is an important part of diagnosis and a necessary procedure in treatment planning of cleft lip and cleft
palate. In the study and treatment of cleft lip and palate, observations must be recorded in a form that can be duplicated
for scientific confirmation and that will be understood by various types of medical and dental specialists. There is an urgent
need for a classification method that is neither too detailed nor
inaccurate or incomplete due to oversimplification and that will
facilitate the inter- and intradisciplinary communication necessary to develop comprehensive treatment plans. This article
presents an alternate classification system that is accurate and
flexible in order to be consistent with the functional requirements of a good classification of cleft lip and cleft palate.

clefting of lip and palate. Furthermore, these classification systems do not provide for detailed descriptors (e.g., laterality and
presence/absence of vomer attachment; rotation and presence/
absence of prepalate; the amount of prepalate protrusion).
These descriptors form an integral part of any surgical and
orthodontic diagnosis and treatment planning. As a result,
many modifications to the existing and recognized classification schemes are required to make them functional. The implications of this wide diversity of opinion about fundamental
requirements of a classification system should disturb all specialists concerned with the study and treatment of cleft lip and
palate, sharing a common body of scientific knowledge. Despite past attempts to produce acceptable descriptive schemes
(Kernahan, 1971; Schwartz et al., 1993; Royal College of Surgeons, 1995), the need for a universal and consistent method
of classification remains. The ideal system should be simple
but concise, descriptive, and flexible. Arriving at a universal
acceptance and representing accurate data can, indeed, be quite
difficult, but it is the goal toward which we should all strive.

THE NEED
The lack of a specific and accurate but flexible procedure
for recording cleft lip and palate malformations has long been
a handicap to cleft lip and palate teams. Past classification
systems essentially focused on numerals and codes, which require referrals to identify structures and have different meanings in different classification systems. This inhibits comprehension and interferes with communication. These schemes
may be easy-to-grasp-concepts that are rarely accurate and are
not flexible enough to represent all composite conditions of

PROPOSED NEW CLASSIFICATION SYSTEM

To encompass both accuracy and flexibility, a classification
system was developed, referred to here as the cleft lip and
palate Expression System. This Expression System comprises
two components: (1) anatomical nomenclature (text) and (2)
symbols.
The proposed Expression System is based on the phrase lip
and palate. Because these words are the actual terms for the
anatomical structures affected by clefts, the expressions (written or typed indications) for the clefted structures immediately
conjure up an image of the concerned structures and deformities, permitting precise, effective communication of the particular abnormalities. The letters in each term (or, in the case
of palate, the letters of each syllable) represent the extent,

Dr. Koul is Professor, Orthodontics, BLDEAs Sri B.M. Patil Medical College and Research Centre, Bijapur, India.
This paper was presented orally at the Department of Dentistry, BLDEAs
Sri B.M. Patil Medical College and Research Center, Bijapur, India, on September 15, 2005.
Submitted June 2006; Accepted January 2007.
Address correspondence to: Dr. Koul, Orthodontics, BLDEAs Sri B.M. Patil
Medical College and Research Centre, Bijapur, India, H. No. 331-A, Lane 11,
Canal Road, Shakti Nagar, Jammu Tawi (J&K). E-mail kxcama@yahoo.co.in.
DOI: 10.1597/06-111.1
585

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Cleft PalateCraniofacial Journal, November 2007, Vol. 44 No. 6

TABLE 1 Basic Structure of the Expression System

Code

Anatomic Component

Anatomic Nomenclature

FIGURE 2 Format for development of the Expression.

in thirds, of the anatomical structure denoted by the term, and

thus convey the exact site and severity of the cleft without any
recourse to reference materials for decoding.
THE EXPRESSION SYSTEM DESCRIBED
Table 1 indicates the basic structure of the Expression System. The format for this system was developed from the normal sequence of the relevant structures in a sagittal plane from
front to back, as shown in Figures 1 and 2. Thus, the order of
the written or typed expression indicates the corresponding
anatomy, obviating the need for a code guide. The expression
is further defined using uppercase and lowercase letters, as
well as several symbols to indicate laterality, rotation, absence
of structures, and subsurface clefts, as illustrated in Tables 2
and 3, and defined in the footnote to Table 2. Table 3 also

FIGURE 1 An outline of structures liable to be affected by clefts.

illustrates ways in which the Expression System provides more

precise and specific descriptions of abnormalities than the previous methods do.
The Expression System is flexible enough to permit the addition of other symbols to register even more detail, such as
S or S at the start of the expression to indicate prepalate
rotation to the right or left, and V or V at the end of
expression to indicate right or left vomer attachment (for the
use of surgeons and orthodontists). The symbols S0 and V0
can signify no septal or no vomer attachment, respectively.
Extent of prepalate protrusion can be denoted using the symbols S1, S2, S3, and S4 for protrusions of 0.5, 0.5 to 1, 1 to
1.5, and 1.5 cm, respectively.
The Expression System is compatible with both the Kernahan and Stark (1958) and the American Cleft Palate Association (Harkins et al., 1962) classifications, in which preinTABLE 2 Description of Abnormalities Using the Expression
System
Condition

Expression*

Intact structures without cleft

Incomplete hard palate and complete soft palate
cleft
Incomplete lip cleft
Lip indentation up to red part of lip
Bilateral complete cleft
Left incomplete lip and right hard palate and
soft palate
Cleft of uvula and bilateral cleft of lip and premaxilla
Cleft of uvula
Median incomplete cleft of upper lip
Subsurface cleft of left lip
Submucous cleft of hard and soft palate with
cleft of uvula
Absence of prolabium with midline alveolar
cleft

LIP AND PALATE

PAlate
liP
lIP
lip and palate
liP AND palate
lip and PALATe
PALATe
liP
(LIP)

PA(LAT)e
#lip aND

* Uppercase letters signify normal structures and lowercase letters signify cleft. Laterality
of clefts is expressed by: for right side, for left side, for median, and for bilateral.
Absence of an anatomical unit is denoted by #, with the segment denoted by small letters,
and submucosal cleft by () defining the extent of cleft and surface structures represented by
uppercase letters. When the symbol applies only to one structure in the expression, no space
is inserted between the symbol and the structure (e.g., liP AND palate or liP AND
palate). When the symbol applies to all structures in an expression, a space is inserted
between the symbol and the structures (e.g., lip and palate).

Koul, CLEFT LIP AND PALATE CLASSIFICATION

587

TABLE 3 Recording of Cleft Lip and Palate Abnormalities Using Modified Kernahan, RPL, LAHSAL, and Expression System
Classifications*
Cleft

Right(LIP ALV PRMX)

Left(LIP ALV PRMX)HPAL SPAL SUBMUCOUS
Right(LIP ALV PRMX) Left(LIP ALV PRMX)
Right(LIP ALV) Left(LIP ALV PRMX)
Right(LIP) Left(LIP ALV PRMX)
Left(LIP ALV PRMX)
Left(LIP ALV)
Left(LIP)

Modified Kernahan

RPL

LAHSAL

Expression System

12345678

333

LAHSAL

lip and (pal)ate

123456
12456
1456
456
45
4

303
203
103
003
002
001

LA AL
La AL
L AL
AL
aL
L

lip
lip
lip
lip
lip
lip

and
and
and
and
aND

* ALV alveolus; PRMX premaxilla; HPAL hard palate; SPAL soft palate.

cisive foramina and postincisive foramina cleft are described

separately (although in the American Cleft Palate Association
classification, the alveolar clefts also can be registered separately). The minimal functional unit in the Expression System
is LIP or AND, or LIP AND. In either case, the palatal clefts are recorded with the six letters of the word PALATE. With this Expression System, our functional goals of
accuracy and flexibility remain in place but can be evaluated
in the context of embryology and genetics.
DISCUSSION
Classification of cleft lip and palate is based on embryology,
laterality, location, and severity of the cleft (Kernahan and
Stark, 1958; Harkins et al., 1962; International Confederation
for Plastic and Reconstructive Surgery, 1968). Because the lip,
alveolus, primary palate, and the secondary palate develop
from different embryogenic sources (Sperber, 2001), many
combinations of clefting are possible. The configurations range
from minimal involvement, such as linear lip indentations with
or without nostril deformity, bifid uvula, lateral upper lip fistula, and submucous palatal cleft (Gorlin et al., 2001), to complete bilateral cleft of the lip, alveolus, premaxilla, hard palate,
and soft palate. Even isolated clefts vary in shape and length.
Although there is great clinical variation in the types of clefts,
clinicians and researchers should be consistent in reporting observations, which requires a system that is compatible with
existing classifications and is acceptable to different kinds of
medical and dental specialists. The previous classification
schemes can be grouped as follows: (1) pictorial representation
and (2) symbolic recordings. Pictorial representations can be
accurate and expressive, but the time and effort required for
reproducibility, labeling, and recording makes this method inconvenient.
The symbolic classifications commonly in use today are (1)
the striped Y classification of Kernahan (1971); (2) the RPL
system of Schwartz et al. (1993), and (3) the LAHSAL system
of the Royal College of Surgeons (1995), or modifications of
these systems. Kernahan (1971) introduced a diagram in the
Y configuration with the incisive foramen as the focal point
and three limbs of three segments each to represent the anatomic structures affected by clefts. The first upper limb of the
Y represents right lip, right alveolus, and right premaxilla (1,

2, and 3, respectively); the second upper limb represents left

lip, left alveolus, left premaxilla (4, 5, and 6, respectively);
and the lower limb represents hard palate and soft palate (7
8 and 9, respectively). Schwartz et al. (1993) created a modified Kernahan system with the same configuration, except that
the hard palate was restricted to the number 7 segment, the
soft palate is identified as the number 8 segment, and the submucous area is assigned the number 9 segment at the base of
the Y. The three limbs of Y thus form a three-digit (RPL)
identification scheme. The right limb represents right lip, right
alveolus, and right premaxilla; the base represents hard palate,
soft palate, and submucous area; and the left limb represents
left lip, left alveolus, and left premaxilla. The LAHSAL code
of the Royal College of Surgeons (1995), uses the same Y
configuration, but the upper two limbs of the Y represent the
lip and alveolus on the right and left sides and the lower limb
represent the hard and soft palate. Complete clefts are represented by capital letters and incomplete clefts are represented
by small letters. Due to oversimplification, this method cannot
record bilateral clefts of the hard palate.
Other limitations are inherent in the currently available systems. Constant referral to reference materials for these classification methods is required to decode the numerical or letterbased codes, which have different meanings in different classification methods. This requirement inhibits comprehension
and interferes with communication. Also, none of the commonly used methods defines the extent of a cleft in a particular
unit, so that, for example, lip indentation limited to the vermilion border and complete unilateral lip cleft have the same
identification number in the RPL system, and lip indentations
limited to the red part of the lip and an incomplete cleft of lip
have the same code in the LAHSAL method of classification.
Various degrees of clefting of other structures are not reflected
in these classification methods; neither subsurface lip clefts nor
the limits of submucous clefts of hard palate and soft palate
can be recorded using them. These classifications do not have
the flexibility of recording the wide spectrum of variations of
cleft lip and palate condition. They also do not provide for
addition of detailed descriptors for a full understanding of the
clinical condition.
As explained in the description of the proposed new classification system, the Expression System is accurate and flexible to record the degree and variations of clefting of the lip

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Cleft PalateCraniofacial Journal, November 2007, Vol. 44 No. 6

represent the specific anatomical structures simplifies data

gathering (because these words have consistent connotations),
obviates the need for numerals or codes, and allows description
of microform clefts, indentations, and occult or subsurface
clefts. The Expression System provides for addition of detailed
descriptors so that every member of the cleft team has a full
understanding of what to expect and initiate appropriate treatment measures. A visual of the Expression System is comparable to any pictorial representation of the malformation without the disadvantages of inconvenience in reproducing, labeling, and recording the condition (Fig. 3).
The procedure of using text and symbols does not parallel
other established classification systems that use numerals or
codes. The purpose, rather, is to account for individual descriptions of the cleft that have produced composite pattern in any
given individual patient, with the coincident disadvantage of
parsing the results to the point of preventing characterization
of groups, which is possible with other classification systems
currently in use. Table 4 presents, for the purpose of comparison, a few examples of the three systems described above and
of the proposed Expression System.
CONCLUSIONS

FIGURE 3 Representative outlines of the clefts and structures involved,

for explanation of the Expression.

and palate. This is possible because the Expression System

identifies up to the thirds of each anatomical unit involved in
the cleft and these subunits can be combined in any number
of ways in conjunction with the symbols to record the variations in the types of cleft. Expression using words that actually

A universally acceptable anatomical nomenclature of the

structures liable to be affected by clefts also can be a universally acceptable expression for recording such clefts. The Expression System is both clearer and more precise than prior
symbolic cleft lip and palate classification methods. The simplicity and precision of this system, which overcomes several
limitations of previous methods, will benefit dental and medical specialists by furthering interand intradisciplinary communication. The model provides a framework for evaluation
of the treatment needs of each particular patient and requirements of specialists on a cleft lip and palate team. It is a departure from the traditional approach to classifying cleft lip
and palate malformations, which is based exclusively on codes
and numerals. Because the traditional classifications have become accepted and are useful, the proposed classification provides an alternative but not necessarily a replacement for them.
Acknowledgment. The author thanks Dan Liberthson, Ph.D., of San Francisco,
California, for his editorial assistance.

TABLE 4 Additional Examples of Cleft Lip and Palate Abnormalities Described Using the Various Classification Systems
Cleft

Complete bilateral cleft

Right complete cleft of lip
Left incomplete cleft lip
Left incomplete cleft limited to red part of lip
Incomplete cleft of hard palate and complete cleft of
soft palate
Bilateral complete cleft of lip, complete cleft of right
alveolus, and incomplete cleft of left alveolus
Right incomplete cleft of lip

Modified Kernahan

RPL

LAHSAL

Expression System

123456789
1
4
4
78

333
100
001
001
020

LAHSAL
L
l
l
h S

lip and palate

lip
liP
lIp
Palate

1245

202

LA aL

lip a nd

100

liP

Koul, CLEFT LIP AND PALATE CLASSIFICATION

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International Confederation for Plastic and Reconstructive Surgery. Cleft lip
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Kernahan DA. The striped Y. A symbolic classification for cleft lip and palate.
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