Reconstruction of the Maxilla with Prefabricated Scapular Flaps in Noma Patients

Noma (cancrum oris) is a devastating gangrenous disease that leads to severe tissue destruction in the face and is associated with a high rate of mortality. When untreated, it results in disfiguring midface defects and severe scarring. Ideal reconstruction of complex maxillofacial defects requires the restitution of bone, dental implants, soft tissue, and the thin and durable lining of the oral and paranasal cavities. Prefabricated composite grafts from the scapula are used to restore the maxilla in patients with this disease. A new concept of osteosynthesis involving titanium plates connected to dental implants, achieving greater mechanical stability of the reconstructed bony framework, is described. Nine complex midface defects were reconstructed with dermis-prelaminated scapular flaps. A bone flap from the lateral margin of the scapula was taken and osseointegrated implants were inserted. The bone flap was then prelaminated with dermis and covered with a Gore-Tex sheath to prevent adhesion. Two to 3 months later, the composite flap was transferred to the midface. Restoration of a maxilla with pneumatized paranasal cavities and a keratinized attached epithelium covering the alveolus and hard palate was successfully performed in all noma patients. The reconstructed "masticatory gingiva" and osseointegrated dental implants enabled patients to exercise oral functions shortly after surgery. Long-term observation of selected noma patients showed restoration of oral function and stability of the maxilla after several years.