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Short communication

SPINA classification of cleft lip and palate: A suggestion for a

complement
R. Rodrigues a,b, M.H. Fernandes a,c, A. Bessa Monteiro d, R. Furfuro d, T. Sequeira b,
C. Carvalho Silva b, M.C. Manso c,e,*
a
Faculty of Dentistry, University of Porto, R. Dr. Manuel Pereira da Silva, 93, 4200-393 Porto, Portugal
b
Faculty of Health Sciences, University Fernando Pessoa, Praça 9 de Abril, 349, 4249-004 Porto, Portugal
c
LAQV/REQUIMTE, University of Porto, 4051-401 Porto, Portugal
d
Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, s/n, 4200-319 Porto, Portugal
e
Faculty of Health Sciences, University Fernando Pessoa, Fernando Pessoa Energy, Environment and Health Research Unit (FP-ENAS), Praça de 9 de Abril, 349,
4249-004 Porto, Portugal

A R T I C L E I N F O A B S T R A C T

Article history: Spina’s classification uses the incisive foramen as an anatomic reference to define groups I, II, and III. In some
Received 1st June 2018 cases, the morphological manifestation of the cleft arises simultaneously pre- and postforamen, but without
Accepted 18 August 2018 communicating. Considering that group I refers to isolated clefts of the primary palate and group III includes
Available online xxx
isolated clefts of the secondary palate, the authors suggest the classification group IIa for the association of
these two occurrences in the same patient, thus associating two classifications. The original structure
Keywords: proposed by Spina is maintained and simply complemented and updated to Spina-A classification.
Classification C 2018 Elsevier Masson SAS. All rights reserved.
Cleft lip
Cleft palate and embryology

1. Introduction foramen as the reference to typify the various incidences of the

The classification of pathologies serves as a useful guide to
professionals in related areas by allowing critical communication
in identifying and qualifying the level or degree of a particular
pathology.
In general, classifications can be broad and comprehensive, or
restricted and simple. Often broad classifications are excessively
complex and their use becomes less consensual. On the other hand,
simpler classifications, although not so inclusive, achieve great
acceptance in scientific and academic circles.
Since 1922, several classifications have been presented for cleft
lip and palate [1–6]. In these classifications, several references
have been used, seeking unanimous rational criteria that allow
interactions and transmission of information among professionals,
exclusively using the classification nomenclature.
This issue is still debated, as shown by very recent reports
[7,8]. Updates seek to introduce complementary information
aiming for more comprehensive and explanatory classifications,
while attempting to retain simplicity. Spina’s classification [6],
introduced in 1973, reached greater adhesion because of its
simplicity. This classification, like others [3,4], uses the incisive
* Corresponding author. Faculty of Health Sciences, University Fernando Pessoa,
Praça de 9 de Abril 349, 4249-004 Porto, Portugal.
E-mail address: M.C.Mansoce*cmanso@ufp.edu.pt (M.C. Manso).
cleft. The incisive foramen is an embryonic vestige, which results
from the fusion of the premaxilla with the maxillary processes.
Used as a classification reference, it does not cover certain possible
combinations of distinct occurrences, resulting in information
being neglected in routine cleft identification and classification.
This paper aims to propose a complement to the Spina
classification.
2. Embryology
Face and oral cavity formation occurs in an early embryonic
stage and involves the development of multiple tissue processes
that must be joined and fused in an extremely orderly manner.
Face development begins by the 5th week of intrauterine life, when
the five facial prominences are formed and then merged: a
frontonasal eminence, two maxillary processes, and two mandib-
ular processes [9].
Palate formation results from the union of its two contribu-
tions: the primary and secondary palates. The primary palate
develops first, at the end of the 5th week of intrauterine life from
the innermost portion of the intermaxillary segment. This
segment, formed by the fusion of the medial nasal processes, will
form the anterior portion of the maxilla, housing the incisor teeth.
The primary palate is located in the anterior part of the incisive
foramen [9].

https://doi.org/10.1016/j.arcped.2018.08.001
0929-693X/ C 2018 Elsevier Masson SAS. All rights reserved.

Please cite this article in press as: Rodrigues R, et al. SPINA classification of cleft lip and palate: A suggestion for a complement. Archives
de Pédiatrie (2018), https://doi.org/10.1016/j.arcped.2018.08.001
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Fig. 1. Patient with cleft lip and palate group IIa: Spina classification group I
complete and group III incomplete.
The secondary palate, integrating the hard and soft parts of the
palate, results from the growth of the maxillary processes forming
two lateral palatine processes that will extend from both sides of
the developing oral cavity and will fuse in the midline. Initially,
these palatine processes grow down on each side of the developing
tongue, but as the jaw and neck develop, the tongue moves
downward, allowing a new positioning that will allow its future
fusion. The fusion between the nasal septum and the palatine
processes begins anteriorly during the 9th week, progresses
medially, and is completed posteriorly by the 12th week, forming
the uvula region [9]. Therefore, pre- and postincisive foramen
malformations occur at different embryological times.
3. Spina classification and proposed complement
The Spina classification uses the incisive foramen as an anatomic
reference and provides a division of the congenital malformations of
the face into four groups (I, II, III, and IV). In this case, the various
groups refer to the type of cleft, namely: group I, preforamen
(complete, incomplete); group II, transforamen; group III, post-
foramen (complete, incomplete), and group IV associated with rare
clefts of the face that are not related to the incisive foramen [6].
Clefts that arise pre- and postforamen in the same patient, since
they are both complete, are classified as group II or transforamen,
as mentioned above. In this case, the Spina classification defines
the cleft by the structures involved, in spite of their embryonic
moments, but with a clear focus on the anatomical features.
Although rare, in some cases, the morphological manifestation
of the cleft arises simultaneously as pre- and postforamen, with no
connection, e.g., isolated from each other. In this case, only one of
the clefts is complete and the other is incomplete or both are
incomplete. This situation shows that two independent groups
Fig. 2. Patient with cleft lip and palate group IIa: Spina classification group I incomplete (a) (Keith lip scar) and group III complete (b).
Please cite this article in press as: Rodrigues R, et al. SPINA classification of cleft lip and palate: A suggestion for a complement. Archives
de Pédiatrie (2018), https://doi.org/10.1016/j.arcped.2018.08.001
were affected, namely Spina group I (preforamen) and group III
(postforamen), although the embryonic moments are distinct.
In this case, the cleft does not occur through the foramen in a I–
III communicating way (the foramen may or may not be closed),
and it is observed at the end of the structures that are in an
embryonic sequence, occurring as a consequence of the inadequate
closure of the maxillary processes. Following the same reasoning
that guides other classifications, we are faced with a situation of
partial or incomplete union of the structures, thus an incomplete
cleft. Group II of the Spina classification does not considere the
division as being complete or incomplete.
In a classification, the distribution by classes, categories, or
groups with similar characteristics, according to certain criteria,
should be explanatory and aggregating in their essence, avoiding
duplication or ambiguity.
In the case of isolated pre- and postforamen clefts occurring
simultaneously, the classification with the double association
(groups I and III) does not fulfill part of the requirements of Spina’s
classification.
To fill in this gap, the authors propose to update this
classification, rendering it more comprehensive and enlightening,
but without detracting from the simplicity and accessibility of the
original classification.
The first approach to the problem led us to consider adding the
subcategory ‘‘incomplete’’ to the original Spina group II. This
option was discarded as the two processes occur in distinct
embryonic moments, in distinct anatomical structures, and the
foramen may be not affected at all. Therefore, this proposal would
be academically controversial and anatomically incorrect.
Considering that group I is composed of isolated clefts of the
primary palate and group III includes the isolated clefts of the
secondary palate, the group IIa category is suggested for the
association of these two occurrences in the same patient, thus
associating two categories. The original structure proposed by
Spina is maintained and is simply complemented: Spina-A
classification, updated. According to the proposed modification
(cleft lip and palate group IIa), three different situations exist:
 Spina classification group I incomplete and group III incomplete,
or;
 spina classification group I complete and group III incomplete
(Fig. 1), or;
 spina classification group I incomplete (in this case a Keith lip
scar) and group III complete (Fig. 2).
4. Conclusion
The current proposal can complete the gap in a classification
that has become an extremely important tool in communication
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and scientific organization regarding congenital malformations of
the face.
This type of classification allows the practical and scientific
application of a rational thought structure, which can be broadly
applied. This new addition to a previously established and widely
used classification improves communication and the essential
maintenance.
Disclosure of interest
The authors declare that they have no competing interest.
Acknowledgements
The second author acknowledges the financial support from the
European Union (FEDER funds POCI/01/0145/FEDER/007265) and
National Funds (FCT/MEC, Fundação para a Ciência e Tecnologia
and Ministério da Educação e Ciência) under the Partnership
Agreement PT2020 UID/QUI/50006/2013.
Please cite this article in press as: Rodrigues R, et al. SPINA classification of cleft lip and palate: A suggestion for a complement. Archives
de Pédiatrie (2018), https://doi.org/10.1016/j.arcped.2018.08.001
3
The last author acknowledges Fundação para a Ciência e a
Tecnologia through grants UID/Multi/04546/2013 and UID/QUI/
50006/2013 - POCI/01/0145/FERDER/007265.
All authors acknowledge the support of Prof. Dr. Tiago Coelho.
References
[1] Davis JS, Ritchie HP. Classification of congenital cleft of the lip and palate: with a
suggestion for recording these cases. JAMA 1922;79:1323–7.
[2] Brophy TW. Cleft lip and palate. Ann Surg 1924;79:154–7.
[3] Fogh-Andersen P. Genetic and non-genetic factors in the etiology of facial clefts.
Scand J Plast Reconstr Surg 1967;1:22–9.
[4] Kernahan DA, Stark RB. A new classification for cleft lip and cleft palate. Plast
Reconstr Surg Transplant Bull 1958;22:435–41.
[5] Harkins CS, Berlin A, Harding RL, et al. A classification of cleft lip and cleft palate.
Plast Reconstr Surg Transplant Bull 1962;29:31–9.
[6] Spina V. A proposed modification for the classification of cleft lip and cleft
palate. Cleft Palate J 1973;10:251–2.
[7] Elsherbiny A, Mazeed AS. Comprehensive and reliable classification system for
primary diagnosis of cleft lip and palate. J Craniomaxillofac Surg 2017;45:1010–
7.
[8] Allori AC, Mulliken JB, Meara JG, et al. Classification of cleft lip/palate: then and
now. Cleft Palate J 2017;54:175–88.
[9] Nanci A. Ten Cate’s Oral Histology-E-Book: development, structure, and func-
tion. Missouri: Elsevier Health Sciences; 2017.