case_images: PMC10067983_01
case_images: (A and B) Preoperative frontal view; (C) Preoperative left lateral view; (D) Radiographic view
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case_images: PMC10067983_01_ijcpd-16-153-g001.jpg
case_images: F1
case_images: 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).
case_images: (A) Muslin cloth placed over mixed impression material; (B) Impression making; (C) Obtained impression; (D) Master Stone model
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case_images: PMC10067983_01_ijcpd-16-153-g002.jpg
case_images: F2
case_images: Functional impression was obtained through reflex suckling movement (Figs 2A to C). Impression was poured to obtain the Master Stone model (Fig. 2D).
case_images: (A) PNAM appliance; (B) Materials used for extraoral anchorage and PNAM appliance
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case_images: PMC10067983_01_ijcpd-16-153-g003.jpg
case_images: F3
case_images: The retention button was planned to provide anchorage to the molding plate and positioned at an angle of a 45  plate (Fig. 3A).
case_images: (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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case_images: PMC10067983_01_ijcpd-16-153-g004.jpg
case_images: F4
case_images: 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).
case_images: (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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case_images: PMC10067983_01_ijcpd-16-153-g006.jpg
case_images: F6
case_images: It was extended and curved backward and was placed 3-4 mm deep into the nostril aperture (Fig. 6).
case_images: (A) Before PNAM; (B) After PNAM
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case_images: PMC10067983_01_ijcpd-16-153-g007.jpg
case_images: F7
case_images: A significant approximation of the cleft segments was achieved in 4.5 months (Fig. 7).
case_images: (A and B) Immediate postsurgical closure view; (C and D) 1-week postsurgery frontal and duck view
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case_images: PMC10067983_01_ijcpd-16-153-g008.jpg
case_images: F8
case_images: 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).