8/18/2019 Orbital Prosthesis a Novel Reconstructive Approach 2247 2452.1000653

1/3690

Introduction"It is the God given right of every human being to appearhuman". - Ernest L. DaBreo

Eye is a vital organ not only in terms of vision but also being an important component of the facial expression. Mostcommon tumors that affect the eye, ocular cavity, or the orbitalregion are Basal Cell Carcinoma (BCC), Retinoblastoma(RB), malignant melanoma, squamous cell carcinoma of theconjunctiva, and rhabdo myosarcoma; that may require partialor complete resection of eyeball or eyeballs [1-4]. Removal of

this organ may be also be indicated in cases of a severe trauma,congenital abnormality or disease such as an infection oruntreatable painful glaucoma This results in great dif cultiesfor post-surgical rehabilitation, aesthetical recovery, and socialintegration of the patient [5,6].

Surgical procedures adopted for the removal of an eyewere classi ed by Peyman, Saunders and Goldberg into threegeneral categories: Enucleation, evisceration and exenteration[7]. Enucleation is a surgical procedure in which the globe andthe attached portion of the optic nerve are excised from theorbit. Evisceration is removal of the contents of globe whileleaving the sclera and extraocular muscles intact. Exenteration

is the most radical of the three procedures and involvesremoval of the eye, adnexa, and the part of the bony orbit [8].

Orbital rehabilitation is a complex process which requiresspeci city in technique according to a particular patient. Anorbital prosthesis is created to restore a more normal anatomicalstructure and cosmetic defect created by these conditions ina person. Prosthesis is generally constructed after completehealing (usually 2 to 4 months).

A successful facial prosthesis depends on several factorslike durability, biocompatibility, exibility, weight, color,hygiene, thermal conductivity, ease of use, texture, andavailability. No maxillofacial material has all of these ideal

properties although several materials are available that possessmost of these properties with increased tear resistance andtensile strength and signi cant durability [9-11]. Prosthesi s fororbital defects is made from a variety of materials, such as

poly(methyl methacrylate), polyurethane elastomer, siliconeelastomer or urethane backed medical grade silicone. Siliconeelastomer is widely used material which is relatively colorstable and can be colorized very easily. They are mainlyretained using mechanical means of anatomical undercuts,spectacle frames, magnets or by the use of osseointegratedextra oral implants [8]. Present paper highlights a simple andeconomical technique to rehabilitate a patient with siliconeorbital prosthesis.

Patient and MethodsA 61-year-old male patient had reported to the Departmentof Prosthodontics, All India Institute of Medical Sciences(AIIMS), with a chief complaint of missing right eye since 6months. Surgical exenteration of the right eye was done dueto fungal infection. Patient gave the history of diabetes forwhich the patient was put on insulin for the past seven years.Extraoral examination of the patient showed a large orbitaldefect on right side ( Figure 1a ). A de nite bony undercut wasfound on the superior border of the orbit which eventuallyhelped in the retention of the prosthesis.

Orbital Prosthesis: A Novel Reconstructive Approach

Bhavita Wadhwa Soni 1, Nitin Soni 2, Mohit Bansal 3

1Senior Resident, Department o Prosthodontics, Oral Health Sciences Center, Post Graduate Institute o Medical Education andResearch, Chandigarh, India. 2Reader, Department o Periodontology, Daswani Dental College, Kota Rajasthan, India. 3SeniorResident, Department o Community Dentistry, Oral Health Sciences Center, Post Graduate Institute o Medical Education and

Research, Chandigarh, India.

AbstractRehabilitation o acial de ects is a daunting task, requiring an individualized design o the technique or each patient. Te disgurementassociated with the loss o an eye may result in signicant physical and emotional problems. Various treatment modalities are available,one o which is the use o implants. Although implant-supported orbital prosthesis has a superior outcome, it may not be advisablein all the patients due to economic actors. Te present article describes a reconstructive approach or a patient with exenterated righteye using silicone orbital prosthesis which improved his psychological, physical, social, unctional, emotional and spiritual needs.Multidisciplinary management and team approach are essential in providing accurate and effective rehabilitation.

Key words: Orbital, Prosthesis, Rehabilitation, Management

Corresponding author: Dr. Mohit Bansal, Senior Resident, Department o Community Dentistry, Oral Health Sciences Center, PostGraduate Institute o Medical Education and Research, Chandigarh, India. el: 09855701797; e-mail : mohit.bansal51@gmail.com

Figure 1a . Pre treatment photograph.

mailto:mohit.bansal51@gmail.commailto:mohit.bansal51@gmail.com

8/18/2019 Orbital Prosthesis a Novel Reconstructive Approach 2247 2452.1000653

2/3691

OHDM - Vol. 13 - No. 3 - September, 2014

Recording the impressionsThe patient was draped for impression procedures and

patient’s eyebrows and eyelashes were lubricated with petroleum jelly in order to facilitate removal of the impressionmaterial and minimize discomfort to the patient. Lines weremarked on the patient’s face with an indelible pencil for

symmetrical placement of the orbital prosthesis. Impressionof the orbital defect was made using irreversible hydrocolloid(Zelgan, Dentsply India Ltd.) backing with impressioncompound and cast was poured in dental stone for bettersurface details and strength ( Figure 1b ). A conformer oforbital defect was made with the auto polymerizing resin(DPI cold cure, Dental Product of India, Mumbai, India) andwas tried on patients face. Measurements were made from the

patient’s facial midline to the center of the pupil to the facialmidline and from the inner canthus of the eye to the nasal

bridge. Both the measurements were made when the patientwas asked to look and x the contralateral eye at distant gaze .

These measurements were transferred on the cast to help inthe position of the ocular portion of the orbital prosthesis.A suitable stock ocular prosthesis was selected that closelymatched the color, size and shape of the iris and sclera ofthe other eye. The ocular portion needed minor alterations tomake it t into the socket as the defect was relatively large.Fabrication of silicone orbital prosthesisThe right eye prosthesis was carved in modeling wax using thestock eye which was selected according to the color of the lefteye. It was tried on the patient’s face to check the orientationof pupil, color, size and volume of sclera visible as comparedto the contra lateral eye. The eye was then secured in position

on a bed of modelling wax according to the position gainedusing the measurements of the other eye. The antero posterior

position was adjusted and veri ed on the patient whenobserved from pro le and from the top of the head. Once the

position was con rmed, the eyelids and the remaining portionwas sculpted in wax and tried in the patient’s orbital defect.The wax sculpted prosthesis with the duplicated cast was

asked and dewaxed ( Figures 2a and 2b ). Room TemperatureVulcanizing (RTV) medical-graded silicone material (factorII) was mixed according to manufacturer’s instructions.Pigment stains were blended into the base color of silicone forintrinsic staining at the time of mix to gain the approximate

skin shade of the patient. Following polymerization the

prosthesis was de asked, retrieved and nished. Natural hairwas stitched over eyebrow area and upper, lower eyelids ofthe silicone prosthesis using 23 gauge syringe needle. Theeyeglass frame was selected and tried on the patient ( Figure2c). Finally home care instructions were given, and frequentfollow-up was carried out for the evaluation of function of

prosthesis. The patient was satis ed with the function andesthetics provided by the prosthesis, as it made him socially

presentable for his remaining days.

Results and DiscussionsTotal orbital exenteration is a radical surgical procedurewhich typically involves the removal of the entire contentsof the orbit, including peri orbita. Ablative surgical procedureincurs major nancial burden, and hence the patient may seeka prosthetic treatment that is economical. Orbital prosthesis

presents as simple, attractive and viable alternative whenesthetic and functional needs are beyond the reach of localreconstructive procedures [12].

In patients with facial deformities, surgical resectioncan frequently be extremely mutilating and dis guring,

presenting exceptional challenges for both the surgeon and themaxillofacial prosthodontist to achieve acceptable aesthetic

and functional solutions. However clinical conditions, lack of psychological support and specialized professionals workingin multidisciplinary team frequently limit the possibilitiesfor satisfactory treatment [13]. Rehabilitation of facialdis gurement following the surgery for cancer treatmentleads to reconstruction of personality, self –image and feelingFigure 1b . Diagnostic impression.

Figure 2a . Final wax trial.

Figure 2b . Final wax up.

8/18/2019 Orbital Prosthesis a Novel Reconstructive Approach 2247 2452.1000653

3/3692

OHDM - Vol. 13 - No. 3 - September, 2014

of having overcome the disease. These individual experiencesare complex, challenging and have striking effects on theirlives. Multidisciplinary approach should be opted for theirreintegration into the society and reducing the prejudice andstigma of disease and dis gurement [14].

Present case came with an urge for cosmetic as well asocial concern which was successfully treated by siliconeorbital prosthesis that is practical, trouble-free and cost-effective. Selection of a reasonable maxillofacial prostheticmaterial and economically feasible retentive aid should be thegoal of rehabilitating such pati ents. Since silicone has bettermarginal adaptation and lifelike appearance, it has been usedfor the fabrication of orbital prostheses .

Silicones have been used for over 50 years in the eld of

maxillofacial prosthetics, with desirable material propertiesincluding exibility, biocompatibility and ability to acceptintrinsic and extrinsic colorants, chemical and physicalinertness and mouldability [15].

The most commonly used conventional method to retainorbital prostheses is the eyeglass frames and anatomicretentive undercuts [16]. The patient treated in this reporthad a favourable anatomical undercuts in the defect whichwas used to retain the silicone orbital prosthesis. The silicone

prosthesis has advantage of light weight, better esthetics withlifelike appearance than acrylic prosthesis. The thin ash ofthe silicone eye merged with the adjacent skin to give a lifelikeappearance. Use of adhesive was minimal as prosthesis wasretained by favourable anatomical undercut. So, the chanceof allergic reaction caused due to the use of adhesives wasreduced to minimal. Further, instead of sticking arti cial eyelashes, natural hair was stitched over eyebrow area and upper,

lower eyelids of the silicone prosthesis using syringe needle.This enhanced the natural touch to the arti cial eye givingnatural appearance.

ConclusionExenteration o the orbital contents with an ablative surgerycan severely affect a person in terms o unction, estheticsand psychological trauma. A well retained, user- riendly,removable maxillo acial prosthesis is the key to success ulprosthetic rehabilitation in such cases. So, as a dentalpro essional it is our duty to implement our knowledge intopracticality and abricate the prosthesis in an acceptable

ashion to meet the physiologic, anatomic, unctional andcosmetic requirements o the patient so as to boost onescondence and lead a better li e.

Figure 2c. Post treatment photograph.

References1. Heckmann M, Zogelmeier F, Konz B. Frequency o acial

basal cell carcinoma does not correlate with site-specic UV almolexposure. Archives of Dermatolology . 2002; 138 : 1494-1497.

2. Aerts I, Rouic LL, Gauthier-Villars M, Brisse H, Doz F,Desjardins L. Retinoblastoma. Orphanet Journal of Rare Diseases.2006; 1: 1-11

3. Bonanoni M BC, Almeida M A, Cristo ani LM, Filho VO.Retinoblastoma: A three-year-study at a Brazilian Medical SchoolHospital. Clinics. 2009; 64: 427-434.

4. Chintagumpala M, Barrios CP, Paysse EA, Plon SE, HurwitzR. Retinoblastoma: Review o current management. Oncologist .2007; 12: 1237-1246.

5. Goel BS, Kumar D. Evaluation o ocular prosthesis. Journal of All India Ophthalmol Society . 1969; 17: 266-269.

6. Nath K, Gogi R. Te orbit. Indian Journal of Ophthalmology .1976; 24: 1-14.

7. Peyman GA, Sanders DR, Goldberg MF. Principles andPractice of Ophthalmology . 1987; 3: 2.

8. Mishra SK, Ramesh C. Reproduction o custom-made eyeprosthesis manoeuvre: A case report. Journal of Dentistry and OralHygiene. 2009; 1: 59-63.

9. Beumer J, Ma , Marunick M, et al. (Editors) Restoration oacial de ects: Etiology, disability, and rehabilitation. Maxillo acial

rehabilitation: Prosthodontic and surgical considerations. St Louis:Ishiyaku EuroAmerica; 1996; pp. 377-453.

10. Heller HL, McKinstry RE (Editors) Facial materials.Fundamentals o acial prosthetics. Arlington: ABI ProfessionalPublications; 1995. pp. 79-97.

11. Begum Z, Kola MZ, Joshi P. Analysis o the propertieso commercially available silicone elastomers or maxillo acialprostheses. International Journal of Contemporary Dentistry . 2011; 2.

12. Konstantinidis L, Scolozzi P, Hamedani M. Rehabilitation

o orbital cavity afer total orbital exenteration using oculo acialprostheses anchored by osseointegrated dental implants posed asa one-step surgical procedure. Klin Monbl Augenheilkd . 2006; 223 :400–404.

13. Sirianni D, Leles CR, Mendonca EF. A 12- year retrospectivesurvey o management o patients with malignant neoplasms inthe orbital cavity in a Brazilian cancer hospital. Te Open Dentistry Journal . 2013; 7: 140-145.

14. Costa EF, Nogueira E, Lima NCS, Mendonça EF, Leles CR.A qualitative study o the dimensions o patients’ perceptions o

acial disgurement afer head and neck cancer surgery. Special CareDentistry Association. 2014; 34: 114-121.

15. Jani RM, Schaa NG. An evaluation o acial prostheses.Te

Journal of Prosthetic Dentistry . 1978; 39: 546-550.16. Parel SM. Diminishing dependence on adhesives orretention o acial prosthesis. Te Journal of Prosthetic Dentistry .1980; 43: 552-560.