Dr.

Bhavan Chand

CONTENTS

Introduction Definition Review of Literature Classification Fabrication Recent Advancement Conclusion and Summary

DEFINITION
The maxillofacial prosthodontics is the branch of prosthodontics concerned with restorations and replacement of stommatognathic and craniofacial structure with prosthesis that may be removed on a regular or elective basis.
(GPT 8)

INTRODUCTION
Physical defects that compromise appearance or function which prevents an individual from leading a normal life usually prompt the individual to seek treatment that will reinstate acceptable normalcy.

The loss of an eye impair the patient's visual function, yet also result in noticeable deformity. A prosthesis should be provided as soon as possible to raise the spirit and ease the mind of the afflicted.

Orbital prosthesis: A prosthesis that artificially restores the eye, eyelids, and adjacent hard and soft tissue lost as a result of trauma or surgery - GPT 2005

Ocular prosthesis: A prosthesis that artificially replaces an eye missing as a result of trauma, surgery, or congenital absence. - GPT 2005

Opthalmologist

Maxillofacial Prosthodontics

Ocular Prosthesis

Plastic Surgeon

HISTORY
2613-2494 B.C First ocular prosthesis in Egypt; excavation of tombs provided evidence of eye replacement by using precious stones, earthenware, enemelled bronze ,copper and gold.

(1510-1590)
Ambrose Par , a famous French surgeon, was the first to describe the use of artificial eyes to fit an eye socket. These pieces were made of gold and silver,

Adv Ophthalmic Plast Reconstr Surg. 1990;8:1-10. Danz W Sr.

1820s-1890s);

Enamel prostheses were attractive color suitable for a prosthetic eye. German craftsmen are credited with this invention in 1835

19 century: Dental crop, Army of USA Fabrication of plastic eye :Various material like vulcanite and celluloid were introduced to improve this artificial eye prosthesis

Adv Ophthalmic Plast Reconstr Surg. 1990;8:110. Danz W Sr.

20 th century second world war: A definitive technique was used by United States Naval Dental and Medical School use of acrylic eye.

Ocular Implant;

Adv Ophthalmic Plast Reconstr Surg. 1990;8:1-10 Danz W Sr.

CLASSIFICATION OF OCULAR

PROSTHESIS
Material Availability

Custom made eyes

Stock eyes

Glass made

Acrylic made

WHAT IS THE ADVANTAGE OF CUSTOM MADE EYES OVER STOCK EYES

Close adaptation to the tissues. It minimizes the infection

Optimum cosmetic and functional result

Less chair side time.

Joseph R JPD 1982 VOL 48 No 6

WHAT IS THE ADVANTAGE OF PLASTIC EYES OVER GLASS EYES

It prevents socket dissolution. Fear of breakage is less. It can be reparable. It can be worn at night time The eye glasses are roughen and discolor caused by tears and secretion.

Chalian A Text book of Maxillofacial Prosthodontics

Normal eye

diagram

Etiology of eye loss;

Infection Trauma Malignancy

Gerodontology 2007 March 21 Sanjayagouda B.Patil, Roseline Meshramkar,B.H Naveen and N.P Patil

Surgical Management Three approaches(3E)

Evisceration; is a surgical procedure wherein the intraocular contents of the globes are removed, leaving a sclera, Tenons capsule, conjunctiva extra ocular muscle and optic nerves are undisturbed; cornea may be retained or exicised. Enucleation; is the surgical removal of the globe and a portion of the optic nerve from the orbit. Exenteration: Block dissection of eye.

EVISCERATION

ENUCLEATION

EXENTERATION

Steps in Fabrication ocular prosthesis:

Patient evaluation
Ocular impression

Wax Try in
Characterization of Prosthesis

Final polishing and finishing of prosthesis

Taylor Maxillofacial Prosthesis

Patient Evaluation:
The pt evaluation includes physical and psychological appraisal of the patient, including the desires and expectation of the patient related to the proposed prosthesis.

Patient has to be counseled regarding expected results, with specific emphasis on the role of both during the treatment phase and after completion of the prosthesis.

Patient examination ;

Proper healing Presence of the any contracture Irritation due to any existing prosthesis Evaluation of the muscles control
Robert B Welden and John v Niranee JPD Vol 6 No 2 1956

Impression Techniques:
Criteria for an acceptable impression:

Accuracy of recording the posterior wall

Position of the palpebral in relation to the posterior wall.

Greatest extent of the superior and inferior fornics.

Mark F.Mathew,Alan J Sutton J.Prosthodontics 2000,9,210-216

Review of Literature of Various Impression Technique

Bartlett and Moore.

Mixing alginate material with excess water until it is very free flowing

fill the mix in a disposable syringe and

the eye lids are drawn apart and impression material is introduced at the inner side of the palpebral fissure.

Bartlett and Moore. Journal of prosthodontics Dentistry A Physiologic System 1973 29 450-459

Brown:
advocated an external impression tray tech in which the ophthalmic irreversible alginate is mixed and injected into the ocular defects by means of the syringe and later he recommended an edentulous perforated trays with additional impression materials to combine with the extruded material.

diagram

diagram Kenneth E Brown JPD 1970 vol 24 no 2

Taylor :Modified External tray impression technique:

He advocated placing the perforated acrylic resin backing tray for reinforcement.
Perforated acrylic backing

Weldon and Nilranee: they selected esthetics stock tray.

Stock tray

:Weldon and Nilranee, JPD 0cular prosthesis

1956 vol 6 no 2

Allen and Webster; recommended a stock ocular tray which is perforated which helps in the retention of alginate for making ocular impression. Cain: He suggested using the impression trays with a hollow stem in the shape of the ocular prosthesis. Once the impression set, he recommended making a two piece dental stone mold to make the wax conformer.
Cain JR jpd 1982,48, 690-4

Two piece dental stone

Englemeier:

Suggested casting a set of stock trays in ticonium which is a nonprecious removable partial denture alloy which can be sterilized in an autoclave for reuse. Stock metal tray

Englemeier jpd 1987 ,58 121-212

Benson : advocated Wax scleral Blank Tech;

Tissue side of prosthesis poured in the stone

Perforations are placed in the tray Benson : journal of prosthodontics1997, 78 218-222

Tip of the syringe shortened

Syringe tip secured in the tray

Benson : journal of prosthodontics1997, 78 218-222

Syringe is screwed into the tray

Resulting impression

Fitting the Sclera Wax Pattern:

Two piece cast

Molten base plate cast poured

Retrieving the wax pattern

Sharp edges are removed

Scleral wax pattern in place

CHARACTERIZATION OF PROSTHESIS
1.

Paper Iris Disk Technique:

Iris is marked on scleral blank

Size and location of iris are verified

Completed iris painting

Verification of iris painting

Use of an ocular blank

Processing of prosthesis done

Digital imaging:
The digital image provides acceptable esthetics results because it closely replicates the patients with minimum color adjustment and modification. Advantages: Techniques is simple

Less treatment time

Requires minimal artistic skill.

J Prosthet Dent. 2006 Apr;95(4):327-30 Mathews MF, Smith RM, Sutton AJ, Hudson R

Digital photograph of patient

Ocular button positioning on paper iris

Disk assembly attached to wax pattern

Complete ocular prosthesis matching pt iris

J Prosthet Dent. 2006 Apr;95(4):327-30 Mathews MF, Smith

RM, Sutton AJ, Hudson R

PATIENT INSTRUCTIONS

Wear the prosthesis day and night It has to washed with soap solution once in every two weeks.

Once the prosthesis removed the soft tissues are irrigated with ophthalmic irrigation
Daily ocular hygiene can be maintained using ophthalmic irrigation solution as a eye drops to clean anterior portion of the prosthesis

Reline of ocular prosthesis

Borders of prosthesis modified with the wax

Impression is made with korecta wax

Rick M. Smith., J. Prosthodontics, 1995:4; 160-163

Prosthesis after relining with clear acrylic

OCCULAR IMPLANT

Placed in the tissue bed to facilitate construction of ocular prosthesis.

ADVANTAGES:

Prevents sunken appearance of orbit.

Better movement of overlying prosthesis muscles attached.

In growing children additional benefit restored muscle function creates additional tension on the orbital walls and ensures normal pattern of orbital growth.

Following enucleation not all patients are candidates for placement of an ocular implant:

Pemphigus, trachoma etc which predispose

to severe scarring implant placement not

possible.

If there is insufficient tissue to cover the implant following surgery.

MATERIALS USED FOR OCULAR IMPLANTS

First material glass. Introduced byMules(1884)

Many materials have been tried: Bone, gold ivory, rubber, paraffin etc.
In recent years inert resin polymers are used. (Most of the implants are made of methyl methacrylate resin) .

Hydroxyapatite

CLASSIFICATION OF IMPLANTS

1. Integrated 2. Semi integrated 3. Non integrated

1. Buried 2. Non buried

Hydroxyapetite motility implant in ocular prosthesis: Volume deficiency syndrome

In 1995 Dr Arthur Perry introduced HA motility implant

Advantages:

Inherent biocompactibility and proclivity to become fibrovascularity integrated with resiudual muscle and tissue. It also minimize the fear of the bacterial infection.
Dr Arthur Perry jpd 1995 vol73 67-69

Disadvantages:

Extended operative time required to locate and attach the extraocular muscle to the motility sphere. Cost effective.

Magnetically integrated microporous implant:

This study establishes the safety of microporous highdensity polyethylene implants in the rabbit model. CLINICAL RELEVANCE: This technique may offer an alternative to patients with previously implanted microporous high-density polyethylene implants seeking enhanced cosmesis and prosthetic motility.
Escalona-Benz E, Benz MS, Murray TG, Hayden BC, Hernandez E, Garonzik SN, Cicciarelli NL. Arch Ophthalmol. 2007

Nov;121(11):1596-600

MICRO-OPTICAL ARTIFICIAL COMPOUND EYES.

For small invertebrates such as flies or moths, compound eyes are the perfectly adapted solution to obtaining sufficient visual information about their environment without overloading their brains with the necessary image processing.

In this paper, it is shown that such optical systems can be achieved using state-of-the-art micro-optics Systems.
Duparr JW, Wippermann FC Bioinspir Biomim. 2006 Mar;1(1):R1-16. Epub 2006 Apr 6

CONCLUSION
The art of replacing missing eye with a prosthesis has been carried out many years and these can be stock or custom made. The use of an ocular prosthesis of appropriate size, contour and contour can prove to be of value functionally as well as aesthetically. It promotes physical and psychological healing for the patient and improve social acceptance.

Beumer J. Maxillofacial rahabilitation

Modified impression tech of artificial eyes: Am J Opthalmol:

1969:67:189

Ocular prosthesis: JPD 1973:38:532 Fitting of ocular prosthesis:JPD: 1977:38:532 Custom ocular prosthesis: JPD 1982:48:690 HA motility implants: JPD 1995:73:267

Vein application: JPD 1975:34:193

Kumar D krishna:contact lens research integrated

implants:JPD 1974:32:439

Custom oc prosthesis:JPD 1997:78:218 Post insertion care: JPD 1983:49:220 Surgical considerations:JPD 1983:49:379 Pupil alignment: JPD 1969:22:487-489

History of eyes: Am J Opth:1969:67:167

Modified ocular prosthesis tech: jpd 1986:55:482

Snells clinical anatomy

Taylor: clinical maxillofacial prosthetics

Modified stock prosthesis: JPD 1985:54:95