PMC10067983_01
(A and B) Preoperative frontal view; (C) Preoperative left lateral view; (D) Radiographic view
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F1
Extraoral examinations revealed a bilateral cleft of the upper lip with a complete cleft of the right alveolus (Figs 1A to C). Radiographic examination was done using radiovisography, and a significant cleft was observed on the right paramedian area (Fig. 1D).
(A) Muslin cloth placed over mixed impression material; (B) Impression making; (C) Obtained impression; (D) Master Stone model
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F2
Functional impression was obtained through reflex suckling movement (Figs 2A to C). Impression was poured to obtain the Master Stone model (Fig. 2D).
(A) PNAM appliance; (B) Materials used for extraoral anchorage and PNAM appliance
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F3
The retention button was planned to provide anchorage to the molding plate and positioned at an angle of a 45  plate (Fig. 3A).
(A) The strap of PNAM was positioned with a three wire hook clasp with the eye; (B) Force was measured with a Dontrix gauge; (C) PNAM appliance in situ; (D) Lip taping
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F4
Two elastics on each side of the midline were engaged with a retention button onto the midline and stainless hooks on the other hand (Figs 4A to C). To achieve soft tissue molding over the lip area, 3M Steri-Strip (a quarter inch in width and about 3-4 inches in length) tape was secured over the area extending from midline to the cheek after securing the segments in the most feasible approximated position (Fig. 4D).
(A) Previous PNAM plate; (B) Addition of nasal stent to PNAM plate; (C) Addition of soft denture liner onto the tip of the nasal stent; (D) PNAM plate with a nasal stent in situ
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F6
It was extended and curved backward and was placed 3-4 mm deep into the nostril aperture (Fig. 6).
(A) Before PNAM; (B) After PNAM
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F7
A significant approximation of the cleft segments was achieved in 4.5 months (Fig. 7).
(A and B) Immediate postsurgical closure view; (C and D) 1-week postsurgery frontal and duck view
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F8
After completion of PNAM, the primary surgical closure of bilateral lip alignment with primary rhinoplasty was performed at the age of 4.5 months under general anesthesia (Fig. 8).