A new method for fabricating orbital

prosthesis with a CAD/CAM negative

mold
Yunpen Bi, DDS, PhD,a Shuyi Wu, DDS, PhD,b
Yimin Zhao, DDS, PhD,c and Shizhu Bai, DDS, PhDd
Department of Prosthodontics, School of Stomatology, Fourth
Military Medical University, Xi’an, China
The challenge of fabricating an orbital prosthesis is how to position the iris and pupil properly. Computer simulation can
be a more effective and simpler approach to measuring and evaluating these features than the conventional method.
However, transferring the optimal position of the iris determined in the virtual design procedure to the real definitive
prosthesis can be difficult. The purpose of this article is to demonstrate a method of fabricating an orbital prosthesis
with a negative mold designed and produced by a computer-aided design and computer-aided manufacturing technique.
With this method, the iris can be designed in the most favorable position, and this position can be transferred to the
silicone prosthesis correctly. (J Prosthet Dent 2013;110:424-428)

Patients with an orbital defect have to
cope with loss of vision and the inherent
change in their lifestyle. Their deformed
facial appearance is difficult to camou-
flage, and even with the advent of micro-
vascular surgery and free tissue transfers,
they face emotional stress because surgi-
cal reconstruction alone cannot fully
restore this area. The development of
facial prosthetic devices that allow the
restoration of the facial appearance has
provided clinicians with another option
for these patients. These devices provide
the majority of patients with a satisfactory
facial match that resolves their esthetic
concerns.1 However, the fabrication of an
orbital prosthesis is probably the most
challenging task in facial prosthetics.2 The
conventional method of fabricating this
type of prosthesis includes a variety of
complex production steps. It is a labor-
intensive and time-consuming task, and
the end results are heavily dependent on
the experience of the clinician.3
Computer-aided design and computer-
aided manufacturing (CAD/CAM) appli-
cations for the restoration of orbital and
complex facial defects have been
described.4-10 Prosthetic fabrication us-
ing this technology for pattern modeling
is simple and could reduce the cost,
improve productivity, and enhance the
technical quality of care. In these
methods, however, the thin margins of
the patterns are prone to damage after
rapid prototyping fabrication. Conse-
quently, the patterns also need to be
evaluated and refined to generate real-
istic silicone prostheses.
In recent years, methods have been
developed for designing and producing
negative molds to directly fabricate
nasal and auricular prostheses.11-15 The
thin margins of the prosthesis are rep-
resented as the cavity in the negative
mold to enable the fragility of the
pattern edge to be avoided completely.
With CAD/CAM negative molds, con-
ventional flasking and investing pro-
cedures could be eliminated. However,
no viable methods for designing and
producing the negative molds for an
orbital defect have been reported. For
an orbital prosthesis, therefore, how to
determine the optimal position of the
iris in the pattern and how to accurately
transform this simulated position in the
computer to the real position in the
definitive prosthesis are significant
challenges.
A new method has been developed
for the direct design and production of
orbital prostheses with CAD/CAM
negative molds. By using this method,
the iris can be placed at the most
favorable position, and this position
can be transferred to the silicone
prosthesis correctly. The purpose of
this study was to illustrate how to
create an orbital prosthesis with this
method.
CLINICAL REPORT
Two male and 3 female patients
with orbital defects were treated with
orbital prostheses from February 2011
to June 2012. Two patients underwent
an orbital exenteration and post-
operative radiotherapy for carcinomas
of the maxilla with orbital invasion; the

This work was funded by the National Natural Science Foundation of China (Grant 81271188) and supported by National Key Technology
R&D Program of China (Project 2012BAI07B02).
a
Lecturer, Department of Prosthodontics.
b
Lecturer, Department of Prosthodontics.
c
Professor, Department of Prosthodontics.
d
Lecturer, Department of Prosthodontics.

The Journal of Prosthetic Dentistry Bi et al

November 2013 425
tumors did not recur after 5 years, and
the missing maxilla and teeth were
restored with removable obturators
before fabrication of the orbital pros-
theses. The 3 other patients were
injured by accidental trauma. All 5 pa-
tients chose to accept an adhesive-
retained orbital prosthesis.

Data acquisition

The data acquisitions of the pa-

tients’ faces were performed with a
3-dimensional (3D) scanning system
(3DSS-STD-II; Digital Manu). Before
scanning, the patients were positioned 1 Original 3D facial image generated
with their heads stabilized and with from data of 3D sensing system. Red
circle according to margin of preselected
their remaining eye open and a normal
eyeglasses and border of defect was also
expression. A red circle was marked
recorded.
with a pen on the skin surface accord-
ing to the margins of the preselected
eyeglasses and the border of the de-
fects; the red circle could be recorded
with the following 3D scans. To prevent
incomplete data caused by an undercut
of the scanning perspective, anterior left
and right 45-degree scans were per-
formed. The 3D point cloud data of
the facial surface was input into a per-
sonal computer. The 3D facial models
of the patients were generated by
merging the 2 perspective data sets and
were saved in STL format with 3D
software (Geomagic Studio 11.0; Geo-
magic Inc) (Fig. 1). Prefabricated ocular
prostheses were selected according to 2 Each ocular model in database has same contour and
the remaining eye. same size as corresponding prefabricated ocular prostheses;
iris and pupil regions on ocular model were outlined against
Design process other areas of model according to sections on real ocular
prosthesis.
The patients’ facial morphology was
observed when he or she was asked to
sit up straight and maintain a normal horizontal lines referring to the center, prosthesis pattern was created after the
expression. The 3D facial models were inferior, and superior limits of the iris nonessential part of the mirrored
then oriented to the natural head po- were measured to evaluate the bilateral model had been removed. The wrinkles,
sition.16 The midplane was generated symmetry. The mirrored model was surface textures, double eyelid, and
through the nasion, pronasale, and moved manually until its position was other detailed features of the pattern
gnathion. The facial model was acceptable from the front, left-right, were sculpted with the Sculpt Knife tool
mirrored according to the midplane, and superior-inferior views and was of the software.
and the healthy side of the mirrored approved by the patients and their Every prefabricated ocular pros-
model covered the defect area in the families. thesis kept by the department was
original model. On both sides, the dis- The prosthesis margin was defined scanned by the same scanning system
tances from the midline to the medial to cover the border of the defect area, (3DSS-STD-II; Digital Manu Corp) to
and lateral canthus and from the and the red circle served as the obtain 3D ocular models, and then a
midline to the pupil as well as the reference. A preliminary simulated digital ocular prosthesis database was
Bi et al
426 Volume 110 Issue 5
constructed. Each ocular model had
the same contour and the same size as
the corresponding prefabricated ocular
prostheses; the iris and pupil regions on
the model were outlined against other
areas of the model according to the
section on the real ocular prosthesis
(Fig. 2). During the design process, the
corresponding 3D models of the
selected prefabricated ocular prosthe-
ses were selected from the digital ocular
prosthesis database. After the iris
and pupil regions on the model were
aligned with the same areas on the
3 Corresponding 3D model of selected
prosthesis pattern, the ocular model
ocular prosthesis was fitted within
was fitted within the provisional virtual interim virtual prosthesis, and then
prosthesis. Then a 2-mm-diameter, 2-mm-diameter, 3-mm-long locating
3-mm-long locating cylinder was cylinder was attached vertically on its
attached vertically on the pupil region pupil region. Margin of prosthesis was
of the ocular model (Fig. 3). The com- expanded outward by 8 mm on skin
bined 3D models of the ocular pros- surface to construct negative mold.
thesis were saved in the STL format
file before they were merged with the
preliminary pattern.
The defect hole in the original model
was filled and deformed, approaching
the bottom of the digital ocular model
with a distance of approximately 2 mm.
The margin of the prosthesis was
expanded outward by 8 mm on the skin
surface of the defect side, and then the
border of the expanded area was
extruded 10 mm backward along the
sagittal axis. After closing the extruded
bottom, the lower piece of the negative
mold was obtained. The patches of this
8-mm expanded area were duplicated
and stitched with the margin of the 4 Lower and upper pieces of negative
pattern, and then the outer border of this mold were designed; internal space for
duplicated area was extruded 20 mm orbital prosthesis is shown after assem-
bling these pieces.
forward along the sagittal axis. The up-
per piece of the mold was obtained after
closing the new extruded bottom, and
there was a 2-mm-diameter, 3-mm-long
hole in the pupil region. Both pieces were
saved in the STL format (Fig. 4).

Prosthesis fabrication

Resin pieces of the molds and the

combined 3D ocular models were
fabricated with a Stereo Lithography
(SLA) rapid prototyping machine
(SPS350; Hengtong Inc). The resin
combined ocular models were placed
The Journal of Prosthetic Dentistry
5 Resin pieces of mold and combined ocular model were
fabricated with Stereo Lithography (SLA) machine, and then
ocular component was set on upper piece of mold. Silicone
prosthesis was obtained by routine procedures.
Bi et al
November 2013
6 Prefabricated ocular prosthesis was
inserted into socket of definitive pros-
thesis. Structures of eyelid and wrinkles
were clear.
7 Definitive silicone prosthesis was
generated after extrinsic coloring.
on the upper pieces of the mold after adhesive (Daro Adhesive Extra
the location cylinders were inserted into Strength; Factor II Inc).
the corresponding holes. The definitive The total clinical time used to
silicone prostheses were achieved by perform these procedures for each
using routine procedures (A-RTV-30 patient was only 5 hours on average
V50011 A&B KIT; Factor II Inc) (Fig. 5). over 2 appointments. In addition to
After the silicone material was poly- this time, approximately 13.5 hours on
merized, the lower pieces were sepa- average was needed to complete the
rated first, and the resin ocular models design and fabrication processes. The
were carefully removed from the pros- structures of the eyelid and the wrin-
thesis after they had been separated kles were clear; the size, contour, and
from the upper pieces. The purpose of margin fitness of the prosthesis were
this sequence was to ensure no damage acceptable. The patients were satisfied
to the silicone prosthesis. The pre- with the appearance of the prostheses
fabricated ocular prosthesis instead of designed and fabricated with this
the resin ocular model was inserted method.
into the socket of the definitive pros-
thesis (Fig. 6). Finally, the extrinsic SUMMARY
coloring was finished, and the definitive
silicone prostheses were applied to the The optical scanning technique,
patients (Fig. 7). Sufficient retention computer-aided design, and rapid pro-
was obtained with a prosthetic totyping technology were integrated and
Bi et al
427
applied to the design and fabrication of
orbital prostheses. With a CAD/CAM
negative mold, the definitive prosthesis
could be fabricated directly and quickly.
The orbital defect was accurately
reconstructed, and the ocular prosthesis
was precisely positioned.
REFERENCES
1. Carter KD, Nerad JA. Orbital defects: tissue-
integration reconstruction. In: Brånemark PI,
Tolman DE, editors. Osseointegration in
craniofacial reconstruction. Chicago:
Quintessence; 1998. p. 179.
2. Andres CJ, Haug SP. Facial prosthesis
fabrication: technical aspects. In: Taylor TD,
editor. Clinical maxillofacial prosthetics.
Chicago: Quintessence; 2000. p. 237.
3. Hooper SM, Westcott T, Evans PL,
Bocca AP, Jagger DC. Implant-supported
facial prostheses provided by a maxillofa-
cial unit in a UK regional hospital:
longevity and patient opinions.
J Prosthodont 2005;14:32-8.
4. Ciocca L, Scotti R. CAD-CAM generated ear
cast by means of a laser scanner and rapid
prototyping machine. J Prosthet Dent
2004;92:591-5.
5. Reitemeier B, Notni G, Heinze M, Schone C,
Schmidt A, Fichtner D. Optical modeling of
extraoral defects. J Prosthet Dent 2004;91:
80-4.
6. Al Mardini M, Ercoli C, Graser GN.
A technique to produce a mirror-image
wax pattern of an ear using rapid
prototyping technology. J Prosthet Dent
2005;94:195-8.
7. Chandra A, Watson J, Rowson J,
Holland J, Harris R, Williams D. Appli-
cation of rapid manufacturing techniques
in support of maxillofacial treatment:
evidence of the requirements of clinical
applications. Proc IME B J Eng Manufact
2005;219:469-75.
8. Wu G, Zhou B, Bi Y, Zhao Y. Selective laser
sintering technology for customized fabrica-
tion of facial prostheses. J Prosthet Dent
2008;100:56-60.
9. Wu G, Bi Y, Zhou B, Zemnick C, Han Y,
Kong L, et al. Computer-aided design and
rapid manufacture of an orbital prosthesis.
Int J Prosthodont 2009;22:293-5.
10. Feng Z, Dong Y, Zhao Y, Bai S, Zhou B, Bi Y,
et al. Computer-assisted technique for the
design and manufacture of realistic facial
prostheses. Br J Oral Maxillofac Surg
2010;48:105-9.
11. Ciocca L, Bacci G, Mingucci R, Scotti R.
CAD-CAM construction of a provisional
nasal prosthesis after ablative tumour surgery
of the nose: a pilot case report. Eur J Cancer
Care (Engl) 2009;18:97-101.
12. Yoshioka F, Ozawa S, Okazaki S, Tanaka Y.
Fabrication of an orbital prosthesis using a
noncontact three-dimensional digitizer and
rapid-prototyping system. J Prosthodont
2010;19:598-600.
428
13. Ciocca L, De Crescenzio F, Fantini M,
Scotti R. CAD/CAM bilateral ear prostheses
construction for Treacher Collins syndrome
patients using laser scanning and rapid pro-
totyping. Comput Methods Biomech Biomed
Engin 2010;13:379-86.
14. Ciocca L, Mingucci R, Gassino G, Scotti R.
CAD/CAM ear model and virtual construc-
tion of the mold. J Prosthet Dent 2007;98:
339-43.
The Journal of Prosthetic Dentistry
Volume 110 Issue 5
15. Liacouras P, Garnes J, Roman N, Petrich A, Corresponding author:
Grant GT. Designing and manufacturing Dr Yimin Zhao
an auricular prosthesis using computed Department of Prosthodontics
tomography, 3-dimensional photographic School of Stomatology
imaging, and additive manufacturing: a Fourth Military Medical University
clinical report. J Prosthet Dent 2011;105: Changle West Road 145
78-82. Xi’an 710032 PR
16. Jiang J, Xu T, Lin J. The relationship between CHINA
estimated and registered natural head posi- E-mail: zhaoym@fmmu.edu.cn
tion. Angle Orthod 2007;77:1019-24.
Copyright ª 2013 by the Editorial Council for
The Journal of Prosthetic Dentistry.
Bi et al