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					                                    PRASHANTA SHRESTHA

                                      GA-2, 528 Kamalpokhari
                                         Kathmandu, Nepal
                             Telephone: 977-1- 4410060, 9851035915
                              E mail:

Academic Qualifications: BDS, Dr Dent Medicine, PhD (Asahi University,
Professional Registration: Specialist in Oral and Maxillofacial Surgery (Nepal
                           Medical Council)

Present appointment
      Associate Professor, Division of Oral and Maxillofacial Surgery,
       Kathmandu University Medical School, B and B Hospital, Kathmandu,
      Director, National Center for Oral and Maxillofacial Surgery, The Rotary
       Foundation Project at National Dental Hospital, Kathmandu, Nepal

Immediate Past Appointments
      Research Associate, Department of Oral and Maxillofacial Surgery, Asahi
       University, Japan (1991-1996)
      Visiting Teaching Fellow at the Faculty of Dentistry, University of Malaya,
       Malaysia (1997).

Major Publications
      Author and coauthor to more than 50 research papers on oral
       carcinomas, salivary gland tumors and odontogenic tumors published in
       various International Journals from the UK, Germany, France, Denmark,
       Greece, Bangladesh, Malaysia, Japan and USA.
      Author of a book on carcinogenesis and extra cellular matrix proteins in
       tumors and carcinomas from RG Landes, Austin, Texas, USA (1997)and
       co-author of a book on S100 proteins in human tumors in a series of
       experimental tumor research published from Asahi University
       Publications, Japan (2002)

Clinical and Research interest
      Craniofacial anomalies including cleft lip and palate, oral mucosal
       lesions, oral carcinoma and salivary gland tumors, oral and maxillofacial
       pathology and reconstruction surgery

Professional Associations and affiliations
      Member of the council of the Asian Association of Oral and maxillofacial
      Member, American Cleft-Palate Association
      Fellow of International Association of Oral and Maxillofacial surgeons
      Life member of Nepal Medical Association, Nepal Dental Association and
       Indian Association for Cancer Research

Guest speaker in a number of international and national meetings and various
universities in Bangladesh, India, Thailand, Malaysia, Taiwan, South Korea,
Vietnam, Cambodia, Japan, Canada, UK and USA

           Reconstruction Surgery for Correction of the Deformity
          in the Maxillofacial Region due to Cancrum Oris (Noma).

                       Prashanta Shrestha, PhD (Japan)
                   Division of Oral and Maxillofacial Surgery
    B and B Hospital, Kathmandu University Teaching Hospital, Kathmandu
University Medical School and National Center for Oral and Maxillofacial Surgery,
                               Kathmandu, Nepal

Noma, or Cancrum oris, is a gangrenous stomatitis and was known to the human
civilization since the time of Hippocrates, Galen and Celcius. The term, cancrum
oris (noma) was used to describe the disease in 1848 which is derived from the
Greek, nome, meaning “to devour”. The disease, however, has been largely
disappeared, except with rare exceptions, from countries in North America and
Western Europe. But in parts of Asia, Africa and South America, the disease is
still seen and affects mostly children.
The presentation describes our experience of treating eight patients presenting
with Noma, since January 2003 in Nepal and had presented with a deformity
either of the soft tissue or along with the bony skeleton in the maxillofacial region
and the reconstruction of which often involved multiple procedures and was a
real challenge to the clinician. It is difficult assess the frequency and the nature
of onset of the disease as we have not seen the acute phase of the disease
being presented to us. These patients had their disease during their childhood
and they lived in remote areas of this mountainous country.
Their age at the time of presentation ranged from 12 to 52 years, 3 males and 5
females. The acute phase of the disease, in all patients dated back to their
childhood – ranging from 6-12 years when they had a painful swelling, ulceration
followed and over a course of several days, blue and black area appeared on the
skin of cheek, lips or nose and sloughing of the tissues left deep and perforating
wounds. The teeth were exposed except in one. Healing then occurred with
fibrosis and scar tissue formation leaving loss of parts of lips, nose, alveolar
bone or teeth and constriction and deformation of the affected area resulted in a
considerable deformity in the maxillofacial region. One had fusion of the
coronoid process of the mandible with the posterior maxilla leading to complete
inability to open the mouth.
During the acute phase of disease, usually predisposing predisposing factors
such as exanthematous fever, malnutrition, several infectious diseases or poor
oral hygiene may have a role which, however, could not be elicited in our series
of patients. At the time of presentation, no acute form of the disease was seen
and the patients were clinically healthy, with no malnutrition or chronic illness or
other infections and complete blood counts within acceptable limits that did not
contraindicate surgery under general anesthesia. All patients had surgery under
general anesthesia. Local flaps were used to reconstruct the upper lip and angle
of the mouth defects. In one a defect on the angle of the mouth which was quite
extensive, a deltopectoral flap was used for coveting the defect. All nasal
deformity was reconstructed using nasolabial and/or fore-head flaps.
The post operative healing was uneventful in all the cases and a reasonably
satisfactory reconstruction of the deformity resulting from noma was achieved by
the use of local or distant pedicled flaps and multiple surgical procedures and
revisions were necessary.