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 are
descriptions of the components involved in the cleft, but they do not consider in
detail the severity of distortion. We sought to establish a new diagram (the
Clock Diagram) for cleft lip and palate, which describes the pathology according
to 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 lip
and palate patients operated by the author between 1996 and 2007, under the
protocol based on our classification. To further illustrate the classification and
diagram method, two types of clefts are described, using the proposed diagram
and compared with Kernahans diagram.
Results: This new diagram describes the clefts severity using terminology
from our clinics classification of cleft severity. In comparison with Kernahans
diagram, the Clock Diagram more effectively demonstrates a clefts severity. I
have observed a higher incidence of lip and palate revision in severe clefts.
Conclusions: The Outreach Program Lima Clock Diagram classifies the
severity of the cleft and affords an individualized description of cleft
morphology. I have observed a direct relation between cleft severity and the
number 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 Starks 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 Kernahans 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
patients 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 planning. The use of presurgical orthopedics and modifications
of traditional surgical techniques are examples of individualized 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.

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 prossell3p@hotmail.com.
DOI: 10.1597/08-070.1

METHODS
The method used is based on surgical results obtained
from 1043 patients with cleft lip and palate who were
305

306 Cleft PalateCraniofacial Journal, May 2009, Vol. 46 No. 3

TABLE 1

Unilateral Cleft Lip Classification of Severity

Type

Nose

Outreach Surgical Center, Lima, Peru

Primary Palate

Lip

A. Mild

Mild

Cleft less than 5 mm

B. Moderate

Moderate

Cleft between 5 and 15 mm

C. Severe

Severe

Cleft wider than 15 mm

TABLE 2

A1. Cupids bow less than 30 degrees

A2. Cupids bow between 30 and 60 degrees
A3. Cupids bow higher than 60 degrees
B1. Cupids bow less than 30 degrees
B2. Cupids bow between 30 and 60 degrees
B3. Cupids bow higher than 60 degrees
C1. Cupids bow less than 30 degrees
C2. Cupids bow between 30 and 60 degrees
C3. Cupids bow higher than 60 degrees

Bilateral Cleft Lip Classification of Severity

Outreach Surgical Center Program, Lima, Peru

Type

A. Mild
B. Moderate
C. Severe

Nose

Columella 1/3 to 2/3 of nasal length

Columella up to 1/3 of nasal length
No nasal columella

Primary Palate

Cleft less than 5 mm

Cleft between 5 and 15 mm
Cleft wider than 15 mm

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)

Lip

Mild: There is only horizontal displacement of the nose

on the cleft side.
b) Moderate: There is horizontal and vertical displacement of the nose.

c)

Prolabium 2/3 or more of lateral segment length

Prolabium 1/3 to 2/3 of lateral segment length
Prolabium 1/3 or less of lateral segment length

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 3

Outreach Surgical Center Lima, Protocol

Outreach Surgical Center, Lima, Cleft Lip Protocol

Type

Mild

Cleft Morphology

Microform
Unilateral complete or
incomplete
Bilateral complete or
incomplete
Alveolar cleft
Moderate Unilateral complete cleft
Bilateral complete cleft
Moderate nose deformity
Moderate alveolar cleft
Severe
Unilateral complete cleft
Bilateral complete cleft
Severe nose deformity
Severe alveolar cleft
Nasoalveolar molding or
lip adhesion

Technique

Time

Mulliken
Reichert-Millard

3 months old
3 months old

Mulliken modified

3 months old

Alveolar bone graft

Reichert-Millard
Mulliken modified
Primary rhinoplasty
Alveolar bone graft
Reichert-Millard
Mulliken modified
Primary rhinoplasty
Alveolar bone graft
12 months old

68 years
3 months
3 months
3 months
68 years
3 months
3 months
3 months
68 years

old
old
old
old
old
old
old
old
old

Outreach Surgical Center Lima, Cleft Palate Protocol

Cleft Morphology
Technique
Time
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 1.5 years old
repair
Alveolar molding
12 months
old
Type
Mild

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

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

b) Moderate: Cupids bow rotation between 30 and 60 degrees.

c) Severe: Cupids bow rotation greater than 60 degrees.

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 cupids bow rotation to
estimate the tissue deficiency in the lip component. Therefore,
high rotation of cupids bow leads to more tissue deficiency in
the medial lip component; whereas, with a low rotation of
cupids 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: Cupids bow rotation less than 30 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 cleft
and noncleft sides for unilateral clefts and the difference
between both sides for bilateral clefts.
I compare the distance from the noncleft cupids bow
peak to the noncleft commissure and the distance measured

308 Cleft PalateCraniofacial Journal, May 2009, Vol. 46 No. 3

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

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.

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

c) Severe: Cleft width greater than 15 mm.

Secondary Palate
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
Simonarts 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 is
represented 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.

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 the
clefts 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 secondary palate component is as follows:
a)

Mild: Ratio is less than 0.20.

Rossell-Perry, NEW DIAGRAM FOR CLEFT LIP AND PALATE 309

FIGURE 3 Unilateral and bilateral primary palate component severity.

b) Moderate: Ratio is between 0.20 and 0.40.

c) Severe: Ratio is greater than 0.40.

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:

THE CLOCK DIAGRAM

a)
This is a circle divided into four areas, one for each cleft
component. Each area is subdivided into three segments,

Right superior quadrant (nasal deformity).

Degrees: Mild (1), Moderate (2), Severe (3).
b) Right inferior quadrant (medial segment lip and
prolabium deformity).
Degrees: Mild (4), Moderate (5), Severe (6).
(The lateral segment lip deficiency is less common than
the medial segment deformity, so I include its
description in the cleft codesee below.)
c) Left inferior quadrant (primary palate severity).
Degrees: Mild (7), Moderate (8), Severe (9).
(For bilateral clefts, I describe both sides in the
diagram.)
d) Left superior quadrant (secondary palate severity).
Degrees: Mild (10), Moderate (11), Severe (12).

The Cleft Code

FIGURE 4 Secondary palate component severity.

The cleft consists of four numbers, one from each cleft

component described on the cleft diagram. These four digit

310 Cleft PalateCraniofacial Journal, May 2009, Vol. 46 No. 3

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 Kernahans diagram.
Type 1: Unilateral Cleft Lip (Fig. 6)

FIGURE 5 The clock diagram.

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).

Two complete unilateral cleft lips are illustrated.

Kernahans 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
clefts width and degree of lip tissue deficiency is not
addressed on Kernahans 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. Kernahans 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 6 Comparison of Kernahans method and clock diagram for unilateral cleft lip cases.

Rossell-Perry, NEW DIAGRAM FOR CLEFT LIP AND PALATE 311

FIGURE 7 Comparison of Kernahans method and clock diagram for bilateral 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 clinics cleft severity classification and better
describes individual cleft deformity in comparison with
Kernahans diagram. The code in Kernahans 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
TABLE 4

Number of Patients and Type of Cleft

Type of Cleft

Unilateral cleft lip

Bilateral cleft lip
Complete cleft palate
Incomplete cleft palate

460
125
388
77

44.1
11.9
37.2
7.4

this feature represents the most important difference from

other well-described classifications such as Mortiers and
Ortiz-Posadass. 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
TABLE 5

Unilateral and Bilateral Types of Cleft

Type of Unilateral Cleft

192
181
87
460

41.73
39.35
18.91
100

Type of Bilateral Cleft

Mild
Moderate
Severe
Total

24
36
65
125

19.2
28.8
52
100

Type of Cleft Palate

Mild
Moderate
Severe
Total

50
252
156
458

10.91
55.02
34.06
100

Mild
Moderate
Severe
Total

312 Cleft PalateCraniofacial Journal, May 2009, Vol. 46 No. 3

FIGURE 8 Cleft description for unilateral cleft lip and palate.

bilateral cleft lip. In addition, severe forms of cleft palate

have 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.

Using our diagram, it is possible to incorporate elements

that are not considered in other approaches and to describe
all 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).

CONCLUSIONS

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

assistance with native English speaker manuscript revision.

A diagram was developed to characterize clefts according

to their severity. Traditional methods that have been
developed involve diverse cleft characteristics but are
limited in their description or are too cumbersome for
application. In addition, there is no correlation between
these classifications and management protocols.

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