Introduction: Management of cleft patients is quite challenging and controversial. Advances in reconstructive surgery have significantly improved the quality of repair for cleft of the lip, alveolus and palate. This case report describes a new approach of presurgical nasoalveolar molding (PNAM) therapy in a 5 day old infant using PSIO-J hook appliance. Methods: Lip taping was started on the initial visit using 3M Steri- Strip. Initial impressions were made to fabricate the PSIO appliance. On second visit appliance was delivered to approximate the cleft alveolus. Once the cleft gap has been reduced to approximately 5 mm a J- hook modification was given to avoid bulkiness and thereby enhancing retention. Conventional nasal stent exerts a reciprocal intraoral molding force against the alveolar segments hence this drawback was eliminated by using J-hook modification appliance. Following surgical repair of lip, the lip was taped for several weeks and the use of PSIO-J hook appliance was discontinued. Results: There was significant improvement in nasal tip projection, columella size on cleft side and position of lower lateral cartilages as well as approximation of the lip segments. Additionally the alveolar defect reduced from 14mm to 3mm from pre NAM to post NAM. Conclusion: The pre-surgical nasoalveolar molding assisted primary reconstruction using PSIO-J hook appliance results is an overall improvement in the esthetics of the nasolabial complex in cleft conditions while minimizing the extent of surgery and the overall number of surgical procedures.