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Imaging Diagnosis

Radiographs of the jaw and facial bones reveal loss of the lamina dura and erosion around the affected teeth in the mandible and/or maxilla in the initial phase of development of noma (Figs. 39.6 and 39.7). The affected teeth appear loosened in their sockets. The loss of developing, erupting teeth, secondary dentition, and germinal follicles can be better determined on good- quality radiographs of the tooth-bearing areas of the mandible and maxilla than by clinical observation.

As the disease progresses, there will be radiographic evidence of osteomyelitis of the jaw with extensive motheaten destruction of involved bone (Figs. 39.7, 39.8). Periosteal reaction and sequestra formation may be noted with advanced bone involvement. Large soft tissue defects around the cheek and jaw will be apparent (Fig. 39.8).

Of considerable concern to the patient and the plastic surgeon is the cicatricial fibrosis that is the chief cause of trismus and inability to move the jaw properly. Radiological examination of the temporomandibular joint, including tomograms, is vital to determine deformity, ankylosis, or septic arthritis of the joint; CT or MRI will be very helpful, but are rarely available in most areas where noma occurs. Bone formation akin to myositis ossificans may be present in the fibrous tissue in the pterygoid, masseter or temporalis muscles. As a result of stress on the developing jaw from cicatricial tethering, malformations may occur, including mandibular hypoplasia with recession of the lower jaw and compensatory hypertrophy of the coronoid process. In rare cases of cancrum auris (noma involving the ear), the temporomandibular joint is usually affected.


Fig. 39.6 A,B Cancrum oris involving the mandible of a Nigerian child. There is loss of the lamina dura and erosion of bone around multiple teeth, primarily the premolar and canine teeth, involving both sides of the mandible. (Courtesy of Dr. Stanley Bohrer).

Fig. 39.7 Cancrum oris in an Indian child showing extensive moth-eaten destruction of the mandible anteriorly.



Fig. 39.8 A-D Noma of the central maxilla in an 8-year-old black girl with a 2-month history of a destructive lesion of the upper lip, alveolar ridge, and central maxilla (A). A foul smelling sequestrum of the anterior portion of the maxilla was removed and replaced with a prosthesis. (B) Posteroanterior, (C) occipitomental, (D) occlusal submentovertex views of the maxilla and facial bones reveal a gaping hole in the central maxilla with extensive loss of bone, especially from the alveolar ridge and anterior maxilla. The upper incisor teeth have been lost. The area of bone destruction is rather well defined. Note the extensive loss of soft tissues over the upper lip and central maxilla in the clinical photograph (A). (Courtesy of Dr. William Thomas, McLean, Virginia).

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