Orbital Prosthesis: A Novel Reconstructive Approach

Bhavita Wadhwa Soni1, Nitin Soni2, Mohit Bansal3

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

Abstract

Rehabilitation of facial defects is a daunting task, requiring an individualized design of the technique for each patient. The disfigurement
associated with the loss of an eye may result in significant physical and emotional problems. Various treatment modalities are available,
one of which is the use of implants. Although implant-supported orbital prosthesis has a superior outcome, it may not be advisable
in all the patients due to economic factors. The present article describes a reconstructive approach for a patient with exenterated right
eye using silicone orbital prosthesis which improved his psychological, physical, social, functional, emotional and spiritual needs.
Multidisciplinary management and team approach are essential in providing accurate and effective rehabilitation.
Key words: Orbital, Prosthesis, Rehabilitation, Management

Introduction

poly(methyl methacrylate), polyurethane elastomer, silicone

elastomer or urethane backed medical grade silicone. Silicone
elastomer is widely used material which is relatively color
stable and can be colorized very easily. They are mainly
retained using mechanical means of anatomical undercuts,
spectacle frames, magnets or by the use of osseointegrated
extra oral implants [8]. Present paper highlights a simple and
economical technique to rehabilitate a patient with silicone
orbital prosthesis.

"It is the God given right of every human being to appear

human". - Ernest L. DaBreo
Eye is a vital organ not only in terms of vision but also
being an important component of the facial expression. Most
common tumors that affect the eye, ocular cavity, or the orbital
region are Basal Cell Carcinoma (BCC), Retinoblastoma
(RB), malignant melanoma, squamous cell carcinoma of the
conjunctiva, and rhabdo myosarcoma; that may require partial
or 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 or
untreatable painful glaucoma This results in great difficulties
for post-surgical rehabilitation, aesthetical recovery, and social
integration of the patient [5,6].
Surgical procedures adopted for the removal of an eye
were classified by Peyman, Saunders and Goldberg into three
general categories: Enucleation, evisceration and exenteration
[7]. Enucleation is a surgical procedure in which the globe and
the attached portion of the optic nerve are excised from the
orbit. Evisceration is removal of the contents of globe while
leaving the sclera and extraocular muscles intact. Exenteration
is the most radical of the three procedures and involves
removal of the eye, adnexa, and the part of the bony orbit [8].
Orbital rehabilitation is a complex process which requires
specificity in technique according to a particular patient. An
orbital prosthesis is created to restore a more normal anatomical
structure and cosmetic defect created by these conditions in
a person. Prosthesis is generally constructed after complete
healing (usually 2 to 4 months).
A successful facial prosthesis depends on several factors
like durability, biocompatibility, flexibility, weight, color,
hygiene, thermal conductivity, ease of use, texture, and
availability. No maxillofacial material has all of these ideal
properties although several materials are available that possess
most of these properties with increased tear resistance and
tensile strength and significant durability [9-11]. Prosthesis for
orbital defects is made from a variety of materials, such as

Patient and Methods

A 61-year-old male patient had reported to the Department

of Prosthodontics, All India Institute of Medical Sciences
(AIIMS), with a chief complaint of missing right eye since 6
months. Surgical exenteration of the right eye was done due
to fungal infection. Patient gave the history of diabetes for
which the patient was put on insulin for the past seven years.
Extraoral examination of the patient showed a large orbital
defect on right side (Figure 1a). A definite bony undercut was
found on the superior border of the orbit which eventually
helped in the retention of the prosthesis.

Figure 1a. Pre treatment photograph.

Corresponding author: Dr. Mohit Bansal, Senior Resident, Department of Community Dentistry, Oral Health Sciences Center, Post
Graduate Institute of Medical Education and Research, Chandigarh, India. Tel: 09855701797; e-mail: mohit.bansal51@gmail.com
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Recording the impressions

The patient was draped for impression procedures and
patients eyebrows and eyelashes were lubricated with
petroleum jelly in order to facilitate removal of the impression
material and minimize discomfort to the patient. Lines were
marked on the patients face with an indelible pencil for
symmetrical placement of the orbital prosthesis. Impression
of the orbital defect was made using irreversible hydrocolloid
(Zelgan, Dentsply India Ltd.) backing with impression
compound and cast was poured in dental stone for better
surface details and strength (Figure 1b). A conformer of
orbital defect was made with the auto polymerizing resin
(DPI cold cure, Dental Product of India, Mumbai, India) and
was tried on patients face. Measurements were made from the
patients 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 made when the patient
was asked to look and fix the contralateral eye at distant gaze.
These measurements were transferred on the cast to help in
the position of the ocular portion of the orbital prosthesis.
A suitable stock ocular prosthesis was selected that closely
matched the color, size and shape of the iris and sclera of
the other eye. The ocular portion needed minor alterations to
make it fit into the socket as the defect was relatively large.
Fabrication of silicone orbital prosthesis
The right eye prosthesis was carved in modeling wax using the
stock eye which was selected according to the color of the left
eye. It was tried on the patients face to check the orientation
of pupil, color, size and volume of sclera visible as compared
to the contra lateral eye. The eye was then secured in position
on a bed of modelling wax according to the position gained
using the measurements of the other eye. The antero posterior
position was adjusted and verified on the patient when
observed from profile and from the top of the head. Once the
position was confirmed, the eyelids and the remaining portion
was sculpted in wax and tried in the patients orbital defect.
The wax sculpted prosthesis with the duplicated cast was
flasked and dewaxed (Figures 2a and 2b). Room Temperature
Vulcanizing (RTV) medical-graded silicone material (factor
II) was mixed according to manufacturers instructions.
Pigment stains were blended into the base color of silicone for
intrinsic staining at the time of mix to gain the approximate

Figure 2a. Final wax trial.

Figure 2b. Final wax up.

skin shade of the patient. Following polymerization the

prosthesis was deflasked, retrieved and finished. Natural hair
was stitched over eyebrow area and upper, lower eyelids of
the silicone prosthesis using 23 gauge syringe needle. The
eyeglass frame was selected and tried on the patient (Figure
2c). Finally home care instructions were given, and frequent
follow-up was carried out for the evaluation of function of
prosthesis. The patient was satisfied with the function and
esthetics provided by the prosthesis, as it made him socially
presentable for his remaining days.

Results and Discussions

Total orbital exenteration is a radical surgical procedure

which typically involves the removal of the entire contents
of the orbit, including peri orbita. Ablative surgical procedure
incurs major financial burden, and hence the patient may seek
a prosthetic treatment that is economical. Orbital prosthesis
presents as simple, attractive and viable alternative when
esthetic and functional needs are beyond the reach of local
reconstructive procedures [12].
In patients with facial deformities, surgical resection
can frequently be extremely mutilating and disfiguring,
presenting exceptional challenges for both the surgeon and the
maxillofacial prosthodontist to achieve acceptable aesthetic
and functional solutions. However clinical conditions, lack of
psychological support and specialized professionals working
in multidisciplinary team frequently limit the possibilities
for satisfactory treatment [13]. Rehabilitation of facial
disfigurement following the surgery for cancer treatment
leads to reconstruction of personality, self image and feeling

Figure 1b. Diagnostic impression.

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maxillofacial prosthetics, with desirable material properties

including flexibility, biocompatibility and ability to accept
intrinsic and extrinsic colorants, chemical and physical
inertness and mouldability [15].
The most commonly used conventional method to retain
orbital prostheses is the eyeglass frames and anatomic
retentive undercuts [16]. The patient treated in this report
had a favourable anatomical undercuts in the defect which
was used to retain the silicone orbital prosthesis. The silicone
prosthesis has advantage of light weight, better esthetics with
lifelike appearance than acrylic prosthesis. The thin flash of
the silicone eye merged with the adjacent skin to give a lifelike
appearance. Use of adhesive was minimal as prosthesis was
retained by favourable anatomical undercut. So, the chance
of allergic reaction caused due to the use of adhesives was
reduced to minimal. Further, instead of sticking artificial eye
lashes, 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 artificial eye giving
natural appearance.

Figure 2c. Post treatment photograph.

of having overcome the disease. These individual experiences

are complex, challenging and have striking effects on their
lives. Multidisciplinary approach should be opted for their
reintegration into the society and reducing the prejudice and
stigma of disease and disfigurement [14].
Present case came with an urge for cosmetic as well a
social concern which was successfully treated by silicone
orbital prosthesis that is practical, trouble-free and costeffective. Selection of a reasonable maxillofacial prosthetic
material and economically feasible retentive aid should be the
goal of rehabilitating such pati ents. Since silicone has better
marginal adaptation and lifelike appearance, it has been used
for the fabrication of orbital prostheses.
Silicones have been used for over 50 years in the field of

Conclusion

Exenteration of the orbital contents with an ablative surgery

can severely affect a person in terms of function, esthetics
and psychological trauma. A well retained, user-friendly,
removable maxillofacial prosthesis is the key to successful
prosthetic rehabilitation in such cases. So, as a dental
professional it is our duty to implement our knowledge into
practicality and fabricate the prosthesis in an acceptable
fashion to meet the physiologic, anatomic, functional and
cosmetic requirements of the patient so as to boost ones
confidence and lead a better life.

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