|Year : 2017 | Volume
| Issue : 3 | Page : 20-24
A new classification approach: Center of integral care of cleft lip palate “SUMA” center (México)
Jose Maya Behar, Daniel De Luna Gallardo, Rodrigo Morales De La Cerda, Silverio Tovar Zamudio
Cleft Lip Palate Center “SUMA”, México City, Mexico
|Date of Web Publication||21-Nov-2017|
Jose Maya Behar
Av. Nuevo León 159, Hipódromo 06100, Ciudad de México, CDMX
Source of Support: None, Conflict of Interest: None
The cleft lip palate (CLP) is characterized by multiple phenotypic presentations in relation to the degree of severity and complexity that may involve its embryology. These characteristics largely determine the approach and therapeutic plan. There have been many descriptive, diagrammatic, and coding systems throughout history that have tried to define and unify the malformation. However, there are only a few that have stood the test of time. The objective of the present study is to propose a new classification of CLP (“SUMA”) by an observational study implemented in 410 patients. We use the criteria proposed by Hakins (1961) for an “Ideal” classification to evaluate our system. The 406 patients (99%) fulfilled the criteria in their totality being able to be classified adequately. Proving that the “SUMA” system corresponds to a unique, descriptive, reproducible, clear, and specific tool that promises to unify the classification in the CLP.
Keywords: Classification, cleft lip and palate, nomenclature, SUMA, terminology
|How to cite this article:|
Behar JM, Gallardo DD, De La Cerda RM, Zamudio ST. A new classification approach: Center of integral care of cleft lip palate “SUMA” center (México). J Cleft Lip Palate Craniofac Anomal 2017;4, Suppl S1:20-4
|How to cite this URL:|
Behar JM, Gallardo DD, De La Cerda RM, Zamudio ST. A new classification approach: Center of integral care of cleft lip palate “SUMA” center (México). J Cleft Lip Palate Craniofac Anomal [serial online] 2017 [cited 2022 Jan 27];4, Suppl S1:20-4. Available from: https://www.jclpca.org/text.asp?2017/4/3/20/218902
| Introduction|| |
The nature of the cleft and lip palate (CLP) is characterized by multiple phenotypic presentations in relation to the degree of severity and complexity that may be involved in its development. These characteristics largely determine the approach and therapeutic protocol. In this sense, the specific and detailed diagnosis represents a fundamental step in the approach of the malformation, creating the need to create a methodology that allows the multidisciplinary group to classify and determine the appropriate and individualized treatment for each patient.
The objective of the present study is to propose a new classification that was developed and implemented in the Integral Care of CLP “SUMA” center (México). Which categorizes the fissure based on its embryological development, incorporating all the anatomical variants and specific complexity that can be presented in an abbreviated scheme. In this way we created a unique, descriptive and universal platform for use in any Cleft Palate Cleft Center.
Evolution of system classifications
Throughout the history, multiple classifications have been developed that try to describe and categorize CLP. Among pioneers, Davis and Ritchie and Veau stand out., However, they lacked detail in the severity and magnitude of the cleft.
Among the most popular classifications, highlights the proposal by Kernahan and Stark, the cleft is categorized in relation to the embryological development of the primary and secondary palate, represented schematically in the form of “Y.” This classification has been taken up and modified by several authors such as Kernahan and Stark(1971) and Elsahy. The degree of protrusion of the premaxilla and the velopharyngeal competence are incorporated.
Spina and Spina, proposed a new precise and unambiguously terminology. Fostering the use of Latin vocabulary to name each specific anatomical structure involved in the malformation, which would make CLP classification easier to teach and memorize, as well as applicable to interdisciplinary and international communication.
Millard presented a new classification that includes a detailed description of the nasal involvement with respect to the cleft. Mortier and Martinot created a bimodal classification, in which the first component establishes an initial severity index, and subsequently, a second component that reflects the postoperative outcome index (PRS). Both classifications allow to establish an objective comparison of the postoperative results based on the degree of severity of the fissure, having as limitation of its application in the bilateral clefts.
Ortiz-Posadas et al. and Ortiz-Posadas, established a new and innovative classification that categorizes the fissure in relation to the three main anatomical components involved in the malformation (Nasolabialis, primary and secondary palate), describing numerically the deficiency of affected lip length, muscular integrity, and sulcus depth, among others.
Liu et al. established a simple and precise classification based on five digits (Arabic numbers) in order of right lip, right alveolus and primary palate, secondary palate, left alveolus and primary palate, and left lip. The extent of cleft is represented by the Arabic numerals 0–4, in order of its severity.
Grawal made a modification to the Indian classification published in 1975. Classifying the cleft in three main groups depending on the CLs involvement, alveolus, and palate in continuity, adding to the original version an abbreviation system which stands out for being descriptive and easy to use.
Among the newest classifications, we found Allori et al. proposal in 2015, in which they proposed a new terminology based on the most representative elements of the classifications mentioned above. This classification is characterized for being integrally and widely applicable to the clinical field.
Reflecting on the complex history of CLP classification, we observed a gradual progression of thoughts that has led to more advanced concepts, but still incomplete, mainly in its description of the severity involved in the cleft. With great honor for those authors on whose shoulders we are, we propose the “SUMA” classification of CLP.
| Materials and Methods|| |
The following article presents an observational and descriptive study with a longitudinal-time in a total number of 410 patients of Integral Care of CLP “SUMA” center with CLP diagnosis, in a period of time from July 2013 to August 2017 [Table 1].
The “SUMA” classification categorizes the cleft in relation to the embryological development of the primary and secondary palate, including in its description of the severity and magnitude of the cleft, as well as the anatomical variants that can be present and the relation with the structures involved, which can be used routinely and systematized in the clinical field [Figure 1].
It is necessary to define the abbreviations and concepts that are used in the classification [Table 2]. It is understood as a cleft to the congenital abnormality that is characterized by the separation of the components in the primary, secondary palate or both.
The embryological development of the primary palate results after the fusion of the palatine processes, anatomically established by the upper lip, the maxillary alveolar process, to the incisive foramen. Primary palate cleft (PPC) can be classified as:
- Complete: It extends through the entire length of the lip to the floor of the nose, without presenting healthy tissue in its path. It can be unilateral (right and left) or bilateral
- Incomplete: It presents partial muscle segments and cutaneous tissue, covering two anatomical variants according to the length of the partial fissure, being categorized in PPC one-third and two-third, depending on the total length involved in the partial fissure. It can be unilateral or bilateral.
At the same time, the complete PPC is classified according to the separation between alveolar processes in:
- Contact between segments: The segments of the alveolar process in the primary palate have contact in their path
- Without contact between segments: The segments of the alveolar process in the primary palate do not present contact in their path, determining in millimeters the distance between them.
The secondary palate (SP), comprises of' the structures posterior to the incisive foramen, developed after the fusion of the lateral palatine processes. The lack of fusion of the palatine processes in the embryonic period causes a cleft of variable amplitude and length. Therefore, the SPC can be classified according to its anatomical: Length involved and its degree of separation between palatal processes.
By its length it is classified in:
- Submucosal: Incomplete cleft of the secondary palate, characterized by velopharyngeal insufficiency, bony notch at the posterior border of the maxilla, and with or without bifid uvula
- Incomplete: It presents partial segments of secondary palate, being categorized into SPC one-third and two-third depending on the total length involved in the partial cleft
- Complete: It extends across the entire length of the secondary palate.
By their degree of separation:
- Severity I (minimum): The width of palate shelf greater than width of cleft
- Severity II (moderate): Width of palate shelf equal that width of cleft
- Severity III (severe): The width of the palatine shelf is less than the width of the cleft.
To improve the practicality of “SUMA” classification and to facilitate the teaching, a pre-established template with structured abbreviations was developed, which allows to establish the different combinations that detail the specific cleft of each patient [Figure 1]. It stands out as an accessible, graphic, descriptive understandable, and predictable tool.
As discussed, CLP occurs in various combinations depending on the involvement of the primary, secondary, or both palate. This is why we illustrate several representative cases classified with the “SUMA” system [Figure 2], [Figure 3], [Figure 4].
|Figure 2: Front and intraoral photographs of a child classified as a secondary palate cleft two-third coded as SPC 2/3|
Click here to view
|Figure 3: Front and intraoral photographs of a child classified as complete left primary palate cleft without contact of segments 5 mm + secondary palate cleft SII. Coded as C-primary plate cleft - without contact between segments 5 mm + C-secondary plate cleft SII|
Click here to view
|Figure 4: Front and intraoral photographs of a child classified as complete left-right primary palate cleft without contact of segments (right 8 mm and left 11 mm) + secondary palate cleft SIII|
Click here to view
| Results|| |
The Mexican classification was implemented in 410 patients during a period of 4 years and 1 month. To evaluate the use of the “SUMA” classification in our population, the three criteria for an “Ideal” classification scheme published by Harkins et al. and added to the Nomenclature Committee of the American Association for Cleft Lip Rehabilitation Palate were used [Table 3].
From our total population, 406 patients (99%) fulfilled the three criteria in their totality being able to be classified adequately. Four patients (1%) belonging to the referred group (100%) could not be classified with our system because of the anatomy presented by their postoperative sequels.
| Discussion|| |
CLP corresponds to a craniofacial malformation with a broad spectrum of phenotypical presentation. The initial classification is a fundamental step in the comprehensive approach to pathology.
Currently, each CLP care center uses different classification schemes. These systems are difficult to communicate or use in routine clinical practice, creating disagreements between them.
A correct classification of the cleft allows to determine the necessary requirements for an integral treatment. The “SUMA” system allowed to establish a correct and integrated classification in 99% (406 patients) of all the CLP of our population.
A significant limitation was found in postoperative patients who presented some complication during the surgical treatment because of its complexity and anatomy they could not be described in its totality.
| Conclusion|| |
The “SUMA” classification created and implemented in the Integral Care of CLP “SUMA” center (Mexico) corresponds to a unique, descriptive, reproducible, clear, and specific tool that promises to unify terminology in relation to the degree and severity of the fissure, establishing an integral terminology for each patient at any LPH care center worldwide.
This contribution to the literature is essential to propose a new classification system available to all CLP clinics worldwide. A follow-up article will also describe the great compatibility of this method classification with our care protocol system, establishing the specific treatment to be followed in each patient from its initial approach, as well as the resources and multidisciplinary team required in their attention.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Davis JS, Ritchie HP. Classification of congenital clefts of the lip and palate with a suggestion for recording these cases. JAMA 1922;79:1323-7.
Veau V. Palatine anatomy. Paris: Masson; 1931.
Veau V. Cleft Lift and Palate. Clinical presentation. Surgery. Paris: Masson; 1938.
Kernahan DA, Stark RB. A new classification for cleft lip and palate. Plast Recons Surg 1958;22:435.
Kernahan DA. The striped Y a symbolic classification for cleft lip and palate. Plast. Recons. Surg. 1971; 47: 469-70.
Elsahy NI. The modified striped Y – A systematic classification for cleft lip and palate. Cleft Palate J 1973;10:247-50.
Spina V. Surgery treatment of complete, unilateral and bilateral cleft, lip and palate. Evolutionary study by craniometry and modeling. Latin American Journal of Plastic Surgery 1961; 5: 38-79.
Spina V. A proposed modification for the classification of cleft lip and cleft palate. Cleft Palate J 1973;10:251-2.
Millard RD Jr. The naming and classifying of clefts. In: Cleft Craft. Vol. I. Boston: Little, Brown, and Co.; 1976. p. 41-55.
Mortier PD, Martinot VL. Evaluation of the results of cleft lip and palate surgical treatment: Preliminary report. Cleft Palate Craniofac Surg J 1997;34:247-55.
Ortiz-Posadas MR, Maya-Behar J, Lazo-Cortes M. Evaluation of cleft lip and palate surgery with the logic-combinatorial approach of pattern recognition theory. RBE-Biomed Engineering Report 1998; 14: 7-21.
Ortiz-Posadas M. A new approach to classify cleft lip and palate. Cleft Palate Craniofac Surg J 2001;38:545-50.
Liu Q, Yang ML, Li ZJ, Bai XF, Wang XK, Lu L, et al.
A simple and precise classification for cleft lip and palate: A five-digit numerical recording system. Cleft Palate Craniofac J 2007;44:465-8.
Grawal K. Classification of cleft lip and palate: An Indian perspective. J Cleft Lip Palate Craniofacial Anomalies 2014;1:78-84.
Balakrishnan C. Indian classification of cleft lip and palate. Indian J Plast Surg 1975;8:23-4.
Allori AC, Mulliken JB, Meara JG, Shusterman S, Marcus JR. Classification of cleft lip/Palate: Then and now. Cleft Palate Craniofac J 2017;54:175-88.
Harkins, CS, Berlin A, Harding RL, Longacre JJ, Snodgrasse RM. A Classification of cleft lip and cleft palate. Plast Reconstr Surg 1962;29:31-9.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]