Abstract
Objective
To evaluate the attitudes and levels of knowledge regarding Naso-alveolar molding (NAM) treatment for cleft patients across different dental specialties.
Material and methods
This cross-sectional study was conducted at Saidu College of Dentistry, Swat, KPK, Pakistan. A structured questionnaire survey was carried out among 196 dental specialists including Pediatric Dentists, Orthodontists, Prosthodontists and Oral & Maxillofacial Surgeons. Data collection involved 30 responses obtained through personal interviews and 166 responses collected via Google Forms. The questionnaire covered:
(1) Demographic data (specialty, years of experience, academic or clinical role), (2) Knowledge and attitudes towards NAM, including sources of knowledge and personal views on NAM treatment.
The study excluded dental students, general dentists, non-practicing specialists and individuals not involved in cleft care.
Results
A total of196 responses were analyzed (mean age 41.3±5.1 years, 58.2% male). Orthodontists formed the largest group with majority having 05-10 years of experience.Knowledge levels, practice patterns and collaboration differed across specialties.Identified Key challenges included inconsistent treatment protocols and communication gaps. Participants emphasized the importance of interdisciplinary collaboration and recognized the potential role of technological advancements in improving NAM therapy.
Conclusion
The study demonstrated significant variations in knowledge, practice and interdisciplinary collaboration among dental specialties. Key challenges included differing treatment approaches and communication barriers. It is essential to enhance interdisciplinary teamwork and adapt technological innovations for improving NAM therapy outcomes in cleft care.
Introduction
Cleft lip and palate (CLP) are the most common congenital anomalies of the craniofacial skeleton [1]. It occurs due to the failure of fusion between the lateral nasal process, medial nasal process and maxillary process during the first six weeks of pregnancy. In USA and UK, the incidence of CLP is approximately 1 in 700 births, accounting for 11% to 15% of all congenital dysplasia cases. In Pakistan, despite the limited data, the burden of CLP is disproportionately high, with rural regions bearing the greatest burden due to limited healthcare access and prenatal care, a recent study found that CLP is the most common birth abnormality with the prevalence exceeding the global prevalence of CLP reported as 1.43 in every 1000 births, among them 62.4% of cases occurred in males with isolated cleft lip (53.8%) more prevalent than combined cleft lip and palate (25.2%) and left-sided clefts being more common than on the right-side. Meanwhile, females are more likely to present with isolated cleft palate unlike males expected to have cleft lip (with or without palate). In our region despite the fact that comprehensive epidemiological data remain sparse with most studies focusing on single-center reports or outdated surveys. Existing research highlights the latest data regarding the incidence of CLP in Pakistan extracted from medical records, surgical registries and outpatient logs from January 2021till December 2022 [2, 3].
The management of CLP begins at birth and continues into adulthood through various surgical and nonsurgical therapies. Surgical procedures for CLP include lip repair, myringotomy, palate repair, pharyngo-plasty, Palatal expansion, alveolar bone grafting, orthognathic surgery and rhinoplasty. Management typically follows a multidisciplinary approach involving pediatricians, plastic, maxillofacial, ENT and pediatric surgeons along with speech therapists, orthodontists, pediatric dentists and nurse specialists [4–6].
The holistic treatment strategy for CLP includes pre-surgical orthopedics, surgical reconstruction and management of associated complications namely, speech, hearing and dental issues [7]. Surgical correction of the anatomical defect is the only definitive method to reduce the negative impacts. However, it is not feasible in the early months of infancy thus delaying the definitive repair. During this interim period, the child and the guardians may experience significant functional and psychological issues that require medical management.
Pre-surgical Infant Orthopedics (PSIO) is the recent advancement in cleft care that can help bridge this gap before surgery and reduce both functional and psychological stress [8]. It serves as the foundational stage in the long-term orthodontic management of CLP patients. The orthodontic treatment timeline can be considered in four stages: (1) PSIO in neonates or infants, (2) Orthodontics during primary dentition, (3) Mixed dentition Orthodontics, including preoperative planning for alveolar bone grafting and (4) Orthognathic surgery, which involves coordinated orthodontic and surgical correction of skeletal and dental malocclusion in permanent dentition [9].
To improve the lip and nasal symmetry before primary lip surgery, one of the innovations of Pre Surgical Infant Orthopedics, Naso-Alveolar Molding (NAM) has gained global attention [10]. Expanding deficient tissues and aligning displaced segments before surgery enables less invasive procedures to achieve more predictable esthetic and functional outcomes. McNeil (1950) introduced the concept of PSIO and since then numerous appliances and techniques with variable adjustment mechanisms have been developed [11]. NAM emerged as therapeutic strategy that has been successfully utilized for patients with both unilateral and bilateral CLP. Grayson and Cutting were among the earliest to introduce combine preoperative care with pre-surgical orthopedics. The use of PSIO devices can help achieve ideal maxillary arch formation, columella lengthening and symmetry in nostril shape and height [12, 25].
Long-term studies have shown that NAM improves outcomes for patients with unilateral CLP more effectively than surgery alone [12, 13]. One of the study reported that 60% of surgeons preferred NAM before surgery. Dental specialists expressed strong support for NAM in cleft patients, with a majority acknowledging its positive effect on surgical aesthetics [7].
Understanding how different dental specialties perceive and implement NAM would strengthen interdisciplinary collaboration, optimize patient outcomes and highlight areas needing further education and communication. Positive attitudes and knowledge about the psychological advantages of NAM can enhance patient and caregiver satisfaction, therefore, the aim of this study was to evaluate the attitudes and knowledge levels of various dental specialties regarding NAM in patients with CLP.
Material and method
This cross-sectional study was conducted at Saidu College of Dentistry, Swat, following approval from the institutional ethical review board under ERB# 161-ERB/023. Participants were recruited after obtaining informed consent. This questionnaire was adapted from doddamini et al. [7] and utilized the expertise of Consultants to review the questionnaire who ensured that the questions were relevant to the objectives of the study and covers all the necessary aspects. Participation was entirely voluntary and confidentiality was maintained throughout the study, the questionnaire were distributed in person and via email to the participants who were from all the provinces of the country and responses were recorded.
Most participants belonged to the age group 31–40 years with clinical experience of more than 5 years. There was a wide variation in the responses among the participants. A total of 196 responses were recorded, comprising Pediatric Dentists, Orthodontists, Prosthodontists and Oral surgeons. Out of 196, 30 responses were completed through direct personal interviews, while the remaining 166 were disseminated via Google Forms. The structured questionnaire aimed to gather data in two main areas: (1) Demographic details and professional role (academic, clinical or both).
(2) Knowledge and attitudes regarding NAM, covering sources of knowledge acquisition and individual perceptions toward NAM treatment.
The study targeted dental specialists with inclusion criteria limited to those specialized in clinical dentistry; Orthodontics, Pediatric dentistry, Prosthodontics and Oral and maxillofacial surgery. Exclusion criteria applied to dental students, general dentists, non-practicing specialists and dentists not involved in cleft care.
By assuming that 50% of targeted population have familiarity of NAM treatment in cleft patients. Using 95% CI and 7% margin of error, a sample of 196 was required. Open-Epi software (Open Source Epidemiologic Statistics for Public Health) was used to calculate sample size. The study findings were interpreted and reported clearly and concisely with the focus on the knowledge and attitude among various dental specialties regarding NAM.
Data analysis was performed utilizing version 23 of the Statistical Package for Social Sciences (SPSS Inc.). The association between two variables was evaluated through the chi-square test and the Mann-Whitney U test. Additionally, comparisons between two values were conducted using the Kruskal-Wallis test.
Results
Total 196 complete responses were received and analyzed. Mean age of participants was 41.3 ± 5.1 years. More than half of participants were males (58%). Around half of participants working in specialty of orthodontics (48%), having more than 5–10 years of work experience (47%) and working as practitioner (48%). Participants’ sociodemographic profile is presented in Table 1.
Table 1.
Summary of participants’ sociodemographic profile
| Variable | Frequency | Percentage |
|---|---|---|
| Gender | ||
| Male | 114 | 58 |
| Female | 82 | 42 |
| Specialty | ||
| Orthodontics | 95 | 48 |
| Oral and maxillofacial surgery | 51 | 26 |
| Pediatric dentist | 16 | 8 |
| Prosthodontics | 34 | 17 |
| Currently working | ||
| Academician | 34 | 17 |
| Practitioner | 94 | 48 |
| Both | 68 | 34 |
| Work experience | ||
| 1–4 years | 46 | 23 |
| 5–10 years | 92 | 47 |
| 11–14 years | 53 | 27 |
| 15 years or above | 5 | 3 |
Table 2 displayed response distribution for knowledge items.
Table 2.
Response distribution of study participants on knowledge items
| Knowledge items | Responses | Count (n) | Percentage % |
|---|---|---|---|
| In your opinion when is the ideal time to consult a pediatric dentist regarding NAM protocols in cleft care? | Prenatal stage | 9 | 5 |
| At birth or shortly after | 151 | 77 | |
| During infancy | 30 | 15 | |
| Toddler years | 2 | 1 | |
| Preschool years | 4 | 2 | |
| How does NAM contribute to improved aesthetic outcomes in cleft surgeries? | By elongating the columella | 12 | 6 |
| By aligning the maxillary arch | 12 | 6 | |
| By reshaping the cleft area before surgery, NAM minimizes the severity of the cleft and reduces scarring post-surgery | 23 | 12 | |
| By creating symmetrical nostril heights and widths | 13 | 7 | |
| all of the above | 136 | 69 | |
| Which technique in NAM care, akin to Latham’s approach, demonstrates superior outcomes? | Grayson technique, focusing on passive molding with an acrylic plate. | 17 | 9 |
| Figueroa technique, emphasizing active molding through finger pressure | 10 | 5 | |
| Millard technique, utilizing a custom-made nasal stent and lip taping. | 117 | 60 | |
| Matsuo method, employing a presurgical infant orthopedic appliance. | 16 | 8 | |
| Brecht method, employing a nasal alar lift mechanism for improved nasal symmetry. | 36 | 18 |
Table 3. comparison of correct knowledge among different types of practitioners For all three knowledge items, higher frequency of correct knowledge was seen in Orthodontics n(48.5%) followed by Oral and Maxillofacial surgeon n(26%), Prosthodontics n(17.3%) and Pediatric dentist n(8.2%) with significant differences in proportion of correct knowledge.
Table 3.
Comparison of knowledge among different types of practitioners
| Knowledge items | Specialty | p-value | |||
|---|---|---|---|---|---|
| Orthodontics | Oral and Maxillo facial surgery | Pediatric dentist | Prosthodontics | ||
| n (48.5%) | n (26%) | n (8.2%) | n (17.3%) | ||
| In your opinion when is the ideal time to consult a pediatric dentist regarding NAM protocols in cleft care? | 86(86) | 35(69) | 8(50) | 22(65) | *<0.001 |
| How does NAM contribute to improved aesthetic outcomes in cleft surgeries? | 82(86) | 32(63) | 4(25) | 18(53) | |
| Which technique in NAM care, akin to Latham’s approach, demonstrates superior outcomes? | 77(81) | 26(51) | 1(6) | 13(38) | |
All p-values are computed using Fisher-Exact test
*Significant at p<0.05
Table 4.comparison of knowledge sources among different types of practitioners found significant differences in knowledge sources. Frequency of knowledge source through clinical practice and post-graduate training was higher in Orthodontics n(48.5%) followed by Oral and Maxillofacial Surgery n(26%), Prosthodontics n(17.3%) and Pediatric dentist n(8.2%). Pediatric dentists were more frequently acquiring knowledge through workshop based training.
Table 4.
Comparison of knowledge sources among different types of practitioners
| Variable | Groups | Specialty | p-value | |||
|---|---|---|---|---|---|---|
| Orthodontics | Oral and Maxillo facial surgery | Pediatric dentist | Prosthodontics | |||
| n (48.5%) | n (26%) | n (8.2%) | n (17.3%) | |||
| How did you primarily acquire knowledge about NAM procedure? | Conferences/Seminar | 0(0) | 8(16) | 3(19) | 4(12) | *<0.001 |
| Clinical practice/postgraduate training | 84(88) | 32(62) | 6(37) | 21(62) | ||
| workshop-training programs | 7(7) | 5(10) | 4(25) | 4(12) | ||
Table 5.comparison of attitudes among different practitioners. When asked about which dental specialties to be considered primary cleft care providers, all practitioners said all of the above except pediatric dentists who said pediatric dentist (p < 0.001). Majority agreed upon the necessity for dental specialists to collaborate in implementing NAM therapy for cleft patients (I < 0.001). Also, they had the opinion that monthly follow-up for the first year post-NAM should be the approach for best outcomes (p < 0.001). Frequency of collaboration with other dental specialties in managing cleft patients was not significantly different (p = 0.069). When asked about key challenges in collaborative efforts most of the participants had difference of opinion regarding treatment approaches whereas Pediatric dentists claimed communication barriers (p < 0.001) to be a key challenge.
Table 5.
Comparison of attitude among different types of practitioners
| Attitude items | Groups | Specialty | p-value | |||
|---|---|---|---|---|---|---|
| Orthodontist n% |
Oral and Maxillo facial surgery n% |
Pediatric dentist n% |
Prosthodontics n% |
|||
| In your opinion, which of the following dental specialties do you consider to be primary in cleft care? | Orthodontics | 30(32) | 8(16) | 4(25) | 6(18) | *<0.001 |
| Oral and maxillofacial surgery | 0(0) | 11(21) | 3(19) | 1(3) | ||
| Pediatric dentistry | 2(2) | 4(8) | 5(31) | 7(21) | ||
| Prosthodontics | 0(0) | 3(6) | 1(6) | 5(15) | ||
| all of the above | 63(66) | 25(49) | 3(19) | 15(44) | ||
| In your opinion how important do you think it is for dental specialists to collaborate in implementing NAM therapy for cleft patients? | Extremely important | 81(85) | 28(54) | 7(44) | 20(59) | *<0.001 |
| Important | 12(13) | 14(27) | 5(31) | 9(26) | ||
| Somewhat important | 1(1) | 3(6) | 1(6) | 0(0) | ||
| Not important | 0(0) | 3(6) | 0(0) | 4(12) | ||
| Not applicable | 1(1) | 3(6) | 3(19) | 1(3) | ||
| Which post-NAM follow-up approach demonstrate the best outcomes? | Monthly follow-ups for the first year post-NAM | 79(83) | 33(64) | 5(31) | 20(59) | |
| Bi-monthly check-ups for the initial six months post-NAM | 5(5) | 10(19) | 4(25) | 5(15) | *<0.001 | |
| Quarterly appointments during the first two years post-NAM | 5(5) | 4(8) | 5(31) | 3(9) | ||
| Semi-annual evaluations for the first three years post-NAM | 2(2) | 2(4) | 0(0) | 1(3) | ||
| Annual assessments after NAM therapy completion | 4(4) | 2(4) | 2(12) | 5(15) | ||
| How often do you collaborate with other dental specialties in managing cleft patients? | Very often | 27(28) | 18(35) | 2(12) | 8(23) | 0.069 |
| Often | 23(24) | 15(29) | 2(12) | 10(29) | ||
| Sometimes | 39(41) | 15(29) | 7(44) | 9(26) | ||
| Rarely | 3(3) | 2(4) | 2(12) | 4(12) | ||
| Never | 3(3) | 1(2) | 3(19) | 3(9) | ||
| In your opinion, what are the key challenges in collaborative efforts among dental specialists in implementing NAM therapy for cleft patients? | Lack of awareness | 5(5) | 10(19) | 4(25) | 6(17) | *<0.001 |
| Communication barriers | 21(22) | 7(14) | 6(37) | 10(29) | ||
| Differences in treatment approaches | 67(70) | 32(62) | 3(19) | 18(53) | ||
| Time constraints | 2(2) | 2(4) | 3(19) | 0(0) | ||
| What improvements do you think can be made in the current protocols of NAM therapy for cleft patients? | Enhancing interdisciplinary collaboration | 82(86) | 31(60) | 6(37) | 24(71) | *<0.001 |
| Enhancing patient education | 5(5) | 6(12) | 5(31) | 1(3) | ||
| Improving device design | 6(6) | 10(19) | 4(25) | 7(21) | ||
| Streamlining treatment protocols | 2(2) | 4(8) | 1(6) | 2(6) | ||
| In your opinion What is the anticipated future of NAM in cleft care? | Continued refinement with technological advancements | 80(84) | 26(51) | 5(31) | 21(61) | *<0.001 |
| Integration into comprehensive cleft care protocols | 5(5) | 7(14) | 1(6) | 4(12) | ||
| Limited use due to emerging alternative treatments | 4(4) | 9(18) | 2(12) | 3(9) | ||
| Uncertain, pending further research and clinical trials | 2(2) | 4(8) | 6(37) | 4(12) | ||
| Widespread adoption as the standard pre-surgical therapy | 4(4) | 5(10) | 2(12) | 2(6) | ||
| What additional research areas do you think are necessary to further explore the efficacy and benefits of NAM therapy? | Comparative studies with surgical approaches | 74(78) | 26(51) | 6(37) | 16(47) | *<0.001 |
| Cost-effectiveness analyses | 1(1) | 10(19) | 4(25) | 5(15) | ||
| Long-term outcomes | 15(16) | 9(18) | 6(37) | 8(23) | ||
| Patient satisfaction surveys | 5(5) | 6(12) | 0(0) | 5(15) | ||
| In your opinion, what is the most effective approach to cleft care? | Cleft care as a specialty with teams of specialists collaborating | 86(90) | 33(64) | 6(37) | 21(62) | *<0.001 |
| General dentists handling cases individually | 0(0) | 6(12) | 4(25) | 2(6) | ||
| One specialized dentist managing all aspects of cleft care | 1(1) | 1(2) | 4(25) | 2(6) | ||
| Referral to different specialists based on specific needs | 4(4) | 4(8) | 1(6) | 3(9) | ||
| not sure | 4(4) | 7(14) | 1(6) | 6(18) | ||
| Where do you foresee the future interface of NAM in relation to orthodontic, orthognathic, and cleft care treatment approaches? | Global Accessibility | 21(22) | 12(23) | 2(12) | 9(26) | *<0.001 |
| Research and Innovation Hub | 3(3) | 5(10) | 5(31) | 4(12) | ||
| Seamless Integration | 5(5) | 4(8) | 2(12) | 7(21) | ||
| Specialized Collaboration | 6(6) | 14(27) | 3(19) | 3(9) | ||
| Technological Advancements | 60(63) | 16(31) | 4(25) | 11(32) | ||
All p-values are computed using Fisher-Exact test
*Significant at p<0.05
Majority had the consensus that interdisciplinary collaboration can be enhanced to improve current protocols of NAM therapy for cleft patients (p < 0.001) furthermore except Pediatric dentists, all the participants agreed that continued refinement with technological advancements is the anticipated future of NAM in cleft care, further research and clinical trials would be needed to anticipate future of NAM in cleft care (p < 0.001). Among all types of dental practitioners, majority had view that comparative studies with surgical approaches are the additional research areas to be explored to find out the efficacy and benefits of NAM therapy (p < 0.001). Moreover, majority responded cleft care as a specialty with team of specialists collaborating as the most effective approach to cleft care (p < 0.001). Most of the practitioners had view that technological advancements is the future interface of NAM in relation to orthodontic, orthognathic and cleft care treatment approaches (p < 0.001).
Discussion
Clefts lip and palate disorders are broadly categorized into isolated cleft palate and cleft lip with/without cleft palate, signifying a heterogeneous group of conditions affecting the face and oral cavity. The incidence of defect is about 1.7 per 1000 live births with ethnic and geographic variation. It is a well-established fact that in Southeast Asia specifically in Pakistan, facial deformities including cleft lip and palate are prevalent, even though with the passage of time community awareness has improved, significant deficiencies persist concerning knowledge, contribution or practices of parents, the oral healthcare practitioners and/or other medical professionals. [13–15]
The findings of this study emphasize that different specialists and consultants from dentistry discipline recognize the approach to cleft care from a multidisciplinary lens, a crucial decisive factor, especially when it comes to NAM protocol adoption.
This study contextualizes the results within the existing body of literature with particular emphasis over the implications of advancing clinical practice and promoting interdisciplinary collaboration.
In line with previous findings by Doddamani et al. [7], who reported significant differences in NAM-related knowledge (p < 0.001), the current study revealed variability in awareness and attitudes among respondents. It is noteworthy to mention here that 99% of participants supported NAM before cleft surgery whereas 39% preferred Pedodontists to oversee the procedure [10]. Their study conducted personal interviews and online questionnaires emphasizing a generally positive perception for pre-surgical orthopedic interventions.
The current study surveyed 196 dental specialists with orthodontists represented as the largest group (48%). Their responses were similar to the results from other studies and indicated NAM to be broadly categorized a valuable adjunct to CLP treatment protocol, however, variances were found in terms of which specialty would be perceived as the best suited to deliver this therapy and the extent of formal training received [17, 20, 22].
Majority of practitioners had an experience of more than 5–10 years, emphasizing the significance of practical experience in the discipline to be paramount [7, 10, 13] These findings also suggested that a diverse professional pool reveals the importance of a multidisciplinary approach in cleft care, particularly following NAM protocols.
Most respondents (77%) identified the ideal time to consult pediatric dentist was “at birth or shortly after.” This aligns with existing clinical practice of early intervention for optimal outcomes. Additionally the findings proved (69%) that NAM contributed to improved aesthetic outcomes in cleft surgeries due to remodeling the cleft are [10, 14, 19]. The source of information was a crucial element in assessing the depth of knowledge, consequently, knowledge and experiences mentioned were not related to one another across the various specialties [7, 14, 15, 19]. Orthodontists demonstrated the highest level of correct knowledge across all NAM-related items when compared to other specialist’s primarily due to pre-surgical orthopedics being practiced as part of their post graduate training. The significant difference in knowledge levels (p< 0.001) across specialties highlights the need for continuous education and interdisciplinary collaboration especially as pediatric dentists reported comparatively lower knowledge levels this finding correlated with other studies [9, 10, 16, 17]. Orthodontists primarily acquired knowledge of NAM through clinical practice during postgraduate training (88%), while pediatric dentists would rely more on workshop-based training (25%), short courses or conferences (19%). These differences underscore varying approaches to continuing education among specialties highlighting the importance of integrating NAM training into both academic and practical frameworks.
Collaboration among dental specialists remained extremely important for implementing NAM therapy. Interestingly, Pediatric dentists were less likely to agree, only 43.8% considering collaboration as “extremely important.” This finding was suggestive of potential barrier for establishing the concept of teamwork approach, contrary to what Orthodontists, Oral surgeons and Prosthodontists designated crucial [15–19]. Pediatric dentists, on the other hand, quoted communication barriers as the primary challenge (p < 0.001).
A significant portion of participants viewed technological advancements particularly advanced orthodontic appliances using CAD-CAM techniques and aligners as an effective treatment tool would transform the future of NAM [18, 19], specialists Orthodontists (84.2%), being the primary caregivers suggested dynamic regimen change will follow cleft care protocols validating the findings of Tyler R et al., [17] and Ali A.et al., [20] Pediatric dentists, however, expressed uncertainty, 37.5% representing that the future of NAM remains pending with a need for further research and clinical trials. This difference in opinion reflects a gap in consensus regarding NAM’s long-term utility and the importance of continued research, it however emphasizes the crucial role of dentists to counsel the patients regarding the esthetic needs to be fulfilled in order to have a long term impact over the later developmental stages. The current study participants had a consensus that NAM is an efficient pre-surgical treatment modality for complete cleft lip and palate patients and had shown numerous benefits, comprising improved facial profile, improved nasal contour with comparatively reduced surgical scars & alveolar bone gap, functioning as feeding plate. Adapting this protocol does increase the likelihood of lessened number of correcting surgical procedure in future [21–24]. The study had shown a positive attitude towards adapting the NAM protocol before proceeding for Surgical Repair, although it was designated as controversial by few authors owing to less or no significant results following the protocol [12, 25], like the findings of the current research, several other studies have suggested the results to be promising in terms of improving the Facial profile, nasal contour and Alveolar development ultimately improved psychosocial impact over the patient`s oral health related quality of life [26–28].
Limitations
This study was a comparative analysis and further long term studies with concentrated sample size would be needed to confirm the findings with long-term follow-up crucial for population specific data. Suggestion would be further elaborate investigations with data used to reinforce the evidence to confirm long-term benefits of NAM in CLP birth defects and associated anomalies. This study utilized convenience sampling and mixed data collection approach combining personal interviews and online Google Forms which may introduce selection bias, potentially affecting representativeness. Additionally, interviewer bias may be present in personal interviews and may limit the generalizability of the findings to the broader population of dental specialists.
Conclusion
Effects on speech, hearing, appearance and psychology in CLP might have everlasting adverse outcomes for health and social integration. Characteristically, children with CLP require multidisciplinary care encompassing interventions from birth to adulthood, despite the fact that significant differences exist across specialties when comparing knowledge acquisition, clinical practice and collaboration. The Key Challenges are adaption of variable treatment approaches and communication barriers among the consultants dealing with such cases. Even though awareness and access to optimal care has improved in recent years, quality of care still varies substantially demanding multidisciplinary line of action as a prerequisite to ensure incorporation of technological advances as till date there exist significant differences across specialties when comparing knowledge acquisition, clinical practice and collaboration. Consequently interdisciplinary collaboration for effective NAM therapy is indispensable with most practitioners anticipating continued refinement and innovation in its care.
Supplementary Information
Acknowledgements
The authors want to acknowledge the participants of the study for their help with data collection and the Department of Orthodontics Dow Dental College for his help with data analysis and writing assistance.
Abbreviations
- CI
Confidence Interval
- PSIO
Pre-surgical Infant Orthopedics
- NAM
Naso Alveolar Molding
- CLP
Cleft Lip & Palate
- CAD- CAM
Computer aided Design- Computer aided Manufacturing
Authors’ contributions
EN and KK contributed to data analysis, interpretation of data and writing the original manuscript.EN, AHQ and NA contributed to data collection.NA, KK, SS and SA contributed to interpretation of data and contributed to reviewing and editing the original manuscript.All authors approved the final manuscript.
Funding
The authors received no financial support for the research, authorship or publication of this article.
Data availability
The data used and/or analyzed during the current study are availablefrom the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The study was conducted according to the guidelines of the Declaration of Helsinki. Ethical approval was taken from the Institutional Ethical Review Board of Saidu College of Dentistry, Swat. Informed consent was obtained from all participants prior to their inclusion in the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Sharif F, Mahmood F, Azhar MJ, Asif A, Zahid M, Muhammad N, Rehman IU, Neil SM. Incidence and management of cleft lip and palate in Pakistan. J Pak Med Assoc. 2019;69(5):632–9. [PubMed] [Google Scholar]
- 2.Ahmed MM, Shahid N, Mumtaz N, Saqulain G. Psychological and social aspects of quality of life of cleft lip and/or palate patients: age group and gender perspective. Rawal Med J. 2024;49(1):82–82. [Google Scholar]
- 3.Mai CT, Isenburg JL, Canfield MA, Meyer RE, Correa A, Alverson CJ, Lupo PJ, Riehle-Colarusso T, Cho SJ, Aggarwal D, Kirby RS. National population‐based estimates for major birth defects, 2010–2014. Birth Defects Res. 2019;111(18):1420–35. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Sami QU, Ali B, Farooqui WA. Effects of Alt-RAMEC protocol with facemask therapy in cleft lip palate patients in a sample of Pakistani population. BMC Oral Health. 2023;23(1):401. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Salari N, Darvishi N, Heydari M, Bokaee S, Darvishi F, Mohammadi M. Global prevalence of cleft palate, cleft lip and cleft palate and lip: a comprehensive systematic review and meta-analysis. J Stomatol Oral Maxillofac Surg. 2022;123(2):110–120.z. [DOI] [PubMed]
- 6.Othman AA, Alassaf MS, Mulla AK, Almohammadi AA, Aljayyar AW, Qazali AA, Alsulaimani M, Abdouh IM. Knowledge assessment for the management of patients with cleft lip and palate among dental and medical interns and practitioners in Medina, Saudi Arabia. Saudi J Oral Sci. 2023;10(2):104–9. [Google Scholar]
- 7.Naik 7DD, Betur SV, Suriyan AP, Nadig S. Knowledge and attitude among various dental specialties regarding nasoalveolar molding procedure in cleft patients—a cross-sectional study. Cleft Palate-Craniofac J. 2022;59(5):609–13. [DOI] [PubMed] [Google Scholar]
- 8.Albustani SH, Dziedzic A, Abid M. The perception and experience of parents of children with cleft lip and palate concerning the use Pre-Surgical infant orthopedics: A Questionnaire-Based Cross-Sectional survey. Children. 2022;9(7):1054. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Loeffelbein DJ, Rau A, Wolff KD. Impression technique for monitoring and virtual treatment planning in nasoalveolar moulding. Br J Oral Maxillofac Surg. 2013;51(8):898–901. [DOI] [PubMed] [Google Scholar]
- 10.Vig KW, Turvey TA. Orthodontic-surgical interaction in the management of cleft lip and palate. Clin Plast Surg. 1985;12(4):735–48. [PubMed] [Google Scholar]
- 11.Saad MS, Fata M, Farouk A, Habib AM, Gad M, Tayel MB, et al. Early progressive maxillary changes with nasoalveolar molding: randomized controlled clinical trial. JDR Clin Transl Res. 2020;5(4):319–31. [DOI] [PubMed] [Google Scholar]
- 12.Lee CT, Grayson BH, Cutting CB, Brecht LE, Lin WY. Prepubertal midface growth in unilateral cleft lip and palate following alveolar molding and gingivoperiosteoplasty. Cleft Palate Craniofac J. 2004;41(4):375–80. [DOI] [PubMed] [Google Scholar]
- 13.Lautner N, Raith S, Ooms M, Peters F, Hölzle F, Modabber A. Three-dimensional evaluation of the effect of nasoalveolar molding on the volume of the alveolar gap in unilateral clefts. J Cranio-Maxillofac Surg. 2020;48(2):141–7. [DOI] [PubMed] [Google Scholar]
- 14.Nagaveni N. Knowledge, attitude, and perception among dental graduate practitioners about presurgical naso-alveolar molding therapy in cleft lip/palate infants: a questionnaire-based survey. J Updates Pediatr Dent. 2023;2:03–11. [Google Scholar]
- 15.Azeem M, Raza A, Mahmood R, Behroz E. Differences among the perceptions of orthodontists, prosthodontists and conservative dentistry specialists regarding buccal corridor widths. J Univ Med Dent Coll. 2021;12(1):44–50. [Google Scholar]
- 16.Dinh TT, Van Nguyen D, Dien VH, Dong TK. Effectiveness of presurgical nasoalveolar molding appliance in infants with complete unilateral cleft lip and palate. Cleft Palate Craniofac J. 2022;59(8):995–1000. [DOI] [PubMed] [Google Scholar]
- 17.Tyler R, Raymond M, Abreu A, Daniel L-B. What’s new in nasoalveolar molding technique: a current literature review. Dent Rev. 2023;3:100075. 10.1016/j.dentre.2023.100075. [Google Scholar]
- 18.Bous RM, Kochenour N, Valiathan M. A novel method for fabricating nasoalveolar molding appliances for infants with cleft lip and palate using 3-dimensional workflow and clear aligners. Am J Orthod Dentofacial Orthop. 2020;158(3):452–8. [DOI] [PubMed] [Google Scholar]
- 19.Ocak I, Akarsu-Guven B, Karakaya J, Ozgur F, Aksu M. Effects of nasoalveolar molding on maxillary arch dimensions and malocclusion characteristics in primary dentition patients with cleft lip and palate. Int J Paediatr Dent. 2024;34(1):94–101. [DOI] [PubMed] [Google Scholar]
- 20.Ali AAA. A comprehensive clinical perspective of nasoalveolar molding (NAM) for the treatment of cleft lip and palate patients. J Clin Exp Dent. 2025;17(5):e552–9. 10.4317/jced.62575. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Alkhames HM, Kodali MV, Nasir EF, Hassan M, Kodali US. Presurgical nasoalveolar molding—efficacy and biomechanics in management of cleft lip and palate: a review of the literature. Eur J Gen Dent. 2023;12(01):007–13. [Google Scholar]
- 22.Padovano WM, Skolnick GB, Naidoo SD, Snyder-Warwick AK, Patel KB. Long-term effects of nasoalveolar molding in patients with unilateral cleft lip and palate: a systematic review and meta-analysis. Cleft Palate Craniofac J. 2022;59(4):462–74. [DOI] [PubMed] [Google Scholar]
- 23.Demirsoy KK, Çalış S, Büyük SK. Obstetrician–Gynecologists’ knowledge and awareness on nasoalveolar molding in newborns with cleft lip and palate. Turk J Orthod. 2022;35(1):16. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Jones TA. The Role of Caregiver’s Perception of Their Child’s Cleft Lip/Palate on Treatment Engagement: An Analysis of Culturally-Bounded Barriers to Healthcare at a Craniofacial Center Doctoral dissertation, Wheaton College. 2023.
- 25.Grayson BH, Cutting CB. Presurgical nasoalveolar orthopedic molding in primary correction of the nose, lip, and alveolus of infants born with unilateral and bilateral clefts. Cleft Palate Craniofac J. 2001;38(3):193–8. [DOI] [PubMed] [Google Scholar]
- 26.Ezzat CF, Chavarria C, Teichgraeber JF, Chen JW, Stratmann RG, Gateno J, et al. Presurgical nasoalveolar molding therapy for the treatment of unilateral cleft lip and palate: a preliminary study. Cleft Palate-Craniofac J. 2007;44(1):8–12. [DOI] [PubMed] [Google Scholar]
- 27.Moghe G, Mauli S, Thomas A, Obed VA. Bridging the gap: addressing challenges toward improvement of cleft teamwork in a tertiary care center in North India: a pilot study. Cleft Palate-Craniofac J. 2013;50(4):473–80. [DOI] [PubMed] [Google Scholar]
- 28.AlAnazi FN, AlHayyan WA, Pani SC. Impact of presurgical nasoalveolar molding on the parental perceptions of oral health-related quality of life of children with cleft lip and palate. J Contemp Dent Pract. 2020;21(2):152–5. [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data used and/or analyzed during the current study are availablefrom the corresponding author on reasonable request.