PEDIATRIC/CRANIOFACIAL

Tessier No. 7 Cleft: A New Subclassification and

Management Protocol
Roger H. Woods, M.B.B.S.,
F.R.A.C.S.
Sanjay Varma, M.B.Ch.B.,
F.R.C.S.(Plast.)
David J. David, A.C., M.D.,
F.R.A.C.S.
Adelaide, South Australia, Australia
Background: Tessier described rare craniofacial clefts anatomically. The no. 7
cleft is a lateral facial cleft consisting of macrostomia, lateral facial muscular
diastasis, and bony abnormalities of the maxilla and zygoma. Early computed
tomographic imaging provided preliminary insight into the bony abnormality.
This article reviews this patient group, defining the clinical and radiological
features, to advise optimal protocol management.
Methods: A retrospective case-note review of 15 patients with Tessier no. 7 clefts
managed by the Australian Craniofacial Unit over the past 25 years was per-
formed. Cases of hemifacial microsomia and Treacher-Collins syndrome were
excluded. Clinical features of the patient group were analyzed with photography
(all clefts) and imaging (seven clefts). Surgical management and outcome are
reviewed.
Results: Fifteen patients and 18 clefts (three bilateral) were treated during the
time period of the study. All patients had macrostomia (mean length, 2 cm) and
94 percent had soft-tissue ridging from muscular diastasis directed toward the
tragus (44 percent), temporal area (28 percent), or lateral canthus (22 percent).
Bony abnormalities included simple clefting of the maxillary molar region in 55
percent, maxillary duplication in 39 percent, and intermaxillary fusion in 6
percent. Surgical intervention included macrostomia repair at the first available
opportunity, resection of maxillary duplication (median age, 4 years), and
alveolar bone grafting to the cleft (median age, 10 years). Optimal follow-up of
these patients is impaired because of long distances required for review. Patients
treated with this management protocol have had good functional and aesthetic
results to date.
Conclusions: This article describes the Tessier no. 7 cleft in great detail and
suggests a new subclassification of the bony abnormality. An adjusted man-
agement protocol is proposed to address the bony abnormalities of cleft and
duplication, with favorable outcomes for treated patients with this
condition. (Plast. Reconstr. Surg. 122: 898, 2008.)

T
essier described an anatomical classification
of craniofacial clefting that provides a nu-
merical pattern from 0 to 14, based on the
direction of the cleft relative to the orbit.1 The no.
7 cleft is a lateral facial cleft with no direct rela-
tionship to the orbit. According to Tessier, the
cleft is centered on the zygomaticotemporal
suture.1
From the Australian Craniofacial Unit, Women’s and Chil-
dren’s Hospital.
Received for publication August 20, 2007; accepted January
4, 2008.
Presented, in part, at the XIIth Biennial International Con-
gress of the International Society of Craniofacial Surgery, in
Salvador, Bahia, Brazil, August 23 through 25, 2007.
Copyright ©2008 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3181811cb6
Van der Meulen et al. described a classification
based on the hypothesis of dysplasia in particular
developmental areas. The no. 7 cleft coincides
with maxillomandibular dysplasia described by
this classification.2
The no. 7 cleft makes up 5.5 percent of Tessier
cleft cases managed by the Australian Craniofacial
Unit3 and 13.9 percent of cases treated in Mexico
by Ortiz-Monasterio et al.4
Tessier described the features of the no. 7 cleft
as comprising the following:
Disclosure: None of the authors has a financial
interest in any of the products described in this
article.

898 www.PRSJournal.com
Volume 122, Number 3 • Tessier No. 7 Cleft
• Absence of the zygomatic arch; variable deformity
of the mandibular ramus, condyle, and coronoid
process; and hypoplastic maxillary alveolus.
• Maxillary cleft in the molar region and be-
tween the maxillary tuberosity and the ptery-
goid process.
• Soft-tissue abnormalities including macrosto-
mia, ear abnormality (preauricular tags or mi-
crotia), temporalis abnormality, and absence
of preauricular hair.1
This article reviews the features of patients with
Tessier no. 7 clefts and provides a detailed descrip-
tion of soft-tissue and bony abnormalities. David has
previously described a protocol for management of
these cases. This consisted of repair of macrostomia
and any associated cleft lip or palate in infancy, speech
and airway management in childhood, alveolar bone
grafting at age 5 to 10 years, and orthognathic surgery
at growth completion.5
The experience of the Australian Craniofacial
Unit in managing Tessier no. 7 clefts over the past
25 years (1982 to 2007) is detailed. Amendments
to the management protocol are suggested.
PATIENTS AND METHODS
A retrospective case note review of all patients
with Tessier no. 7 clefts managed by the Australian
Craniofacial Unit during the 25-year period 1982
to 2007 was undertaken. Ethics approval was ob-
tained at the Women’s and Children’s Hospital
prospectively.
Patients who were diagnosed with hemifacial mi-
crosomia, as evidenced by associated abnormalities
of the ear and mandibular ramus, were excluded
from this study. Likewise, cases of Treacher-Collins
syndrome (initially considered by Tessier as bilateral
no. 6, 7, and 8 clefts) were excluded.
Basic demographic data (e.g., age, sex, coun-
try of origin) were recorded. Photographic and
radiologic documentation (computed tomographic
imaging) was used to assess specific features of the
soft-tissue and bony deformity in these patients. Sur-
gical intervention and supportive care was noted.
Outcomes were assessed by annual follow-up of cases
where possible.
RESULTS
Eighteen clefts in 15 patients (three bilateral)
were identified. Female patients made up a sub-
stantial majority [13 of 15 patients (87 percent)].
Bilateral clefts occurred in 20 percent. Left-sided
clefts were more common (61 percent). One pa-
tient was Australian and 14 patients originated in
the developing world (predominantly Indonesia).
Three patients had isolated no. 7 Tessier clefts
(two unilateral and one bilateral) and the remain-
der (12 patients, 80 percent) had other associated
facial clefts. Eight of the multiple cleft patients (67
percent) had contralateral southbound ocular
clefts (Tessier no. 4, 5, or 6). Three patients had
palatal clefts, and there was one case of occipital
encephalocele. Noncraniofacial associations were
surprisingly rare. One patient had a congenital
ventricular septal defect, and one patient had con-
genital club feet. Typical features of this group of
patients include the following:
• Macrostomia (mean width, 2.0 cm; 33 percent
3 cm or wider, extending posterior to the an-
terior border of the masseter).
• Soft-tissue ridging resulting from muscular di-
astasis.
• The diastasis extended variably to the preau-
ricular area (44 percent), temporal area (28
percent), or lateral canthal area (22 percent).
One patient (6 percent) had minimal ridging.
There was no facial nerve palsy.
• Bony abnormality in the zone of the cleft.
X Fifty-five percent simple cleft of maxillary
dental arch.
X Thirty-nine percent maxillary duplication
(overlapping of segments of bony arch and
supernumerary teeth).
X Six percent (one case) intermaxillary fusion.
The features are summarized in Table 1, and
clinical photography of two typical patients is dis-
played in Figures 1 and 2.
Computed tomographic radiographs were
available in six patients (seven clefts) and exam-
ined in detail. Characteristic features of the bony
abnormality included the following:
• Maxillary cleft typically in the molar region,
positioned between the first and second per-
manent molar teeth (Fig. 3).
• In cases with maxillary duplication, supernu-
merary teeth were present in both segments of
the arch and there was overlap of the two
components of the maxillary arch (Fig. 4). The
arch deficit in this group was also in the molar
region. One case displayed intermaxillary fu-
sion (Fig. 5).
• Shallow intercondylar notch and hypoplastic
coronoid process of mandible.
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 Plastic and Reconstructive Surgery • September 2008

Table 1. Clinical Features of Tessier No. 7 Cleft Patients

Bony
No Side Associated Malformations Sex Macrostomia Muscular Diastasis Malformation
1 Left Right no. 4/5 clefts, cleft F 1 cm Minimal Duplication
palate
2 Left Left no. 6 cleft and F 3 cm Lateral canthus Duplication
microphthalmia
3 Left Nil F 3 cm Preauricular Duplication
4 Left Left no. 9, right no. 5/6 clefts F 2 cm Preauricular Duplication
5 Left Right no. 4 cleft F 2 cm Preauricular Cleft
6 Left Nil F 2 cm Preauricular Duplication
7 Left Right no. 5 cleft, cleft palate M 2 cm Temple Cleft
8 Bilateral Left no. 1/2/3/8/12/13/14 F 1 cm bilaterally Preauricular Cleft bilaterally
clefts bilaterally
9 Right Left no. 4 cleft and F 1 cm Temple Cleft
microphthalmia
10 Bilateral Occipital encephalocele F 4 cm bilaterally Temple bilaterally Cleft bilaterally
11 Right Left no. 4 cleft F 2 cm Lateral canthus Minimal cleft
12 Bilateral Right no. 6 cleft, VSD F 1 cm left, Preauricular left, Duplication left,
groove right temple right cleft right
13 Left Bilateral no. 6 clefts, club feet M 3 cm Lateral canthus Intermaxillary
fusion
14 Right Left no. 6 clefts F 4 cm Lateral canthus Duplication
15 Right Right no. 0/1/10/13/14 clefts, F 1 cm Preauricular Cleft
cleft palate
VSD, ventricular septal defect.

Fig. 1. Bilateral Tessier no. 7 clefts displaying prominent muscu-

lar diastasis.

• Hypoplasia of the lateral body of zygoma with

intact arch. Often a small ridge was present on
the superior aspect of the zygomatic arch in
line with the hypoplasia of the zygomatic body.
A cleft was present in the zygomatic arch in
only one case.
• Orbital dystopia with vertical elongation and Fig. 2. Combined right Tessier no. 6 and 7 clefts with supernu-
inferior displacement occurred only when an merary teeth and maxillary duplication.

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Volume 122, Number 3 • Tessier No. 7 Cleft
Fig. 3. Computed tomographic images of bilateral Tessier no. 7 clefts with alveolar clefts in the
molar region bilaterally.
Fig. 4. Computed tomographic imaging of combined right Tessier no. 6 and 7 clefts with maxillary
duplication.
associated Tessier no. 6 ocular cleft was also
present.
• Fourteen of the patients had surgical interven-
tion, as displayed in Table 2. All had macros-
tomia repair as the first procedure, performed
whenever surgical expertise allowed. As most
of these patients live in Indonesia and other
parts of the developing world, this was usually
in early childhood (median age, 3 years). Five
patients with duplication of the maxilla (in-
cluding one with intermaxillary fusion) had
surgical resection of the duplicated segment
and bone grafting as required. This was typi-
cally undertaken in childhood (median age, 4
years). Two patients had alveolar bone grafting
performed to the lateral maxillary cleft in late
childhood (median age, 10 years).
• Follow-up of the patients was attempted annu-
ally. Unfortunately, because of the difficulty of
attending care in the developing world, many
patients were difficult to follow up. Seven pa-
tients were managed according to protocol
and have had good results to date, though only
two have reached growth completion. The re-
maining eight patients were lost to follow-up
after receiving initial treatment. The surgical
intervention, current progress, and outcome of
these patients are detailed further in Table 2.
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 Plastic and Reconstructive Surgery • September 2008

Fig. 5. Computed tomographic images of left Tessier no. 7 cleft with associated intermaxillary
fusion.

Table 2. Surgical Intervention and Outcomes of Tessier No. 7 Cleft Patients

Macrostomia
No Side Closure Bony Intervention Outcome
1 Left Z-plasty (4 yr) Currently awaiting alveolar bone grafting (16 yr)
2 Left Z-plasty (2 yr) Excision of duplicated Last seen after bone surgery at age 4 yr
maxilla (4 yr)
3 Left Z-plasty (3 yr) Excision of duplicated Last seen after bone surgery at age 4 yr
maxilla (4 yr)
4 Left Z-plasty (2 yr) Excision of duplicated Growth completion, good outcome postorthodontic
maxilla (2 yr), alveolar treatment (16 yr)
bone grafting (9 yr)
5 Left Z-plasty (3 yr) Alveolar bone grafting (11 yr) Last seen at age 12 yr, no further treatment
planned
6 Left Nil Currently awaiting alveolar bone grafting (12 yr)
7 Left Nil Currently awaiting cleft palate repair (1 yr)
8 Bilateral Z-plasty (5 yr) Frontal cranioplasty for Last seen at age 14 yr, no further treatment
medial clefts (5 yr) planned
9 Right Nil Last seen at age 3 yr
10 Bilateral W-plasty (2 yr) Occipital cranioplasty (2 yr) Last seen at age 2 yr
11 Right Nil Last seen at age 1 yr
12 Bilateral Z-plasty (3 mo) Orthodontic maxillary Currently receiving orthodontics, excision of
expansion (10 yr) duplication and alveolar bone grafting planned
(10 yr)
13 Left Z-plasty (3 yr) Release of intermaxillary Current good progress (6 yr)
fusion (3 yr)
14 Right Z-plasty (14 yr) Excision of duplicated Growth completion, good outcome (16 yr)
maxilla plus bone grafting
(14 yr)
15 Right Nil Last seen at age 15 yr; no further treatment
planned

DISCUSSION more accurate description of this specific dis-

Features of the Tessier No. 7 Cleft
The Tessier no. 7 cleft is an uncommon con-
dition and has been incompletely studied. This
large group of patients was collected by the Aus-
tralian Craniofacial Unit over a 25-year period.
Exclusion of patients with hemifacial microso-
mia and Treacher Collins syndrome has allowed
order.
The advent of three-dimensional computed
tomographic scanning has enabled improved un-
derstanding of the bony abnormalities in cranio-
facial clefts. David et al. have previously enlarged
on Tessier’s initial description of the bony
abnormality.6 They noted a bony cleft through the
pterygomaxillary junction with hypoplasia of the

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Volume 122, Number 3 • Tessier No. 7 Cleft
maxillary alveolus in the molar region, producing
posterior open bite. The zygomatic body was mal-
formed, and the mandibular condyle was hypo-
plastic and asymmetric.
This study provides a more detailed descrip-
tion of the bony deformity based on radiographic
images of Tessier no. 7 clefts. The salient features
include the following:
• Maxillary clefting presenting either as hyp-
oplasia or duplication of the maxillary alve-
olus. This was positioned posterior to the first
permanent molar tooth and resulted in pos-
terior open bite.
• Hypoplasia of the lateral body of the zygoma.
• Mild mandibular abnormality with flattening
of the coronoid process and a shallow inter-
condylar notch.
Maxillary duplication, determined by multiple
supernumerary teeth and significant overlap of
the two maxillary arches, occurred in 39 percent
of no. 7 clefts. Maxillary duplication has been pre-
viously described in association with facial clefting
in several case reports.7–10 Detailed review of the
maxillary bony abnormality in the no. 7 cleft
group has not been previously undertaken. Our
results show that the bony malformation occurs in
the molar area, typically posterior to the first per-
manent molar tooth. We recommend a classifica-
tion of the abnormality in this area to support this
distinction:
Tessier 7a: maxillary cleft.
Tessier 7b: maxillary duplication (additional
teeth and overlap of the two maxillary arches).
Features of the soft-tissue deformity include mac-
rostomia (typically 2 cm in length but often
extending posteriorly past the medial border of
the masseter) and soft-tissue ridging caused by
muscular diastasis, which passed variably to the
lateral canthal, temple, or preauricular areas
but was not associated with a coloboma of the
lower eyelid.
Relationship between Tessier No. 7 Cleft and
Hemifacial Microsomia
Previous descriptions of the no. 7 cleft have
had many features in common with hemifacial
microsomia. Hemifacial microsomia is widely ac-
cepted to have mandibular ramus hypoplasia, ear
abnormality, and soft-tissue hypoplasia. Many pa-
tients have associated bony ocular changes causing
dystopia, facial nerve palsy, macrostomia, and
bony clefts in the zygomatic arch. This malforma-
tion has been classified using the classification
systems of David et al.11 and Vento et al.12 Both of
these systems pay specific attention to mandibular
ramus and ear abnormalities.
The group of patients in this study depict the
Tessier no. 7 cleft without ear or major man-
dibular abnormalities. Maxillary clefting or du-
plication was present in all cases. Eighty percent
had other associated craniofacial clefts. As a re-
sult, it is reasonable to suggest that Tessier no.
7 clefts are part of the rare clefting phenomenon
and are distinctly different from hemifacial mi-
crosomia. Maxillary duplication occurred in 39
percent of clefts. The high incidence suggests
that the maxillary alveolar abnormality may oc-
cur with overgrowth or undergrowth at the cleft
site, similar to that described in midline Tessier
clefts.1
Management Protocol for Tessier No. 7 Cleft
The results of this study suggest an altered
protocol for management of Tessier no. 7 clefts as
shown in Table 3.
The macrostomia associated with this defor-
mity should be addressed at the first safe oppor-
tunity. Macrostomia repair has been achieved by
a variety of techniques. The cardinal points are
trilaminar repair with accurate apposition or
interdigitation of perioral musculature to create
a new functional oral commissure.13,14 Skin clo-
sure has been performed by straight-line
closure,15,16 Z-plasty,17,18 W-plasty,19,20 or transpo-
sition flap.21 Our favored approach is a Z-plasty
skin closure, with careful attention to recon-
struction of the modiolus.
During this first procedure, it is also impor-
tant to reappose the buccinator muscle to re-
duce dimpling along the line of the cleft. It is
incredibly difficult to aesthetically address the
soft-tissue ridging, which is caused by muscle
diastasis. Soft-tissue fillers, such as fat injection
Table 3. Optimized Management Protocol for
Management of the Tessier No. 7 Cleft
Age Intervention
Infancy Closure of macrostomia with or
without closure of cleft
lip/palate if present
Early childhood Resection of maxillary duplication
(2–4 yr) if present
Childhood Speech/airway management
Late childhood Bone grafting of maxillary
(5–10 yr) alveolar defect
Growth Orthognathic surgery as required,
completion followed by touch-up soft-tissue
surgical correction
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 Plastic and Reconstructive Surgery • September 2008
or dermofat grafting, may be an option for re-
contouring this area. Unfortunately, the altered
muscular pull creates recurrence of the defor-
mity over time.
Duplication of the maxilla was common in the
study group. Most (80 percent) of these patients
who underwent surgical intervention did so in
early childhood (age 2 to 4 years). At this time, the
extra part of the arch is removed. Typically, nei-
ther of the two arches actually interdigitates with
the mandibular arch; instead, they lie to either
side of it. The arch to be discarded is determined
by position, quality of alveolar bone, and position-
ing of teeth. Our preference is to excise the medial
part of the arch if possible. The lateral arch has a
separate and preservable sensory nerve and blood
supply from the posterior superior alveolar nerve
and artery. Also, postoperatively, it is simpler to
orthodontically narrow the arch than to expand it.
Often, excision of the duplication will leave a re-
sidual alveolar gap, which may be closed later with
bone grafting rather than early fixation, which will
narrow the upper dental arch.
Alveolar bone grafting is widely accepted in
the management of the cleft lip and palate
deformity.22 These principles can also be applied
to the maxillary bony cleft in no. 7 clefts during
late childhood.5 Gingivoperiosteal flaps are raised
in the standard fashion and cancellous bone graft
packed tightly into the bony defect. Alveolar bone
grafting allows (1) later insertion of osseointe-
grated dental implants if desired and (2) a com-
plete stable arch for orthognathic surgery if re-
quired.
Techniques of orthognathic surgery can be
applied to no. 7 clefts for optimal facial aesthetics
and function. Orthognathic surgery is performed
if required for midface hypoplasia at growth com-
pletion. This is facilitated by prior alveolar bone
grafting to attain a complete maxillary dental
arch. A high Le Fort I osteotomy is performed in
standard fashion to advance the maxilla, in accor-
dance with preoperative cephalometrics and plan-
ning. Additional onlay bone grafts are placed on
the zygomatic body to address the contour defect
of the hypoplastic zygomatic body. Final touch-up
soft-tissue surgery is undertaken if required, at
least 6 weeks after addressing the bony deformity.
CONCLUSIONS
This study highlights the features of the de-
formity in the Tessier no. 7 cleft. We believe the
deformity differs from hemifacial microsomia in
features and cause. Maxillary duplication has been
904
a significant finding in our study. It is a common
abnormality in the Tessier no. 7 cleft and has
management implications. A new classification of
the maxillary cleft is described, highlighting the
need for early intervention in cases of maxillary
duplication.
Roger H. Woods, M.B.B.S., F.R.A.C.S.
c/o Australian Craniofacial Unit
Women’s and Children’s Hospital
72 King William Street
North Adelaide, South Australia 5006, Australia
rogerwoods1@gmail.com
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