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Silicon Orbital Prosthesis: A Clinical Report

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Nafij Jamayet Sumaiya Zabin Eusuf Zai

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304 International Medical Journal Vol. 21, No. 3, pp. 304 - 306 , June 2014
OPHTHALMOLOGY

Silicon Orbital Prosthesis: A Clinical Report

Nafij Bin Jamayet1), Sumaiya Zabin Eusuf Zai2), Mohammad Khursheed Alam3)

ABSTRACT
Background: The rehabilitation of facial defects is a complex task requiring a specific design of the technique to be used in
individual patient. The disfigurement associated with the loss of an eye can cause significant physical and emotional problems.
Various treatment modalities are available, one of which is adhesive retained orbital prosthesis. Although implant orbital pros-
thesis has a superior outcome, it may not be advisable in all patients due to economic factors. This clinical report describes the
prosthetic restoration of a patient by orbital prosthesis that had right orbital defect.
Materials & Methods: A 65 year old Thai male, presented to Maxillofacial Prosthetic Service, with the chief complaint of
right orbital defect in. He was previously diagnosed as squamous cell carcinoma in right eye. Then he had undergone removal of
a tumor with exenteration followed by 6 cycles of chemotherapy. The treatment plan was to fabricate a silicone orbital prosthe-
sis by modifying an ocular prosthesis to achieve ideal fit and esthetics.
Result: The patient was esthetically satisfied and further instructions were given for maintenance of the prosthesis. In the 3
months follow up period no evidence of inflammation or irritation has been found.
Conclusion: Orbital prosthesis is recommended for patient with orbital defect. The prosthetic device helps to increase
patient's quality of life. Multidisciplinary management and team approach are essential in providing accurate and effective
rehabilitation.

KEY WORDS
silicone orbital prosthesis, rehabilitation, carcinoma, implant

INTRODUCTION
Deformities closer to midline are usually challenging 1). A large
defect will require an equivalent prosthesis which would call for an
additional retention. An extension of large prostheses on the facial tis-
sues could create open margins during function; therefore, prosthesis
with broader perimeter will be easily noticeable2). An important concern
in patient's satisfaction and acceptance of prosthesis is retention3). A
plethora of techniques were adopted in the literature to retain an orbital
prosthesis. Retention can be derived from anatomical undercut of the
defect; mechanical device such as eyeglasses to retain the prosthesis,
use of adhesive material and an osseointegrated implant4).
Success depends on the available method retaining a prosthetic res-
toration securely without causing irritation to the tissue which it comes
in contact5). Among the available modes of retention, the concept of
mechanical retention is usually not the first consideration when design-
ing the facial prosthesis because disadvantage of attaching the orbital
prosthesis to a mechanical device for example an eye glasses frame,
when the glass are removed, the prosthesis is also removed, which can
cause embarrassment to the patient6,7).
Various types of skin adhesives are available. Selection of appropri-
ate adhesive involves consideration of type of tissue and the type of
prosthetic material used in the construction of the prosthesis. There are a
variety of dermal adhesive available in the market. The first one is
acrylic resin adhesives, for example, Epithane III adhesive (Daro prod-
ucts Inc., Butler, WI). This adhesive is an emulsion of acrylic polymer
in water material, a white watery; liquid upon setting becomes clear and
transparent8). The second one is room-temperature vulcanizing silicones
(RTV) based. Once this adhesive is applied, the solvent evaporates
leaving a tacky adhesive, which may be contact-bonded to the skin9), for
example, Dow corning 355 medical adhesive (Factor II Inc, Lakeside,
AZ). Several factors should be considered when selecting the adhesive
for retaining an orbital prosthesis: these factors include the adhesive
bond to skin, biocompatibility, quality of skin and type of the skin.
Several researches study on the bond strength of the skin and the adhe-
sive to the skin, acrylic resin adhesive is the best adhesive for use with
the facial material6). One of the earliest and available means of deter-
mining effect of chemicals such as adhesive on skin is the patch test, the
biocompatibility of rubber base liquid adhesive was found to cause skin
irritation and acrylic resin adhesive produces none6). Lastly, the type of
quality of skin also influences the selection where thin, friable skin and
irradiated skin is not suitable for repeated reapplication adhesive.
This clinical report describes a detailed procedure for rehabilitation
of a large orbital defect by using anatomical undercut in the defect area
combined with an adhesive to gain more retention.
Clinical report
A 65 year old Thai male, presented at Maxillofacial Prosthetic
Service, Mahidol University with the chief complain of right orbital
defect. He was previously diagnosed as squamous cell carcinoma in
right eye. Then he had undergone removal of a tumor with enucleation
followed by 6 cycles of chemotherapy. The treatment plan was to fabri-

Received on December 7, 2012 and accepted on June 12, 2013

1) Maxillofacial Prosthetic Service, School of Dental Sciences, Health Campus, Universiti Sains Malaysia
16150, Kubang Kerian, Kelantan, Malaysia
2) Department of Public Health, Faculty of Allied Health Science, Daffodil International University
Dhaka, Bangladesh
3) Orthodontic Unit, School of Dental Sciences, Health Campus, Universiti Sains Malaysia
Kota Bharu, Kelantan, Malaysia
Correspondence to: Nafij Bin Jamayet
(e-mail: dr.nafij@gmail.com)

C 2014 Japan Health Sciences University

& Japan International Cultural Exchange Foundation
 Silicone Orbital Prosthesis
Figure 1. Right orbital defect; left lateral view, frontal and right
lateral view.
Figure 2. 2a: Marking of center position before impression, 2b:
Impression of orbital defect, 2c: Ocular prosthesis is in to block the patent openings of the defect.
central position & right lateral view of ocular prosthe- After the defect site was prepared, the patient was instructed to
sis, 2d: Final wax up in cast, 2e: Final wax trial, 2f:
Mold preparation and fixing the rod, 2g: close with
paper pack then pour stone for upper mold, 2h: Upper
half after boling of wax, 2i: Loading silicon, 2j: Room
temperature curing, 2k: Extrinsic stain, 2l: Final pros-
thesis.
cate a silicone orbital prosthesis by modifying an ocular prosthesis to
achieve ideal fit and esthetics. He was diagnosed recurrent squamous
cell carcinoma at the same area: stage T4N0M0, therefore a radical
exenteration was performed with post operative radiotherapy of 6000
cGy. The defect area still had infection; he was also receiving intrave-
nous antibiotics. After the infection was subsided, he was ready for fur-
ther prosthetic rehabilitation.
Procedure
Patient evaluation (Figure 1) is the first step before fabrication of a
facial prosthesis. The defect extended superiorly from the supra orbital
rim sparing the eyebrow slightly and inferiorly not involving the orbital
process of maxilla, making the resultant defect shallow which was not
suitable for holding ocular prosthesis. Therefore, the patient was pre-
pared to prevent psychologically to lower the unrealistic expectation of
the prosthesis. Next step is to evaluate the size of prosthesis; the extent
of the defect dictated a large prosthesis which required proper planning
305
Figure 3. Final prosthesis delivery; left lateral view, frontal and
right lateral view.
Figure 4. Before and after the final prosthesis.
of retention. Undercut was measured for evaluated optimum retention
that be able to flex into the defect site. A combination of anatomical
undercut and adhesive was warranted to retain the prosthesis. The last
step of preparation included the photographic documentation which in
turn aids in studying the defect cavity and fabricating the wax sculpt
before the second session.
First visit
After the above preparation was done the patient was seated in an
upright position comfortably. Eyebrow was lightly lubricated with
petroleum jelly (Vaseline, Unilever Thai Trading Co Ltd, Thailand) to
prevent impression material from sticking. Orientation marks on the
supra orbital rim denoting the nasal midline, medial canthus area, iris,
lateral canthus in the horizontal plane, the interpupil line was also
marked with a point on the nasal bridge of the lateral canthus area
(Figure 2a). These lines will be detected in the impression and trans-
ferred on to the cast which will provide an orientation for the wax
sculpt. Finally, the defect was examined and the cotton gauze was used
close her eye, not to make any facial movement and breathe through
mouth while the impression was on. A pick up impression technique
was planned; firstly a boxing wax framework was prepared extending
from the forehead to the coluumella of the nose, laterally from the outer
canthus of the right eye to the left eye. A gel consistency
Polyvinylxyloxane (Multisil Epithetik; Dreve-Dentamid, Unna,
Germany) was applied on the defect as a first layer and a hard setting
low viscosity polyvinylxyloxane impression material was applied on top
of the previous layer, before the impression material was set; pieces of
tongue blade were incorporated and allowed to set (Figure 2b). The
patient was reclined; the external nares were blocked with cotton pal-
lets. The previously fabricated boxing wax rim was adapted onto the
appropriate location of the face. Regular set alginate (Jeltrate, Densply
Ind, USA) was mixed to a high flow consistency and poured onto the
boxed area, immediately a layer of wet gauze was placed onto the sur-
face of alginate and allowed to set. Once this was set, a layer of plaster
mixed with slurry water was applied onto the surface of gauze. The
completed facial moulage with polyvinylxyloxane incorporated in the
alginate material was carefully removed and examined for any defects.
The orientation points were redefined. The impression was casted by a
none color type IV dental stone (Dental Vision,Thailand) according to
the manufacture instruction and allowed to set. The cast was separated
from moulage and checked for any imperfections. Before sculpting, an
ocular prosthesis was fabricated matching to the patient's companion
eye.
306 Jamayet N. B. et al.
Wax Sculpting
Before the second appointment, basic sculpting was done using
wax, and then we incorporated the fabricated ocular in position by the
help of the orientation marks on the cast and try in on patient (Figure
2c).
Second Visit
Rest of the sculpting session was carried out in presence of the
patient restoring all deficient contours and finally finished with patient
consent. The finalized sculpt was placed on the cast and the margin was
sealed (Figure 2d and e). The seal the margin where evenly thin out for
proper adaptation in the silicone prosthesis.
Mold Fabrication
The sealed wax sculpt was finally given a stippled surface with the
help of a bristle brush. The cast was scaled down in size approximating
to the defect area. Indexing of the cast was done by preparing two
grooves inferiorly and superiorly to the defect. The ocular was also
indexed by attaching plastic rod which was at least 10 cm in length by
cyanoacrylate resin (Figure 2f). The base mold was boxed (Figure 2g),
separating medium applied on to the plaster surface. A mixture of non
colored type IV dental stone was poured on top of the base cast with the
sculpt in place and allowed to set. The set two-piece mold was
immersed in hot water bath for 20 minutes allowing the wax to melt.
The two-piece mold was separated and thoroughly dewaxed. These
dewaxed molds were dried and ready for the next (Figure 2h).
Third visit
Medical grade, room temperature vulcanized silicone MDX 4-4210
(Factor II, Lakeside, AZ, USA), base and catalyst were mixed in the
ratio 10:1 respectively with 1 drop of Thixo agent (Factor II, Lakeside,
AZ, USA ) for every 10 grams of silicone. The skin color of the patient
was obtained by mixing three primary silicone base pigments (red, yel-
low, blue (Factor II, Lakeside, AZ, USA)). Appropriate nylon flocking
mixed into the silicone to obtain color depth of the skin tone. Tin foil
separating medium (Factor II, Lakeside, AZ, USA) was applied onto the
mold. The mixed silicone was carefully loaded onto the mold avoiding
entrapment of air bubbles (Figure 2i). The upper and lower molds were
approximated with the help of preformed indices on the base mold and
secured with bar clamps producing an appropriate pressure of 2.0 PSI.
This was left for 72 hours for attaining a complete cure as per manufac-
turer's recommendations. Following the final set, mold was opened and
the flash was trimmed and ready for extrinsic coloring (Figure 2j).
Fourth visit
Dry pigments (Factor II, Lakeside, AZ, USA) were used as extrinsic
stains, fixed with Epifin (Dreve-Dentamid, Unna, Germany) and
allowed to cure for 30 minutes (Figure 2k). This procedure was carried
in the presence of the patient for a near perfect match. Then the final
prosthesis was ready and inserted applying water based adhesive onto
the margins and tissue undercuts were utilized to retain the prosthesis
(Figure 3). The patient was esthetically satisfied and further instructions
were given for maintenance of the prosthesis. In the 3 months follow up
period no evidence of inflammation or irritation has been found. Before
and after the final prosthesis was shown in Figure 4.
DISCUSSION
Difficulties of orbital prosthesis included movable tissue beds, qual-
ity of prosthesis retention, and associated skin of the patient10). The
method of retention to secure an orbital prosthesis to its proper place
without discomfort and irritation to the tissue is required. The orbital
prosthesis can be retained by anatomical undercut of the defect,
mechanical device, use of adhesive material and an osseointegrated
implant. The use of osseointegrated implant can reduce complication of
orbital prosthesis due to adhesive irritation and have improved long
term success rates for orbital prosthesis10). However, several factors
should be considered for implant retained orbital prostheses. These fac-
tors include the thickness of bone and the load-bearing capacity of the
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implant in bone. If large and heavy orbital prosthesis, the placement of
implant to retain the prosthesis in thin areas of bone adjacent to poten-
tially significant dislodging muscle forces would not be advantageous.
In the orbital defects, implant can be placed in the lateral, inferior and
superior portion of the orbital area that normally have sufficient bone
but in this patient the large defect extended superiorly from the supra
orbital rim to inferiorly involving the orbital process of maxilla and the
defect area still had infection so she had improper Several published
studies have discussed about success rates of orbital prosthesis in the
non-irradiated and the irradiated defect. This topic has caused some
controversy during the years11). Parel et al reported fixture success rates
of 57% and 96% for non-irradiated and irradiated sites, respectively11,12).
This patient have undergone radiotherapy of 6000 cGy that the cellular
bone involving a significant reduction in the number of osteoblasts and
osteocytes. Following this changes, irradiated defects would be risk for
tissue necrosis and integration failure if using implant to retain orbital
prosthesis13). The use of anatomic undercuts for retained orbital prosthe-
sis also had unstable nature of the inferior supporting tissue so an adhe-
sive was necessary. However, by using a flexible in the defect space, it
can decrease the necessity for using adhesives. This is advantageous as
adhesive are irritating to some patients and may damage the thin margin
of the prosthesis during removal. In this case, the patient had sensitive
skin from radiation therapy so easily irrigational responses to adhesives.
The use of anatomical undercuts retained the orbital prostheses, silicone
materials commonly used to flex into the natural undercuts at the defect
site. This situation silicone material may compress sensitive tissue when
repeatedly application and remove the prosthesis. In this case, patient
with irradiated tissue and impaired sensitivity can be harmful by the
abrasive nature of the silicone material. However, if the prosthesis is
properly designed and the patient is motivated to care for the underlying
and supporting tissue by hygiene, then anatomical undercut can be use
successfully to retain a orbital prosthesis.
CONCLUSION
Retention is the one of the important consideration for success of
the orbital prosthesis. The use of anatomical undercut combined with
adhesive to retain orbital prosthesis has been described. In the limitation
of the patient, the prosthesis design is the most important for the success
of the prosthesis.
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