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CASE REPORT

Impressions Techniques for Ocular Prosthesis- A Clinical Review

Ponnanna.A.A, Amit.Porwal, Nikhil.Verma

Abstract Numerous ocular impression and fitting techniques have been described in the literature. Most can be placed into one of several broad categories: direct impression/external impression, impression with a stock ocular tray or modified stock ocular tray, impression with custom ocular tray, impression using a stock ocular prosthesis, ocular prosthesis modification, and the wax Scleral blank technique. The aim of the article is to review the literature on different Clinical impressions techniques used for the fabrication of an ocular prosthesis. Key Words: Impression Techniques, Ocular Prosthesis, Scleral Blank Technique, Ocular Conformer etc. Received on: 16/09/2009 Accepted on: 17/12/2009

Introduction Eyes are generally the first features of the face to be noted(1). The unfortunate loss or absence of an eye may be caused by a congenital defect, irreparable trauma, tumor, a painful blind eye, sympathetic ophthalmia or the need for histological confirmation of a suspected diagnosis(2). The disfigurement associated with loss of an eye can cause significant physical and emotional

consideration(6). Various important steps are there in the fabrication of an ocular prosthesis but the most important is the making an impression of the eye socket. The aim of the article is to review the literature on different impressions techniques used for the fabrication of an ocular prosthesis. Literature Review Numerous ocular impression and fitting techniques have been described in the literature. Most can be placed into one of several broad categories: direct impression/external impression, impression with a stock ocular tray or modified stock ocular tray, impression with custom ocular tray, impression using a stock ocular prosthesis, ocular prosthesis

problems(3). Most patients experience significant stress, due primarily to adjusting to the functional disability caused by the loss and to societal reactions to the facial impairment(4). Replacement of the lost eye as soon as possible is necessary to promote physical and psychological healing for the patient and to improve social acceptance(4). Ocular prostheses are either ready-made or custom-made(5). Fabrication of a custom ocular prosthesis allows infinite variations during construction. However, the use of a stock prosthesis is usually advocated when time is limited and cost is a

modification, and the wax scleral blank technique. The Direct Impression/External Impression Several authors have used a technique in which low viscosity alginate or reversible

hydrocolloid is injected directly into the enucleated socket(7, 8). The patient is instructed to stare straight ahead as the material sets. Additional material is

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applied to the external tissue, and an impression is made using a rigid tray for reinforcement (fig-1,2).

Stock Ocular Tray Modifications Variations of the modified impression method center on the fabrication or configuration of a stock ocular tray. Maloney(11) placed 3 channels through the superior edge of his own set of customized stock trays to prevent air entrapment. Following his method, a raised ring around the stem

Fig. 1

Fig.2

prevents the eyelid from blocking the channels. Engelmeier(12) suggested casting a set of stock trays in Ticonium (CMP Industries, Albany, NY) to permit Sterilization and reuse. (Fig-5)

As a result, the anatomy of the anophthalmic socket and overlying tissues is obtained. A stone mold is made from the impression, and wax is poured into this mold. The wax form or scleral blank acts as a trial ocular prosthesis. It can be tried in the patient and adjusted as necessary to achieve proper tissue contours and fit. Impression with Stock Ocular Tray Perhaps the most common impression technique involves a stock ocular tray to help support the impression material(9, 10). Allen and Webster(9) were early proponents of this technique, calling it the modified impression method. The stock ocular tray is placed in the socket (fig-3). The tray has a hollow stem fastened in the middle through which a runny mix of ophthalmic alginate is injected.

Fig. 5

Fig.6

Sykes, Essop and Veres (13) advocated the use of modeling plastic impression compound as an ocular tray material (fig-6), forming it around one half of a small rubber ball and placing a hollow tube through it. Ophthalmic alginate is injected through the tube to make the impression. Impression with Custom Ocular Tray Miller(14) suggested that a custom ocular tray is necessary in certain situations. For example, the anophthalmic socket could be highly irregular or stock trays may not be available. Millers method involves attaching a solid suction rod to the patients existing prosthesis, conformer, or wax shell and investing it in an alginate mold. After the alginate sets, the prosthesis, conformer, or wax is removed and replaced with clear acrylic resin. Perforations are made in the resulting tray, and a tunnel is cut into the stem through which impression material can be

Fig. 3

Fig.4

Perforations in the tray aid flow and retention of the alginate. Subsequently, the

impression (fig-4) is removed and invested in stone. A wax pattern is fabricated from the mold. This wax trial prosthesis is placed in the socket and 10 minutes allowed for muscle accommodation. The fit of the trial prosthesis is evaluated and modified as needed.

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delivered (fig-7) An impression is made using injected alginate.

sometimes achieve this goal. Alternately, the stock prosthesis can be modified using alginate or soft wax, and then invested and processed. Smith(17) described a reline procedure for an existing prosthesis using a dental impression wax, Korecta-Wax No. 4 (D-R Miner Dental, Orinda, CA). The ocular is reduced peripherally and posteriorly, and modified with baseplate wax. When proper contours and position are achieved, a thin

Fig. 7 Impression Using Stock Ocular Prosthesis Several authors have recommended use of a stock ocular prosthesis as a tray to carry impression material(15).16 The impression technique involves selecting an esthetic stock eye and reducing its peripheral and posterior aspects. It is then lined with a thin mix of ophthalmic alginate and inserted for the definitive impression. Alternately, alginate can be injected directly into the socket and then reinforced by placement of the stock eye(fig-8,9). The resulting impression is processed, providing a customized stock prosthesis. Limitations of this technique include the need to maintain a fairly large supply of artificial eyes and the inability to match all sizes and colors of the iris and pupil.

layer of Korecta-Wax No. 4 is added. The lined prosthesis is warmed, inserted, and adjusted as needed. For definitive refinement, the lined

prosthesis is left in place for 30 minutes while the patient intermittently moves his or her eyes in all directions (fig10). A laboratory reline procedure is then accomplished.

Fig.10

Fig.11

Ow and Amrith(18) advocated use of a tissue conditioner as a reline material because of its biocompatibility and ease of manipulation. The periphery of a stock prosthesis is reduced and subsequently modified with baseplate wax. Viscogel (De Trey Division, Dentsply Ltd, Surrey, England) is added and the prosthesis inserted for 20 minutes. Excess material is removed, and the ocular prosthesis is worn for 24 to 48 hours to create a functional impression (fig-11). If esthetics and adaptation are

Fig.8 Ocular Prosthesis Modification Some clinicians

Fig.9

acceptable, the prosthesis is relined. Wax Scleral Blank Technique

have

advocated

The wax scleral blank has been advocated as the starting point in several techniques. Benson(19) created a wax blank by adapting base plate wax around half of an appropriately sized steel ball. The

modification of an existing prosthesis to gain acceptable fit. Chalian(16) has suggested that trimming and polishing a stock prosthesis will

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resultant pattern is smoothed, tried in, and adjusted. After the addition of an iris button, the pattern is invested and processed. If the socket is not grossly abnormal in configuration, McKinstry(20) suggests using his compression impression technique. He empirically formed a wax pattern based on examination of the site. The pattern is tried in, modified as needed, and processed after addition of an iris. One particular advantage of the empirical wax blank method is that it can be more effective than an actual impression in forming an inferior fornix if the patients lower lid is weak or the fornix is shallow(21). Using a wax blank created from a socket impression, Sykes(22) describes preparing a

4. Artopoulou I, Montgomery P, Wesley P, Lemon J. Digital imaging in the prostheses. The fabrication of ocular of prosthetic

Journal

dentistry2006;95(4):327-30. 5. Erpf S. Comparative features of plastic and/or glass in artificial-eye construction. Arch Ophthalmol 1953;50:737-8. 6. Cain J. Custom ocular prosthetics. The Journal of prosthetic dentistry1982;48(6):690-4. 7. Bartlett S, Moore D. Ocular prosthesis: A physiologic system. The Journal of prosthetic dentistry1973;29(4):450-9. 8. Brown K. Fabrication of an ocular prosthesis. The Journal of prosthetic dentistry1970;24(2):225-35. 9. Allen L, Webster H. Modified impression method of artificial eye fitting. American journal of ophthalmology1969;67(2):189-218. 10. Allen L, Bulgarelli D. Obtaining and

functional impression using poly vinyl siloxane (PVS) material on the intaglio surface. The altered wax pattern is then used to fabricate the final ocular prosthesis. Numerous impression and fitting methods exist. Effectiveness and desirability often depend on the patients presentation, operator experience, and materials and equipment available.
Authors Affiliations: 1. Professor, 2.Senior Lecturer, 3.Associate Professor, Department of Prosthodontics, Pacific Dental College, Udaipur, Rajasthan, India-313024, India.

understanding the alginate impressions. J Am Soc Ocularists1988;19:4-13. 11. Maloney B. Development of impression fitting equipment: A new technique. J Am Soc

Ocularists1979;9:32-3. 12. Engelmeir RL. Autoclavable custom made metal

References 1. Doshi P, Aruna B. Prosthetic management of patient with ocular defect. Journal of Indian Prosthodontic Society2005;5(1):37-8. 13. Sykes L, Essop A, Veres E. Use of custom-made 2. Perman KI, Baylis HI. Evisceration, enucleation, and exenteration. Otolaryngol Clin North Am1988 Feb;21(1):171-82. 3. Lubkin V, Sloan S. Enucleation and psychic trauma. Advances in ophthalmic plastic and 14. Miller B. Custom ocular impression trays. J Facial Somato Prosthet1996;2:109-13. conformers in the treatment of ocular defects. The Journal of prosthetic dentistry1999;82(3):362-5.

impression trays to improve infection control. J Prosthet Dent 1987;58 121-2.

reconstructive surgery1990;8:259.

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15. Rahn A, Boucher L, editors. Orbital and ocular prostheses, in Maxillofacial Prosthetics-Principles

orbital prostheses fabrication. The Journal of prosthetic dentistry 2003;90(1):97-100. 21. LeGrand J. Memories of a Modern Pioneer:

and Concepts. : Philadelphia, PA, Saunders; 1970. 16. Chalian V. Treating patients with facial defects, in Laney WR (ed): Maxillofacial Prosthetics. Littleton, MA, PSG1979:287-8. 22. Sykes L. Custom made ocular prostheses: A 17. Smith R. Relining an ocular prosthesis: A case report. . J Prosthodont1995;4:160-3. 18. Ow R, Amrith S. Ocular prosthetics: use of a tissue conditioner material to modify a stock ocular prosthesis. The Journal of prosthetic dentistry 1997;78(2):218-22. 19. Benson P. The fitting and fabrication of a custom resin artificial eye. The Journal of prosthetic dentistry 1977;38(5):532-8. 20. Mekayarajjananonth T, Salinas T, Chambers M, Lemon J. A mold-making procedure for multiple clinical report. The Journal of prosthetic Joseph A. LeGrand. Journal Of Ophthalmic

Prosthetics 2007;12(1):15.

dentistry1996;75(1):1-3. Address for correspondence Dr. Ponnanna. A.A, MDS, Professor, Department of Prosthodontics, Pacific Dental College, Udaipur, Rajasthan, India- 313024 Ph: + 91. 9828044775 Email: pons100@gmail.com

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