Evaluation and integration of disparate classification systems for clefts of the lip

Abstract

Orofacial clefting is a common birth defect with wide phenotypic variability. Many systems have been developed to classify cleft patterns to facilitate diagnosis, management, surgical treatment, and research. In this review, we examine the rationale for different existing classification schemes and determine their inter-relationships, as well as strengths and deficiencies for subclassification of clefts of the lip. The various systems differ in how they describe and define attributes of cleft lip (CL) phenotypes. Application and analysis of the CL classifications reveal discrepancies that may result in errors when comparing studies that use different systems. These inconsistencies in terminology, variable levels of subclassification, and ambiguity in some descriptions may confound analyses and impede further research aimed at understanding the genetics and etiology of clefts, development of effective treatment options for patients, as well as cross-institutional comparisons of outcome measures. Identification and reconciliation of discrepancies among existing systems is the first step toward creating a common standard to allow for a more explicit interpretation that will ultimately lead to a better understanding of the causes and manifestations of phenotypic variations in clefting.

Keywords: classification system; cleft lip; forme fruste; incomplete cleft; ontology; orofacial clefts.

Figure 1

Example rankings of varying unilateral left and bilateral phenotypic presentations based on subjective interpretations of the ICD-10, LAHSN (Koch et al., 1995), LAPAL (Liu et al., 2007), and Smith's modification of Kernahan's Striped “Y” (Smith et al., 1998). A cleft from Group (A) would be classified as a unilateral or bilateral CL, subtotal cleft, < 1/2 CL, or 1/3 CL, respectively. A cleft from Group (B) would be classified as a unilateral or bilateral CL, subtotal cleft, > 1/2 CL, or 2/3 CL, respectively. A cleft from Group (C) would be classified as a unilateral or bilateral CL, total cleft, complete CL, or 3/3 CL, respectively.