Abstract or medical grade silicone.5 Retention also plays

Abstract

Facial defect rehabilitation is a very critical task requiring the individualized design of the prosthesis for each patient. Eyes are vital organ not only for vision but also for the facial expression. Disfigurement due to loss of an eye and associated structures may cause physical and psychological distress to the patient.  Rehabilitating such patient with a removable orbital prosthesis is an economical and user-friendly which restores the patient’s social as well as the cosmetic value. The present article describes a conventional technique for the fabrication of a spectacle’s retained acrylic resin orbital prosthesis providing accurate and effective rehabilitation.

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Keywords: Facial defect, Rehabilitation, Orbital prosthesis, acrylic resin.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INTRODUCTION

Disfigurement of the face due to exenteration of an eye may be a very traumatic event in a person’s life not only physically but also psychologically and emotionally as face and eyes are the identities of the person. Exenteration is the most radical procedure which involves removal of the eye, adnexa, and the part of the bony orbit.1 Orbital rehabilitation is a complex procedure which requires individuality in fabrication according to the patient. The earliest known examples of restorations dated to the fourth dynasty in Egypt; excavations of tombs have provided evidence of eye replacement by using precious stones, earthenware, copper, gold, enameled bronze in the shrunken socket.2

For the prosthesis to be successful various factors should be taken into consideration like color, contour, texture, biocompatibility, durability, ease of use, weight, and availability. Although several materials are available, no maxillofacial material fulfill all of these ideal properties.3,4 Prosthesis for orbital defects is made from a variety of materials, such as acrylic resin, polyurethane elastomer, silicone elastomer or medical grade silicone.5 Retention also plays a key role in the success of the maxillofacial prosthesis (i.e., adhesives, magnets, eyeglass frames, and osseointegrated implants). Long-term use of adhesives may lead to skin allergies and also necessitate the formulation of a substantial quantity of supportive ingredients in the adhesive to provide a high degree of retention.6

Though expensive sometimes, magnets have been incorporated into the dentures for better retention of the prosthesis.7 On long term use the property of magnetism may be lost or magnets may corrode. Hence the established method of improving retention is by the use of osseointegrated implants,8 but, this type of treatment is contraindicated by factors such as added surgeries, operating cost, insufficient bone, and former radiation to the area.9 Retention by means of eyeglass frames makes it easier for the placement of the orbital prosthesis and guarantees accurate reproducible positioning of the restoration, as the slightest error in position will bear identifiable notice of the prosthesis.10 In addition, frames provide an extra high array of bonding, especially to acrylic prostheses.

This article describes a simplified method for the fabrication spectacle retained polymethylmethacrylate orbital prosthesis.

CLINICAL REPORT

A 26year old, male patient reported to the Department of Prosthodontics and Maxillofacial Prosthetics, People’s Dental College and Hospital, Kathmandu, Nepal, with a chief complain of facial disfigurement due to loss of an eye and associated structure. There is a past history exenteration of orbit five years back for squamous cell carcinoma of the orbit. On clinical examination, the defect was large (4 X 5) cm healed with the fibrotic tissue without any possible undercut for retention. There was also associated healing of wound due to burn on the left side at ala of the nose due to which complete facial impression couldn’t be made. Thus, for complete prosthetic rehabilitation of the patient, with an acrylic orbital prosthesis attached to a eyeglasses frames was planned.

 

MATERIAL AND METHOD

Recording the Impression

Patient is well informed and explained about the procedure, made to rest comfortably for impression making. Petroleum jelly was applied on eyebrows to make removal of impression material easy and to lessen discomfort. The modeling wax was adapted on the defect with adhesive to receive the impression material. Preparations were done to mix alginate in two consistencies, first syringe consistency was mixed and poured gradually and gently until it covers the entire defect which was dispensed using a syringe and second tray consistency was mixed and placed over syringe consistency. Then the stapler pins were placed over the alginate to hold the dental plaster which acts as a matrix for the impression. The impression material along with dental plaster was allowed to set. The impression was gently removed in one piece without tearing the impression m

Wax pattern Fabrication

The cast was poured in die stone to obtain better surface details and strength. Modeling wax was adapted over the cast and tried in patient’s face. Measurements were made from the patient’s facial midline to the center of the pupil to the facial midline and from the inner canthus of the eye to the nasal bridge. Both the measurements were recorded when the patient was asked to look and fix the contralateral eye at the distant gaze. These measurements were transferred on the cast to help in the position of the ocular portion of the orbital prosthesis. Sclera pattern was also fabricated with the help of modeling wax and acrylized in a conventional manner. Sclera was tried in patient and iris orientation was done by asking the patient to look and fix the contralateral eye at distant gaze and by measuring the contralateral iris. Iris painting was done to match the contralateral side, completing the fabrication of the ocular prosthesis.

Fabrication of heat cure orbital prosthesis

The left orbital prosthesis was carved in modeling wax using the custom eye which was carved, dewaxed, acrylized and painted according to the color of the right eye. It was tried on the patient’s face to check the orientation of pupil, color, size and volume of sclera visible as compared to the contralateral eye. The ocular prosthesis was then secured in position on a bed of modeling wax according to the position gained using the measurements of the contralateral eye. The anteroposterior position was adjusted and verified on the patient when observed from the profile and from the top of the head. Once the position was verified and confirmed, the eyelids and the remaining portion was sculpted in wax and tried in the patient’s orbital defect. The wax sculpted prosthesis with the duplicated cast was flasked and dewaxed. Transparent heat cure acrylic resin was mixed according to manufacturer’s instructions. Pigment stains were blended into the base color of heat cure acrylic resin for intrinsic staining at the time of mix to gain the approximate skin shade of the patient. Following polymerization, the prosthesis was deflasked, retrieved and finished. Natural hair was glued over eyebrow area and readymade eyelashes are glued on the eyelids of the acrylic prosthesis. The eyeglass frame was selected and tried on the patient. Finally, home care instructions were given, and frequent follow-up was carried out for the evaluation of the function of the prosthesis. The patient was happy and satisfied as the prosthesis fulfilled the function and esthetic demand which made him social.

Discussion

The rehabilitation of the orbital defect is a complex procedure involving aesthetic element and even the slightest difference in the position of the eye and the color of the prosthesis will reflect on the appearance of the patient. The intensive surgical procedure causes a major financial burden to the patient due to which patient may seek economical prosthetic treatment options. Orbital prosthesis presents as an economical, simple and viable alternative when esthetic and functional needs are beyond the reach of local reconstructive procedures 11. Rehabilitation of facial disfigurement following the surgery with prosthesis leads to the reconstruction of personality, self–image and social acceptability. Desirable material properties includes flexibility, biocompatibility and ability to accept intrinsic and extrinsic colorants, chemical and physical inertness and mouldability12. The most commonly used conventional method to retain orbital prostheses is the eyeglass frames and anatomic retentive undercuts 13. Undercut areas in?uence the selection of material used for fabrication of the orbital prosthesis. Flexible material will be bene?cial for the patients presenting with engageable orbital undercuts. Contrary, in cases with complete loss of orbit and without any possible engageable undercuts, the eyeglass frame retention method may be bene?cial as eyeglass frames are easier to place in an accurate, reproducible prosthesis position. The patient was treated with eyeglass frame retained acrylic resin orbital prosthesis in this case report. Acrylic resin is a durable material, which helps in the better adherence of prostheses to the eyeglass frame. Acrylic prostheses with eyeglass frames are much superior to the older methods of silicone adhesive systems, because heat-cure PMMA has better biocompatibility,14 and silicone orbital prostheses have a relatively short lifespan (on an average of 1.5 to 2 years).15

Conclusion

The use of custom made orbital prosthesis has been a blessing to the patient who cannot afford the expensive treatment options. The procedure used in this case is cost effective, affordable and acceptable which meet the physiologic, anatomic, functional and cosmetic requirements of the patient. In addition, the prosthesis design had incorporated retention during the function, which is the major factor for the success of the prosthesis. This method has provided good results from patient esthetics, acceptance, and satisfaction points of view.Abstract

Facial defect rehabilitation is a very critical task requiring the individualized design of the prosthesis for each patient. Eyes are vital organ not only for vision but also for the facial expression. Disfigurement due to loss of an eye and associated structures may cause physical and psychological distress to the patient.  Rehabilitating such patient with a removable orbital prosthesis is an economical and user-friendly which restores the patient’s social as well as the cosmetic value. The present article describes a conventional technique for the fabrication of a spectacle’s retained acrylic resin orbital prosthesis providing accurate and effective rehabilitation.

Keywords: Facial defect, Rehabilitation, Orbital prosthesis, acrylic resin.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INTRODUCTION

Disfigurement of the face due to exenteration of an eye may be a very traumatic event in a person’s life not only physically but also psychologically and emotionally as face and eyes are the identities of the person. Exenteration is the most radical procedure which involves removal of the eye, adnexa, and the part of the bony orbit.1 Orbital rehabilitation is a complex procedure which requires individuality in fabrication according to the patient. The earliest known examples of restorations dated to the fourth dynasty in Egypt; excavations of tombs have provided evidence of eye replacement by using precious stones, earthenware, copper, gold, enameled bronze in the shrunken socket.2

For the prosthesis to be successful various factors should be taken into consideration like color, contour, texture, biocompatibility, durability, ease of use, weight, and availability. Although several materials are available, no maxillofacial material fulfill all of these ideal properties.3,4 Prosthesis for orbital defects is made from a variety of materials, such as acrylic resin, polyurethane elastomer, silicone elastomer or medical grade silicone.5 Retention also plays a key role in the success of the maxillofacial prosthesis (i.e., adhesives, magnets, eyeglass frames, and osseointegrated implants). Long-term use of adhesives may lead to skin allergies and also necessitate the formulation of a substantial quantity of supportive ingredients in the adhesive to provide a high degree of retention.6

Though expensive sometimes, magnets have been incorporated into the dentures for better retention of the prosthesis.7 On long term use the property of magnetism may be lost or magnets may corrode. Hence the established method of improving retention is by the use of osseointegrated implants,8 but, this type of treatment is contraindicated by factors such as added surgeries, operating cost, insufficient bone, and former radiation to the area.9 Retention by means of eyeglass frames makes it easier for the placement of the orbital prosthesis and guarantees accurate reproducible positioning of the restoration, as the slightest error in position will bear identifiable notice of the prosthesis.10 In addition, frames provide an extra high array of bonding, especially to acrylic prostheses.

This article describes a simplified method for the fabrication spectacle retained polymethylmethacrylate orbital prosthesis.

CLINICAL REPORT

A 26year old, male patient reported to the Department of Prosthodontics and Maxillofacial Prosthetics, People’s Dental College and Hospital, Kathmandu, Nepal, with a chief complain of facial disfigurement due to loss of an eye and associated structure. There is a past history exenteration of orbit five years back for squamous cell carcinoma of the orbit. On clinical examination, the defect was large (4 X 5) cm healed with the fibrotic tissue without any possible undercut for retention. There was also associated healing of wound due to burn on the left side at ala of the nose due to which complete facial impression couldn’t be made. Thus, for complete prosthetic rehabilitation of the patient, with an acrylic orbital prosthesis attached to a eyeglasses frames was planned.

 

MATERIAL AND METHOD

Recording the Impression

Patient is well informed and explained about the procedure, made to rest comfortably for impression making. Petroleum jelly was applied on eyebrows to make removal of impression material easy and to lessen discomfort. The modeling wax was adapted on the defect with adhesive to receive the impression material. Preparations were done to mix alginate in two consistencies, first syringe consistency was mixed and poured gradually and gently until it covers the entire defect which was dispensed using a syringe and second tray consistency was mixed and placed over syringe consistency. Then the stapler pins were placed over the alginate to hold the dental plaster which acts as a matrix for the impression. The impression material along with dental plaster was allowed to set. The impression was gently removed in one piece without tearing the impression material.

           

Making impression of defect

Wax pattern Fabrication

The cast was poured in die stone to obtain better surface details and strength. Modeling wax was adapted over the cast and tried in patient’s face. Measurements were made from the patient’s facial midline to the center of the pupil to the facial midline and from the inner canthus of the eye to the nasal bridge. Both the measurements were recorded when the patient was asked to look and fix the contralateral eye at the distant gaze. These measurements were transferred on the cast to help in the position of the ocular portion of the orbital prosthesis. Sclera pattern was also fabricated with the help of modeling wax and acrylized in a conventional manner. Sclera was tried in patient and iris orientation was done by asking the patient to look and fix the contralateral eye at distant gaze and by measuring the contralateral iris. Iris painting was done to match the contralateral side, completing the fabrication of the ocular prosthesis.

                                                                      

                                               Working cast                                               Wax pattern                                       

                   

                                          Iris orientation                                               sclera orientation

                               

                                     Dewaxing                                                   iris orientation

                                     

                                                                        Eye painting

Fabrication of heat cure orbital prosthesis

The left orbital prosthesis was carved in modeling wax using the custom eye which was carved, dewaxed, acrylized and painted according to the color of the right eye. It was tried on the patient’s face to check the orientation of pupil, color, size and volume of sclera visible as compared to the contralateral eye. The ocular prosthesis was then secured in position on a bed of modeling wax according to the position gained using the measurements of the contralateral eye. The anteroposterior position was adjusted and verified on the patient when observed from the profile and from the top of the head. Once the position was verified and confirmed, the eyelids and the remaining portion was sculpted in wax and tried in the patient’s orbital defect. The wax sculpted prosthesis with the duplicated cast was flasked and dewaxed. Transparent heat cure acrylic resin was mixed according to manufacturer’s instructions. Pigment stains were blended into the base color of heat cure acrylic resin for intrinsic staining at the time of mix to gain the approximate skin shade of the patient. Following polymerization, the prosthesis was deflasked, retrieved and finished. Natural hair was glued over eyebrow area and readymade eyelashes are glued on the eyelids of the acrylic prosthesis. The eyeglass frame was selected and tried on the patient. Finally, home care instructions were given, and frequent follow-up was carried out for the evaluation of the function of the prosthesis. The patient was happy and satisfied as the prosthesis fulfilled the function and esthetic demand which made him socially presentable.

                            

     Try in of orbital prosthesis                                    Flasking                                          Coloration

                       

   Prosthesis after intrinsic color                   Prosthesis after extrinsic color                   post-treatment photograph

 

Discussion

The rehabilitation of the orbital defect is a complex procedure involving aesthetic element and even the slightest difference in the position of the eye and the color of the prosthesis will reflect on the appearance of the patient. The intensive surgical procedure causes a major financial burden to the patient due to which patient may seek economical prosthetic treatment options. Orbital prosthesis presents as an economical, simple and viable alternative when esthetic and functional needs are beyond the reach of local reconstructive procedures 11. Rehabilitation of facial disfigurement following the surgery with prosthesis leads to the reconstruction of personality, self–image and social acceptability. Desirable material properties includes flexibility, biocompatibility and ability to accept intrinsic and extrinsic colorants, chemical and physical inertness and mouldability12. The most commonly used conventional method to retain orbital prostheses is the eyeglass frames and anatomic retentive undercuts 13. Undercut areas in?uence the selection of material used for fabrication of the orbital prosthesis. Flexible material will be bene?cial for the patients presenting with engageable orbital undercuts. Contrary, in cases with complete loss of orbit and without any possible engageable undercuts, the eyeglass frame retention method may be bene?cial as eyeglass frames are easier to place in an accurate, reproducible prosthesis position. The patient was treated with eyeglass frame retained acrylic resin orbital prosthesis in this case report. Acrylic resin is a durable material, which helps in the better adherence of prostheses to the eyeglass frame. Acrylic prostheses with eyeglass frames are much superior to the older methods of silicone adhesive systems, because heat-cure PMMA has better biocompatibility,14 and silicone orbital prostheses have a relatively short lifespan (on an average of 1.5 to 2 years).15

Conclusion

The use of custom made orbital prosthesis has been a blessing to the patient who cannot afford the expensive treatment options. The procedure used in this case is cost effective, affordable and acceptable which meet the physiologic, anatomic, functional and cosmetic requirements of the patient. In addition, the prosthesis design had incorporated retention during the function, which is the major factor for the success of the prosthesis. This method has provided good results from patient esthetics, acceptance, and satisfaction points of view.