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Classification of Cleft Lip/Palate: Then and Now

Article  in  The Cleft Palate-Craniofacial Journal · September 2015

DOI: 10.1597/14-080 · Source: PubMed

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 The Cleft Palate–Craniofacial Journal 00(00) pp. 000–000 Month 2015
Ó Copyright 2015 American Cleft Palate–Craniofacial Association

ORIGINAL ARTICLE

Classification of Cleft Lip/Palate: Then and Now

Alexander C. Allori, M.D., M.P.H., John B. Mulliken, M.D., John G. Meara, M.D., D.D.S., M.B.A., Stephen
Shusterman, D.M.D., Jeffrey R. Marcus, M.D., on behalf of the CleftKit Collaboration

Cleft lip and/or palate (CL/P) is phenotypically diverse, making classification difficult. This article
explores the evolution of ideas regarding CL/P classification and includes the schemes
described by Davis and Ritchie (1922), Brophy (1923), Veau (1931), Fogh-Andersen (1943),
Kernahan and Stark (1958), Harkins et al. (1962), Broadbent et al. (1968), Spina (1973), and others.
Based on these systems, a longhand structured form is proposed for describing CL/P in a way
that is clear, comprehensive, and consistent. A complementary shorthand notation is also
described to improve the utility and convenience of this structured form.

KEY WORDS: classification, CleftKit, cleft lip, cleft palate, nomenclature, nosology, ontology,
taxonomy, terminology

As part of the journal’s ‘‘Then & Now’’ series reflecting
on the development and maturation of cleft care over the
past 50 years, this article explores the rich history of
classification systems used to describe and categorize the
diverse phenotypes collectively called cleft lip and/or
palate (CL/P).
Inaccurate and inconsistent classification continues
to be a problem today. Arguably, the need for a
universal, simple, and practical classification scheme
Dr. Allori is Title, Division of Plastic, Maxillofacial & Oral Surgery,
Duke University Hospital & Children’s Health Center, Durham,
North Carolina; Title, Department of Plastic & Oral Surgery, Boston
Children’s Hospital, Harvard Medical School, Boston, Massachusetts;
and Director, Duke Program for Effectiveness, Quality, Innovation &
Policy in Health Care (EQUIP), Duke University School of Medicine,
Durham, North Carolina. Dr. Mulliken is Title, Division of Plastic,
Maxillofacial & Oral Surgery, Duke University Hospital & Children’s
Health Center, Durham, North Carolina. Dr. Meara is Title,
Department of Plastic & Oral Surgery, Boston Children’s Hospital,
Harvard Medical School, Boston, Massachusetts. Dr. Shusterman is
Title, Department of Dentistry, Boston Children’s Hospital, Harvard
Dental School, Boston, Massachusetts. Dr. Marcus is Title, Division
of Plastic, Maxillofacial & Oral Surgery, Duke University Hospital &
Children’s Health Center, Durham, North Carolina.
Related funding support: Plastic Surgery Foundation 2013 Pilot
Research Grant 273938 (‘‘Development of Cleft Lip and Palate
Outcome Measures’’).
Presented at the 71st Annual Meeting of the American Cleft Palate–
Craniofacial Association, Allori AC, et al., ‘‘Toward Realtime Patient-
Centered Outcomes Assessment and Continuous Quality Improve-
ment: A CleftKit Progress Report,’’ Indianapolis, Indiana, March 29,
2014.
Submitted April 2014; Revised January 2015; Accepted March
2015.
Address correspondence to: Dr. Alexander C. Allori, Program for
Effectiveness, Quality, Innovation & Policy in Health Care (EQUIP),
Assistant Professor of Surgery, Duke Cleft & Craniofacial Center,
Division of Plastic, Maxillofacial & Oral Surgery, Duke University
Hospital & Children’s Health Center, DUMC 3974, Room 110 Baker
House, 200 Trent Drive at Erwin Road, Durham, NC 27710. E-mail
alexander.allori@duke.edu.
DOI: 10.1597/14-080
has never been greater. Modern medicine’s complex
landscape requires a common language understand-
able by clinicians, patients, hospital administrators,
payors, government agencies, and other stakeholders.
As a step toward a universal vocabulary, this article
concludes with a contemplation of the lessons learned
from each historic attempt at cleft classification and
with a synthesis of the central precepts that have
emerged from this experience. Based on this, we
present a detailed, longhand structured form to help
guide accurate and complete phenotypic description,
as well as a corresponding shorthand notation to
improve practicality and versatility in implementation.
SPLITTING HARES
It is difficult to trace the etymologic history of CL/P. The
condition is as old as mankind itself, and it has been
described in different ways by the people of every era. Many
of the early written accounts compare cleft lip with animal
features, most popularly ‘‘harelip’’ (labium leporinum) due
to the resemblance of the mouth of the hare (genus Lepus).
French Renaissance surgeon Pierre Franco (1505 to
1578)—famed colleague and rival of Ambroise Paré (c.
1510 to 1590)—used both terms levre fendu (‘‘split lip’’) and
dents de lièvre (‘‘hare teeth’’) in his works Petit Traité (1556)
and the Traité des Hernies (1561), notably the first surgical
textbooks printed on a Gutenberg press (Franco, 1976).
Three centuries later, Joseph-François Malgaigne (1806 to
1865) still referred to cleft lip as bec-de-lièvre (‘‘beak of the
hare’’; Malgaigne and Ivy, 1976).
A clarion call for abandoning the use of the term
harelip was sounded at the meeting of the American
Medical Association in St. Louis in 1922, where John
Staige Davis of Baltimore and Harry P. Ritchie of St.
Paul declared, ‘‘the term ‘harelip’ should be discarded,

0
0 Cleft Palate–Craniofacial Journal, January 2016, Vol. 53 No. 1
and [instead] the deformity thus named should be
called ‘congenital cleft of the lip’’’ (Davis and Ritchie,
1922). Terminological change came slowly; the con-
vention of referring to cleft lip as ‘‘harelip’’ persisted
well into the 20th Century in many languages, e.g.,
Victor Veau and Jacques Récamier’s Bec-de-Lièvres
(1938), Victor Spina’s ‘‘Tratamento cirurgico do labio
leporino’’ (1961), and Blair O. Rogers’s ‘‘Harelip
Repair in Colonial America’’ (1964).
ANATOMIC AND MORPHOLOGIC PERSPECTIVES
Davis and Ritchie (1922)
Davis and Ritchie went beyond merely recommending
discontinuation of the term harelip. They were among
the first to advocate for a standard system of
classification. They argued,
So far, there have been no generally accepted standard terms
for describing congenital clefts of the lip and palate, and, in
consequence, it is often difficult to understand the
descriptions in some of the numerous articles written on
the subject. One author may use a set of terms to describe
certain of these conditions, while another may use the same
terms to describe those conditions which are surgically
different. Then again an author may have a set of terms
which, it appears on investigation, he alone uses, and the
reader may have to depend on the illustrations to find what
is really meant by the text. In fact, the terminology is
considerably confused. (p. XX)
Davis and Ritchie proposed a simple three-group
system that allowed separate description of the lip,
alveolus, and palate, using the alveolar process as a
dividing line for their categorization:
 Group I: Prealveolar process cleft (clefts affecting the
lip)
1. Unilateral (right/left: complete/incomplete)
2. Bilateral (right: complete/incomplete; left: com-
plete/incomplete)
3. Median (complete/incomplete)
 Group II: Postalveolar process cleft (clefts affecting
the palate)
1. Soft palate
2. Hard palate
 Group III: Alveolar process cleft (any cleft involving
the alveolar process)
1. Unilateral (right/left: complete/incomplete)
2. Bilateral (right: complete/incomplete; left: com-
plete/incomplete)
3. Median (complete/incomplete)
Because CL/P phenotypes may involve multiple
structures, Davis and Ritchie allowed overlap of the
categories. Specifically, they prescribed that cleft lip
with cleft of the secondary palate (but intact alveolus) be
recorded as both group I and group II; however, any
and every case involving a cleft of the alveolus
(irrespective of the integrity of the lip or palate) should
be categorized exclusively as group III. Reading further,
it is apparent that Davis and Ritchie recognized this as a
point of uncertainty (if not weakness) in their classifi-
cation scheme:
In the third group, there is usually an associated cleft of the
[alveolar] process, lip and palate of many degrees anatomically;
but there must be included here that case, of variable
frequency, in which a cleft lip and cleft process are present
with a normal palate, or, if such cases occur, of a cleft palate
and cleft process with a normal lip. The proper classification of
these cases is a subject for debate. . . . It will be more
practicable to record them in the third group as there the
opportunity is given for the direct description of the three
structures. (Davis and Ritchie, 1922, p. X)
Davis and Ritchie considered the alveolar process to
be of central importance to the surgical understanding
of the problem and therefore described cleft phenotypes
in relation to this structure. In their words, ‘‘the alveolar
process forms the foundation for a surgical grouping’’
(Davis and Ritchie, 1922, p. X); the classification system
therefore ‘‘separates the cases according to their special
surgical requirements, and it indicates in every case,
directly instead of by implication, the most important
condition—that of the alveolar process’’ (Davis and
Ritchie, 1922, p. X).
Their supposition that the alveolus formed the basis
of an ‘‘intelligent classification’’ was not universally
accepted and was cause for much debate. Nevertheless,
Davis and Ritchie’s proposal was received favorably by
contemporary surgeons such as James Thompson of
Galveston, Texas, who went on record to say that ‘‘there
is great need of improvement in classification and
nomenclature and that the scheme [by Davis & Ritchie]
is a step in advance’’ (Davis and Ritchie, 1922, p. X).
Vilray Blair of St. Louis was cautiously reserved in his
endorsement of the new scheme:
I am thoroughly in sympathy with and heartily approve of the
whole idea, but we are attempting to project something for
universal adaptation. If it is not universally adopted, it is not
worth while; and, to assure its adoption, it must be the best
plan. If it is not, some one will present something a little better,
upset the one we have adopted and go on. (Davis and Ritchie,
1922, p. X)
Blair’s major criticism of the classification system was
its basis on contemporary surgical perspectives (that
were subject to change) rather than on anatomy alone
(which is immutable):
Dr. Ritchie puts forth . . . that the classification shall be along
surgical lines, abandoning the anatomic lines. Granting that . .
. the surgical classification has the broader appeal, the anatomic
basis is more fixed. To my mind, . . . [we may one day be left
with] a classification based on a surgical conception that had
not stood the test of time. . . . I am not sure we are sufficiently
advanced to make a permanent, logical classification on a
surgical basis. (Davis and Ritchie, 1922, p. X)

Brophy (1921 to 1923)
Truman W. Brophy of Chicago echoed Blair’s sentiment
that a suitable classification should be based on a proper
understanding of anatomy; he was quite vocal in criticizing
the Davis and Ritchie system as being insufficiently
detailed in this regard. In 1921 and 1923, Brophy
published his own exhaustive study of the forms of CL/P
based on an incredible 5076 operations to repair cleft
palate and 2676 operations to repair cleft lip (Brophy,
1921). His intention was to account for ‘‘every muscle and
bone involved in this deformity’’ (Davis and Ritchie,
1922). Accordingly, his classification included 16 distinct
morphological forms of cleft palate with/without cleft lip
(Table 1). Brophy’s classification was lauded by the Annals
of Surgery (McWilliams, 1924), but many surgeons
considered the system overly complex and impractical.
Veau (1931)
In 1931, Victor Veau published his landmark Division
Palatine, which described his approach to evaluation
and management of cleft palate. Veau was respectful of
Brophy but openly critical of his classification system,
stating that it specified a great many ‘‘variétés de la
même forme’’ (‘‘varieties of the same form’’) that should
be grouped together.
Veau’s greatly simplified classification of palatal clefts
consisted of four morphological forms (Table 1):
I. Clefts of the soft palate
II. Clefts of the soft and hard palate, up to the incisive
foramen
III. Clefts of the soft and hard palate extending
unilaterally through alveolus
IV. Clefts of the soft and hard palate extending
bilaterally through alveolus
Of note, while Veau discusses the most intricate of
anatomical findings in Division Palatine, he purposefully
chose to exclude ‘‘confounding’’ details (such as severity)
from the classification system itself, preferring simple
groupings. In his subsequent work dedicated to cleft lip,
Bec-de-Lièvres (Veau and Récamier, 1938), Veau eschews
taxonomical groupings altogether and instead advocates a
clear and concise description of the labial defect (including
laterality [unilateral/bilateral/median] and extent [simple/
total]). The minimalism, morphologic basis, and clinical
relevance of Veau’s approach to classification made it very
attractive to contemporary surgeons.
EMBRYOLOGIC PERSPECTIVES
Fogh-Andersen (1942)
One of the criticisms of the Davis and Ritchie
classification was that the alveolar process as dividing
Allori et al., CLASSIFICATION OF CL/P 0
line between the prealveolar clefts and postalveolar
clefts was arbitrary. Poul Fogh-Andersen of Copenha-
gen was one such surgeon who considered the incisive
foramen, rather than alveolar process, to be a better
dividing line from an embryological perspective.
In his monograph, Inheritance of Harelip and Cleft
Palate (1942), Fogh-Andersen proposed an alternative
to the Davis and Ritchie classification that was
composed of four groups:
1. Harelip (single or double)
2. Harelip with cleft palate
3. Isolated cleft palate
4. Rare atypical clefts, e.g., median cleft lip
Like Davis and Ritchie, Fogh-Andersen’s group 1
clefts (‘‘harelip’’) were anterior, but for Fogh-Andersen,
this meant the cleft was anterior to the incisive foramen
rather than to the alveolar process. Importantly, Fogh-
Andersen noted in his large epidemiologic investigations
that some degree of labial clefting was invariably
observed in association with division of the alveolar
process, suggesting that cleft lip and alveolus were
associated and possibly etiologically related. Thus,
Fogh-Andersen’s group 1 (‘‘harelip’’) effectively in-
cludes cleft lip alone and cleft lip with cleft alveolus,
and his group 2 (‘‘harelip with cleft palate’’) encom-
passed cleft lip and alveolus with cleft palate (e.g., Veau
III and Veau IV) as well as cleft lip and palate with
intact alveolus (e.g., cleft lip with a Veau I or Veau II
cleft palate).
Fogh-Andersen further refined the definition of an
isolated cleft palate (his group 3) as a defect that is
‘‘always median [which] never reaches further than the
incisor foramen’’ (Fogh-Andersen, 1971). This descrip-
tion is equivalent to a Veau I cleft of the soft palate only
or a Veau II cleft of the secondary hard and soft palate.
Veau III and Veau IV cleft palate were necessarily
included in group 2 because Fogh-Andersen believed
some degree of labial clefting to be present whenever the
alveolar process was violated.
Finally, Fogh-Andersen added group 4 to capture the
median cleft lip, which was previously regarded only as
a rare defect rather than as an atypical but distinct
category of cleft lip.
Kernahan and Stark (1958)
Desmond A. Kernahan and Richard B. Stark of New
York were also staunch advocates of basing a cleft
classification system on developmental anatomy. In
1958, they provided support for Fogh-Andersen’s use of
the incisive foramen as the embryologically sound
dividing line by citing evidence from the most current
understanding of facial embryogenesis:
0 Cleft Palate–Craniofacial Journal, January 2016, Vol. 53 No. 1
TABLE 1 Comparison of the Morphologic Classification Schemes of Brophy (1924) and Veau (1932)*
The ‘‘primary palate’’ extends as far posterior as the incisive
foramen; its development is completed by the seventh week of
intra-uterine life. From this ‘‘primary palate’’ are subsequently
formed the central portion of the upper lip and the premaxilla.
Failure of this mesodermal penetration leads to breakdown of
the ectoderm and formation of clefts, although rarely a small
bridge of ectoderm may persist in the form of a Simonart’s band
at the nostril floor.
From one to five weeks later, (i.e. from 7-12 weeks of
intrauterine life) formation of the secondary palate (hard and
soft palate) occurs through the growth medianward and fusion
of two laterally placed palatal shelves. . . . Hanging downward
and lying laterally alongside the tongue at first, these two
palatal processes subsequently assume a position above the
tongue. . . . They meet in the midline and fuse, a process which
begins at the incisive foramen and progresses posteriorly during
the eight to twelfth weeks of intra-uterine life. (Kernahan and
Stark, 1958, p. X)
Kernahan and Stark challenged the use of morphol-
ogy alone as a basis for classification: ‘‘The embryologic
events leading to the deformity, viz., the separate nature
and time formation of the primary and secondary
palates, are well understood;’’ and therefore, ‘‘cleft lip
and palate . . . ideally should be classified on that basis’’
 Allori et al., CLASSIFICATION OF CL/P 0

TABLE 1 Continued
0 Cleft Palate–Craniofacial Journal, January 2016, Vol. 53 No. 1

TABLE 1 Continued
 Allori et al., CLASSIFICATION OF CL/P 0

TABLE 1 Continued

* Brophy’s (1923) system was very detailed but arguably too complex for practical use. Veau himself commented that Brophy’s classification featured a great many ‘‘variétés de la
même forme’’ (‘‘varieties of the same type’’) and aimed to simplify the classification into one that was more utilitarian and clinically significant. Veau I encompasses Brophy classes 1 to
3, Veau II encompasses Brophy classes 4 to 6, Veau III corresponds with Brophy class 7, and Veau IV corresponds with Brophy class 8 (and arguably 13). Differences among the
Brophy classes within these groupings are really matters of severity. Brophy classes 9 to 16 are other combinations of CLþP that are not considered by the Veau classification, which
was limited to describing clefts of the palate (CP) only. According to Veau, ‘‘Pour ma part, je m’y refuse absolument . . . ils sont opérés comme des becs-de-lièvre ordinaire et non
comme des divisions palatines’’ (‘‘For my part, I absolutely refuse [to classify them] . . . they are operated upon like ordinary harelips and not like palatal divisions.’’) Figures
reproduced from Veau V. Division Palatine. Paris: Masson; 1931. Permission requested from Elsevier-Masson press; pending approval.

(Kernahan, 1991, p. X). Based on this understanding,
Kernahan and Stark proposed three groups:
1. Clefts of structures anterior to the incisive foramen
2. Clefts of structures posterior to the incisive foramen
3. Clefts affecting structures anterior and posterior to
the incisive foramen
Modifiers were added to describe laterality (unilat-
eral/bilateral/median) and severity (total/subtotal).
This nosological framework is nearly identical to that
of Fogh-Andersen, although the ordering of the
groups is different. Kernahan and Stark encompassed
median cleft lip in their group 1 (anterior clefts)
0 Cleft Palate–Craniofacial Journal, January 2016, Vol. 53 No. 1
TABLE 2 Criteria for an ‘‘Ideal’’ Classification Scheme*
I. Concise, clear definitions of terms; hence,
A. Rejection of the meaningless, the ambiguous, and the irrelevant
B. Preference for simple, descriptive English terms
C. Retention of established customary terms, where possible, in order
to avoid duplication and confusion
D. Formation of new terms only where necessary
E. Indication of synonomous [sic] terms, especially those of wide usage
such as ones based on Latin or Greek, to facilitate comprehension
and use of the system proposed here
II. Convenience of use through:
A. Economy of expression
B. Logical arrangement of classification conformable with
1. Normal topographic (spatial) relationship of anatomical
structures
2. Normal sequence in embryologic advent and union
C. Standardized methods of measurement
III. Stimulation of scholarly and clinical research by:
A. Standardized procedures for observation and reporting
1. Meaningful in terms of embryologic antecedents
2. Meaningful in describing tissue relationships used to evaluate
need and method of therapy
B. Provision for rare conditions
* In its 1962 report, the Nomenclature Committee of the American Association for
Cleft Palate Rehabilitation published its criteria for an ideal classification scheme
(Harkins et al., 1962). These guiding principles are still very valid.
rather relying on a separate catch-all category for
atypical clefts.1
REFINEMENT
American Cleft Palate–Craniofacial Association
Classification (Harkins et al., 1962)
In 1960, the American Association for Cleft Palate
Rehabilitation appointed a Nomenclature Committee to
formulate a classification system. The Committee was
chaired by Cloyd S. Harkins and included Asa Berlin,
Robert J. Harding, J. J. Longacre, and Richard M.
Snodgrasse. The committee recognized that ‘‘a major
impediment to communication and understanding in
any realm of human endeavor exists when and wherever
terms are inadequately defined and consensus does not
obtain in the classification’’ (Harkins et al., 1962). The
need for a standardized terminology was becoming
increasingly important with the advent of multidisci-
plinary cleft palate teams, which included not only
surgeons and dentists but also new colleagues from
other fields such as speech and language pathology,
genetics, and developmental biology.
In its 1962 report, the Nomenclature Committee
published its criteria for an ideal classification scheme
1
A modern appreciation of fetal facial development clarifies that
a median premaxillary cleft is due to incomplete fusion of the medial
nasal prominences to form the premaxillary segment, whereas the
more common lateral cleft lip with/without cleft alveolus occurs
from aberrant fusion of the right/left maxillary prominences with
the premaxillary segment. In this light, a system organized strictly
according to embryologic principles would indeed classify median
labial clefts separately from lateral labial clefts.
(Table 2; Harkins et al., 1962). The Committee
emphasized precise terms with clear definitions, rejecting
‘‘the meaningless, the ambiguous, and the irrelevant.’’
Specifically, the Committee encouraged the use of Greek
and Latin terms,2 which they believed to be concise,
specific, and universally understandable. The Commit-
tee also advocated for a system that would respect
embryology and surgical anatomy, such that it would be
useful to both clinicians and academicians.
Implementation of this framework required two
principal anatomical demarcations: the ‘‘prepalate,’’
anterior to the incisive foramen and thus including lip,
alveolar process, and primary hard palate, and the
‘‘palate,’’ posterior to the incisive foramen and thus
including secondary hard and soft palate. Of note, the
alveolus was included with the primary hard palate as a
singular unit (prepalate), per Kernahan and Stark;
however, this practice was still a point of contention.
The Committee believed it was important to clarify the
rationale for this recommendation based not only on
embryologic evidence but also on epidemiologic obser-
vations by Fogh-Andersen and others:
Defects seem to appear in accordance with these groupings.
Clefts of the lip occur alone, [as] do clefts of the lip and alveolar
process, not involving the palate. Clefts of the palate occur in
varying degrees from the uvula to the incisive foramen; however,
once past this point, they usually continue through the alveolar
process and lip. (Harkins et al., 1962, p. X)
Anatomic segmentation into the prepalate and the
palate thus permitted separation into four major
categories of orofacial clefts in the American Cleft
Palate–Craniofacial Association (ACPA) classification:
1. Clefts of the prepalate (cleft of lip and embryologic
primary palate)
a. Cleft lip (cheiloschisis)
b. Cleft alveolus (alveoloschisis)
c. Cleft lip, alveolus, and primary palate (cheiloal-
veoloschisis)
2. Clefts of the palate (cleft of the embryologic
secondary palate)
a. Cleft of the hard palate (uranoschisis)
b. Cleft of the soft palate (staphyloschisis or velo-
schisis)
c. Cleft of the hard and soft palate (uranostaphylo-
schisis)
2
The Greek roots used included veíko1/cheı́los (‘‘lip’’); otqamó1/
uran ós (‘‘sky’’), signifying the hard palate; rsáutko1/stáfilos
(‘‘grapes’’), representing the uvula and soft palate; and rvírilo/
schı́simo (‘‘tear’’ or cleft). Latin roots included alveus (‘‘trough’’ or
‘‘hollow’’) for the tooth-bearing alveolar process and velum (‘‘veil’’
or ‘‘sail’’) for the soft palate. Combinations yielded very specific
terms, such as uranostaphyloschisis (a cleft affecting the hard and
soft palate) and alveolocheilopalatoschisis (a cleft affecting the lip,
alveolus, and palate).

3. Clefts of the prepalate and palate (alveolocheilopala-
toschisis)
4. Facial clefts other than prepalatal and palatal
a. Cleft of the mandibular process
b. Naso-ocular clefts
c. Oro-ocular clefts
d. Oroaural clefts
Each cleft could be further characterized by laterality
and severity. Laterality was simply denoted as left, right,
bilateral, or median. With regard to severity, the
Committee chose to use quantitative measurement of
the width of the cleft and semiquantitative description
of the extent of the cleft. Extent was denoted as 1/3, 2/3,
or 3/3 the length or area of the involved structure.
Specific criteria were attached to these descriptors for
each condition on a case-by-case basis, but they may be
thought of as corresponding roughly with ‘‘minor
form,’’ ‘‘incomplete,’’ and ‘‘complete,’’ respectively.
Interestingly, unlike prior surgical classifications, the
Committee ‘‘views all hard palate clefts as midline
(therefore not needing specification [as right, left, or
bilateral]), but encourages the identification of vomer
attachment as a separate observation.’’ The Committee
recommended that certain details that are relevant and
noteworthy to surgeons do not necessarily warrant
adding complexity to the classification.
International Classification (Broadbent et al., 1969)
In 1967, the International Confederation for Plastic
and Reconstructive Surgery convened the 4th Interna-
tional Congress in Rome. The Subcommittee on No-
menclature and Classification was chaired by T. Ray
Broadbent and included Fogh-Andersen, Berlin, Karfik,
David N. Matthews, Gerhard Pfeifer, Gustavo Sanve-
nero Rosselli, Karl Schuchardt, and Stark, many of
whom brought years of nosological and taxonomical
experience to the table. The International Subcommittee
based its framework on the prior work of Fogh-
Andersen, Kernahan and Stark, and Harkins et al. They
devised a two-tier system that categorized clefts of the lip,
alveolus, and palate based on embryologic principles and
rare facial clefts based on topographic findings:
Classification of the lip, alveolus, and palate (based
on embryologic principles):
1. Clefts of the anterior (primary) palate
2. Clefts of the anterior (primary) and posterior
(secondary) palates
3. Clefts of the posterior (secondary) palate
Classification of rare facial clefts (based on topo-
graphical findings):
A. Median clefts of the upper lip, with/without
hypoplasia or aplasia of the premaxilla
Allori et al., CLASSIFICATION OF CL/P 0
B. Oblique clefts (oro-orbital)
C. Transverse clefts (oroauricular)
D. Clefts of the lower lip, nose, and other very rare
clefts
Clefts within each of groups 1 to 3 received
descriptions of all involved structures (lip, alveolus,
hard palate, and soft palate) by laterality and severity
(using the terms total or partial). The International
Subcommittee published its classification in 1969 in the
Transactions of the International Confederation (Broad-
bent et al., 1969).
Spina (1973)
In 1973, Victor Spina of São Paulo suggested a minor
revision of the International Classification’s first tier
with the intent to make the terminology more precise.
Spina argued that the terms anterior and posterior
describing palatal defects in group 1 and group 3,
respectively, raised the question, ‘‘anterior or posterior
to what?’’ (The answer, of course, is the incisive
foramen.) Accordingly, Spina renamed group 1 as pre-
foraminal clefts, group 2 as trans-foraminal clefts, and
group III as post-foraminal clefts. Spina maintained that
basing the terminology on Latin with reference to a
specific anatomic structure would make the classifica-
tion system easier to understand, simpler to teach, more
manageable to memorize, and more applicable to
interdisciplinary and international communication.
TOWARD CONSENSUS
Striped-Y
The extent of adoption of either the ACPA or
International schema is not known, but certainly the
Kernahan and Stark classification persisted in wide-
spread use well beyond their introduction. This can
probably be explained in large part by Kernahan’s
translation of the Kernahan and Stark classification
system into pictographic form (Kernahan, 1971; Fig. 1).
The Kernahan ‘‘striped-Y’’ diagram was designed
principally to simplify record keeping, but it also made
classification a visual process rather than an abstract,
cognitive exercise. Kernahan’s striped-Y and the subse-
quent modifications by Elsahy (1973) and Millard
(1976) served to secure the position of the Kernahan
and Stark classification as the predominant system used
in daily clinical practice.
ACPA Reclassification Committee (Whitaker et al.,
1981)
In 1981, the ACPA Ad Hoc Committee on Nomen-
clature and Classification of Craniofacial Anomalies,
0 Cleft Palate–Craniofacial Journal, January 2016, Vol. 53 No. 1
FIGURE 1 The striped-Y logo designed by Kernahan was as a
pictographic representation of the cleft phenotype and served as a
symbolic correlate of the Kernahan and Stark classification system.
chaired by Linton A. Whitaker, was charged with the
reclassification of craniofacial anomalies. In review of
classification of CL/P, the Committee listed numerous
criticisms of the International Classification of 1969:
First, the ordering and numbering of the groups in the
International Classification was confusing and conflict-
ed with those of other classifications. Second, the
Committee disagreed with the terms anterior and
posterior palate, preferring the embryologically precise
primary and secondary palate (as used by Kernahan and
Stark) or prepalate and palate (as used in the ACPA
Classification by Harkins et al.). A third criticism
concerned listing median cleft lip under rare facial
clefts, when it made more clinical sense to group it with
the other orofacial clefts in the first tier (clefts of the lip,
alveolus, and palate).
The 1981 Committee determined that the Kernahan
and Stark classification of 1955 and the ACPA
Classification of 1962 were better systems, based on
their syntheses of current knowledge and simplicity and
clarity of presentation. It reaffirmed that either system
could be used, and it recommended the striped-Y
diagram as a useful notational tool that was compatible
with both systems.
TO INCLUDE OR EXCLUDE FACIAL CLEFTS?
A discussion of classification of CL/P (or orofacial clefts)
would not be complete without acknowledging the equally
important work devoted to classification of other facial
clefts. Some clinicians thought that there should exist a
unifying classification that included all facial clefts; the
practical constraint, however, was that this usually took the
form of a generic catch-all category that did not adequately
describe the atypical clefts. Other clinicians thought that
facial clefts required their own classification system. For
further discussion of these considerations, the reader is
referred to the following resources: Harkins et al. (1962),
Tessier (1976), and Whitaker et al. (1981).
DISCUSSION: A SYNTHESIS AND PROPOSAL
‘‘If the future is to bring any increase in our understanding of
the cleft lip and palate problem, a uniform method of
classification is essential.’’
—Kernahan and Stark (1958)
Where Are We Now?
In reflecting on the rich history of classification in CL/
P, we see that there has been a stepwise progression of
thoughts and ideas—sometimes complementary and
sometimes discordant—that has led to a state that is
more advanced yet still incomplete.
Millard (1976) in Cleft Craft reviewed the history of
classification systems for CL/P and concluded that
‘‘none has been universally accepted because of lan-
guage differences, inaccuracies, omissions and lack of
simplicity’’ (p. X). While he acknowledged the need for
detail in the medical record (for which he employed his
modification of a striped-Y diagram), he firmly believed
that classification systems per se should remain uncom-
plicated and useful. This sentiment was echoed in chorus
by Davis and Ritchie, Veau, Fogh-Andersen, Kernahan
and Stark, and others.
Reading through Millard’s work, one notices that he
preferred to simply use the descriptive terms cleft lip,
cleft palate, and cleft lip and palate. Veau and Récamier
(1938) also, in Bec-de-Lièvres, chose to describe the cleft
lip rather than to categorize it. Were Veau and Millard
on the right track? Is there really a need to further
classify and categorize, subdivide, and characterize?
What is the utility of a label such as group 1 or type B?
Yet most clinicians and academicians would agree
wholeheartedly that there must exist a way to describe
the cleft phenotype, if not to separate data into different

subgroups for taxonomical purposes, then at least to
facilitate accurate communication among practitioners.
CL/P is phenotypically diverse. The lip, alveolus,
primary palate, secondary hard palate, and soft palate
may each be affected in varying degrees, or not at all,
and the total number of possible combinations is in the
tens of thousands. The challenge is to record this
information in a way that is sufficiently detailed,
accurate, intelligible, and consistent. Moreover, it is
desirable that the method also be adopted universally,
such that data could be shared among groups and
instantly understood.
Detailed awareness of the history of CL/P classifica-
tion allows one to understand the elements that must be
incorporated into an ideal schema. Most enlightening is
the contrast between Brophy and Veau in their
classifications of cleft palate. Whereas Brophy sought
to describe every intricate detail, Veau surmised that
many were mere variations on a theme that did not
warrant separate groups in the classification. Rather,
Veau sought to develop a system that remained as
simple as possible yet could adequately describe as many
of Brophy’s classes as possible.
The importance of a balance between comprehensive-
ness and simplicity was also underscored by the ACPA
Nomenclature Committee in 1965. The committee
emphasized that the terms in the classification needed
to be clear, concise, logically arranged, and convenient
and also accurate from both embryologic (etiologic) and
surgical (therapeutic) perspectives.
An additional challenge is that cleft care is interdis-
ciplinary and complex; there are many perspectives to
consider. A researcher may prefer a system with an
embryologic, genetic, or biochemical foundation; the
clinician, one that is simple and correlates with
treatment goals and principles; the epidemiologist, one
that is comprehensive and versatile; and the adminis-
trator, one that is practical and easily implemented. An
ideal system needs to serve these diverse needs.
Where Do We Go From Here?
Proposal for a Universal Structured Form for Description
of CL/P Phenotypes
With great admiration for those giants upon whose
shoulders we stand, the authors respectfully propose a
unifying synthesis as a standardized method for
description of CL/P phenotypes. This schema is based
on the most enduring elements of the historical
schemata and represents the next step in the natural
progression toward a comprehensive and clinically
useful classification system. Specifically, the system is
based on the following precepts:
Allori et al., CLASSIFICATION OF CL/P 0
1. As posited by Fogh-Andersen, Kernahan and Stark,
and others, the incisive foramen is an embryologi-
cally correct and surgically useful dividing point that
separates preforaminal structures (lip, alveolus, and
primary hard palate) from postforaminal structures
(secondary hard palate and soft palate).
2. Per Harkins et al., a complete description of the CL/
P phenotype requires specifying if the cleft involves
the lip, alveolus (and primary palate), and/or
secondary palate. Moreover, as stressed by Davis
and Ritchie, the state of the integrity of the alveolar
process is a critical detail that must not be omitted. It
has implications for choice of therapy (e.g., dento-
facial orthopedics, nasolabial adhesion, gingivoper-
iosteoplasty, alveolar bone grafting, etc.) as well as
potential outcomes (e.g., effects on dentition, occlu-
sion, and articulatory speech).
3. The laterality and severity of the labial cleft and the
morphology of the palatal cleft should be specified to
the degree necessary to describe morphologic fea-
tures relevant to treatment planning or outcome
assessment.
a. Labial description: As argued by Veau and
Millard, it is more practicable and more easily
understood to describe the cleft lip rather than to
categorize it into taxonomical groups.
b. Palatal description: For simplicity and clinical
utility, we advocate use of Veau’s numbering for
morphologic description of cleft palate. To
Veau’s four types, we would add only ‘‘bifid
uvula’’ and ‘‘submucous cleft palate’’ (with/
without bifid uvula), which covers the minor
forms of cleft palate. Thus, there are only six
forms to consider, which are easily learned by
clinicians of any specialty and level of experi-
ence. In our review of clinical records from
several well-known cleft centers (data not
shown), use of the Veau classification has been
more consistent than descriptive terms such as
complete, incomplete, partial, unilateral, bilateral,
and central. We suggest that these inexact terms
lead to confusion and add little value to a
classification; moreover, we propose that such
terms should be discarded.
4. For simplicity, high-level morphological details (such
as severity of alveolar clefting, protrusion of the
premaxilla, and collapse of the alveolar segments)
should be excluded from the classification. Of course,
these details are of clinical interest and should be
sufficiently described in each patient’s medical
record. As Kernahan keenly emphasized, such
clinical features ‘‘lie outside the scope of a classifi-
cation’’ (Friedman et al., 1991). Too many details
make a classification system so utterly encumbered
and complex that it becomes unusable.
0 Cleft Palate–Craniofacial Journal, January 2016, Vol. 53 No. 1

FIGURE 2 CLAP notation is an acronymic shorthand for the longhand structured form. Uppercase letters summarize the part of the anatomy involved
(L, lip; A, alveolus; P, palate). A lowercase prefix describes the laterality and severity of the preforaminal component (lip) (laterality ¼ u, unilateral; b,
bilateral; med, median; severity ¼ c, complete; i, incomplete; m, minor-form, microform, or mini-microform; a, asymmetric). A lowercase suffix designates
morphology of the postforaminal component (secondary palate; bu, bifid uvula; sm, submucous; v1, v2, v3, and v4, Veau I-IV, respectively). CLAP
notation is read from left to right and translates directly to the structured form. For example, ‘‘right ucCLAPv3’’ translates as ‘‘right unilateral complete
cleft of the lip and alveolus with a palate that is Veau III.’’

Therefore, a complete description of a CL/P pheno-
type should include the laterality and severity of the
labial defect, acknowledgment of an alveolar defect, and
a morphological characterization of the palatal defect
(Fig. 2). Examples are given below:
 Veau-I cleft palate
 Left unilateral incomplete cleft lip (with intact
alveolus and secondary palate)
 Right unilateral complete cleft lip and alveolus with
Veau-III palate
 Bilateral asymmetric cleft lip (right complete and left
microform) with right Veau-III palate
 Median cleft of prolabium and premaxilla
This longhand structured format has been successfully
employed by many experienced clinicians. When such a
system is used routinely, it leaves very little to
question—diagnoses are always clear, treatment proto-
cols can be anticipated from the diagnosis, and even
administrative coding is more straightforward. Unfor-
tunately, many clinicians are inconsistent in describing a
phenotype so thoroughly. We encourage all teams to
adopt this standardized structure for describing CL/P
phenotypes.
Practical Implementation: Shorthand CLAP Notation
Admittedly, writing out this longhand notation every
time the patient is evaluated would be tedious. Also, the
longhand notation does not lend itself easily to grouping
for research or administrative purposes.
To improve the practicality of the system (and
hopefully its rate of adoption and fidelity in implemen-
tation), we developed a complementary shorthand
notation, which is illustrated in Figure 2. The impor-
tance and usefulness of parallel longhand and shorthand
forms was underscored by Balakrishnan (1975).
The proposed shorthand notation is visibly similar to
the informal abbreviations that many clinicians intuitively
use. (A review of clinical notes from several well-known
cleft teams [data not shown] revealed that the rather
common ‘‘right unilateral complete cleft lip and alveolus
with Veau-III palate’’ was recorded with great variability
as ‘‘RUCCL/P,’’ ‘‘RUCLP,’’ ‘‘UCCLP,’’ ‘‘UCCL&P,’’
and ‘‘CUCLP.’’) Unlike these casual abbreviations,
however, our proposed shorthand notation is strictly
structured according to a few rules and definitions.
Briefly, the uppercase C serves as the central reference
point and merely stands for the word cleft. The
anatomic parts are listed acronymically in capital letters
(L for lip, A for alveolus, and P for palate). Therefore,
the notation for a cleft lip alone would feature only the
letters CL; a cleft lip and alveolus with intact palate,
CLA; a cleft lip, alveolus, and palate, CLAP; and a cleft
lip with cleft palate but intact alveolus, CLP. These
uppercase letters specify anatomic involvement.
Preceding this acronym is a lowercase prefix serving
as a preforaminal descriptor of laterality (u, unilateral;
b, bilateral; med, median) and severity (c, complete; i,
 Allori et al., CLASSIFICATION OF CL/P 0

TABLE 3 Standardized ‘‘Superset’’ Groupings for Phenotypic Combinations*

Superset Abbreviation Definition Includes Excludes

{CP} Cleft palate only CPbu CPv1 {CL6A}

CPsm CPv2 {CLþP}
CPv3
CPv4
{uCL} Unilateral cleft lip only (intact alveolus) ucCL {uCLþA}
uiCL {uCLþP}
umCL
{bCL} Bilateral cleft lip only (intact alveolus) bcCL {bCLþA}
biCL {bCLþP}
bmCL
baCL
{uCL6A} Unilateral cleft lip, with/without alveolus {uCL} ucCLA {uCLþP}
uiCLA
umCLA
{bCL6A} Bilateral cleft lip, with/without alveolus {bCL} bcCLA {bCLþP}
biCLA
bmCLA
baCLA
{CL6A} Cleft lip, with/without alveolus {uCL6A} {CLþP}
{bCL6A}
{CLþP} Cleft lip and palate ucCLPv1 ucCLAPv3 {CL6A}
uiCLPv1 uiCLAPv3 {CP}
umCLPv1 umCLAPv3
ucCLPv2 bcCLAPv4
uiCLPv2 biCLAPv4
umCLPv2 bmCLAPv4
baCLAPv4
etc.
{CL6P} Cleft lip, with/without cleft palate {CL6A} {CP}
{CLþP}
{CL/P} Cleft lip and/or cleft palate {CL6A} (no exclusions)
{CP6A}
{CLþP}
* These standardized groupings are proposed for data aggregation and analysis. To specify more detailed phenotypes, the CLAP notation itself may be used. (For clarity, supersets
may be enclosed in optional curly braces, whereas CLAP notation does not.)

incomplete; m, lesser-form [minor-form, microform, or
mini-microform]; and a, asymmetric, which is only
possible for the bilateral case). For unilateral cases, the
terms right and left may be specified, but they are not
abbreviated. This separates the ‘‘side’’ (right/left) from
the ‘‘type’’ (unilateral). For example, both ‘‘right ucCL’’
and ‘‘left ucCL’’ belong to the group ‘‘ucCL,’’ unilateral
complete cleft lip. (To attempt to abbreviate this as
‘‘rucCL’’ and ‘‘lucCL’’ adds unnecessary complexity and
makes the notation harder to read.)
Succeeding the acronym is a lowercase suffix serving a
postforaminal descriptor of the morphology of the cleft
palate: bu (bifid uvula), sm (submucous cleft palate, with/
without bifid uvula), v1 (Veau-I cleft of soft palate), v2
(Veau-II cleft of secondary soft and hard palate, up to
incisive foramen), v3 (Veau-III unilateral cleft of second-
ary soft and hard palate through primary palate and
alveolus), and v4 (Veau-IV bilateral cleft of secondary soft
and hard palate through primary palate and alveolus).
using the longhand structured form described above
(e.g., ‘‘right unilateral complete cleft lip and alveolus
with Veau-III palate’’). The longhand notation should
be summarized parenthetically into the standard short-
hand CLAP notation (e.g., ‘‘right ucCLAPv3’’). All
notes at subsequent encounters may simply reference the
shorthand notation.
Any other details that the team feels to be clinically
relevant (e.g., width of the alveolar gap, degree of
premaxillary protrustion, etc.) should be recorded in the
medical record in the typical fashion. Teams may
continue to employ any ancillary method of detailed
note taking (e.g., pictographic notation such as Kerna-
han striped-Y diagram, or text-based notation such as
LAHSHAL) to which they are accustomed, if they feel
these add value.
Application: Aggregating Groups for Research and
Administration

Application: Patient-Specific Description for Medical
Documentation
Our recommendation is that the medical note at the
time of initial encounter describe the CL/P phenotype
For research and quality improvement, it is desirable
to sort patients into ‘‘meaningful’’ groups for data
aggregation and analysis. The choice of groups depends,
of course, on the particular needs of the researcher,
clinician, or administrator. The CLAP notation is both
0 Cleft Palate–Craniofacial Journal, January 2016, Vol. 53 No. 1
simple and versatile. It greatly facilitates grouping into
both general supersets as well as very specific subsets,
which for clarity may be enclosed within curly braces.
Recommended groupings are based on the standard
abbreviations endorsed by Cleft Palate–Craniofacial
Journal and are shown in Table 3. Note the addition
of the plus sign (þ) to mean ‘‘and,’’ that is, the
combination of two features; the plus-or-minus sign
(6) to mean ‘‘with/without,’’ signifying the optional
inclusion of a second feature; and the virgule (forward
slash, or /) to mean ‘‘and/or.’’ Note specifically that
{CL/P} means ‘‘cleft lip and/or cleft palate,’’ which is
more strictly defined than in casual usage. By conven-
tion, most statistical reports combine cleft lip alone
together with cleft lip and alveolus; thus, we list the
‘‘cleft-lip’’ superset as {CL6A} rather than as the less-
accurate ‘‘CL.’’ To specify more detail in the description
of a particular phenotype, the compete CLAP notation
should be used.
CONCLUSION
Earlier, the rich history of classification of CL/P
phenotypes was explored. Whereas prior classification
systems were firmly rooted in taxonomical divisions,
consisting of groups and subgroups, we propose a system
that is descriptive rather than hierarchical. The clinician
describes the cleft phenotype in words; the requirements of
the longhand structured form ensure that this description is
clear, comprehensive, and consistent. Simple rules guide the
conversion of this longhand structured form into an
intuitive and readable acronymic shorthand that improves
its utility and convenience. This system focuses on clinically
meaningful anatomic differences in cleft types and should
be sufficient for most use cases. A follow-up article will also
describe the great compatibility of this method of
classification and documentation with coding systems, for
example, ICD-10-CM and SNOMED-CT. We hope that
cleft teams everywhere will find this system helpful for
clinical care, research, and administration.
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