Ocular and Orbital prosthesis ANJALI RATHORE

PG STUDENT,DEPARTMENT OF PROSTHODONTICS, RUNGTA COLLEGE OF DENTAL SCIENCES AND RESEARCH

1. ORBITAL / OCCULAR PROSTHESIS PRESENTED BY-ANJALI RATHORE PG 1 ST YEAR DEPT OF PROSTHODONTICS

2. contents Introduction Definition Objective of prosthetic rehabilitation History of ocular prosthesis Glass eye prosthesis vs. acrylic eye prosthesis Different types of acrylic eye prosthesis Impression procedures for occular prosthesis Clinical & laboratory procedures for construction Post insertion care Removal & replacement of prosthesis. Orbital prosthesis Steps in fabrication procedure Positioning of prosthetic eye Coloring technique Retention of prosthesis Implant supported prosthesis Bionic eye Conclusion

3. INTRODUCTION Man's need for artificial replacements to supply missing or lost body parts has probably existed as long as man himself . Body abnormalities or defects compromise appearance, function render an individual incapable of leading a relatively normal life. The replacement of anatomical parts is a challenge to those properly trained to construct acceptable substitutes. Shah and Aeran : Prosthetic management of ocular prosthesis defect The Journal of Indian Prosthodontic Society | June 2008 | Vol 8 | Issue 2

4. DEFINITION MAXILLOFACIAL PROSTHESIS ‘’Maxillofacial prosthetics the branch of prosthodontics concerned with the restoration and/or replacement of stomatognathic and craniofacial structures with prostheses that may or may not be removed on a regular or elective basis’’.-GPT 9

5. OCULAR PROSTHESIS : prosthesis that artificially replaces an eye; doesn't replace missing eyelids, adjacent structures’ ORBITAL PROSTHESIS A maxillofacial prosthesis that artificially restores the eye, eyelids, and adjacent hard and soft tissues.-GPT 9

6. OBJECTIVES OF MAXILLOFACIAL PROSTHETICS

7. ADVANTAGES ADVANTAGES DISADVANTAGES

8. History of ocular prosthesis The Romans & Egyptian priests were the first to make the ocular prosthesis as early as 500 B.C. called as Ectblepharons . The artificial eyes were painted on clay & attached to the cloth & worn outside the socket. In another method eye & lids were incorporated as a single unit attached to flesh colored cloth . During the 16 th C. in 1752 Glass Artificial eyes were introduced .

9. These early glass eyes were crude, uncomfortable to wear, very fragile . But still glass became the material of choice for ocular prosthesis for the next two hundred years . In mid 19 th C. German glass blowers developed the superior technique of making hollow Kryolite glass prosthesis .

10. In mid 19 th C. the glass eye making introduced in united states by immigrant German occularists . The stock glass eyes was another market that flourished among 5 to 7 German families of glass eye makers in North America.

11. Classification of ocular prosthesis Availability Stock eyes Custom made eyes Material Glass made Acrylic made

12. THE TRANSITION FROM GLASS TO PLASTIC OCULAR PROSTHESIS During the world war II the export of Kryolite glass material from Germany to United States was cut off. The department of Navy set up the crash course in applying plastics to the field of ocularists this lead to the development of acrylic ocular prosthesis .

13. DRAW BACKS OF GLASS EYES Inability to approximate the surface irregularities of the anterior surface of the posterior orbit. Fragility of glass & its propensity to fracture. Cannot be polished or altered after completion. Need to be replaced every one or two years as tears & secretions would roughen & discolor the front surface of the glass.

14. ADVANTAGES OF ACRYLIC EYES

15. 3 types of acrylic resin prosthesis used Stock eyes Stock eyes modified by various techniques Custom fitted eyes made from an impression of the socket

16. S tock eyes (shell) Since mucosa can be displaced, some success can be obtained with a stock prosthesis. But patient will definitely experience some discomfort because : The mucosal surface doesn’t snugly fit the prosthesis . Debris collected in the voids also causes the potential irritating factor to the mucosa.

17. C ustom ocular prosthesis Every socket differs in size and shape , hence individually designed prosthesis constructed from an impression of the socket provides : Full physiologic function to the accessory organs of the eye. Provides maximum comfort.

18. 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

19. C ause for loss of eye

20. SURGICAL MANAGEMENT OF AN EYE DEFECT

21. Steps in Fabrication ocular prosthesis: Patient evaluation Ocular impression Wax Try in Characterization of Prosthesis Final polishing and finishing of prosthesis Taylor Maxillofacial Prosthesis

22. 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

23. 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

24. Material used Materials used for fabrication of ocular prosthesis: Glass eyes Acrylic eyes Vulcanite Celluloid Maxillofacial resins used in fabrication of eye prosthesis: Acrylic resins Vinyl plastisols (realistic mediplast ) Latex Polyurethane Siphenylenes Acrylate skin and silicon elastomers

25. Impression techniques 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 JAYAPRAKASH MB THE OCULAR IMPRESSION: A REVIEWTMU J. Dent Vol. 1; Issue 2 Apr –June 2014|

26. 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 Review of Literature of Various Impression Technique

27. 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. Kenneth E Brown JPD 1970 vol 24 no 2

28. The impression is boxed and poured in the dental stone up to the height of contour of the impression. A separating agent is placed and the reminder of the impression is poured Two piece cast Text book of Clinical maxillo facial prosthesis ; Thomas D.Taylor ; Quitessence publication 2006

29. Molten base plate cast poured Sharp edges are removed

30. Scleral wax pattern in place

31. Taylor : Modified External tray impression technique: He advocated placing the perforated acrylic resin backing tray for reinforcement . Weldon and Nilranee : they selected esthetics stock tray. Perforated acrylic backing Stock tray Weldon and Nilranee , JPD 0cular prosthesis 1956 vol 6 no 2

32. S tock tray impression tech nique Material required : Disposable syringe Stock ocular tray STEM Non irritating impression material i.e. opthalmic quality irreversible hydrcolloid

33. IMPRESSION PROCEDURE Patient should be seated in an upright position with head supported by head rest ( allows natural positioning of palpebral and surrounding tissue relative to force of gravity. stock tray is placed in the defect and check for over extension and orientation . Support the lids Irreversible hydrocolloid impression material mixed Loaded in syringe Sufficient material ejected to fill the concavity of the tray

34. The tray reinsert and reorient in the defect Sufficient material is injected to elevate the lid contours similar to that of normal side Assembly removed Impression tray is removed from syringe Proper lid contour and mobility of impression checked If the impression was properly oriented and extended, Proper lid contour and mobility of impression checked Once it sets Examine for defects Replaced in defect Patient asked to look right ,left, up, down .

35. Movement of tray follows pupil of natural eye Proper extension and orientation Lab procedure : Attach stem of the impression tray to an orange wood stick with sticky wax Assembly suspended over a small medicine cup Pour room temperature vulcanizing silicone mold material into the cup to completely cover the impression

36. Mold is cut & spread apart to remove impression tray Mold is replaced in the cup molten wax filled through the hole made by stem of impression tray Cut the sprue and wax pattern removed and smoothened. Wax hard

37. 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

38. variation of Stock tray impression technique Maloney placed three 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 prevents the eyelid from blocking the channels. Sajjad A (December 06, 2012) Ocular Prosthesis - A Simulation of Human Anatomy: A Literature Review. Cureus 4(12): e74.

39. 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. Englemeier jpd 1987 ,58 121-212 Stock metal tray Sykes, et al. [20] advocated the use of modeling plastic impression compound as an ocular tray material, forming it around one-half of a small rubber ball and placing a hollow tube through it.

40. The impression technique using a stock ocular prosthesis: Use of a stock ocular prosthesis of an appropriate size and color, adapted by selective grinding or addition of acrylic resin has been advocated by Laney and Gardener. A stock eye is selected with the correct iris size, color and sclera shape. The periphery and posterior surface is reduced 2-3 mm and retentive grooves are cut into it.

41. Alginate adhesive is painted over these surfaces and alginate is injected into the defect and the modified stock eye is placed into it. Impression is then invested, packed and cured under 3500 psi pressure for at least one hour. 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.

42. Variations of the stock ocular prosthesis impression technique Modification of stock eye prosthesis can also be done using a tissue conditioner as described by Ow and Amrith . This is comfortable and produces a healthy clinical soft tissue response. Its biocompatibility allows the continued clinical use and evaluation of the ocular prosthesis over an extended period of 24 to 48 hours. This method is particularly suitable in growing children where the prosthesis needs to be regularly modified to suitably fit their growing orbits. After 48hours, the elastic tissue conditioner must be converted into heat-cured acrylic resin to complete the prosthesis.

43. Smith described a reline procedure for an existing prosthesis using a dental impression wax, such as Korecta -Wax No. 4 (D-R Miner Dental, Orinda, CA). 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.

44. Impression with Custom Ocular Tray In cases where anophthalmic socket was highly irregular or stock trays may not be available, use of a custom ocular ray was suggested by Miller.

45. Mathews et al Ocular Impression Techniques December 2000, Volume 9, Number 4

46. Perforations are placed in the tray

47. Tip of the syringe shortened Syringe tip secured in the tray Syringe is screwed into the tray

48. Suspend the impression in a small cup using a clothes pin. Pour a new mix of irreversible hydrocolloid into the cup, surrounding the impression. Resulting impression Ophthalmic alginate impression material was mixed & back loaded in syringe. Tray was seated & alginate was injected. After the material set, impression was removed and checked for acceptability.

49. When set, alginate mold was removed with impression from the cup. Mold was partially sectioned, & impression was retrieved. The different mixes of alginate will not adhere to each other. The second alginate impression becomes a mold to form the wax blank. Mold is poured in the cup with ivory wax through the sprue hole created by syringe tip.

50. Ocular Prosthesis Modification Chalian has suggested trimming and polishing of a stock prosthesis to gain acceptable fit. The stock prosthesis can also be modified using alginate or soft wax, and then invested and processed.

51. Wax Scleral Blank Technique The wax scleral blank has been advocated as the starting point in several techniques. Benson created a wax pattern of half of the size of steel ball. The resultant pattern is smoothed, tried in, and adjusted. The pattern is invested and Processed with iris button attached. Chalian et al also followed the same. McKinstry suggested “compression impression” technique in which he empirically formed a wax pattern based on examination of the site. Wax pattern was tried in, modified as needed, and processed after addition of an iris.

52. One particular advantage of the empirical wax blank method is it accurately records and form an inferior fornix if the patient’s lower lid is weak or the fornix is shallow. LeGrand and Hughes20in their “empirical/ impression” technique attached a “dummy” aluminum button to act as a handle.

53. S econd appointment The socket , mould and the wax pattern is inspected Palpebrae is manipulated to ascertain how to contour the scleral surface of the wax pattern ( roughly it should be egg shaped and congruent with natural eye.) Height of convexity should be centered over the pupil, slightly medial to the mid line between inner and outer canthi . After the necessary modifications, a lubricant (petroleum jelly or 25 % methyl cellulose based tear solution) applied before the final try in. The wax pattern is converted to white acrylic resin(resin eye blank)

54. T hird appointment The polished resin eye blank is inserted into the socket and examined carefully. Discrepancies should not exists between the right and left palpebral opening or in the contours. After through comparison with the contralateral eye , a dot of red ink placed in the location of the center of pupil.

55. Measure the diameter of the natural iris , using a transparent plastic strip punched with circular holes in gradation of 0.5mm.. The patient is asked to fix his gaze on operators nose , then the transparent strip is moved up , down , left & right until the hole in front of the iris has the same circumference as that of the iris Since the limbus outline is not distinct , this measurement will be accurate within about 0.25mm.

56. The size of the iris is measured using a millimeter measurement gauge or optical scale. The outline of the iris is then marked on the scleral blank using Carmen red ink. The lower lid should just touch the bottom of circle. If any discrepancy exists remove the blank repeat the procedure until the symmetry is achieved. Iris is marked on scleral blank Size and location of iris are verified Characterization of prosthesis 1. Paper Iris Disk Technique FOURTH APPOINTMENT PAPER IRIS TECHNIQUE BLACK IRIS TECHNIQUE

57. This ink will transfer to the investing stone, facilitating the appropriate placement of the corneal prominence. The blank is tried in again to verify the location and size of the iris. The location of the iris will transfer to the investment and a scraper can then be used to create the corneal prominence of the prosthesis in the investment. A disk of ordinary artist's watercolor paper is punched out using a die. The size selected should be 1 mm smaller than the measured size of the iris. This will allow the iris to appear to be the appropriate size because the corneal prominence will cause a slight magnification of the iris disk. Processing of prosthesis done

58. A good selection of colors for this purpose includes ultra­marine blue, yellow ochre, burnt sienna, burnt umber, yellow oxide, titanium white. Colors should be mixed and reapplied in a layering fashion to mimic the colored striations in the patient's iris. Pupil Medial canthus IRIS ANATOMY

59. Begin by painting the darkest color, the area toward the outer edge of the iris ring ( limbus ). The color of the limbus varies from eye to eye, but it usually is a combination of gray and iris body color. In the natural eye, it can appear as a shadow from the overlapping sclera, covering the edge of the cornea. Next the collarette is painted. It is usually a lighter color than the body of the iris. A black spot should be painted in the center of the disk to represent the pupil. IRIS DISK PAINTING Completed iris painting

60. The diameter should mimic the natural pupil under indoor light conditions. This will make size appear relatively appropriate under most conditions. After the paint has dried, a drop of water is applied to create the magnification of the corneal prominence and the color matched. . Verification of iris painting Using a flat-end bur, a flat surface is prepared in the scleral blank for the iris painting. A sprue wax is luted to the prepared flat surface and tried in. The orientation of the surface is adjusted until the sprue points directly at the observer while the patient looks directly into the observer's eye. This will ensure that the prosthesis and the natural eye will have the same gaze Use of an ocular blank

61. Using a large abrasive stone, the entire anterior surface of the scleral blank is reduced at least 1 mm. The remainder of the prosthesis is then painted to match the sclera of the natural eye. Fine red embroidery threads are placed on the scleral painting to mimic the blood vessels of the patient's natural eye. The entire scleral portion is then coated with monomer polymer syrup to keep the blood-vessel fibers in place and allowed to set.

62. Once the monomer-polymer syrup has set, the scleral blank is replaced into the flask, and the iris painting is placed on the flat section. Clear ocular acrylic resin is mixed and placed into the mold space and the flask trial packed . Once trial packed, the flash is removed and the location of the painting verified to ensure that it has not moved during trial packing.

63. Black iris disk technique : Windsor Newton oil pigment(factor II) are employed. Mixed with monomer-polymer syrup during the painting process. Sequence: Iris disk painting Attachment of lens button to disk This is assembled to wax pattern Checking the position in the patient Final waxing around lens to correct contours, extensions Flasking & packing with white scleral acrylic After polymerization , scleral painting and reflasking Packing with optical grade acrylic resin Final finishing and polishing

64. F ifth appointment Once the ocular prosthesis is inserted ,esthetic appearance, iris symmetry with the contralateral eye , the palpebral openings, and patient’s comfort is reassed . The prosthesis will not have the same sheen or sparkle as the natural eye, because the resin will not be completely wetted by lacrimal fluids. But the appearance will improve during the first two days for the above said reason and also the lids will get adjusted and contoured to the prosthesis. There should not be any discomfort to the patient while he is asked to look in different directions.

65. P ost insertion care 1. Adjusting to the prosthesis : the time required for an individual patient to get used to the prosthesis is variable. some will become accustomed to the prosthesis in a matter of hours, others may require days, and few never get adjusted comfortably. 2. Period of wear - artificial eye need not be removed for cleaning each day ,the patient can wear the prosthesis as long as it remains comfortable & nonirritating regardless whether it is a day, week, a month, or more.

66. 3. Once removed from the socket the prosthesis should be placed in water or contact lens soaking solution. 4. The prosthesis should never be allowed to dry otherwise it causes various layers to separate. 5. The patient should be cautioned to maintain normal facial animation and to avoid habits designed to hide the prosthesis. These exaggerated habits often make the prosthesis more obvious.

67. R emoval & replacement

68. Patient must clean and dry his hand. Looking in the mirror with chin down Top edge of the prosthesis engaged under the upper eye lid, forefinger of the other hand is used to elevate the upper lid. The prosthesis should be gently pushed upward and back ward. While the upper lid is released the lower lid is pulled downward gentle pressure will cause prosthesis rotate backward and inward behind the lower lid to seat the prosthesis.

69. Patient is asked to tilt the chin downward looking at mirror. Forefinger used to pull the lower lid and at the same time pushing prosthesis gently backward and toward the nose. This will disengage the lower edge of the prosthesis and it is removed out. If it is not removed out with the above said procedure, rubber suction cup may be used .

70. R ecall One year recall system should be instituted for all eye prosthesis patients. Normal fat and muscle atrophy will cause the socket to change shape leading to poor fit, poor movement ,loss of retention of fluid collection behind the eye. Hence during recall period- fit, mobility and direction of gaze of the prosthesis should be assed . The prosthesis soon made after surgery before edema subsides or the one made for the growing child may have a sunken appearance,. The prosthesis should be removed and examined for scratches ,chips , bacterial growth and accretions because all these would cause unaesthetic appearance, socket irritation, increased drainage leading to socket infection.

71. Socket secretions and discharge are normal & desirable since they provide mild lubrication & antibacterial properties. But when the secretions amount increases or turn from normal yellow white to yellow , yellow-green , yellow- brown, infection is suspected. In such instances refer to the opthalmologist for bacterial culture and antibiotic treatment. If the prosthesis is not too old and not contaminated with bacterial growth or deeply scratched it should be repolished and inserted.

72. G.R.Parr (1983) has suggested that while polishing –gentle pressure and at a slow speed polishing should be done otherwise the heat generated may pit and roughen the prosthesis or even give clouded appearance to the cornea. Polishing an artificial eye is much more delicate procedure than polishing a denture. Polishing compounds used for dentures are too abrasive and only polishing compounds specifically made for artificial eye should be used.

73. S pecial conditions Following surgery ,some patients are left with inadequate volume of tears to lubricate the artificial eyes & lids. These individuals will experience discomfort and irritation due to friction or to adhesion of the conjunctiva to the prosthesis. Artificial tear replacements : 1. Mineral oil 2.Sunflower oil 3.Alchol based lubricants (contact lens soln.) {problem : evaporates fast &leaving hard irritating methyl cellulose. } 4.Silicone based lubricant. Allergy due to acrylic resins are extremely rare, but associated to this are common such as airborne allergens ( animal hair, plant pollen or poor socket hygiene.)

74. conformers Stock conformer Profile of tissue bed of conformer At the time of surgery or shortly after surgery the conformer(quasi-integrated , buried , muscle cone) should be placed. This rounded cones on the tissue bed side of the conformers, facilitate movement of the prosthesis. Conformers can be a stock made or custom made but should be worn post surgically for a better prosthetic result. Custom made : constructed from irreversible hydrocolloid impression.

75. Joseph R. Cain (1983) suggested custom ocular prosthesis with dilating pupil. The author has described a technique in which adjustable pupil has both constricted and dilated diameter ,which can simulate according to the natural eyes reaction to high & low intensity light. The patient can alter the pupil size without removal by using a small magnet. Dilating pupil Review of literature

76. I rritation of ocular tissues by irreversible hydrocolloids James R.Moergeli (1985) conducted study on irritation caused by dental and ophthalmic irreversible hydrocolloids on rabbits conjunctiva .In his histological study he concluded that the dental irreversible hydrocolloid caused more acute type of inflammatory response than the ophthalmic variety of hydrocolloid impression material.

77. Digital imaging in the fabrication of ocular prostheses Digital photograph of the patient's iris is recorded using a digital camera Photograph is evaluated and compare it to the patient's iris Using graphics software , slight differences in color, brightness, contrast, or hue is adjusted and formatted. If necessary, further customization and color modifications using professional quality color pencils . * Ioli-Ioanna Artopoulou (2006) Digital photo

78. The final image is printed on 20-lb white paper with brightness 87 using a laser printer. The paper iris is covered with 3 light coats of water-resistant spray , used for artwork, and attach it to the ocular disk. Disk assembly is attached to the wax pattern , and evaluated in the patient. Selected scleral acrylic resin is processed at the same temperatures, using the procedure previously described for the conventional technique.

79. Orbital prosthesis

80. IMPRESSION MATERIALS FOR OBTAINING FACIAL MOULAGE Fabrication of orbital prosthesis

81. MODELLING MATERIALS Modelling Clay ( Sculptor’s Clay) - A water based clay which, when allowed to dry, becomes a hard, stonelike substance Plaster Waxes

82. Extraoral impression Essential to a well-fitting and well-fabricated prosthesis. Patient preparation – Should either be reclined on a dental chair or preferably lying on a table with head slightly elevated. Draped with sheet and hair boxed out with cloth towels. Face should be free of make up and eye glasses. Eyelashes, eyebrows and moustache should be coated with vaseline . Deep undercuts blocked out with wet gauze or cotton.

83. STEPS IN THE FABRICATION OF ORBITAL PROSTHESIS The Moulage impression and Working Cast fabrication Sculpture and Formation of the Prosthesis Pattern Fabrication of the Mold Processing of the Prosthesis Material with Intrinsic and Extrinsic coloration Insertion of Eye lashes

84.   When all drapes and protective materials have been applied, cotton balls tied with the help of dental floss are used to plug the nostrils. These cotton balls should be large enough, just to plug the nostrils without distorting them. Then patient is asked to practice breathing through the evacuator tube placed in the mouth to ensure adequate ventilation. After the patient starts breathing comfortably through the tubes, alginate is mixed using water/powder ratio of 1.25 to 1.50 times the normal amount of water. 1.The Moulage impression and Working Cast fabrication

85. After mixing, the alginate is applied to the skin surface with a round-end mixing spatula, taking care to avoid air entrapment. When the area has been covered, opened gauze squares or the bent paper clips are applied over the entire surface using light pressure. There will prosthesis means for mechanical retention for the rigid plaster backing necessary for removal of the impression without distortion.

86. Then fast-set plaster is mixed to a cake-batter consistency and spread over the entire impression surface to a thickness of about 0.25 inch. A thicker ridge of reinforcement may be added at the midline. Surface of the plaster is checked for tapping sound with a blunt instrument after 4-5 minutes to check setting of the plaster. For removal of the impression, the impression is grasped on both sides of the patients’ head and gentle lifting force is applied. During this procedure instruct the patient to wiggle or to produce wrinkles on the face; this will assist in freeing the impression from the skin. Also instruct the patient to release the breathing tube. Patient will usually appear flushed due to the heat and moisture from the impression, but skin color and temperature will rapidly turn to normal

87. Impression is inspected for any voids or distortion, especially in the area around the defect where the margins of the prosthesis will be developed. Small defects or voids not associated with the margin area may be filled in or chipped off the cast. Disinfect the impression. Points to be remembered: Packing an orbital defect before impression should be given special attention. Moist cotton or petrolatum gauze should be used to close the communication if any, with the nasal or oral cavity. Full facial or midfacial impression is preferred. Patient should be cautioned to relax their faces to prevent marked changes in the orbital opening. In cases of extensive defects, intraoral prosthesis should be in place so that soft tissue contours around the mouth and cheek will remain stable.

88. ii. Sculpture and formation of the prosthesis pattern Wax is preferred over modeling clay as residual oils from the clay contaminate the mold surfaces. Wax formula – two sheets of beeswax, - one sheet of hard pink baseplate wax - two strips of clear rope boxing wax Dry earth pigments- to form skin color. A sheet of pink baseplate wax is adapted to the orbital defect which forms the basis for positioning the ocular section of the prosthesis within the defect in the same frontal, sagittal and horizontal planes as the normal eye.

89. Positioning is best accomplished by placing the ocular section on a stalk of soft wax in the wax cup. Assembly placed into orbital defect and ocular section manipulated into the position that matches the gaze of the normal eye when the patient is staring directly at a point at eye level atleast 6 feet away.

90. Positioning the Prosthetic Eye Anatomic references on the skin Vernier caliper 3. Pupillometer An instrument to achieve pupil alignment in eye prosthesis

91. 4. Ruler Tongue blade 5. Profile gauge 6. Bright light

92. McArthur J. Prosthet . Dent. Aids for positiohg prosthetic eyes in orbital prosthesesarch , 1977 7. Ocular locator Ocular locator and fixed caliper. Note the scribed midline and the two horizontal lines. The fixed caliper duplicates the distance between the two horizontal lines.

93. Fabrication. A grid was drawn on graph paper which contained an X and a Y axis and a mirror image of the axes. The X axis was labeled A through F. The distance from A to B was 0.5 inch and was subdivided into five equal parts. The pattern of division and subdivision was repeated for all intervals on the X axis. The Y axis was labeled 1 through 9 and was divided and subdivided in a manner similar to that for the X axis. The grid was photographed with black-and-white film. The negative was printed and enlarged on photographic film to the actual size of the original grid. The product was a black grid on a clear background which was mounted between two sheets of 1/8 inch Plexiglas with an opening in the center for the nose.

94. A)The locator on the patient’s face, a vertical midsagittal mark is made on the forehead and chin (B)fixed caliper is used to determine the intersection of the horizontal lines with the midsagittal mark (C) The locator is placed so that the scribed lines on the locator are superimposed over the markings on the face. (D) The anatomy of the eye is traced onto the surface of the locator with a grease pencil or water-soluble felt-tipped pen. (E)The locator is turned 180 degrees on the midsagittal axis to produce its mirror image. The locator is placed on the stone moulage to aid in the correct placement of the eye.

95. 9. Relating pupil of the prosthetic eye to the existing natural eye by facial measurements 8. Simplified ocular locator 10. Inverted anatomic tracing ( Nusinov 1998)

96. Computer imaging may be used to assist establishment of the correct ocular positioning and lid opening. 11. Computer imaging (Adobe Photoshop)

97. Once the correct positioning of the ocular section has been accomplished and the eyelid aperture established, the soft sculpting wax mixture is added with a glass eye dropper or spatula to roughly fill the remaining contour of the prosthesis out to the area where margins are to be established. Following the completion of the fine details in the pattern, the sculpture should be placed onto the patient and verified for fit, direction of gaze, and eyelid aperture. When satisfied, the pattern is ready for making the mold.

98. III. FABRICATION OF THE MOLD After the stone flasking material has set in the tissue-surface half of the mold, Foil substitute is applied to the exposed stone surrounding the pattern, because it is least likely to contaminate the platinum catalyst of the silicone prosthesis material. Indexing method applied to position the ocular segment of the prosthesis, now incorporated in the wax pattern, back into the mold in its same orientation as in the pattern. Prior to investing, an index in the form of horizontal and vertical pyramids is placed on the surface of ocular segment with sticky wax.

99. Index reproduced in the cope segment of the mold removed from drag to avoid damaging the indexing wax ocular segment removed from the wax pattern and duplicated using alginate impression. duplicate segment including indexing wax poured in dental stone and placed into the index indentations in the cope with cyanoacrylate adhesive. This segment forms a pocket in the final silicone prosthesis for insertion of ocular segment.

100. IV. PROCESSING OF THE PROSTHESIS MATERIAL WITH INTRINSIC AND EXTRINSIC COLORATION. Even when the contours of the prosthesis are not exact duplicates of the contralateral structures and the skin texture not exactly reproduced Many methods are practised … Coloration technique …… a)Micro air-spray techniques. b)Brush-in technique (no distinctive intrinsic color).

101. COLORATION TECHNIQUE

102. V. INSERTION OF EYE LASHES AND EYEBROWS Processed curved natural hair taken from human arm used Broach holder and ‘Y’ needle required. When desirable number of lashes have been thus placed, they are trimmed to alternately long and short lengths to lend a natural appearance.

103. MAINTAINENCE OF THE PROSTHESIS Prosthesis should be removed once a day to be cleaned The adhesive is removed with a rolling motion of the ball of the finger or thumb. Foreign substances should be removed Prosthesis washed with mild soap and brush. Skin in contact with prosthesis should be cleaned.

104. Instructions to the patient. Since the artificial eye does not track with the natural eye of the opposite side, the patient should learn to turn his head when changing his line of vision How to orient and place it How to maintain the hygiene of both tissue and prosthesis (in warm water with a mild soap) How to apply the surgical cement The prosthesis should not be worn while sleeping

105. Additionally, patients should be advised that the color match depends on the color of their tissues, which are susceptible to the seasons as well as activity levels and environmental temperature Prosthesis is stored in a container away from direct light or heat. Isopropyl alcohol may be used to remove the oily residue. To prevent premature discoloration of the prosthesis, it should not be exposed to cigarette smoke.

106. Recent Advancement

107. Ocular Implant Placed in 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 orbital walls..ensures normal pattern of orbital growth.

108. Insertion of implant Muscles attached to implant

109. Materials used for Ocular Implants.. First material  glass.. Introduced by Mules(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

110. Classification of implants.. By Integration Integrated Semi-integrated Nonintegrated By Location Buried Non Buried

111. Buried implants : totally buried in tissues(chance of dehisence  exposure of overlying implant ) Non buried : some part open. (High chance of infection and migration) Integrated implants..

112. Semi integrated.. (Allen implant, Iowa implant, Quad motility implant) Protruding mounds on implant  prosthesis will have a counter contour excellent motility and retention of the prosthesis . Require excellent fit of the prosthesis Most commonly used ( Mules’sphere ) ( 10-22mm) Smooth surface Motility compromised Non integrated Implants..

113. Hydroxyapatite Integrated Ocular Implant Fibrovascular growth after 4-6 months (pores of 500micron) ..less likely to become infected since it is incorporated with host blood vessels.

114. Implant supported prosthesis Not all patients with defects are candidates for implant supported prosthesis. Contraindicated in - Patients with cartilaginous peripheral tissue - Thick layers of skin which cannot be reduced further Implant sites - Superior lateral orbital rim - Superior maxilla

115. Retention of the prosthesis

116. Attachments used in facial prosthesis Magnets (Cobalt – samarium) More recently neodymium, boron and iron magnets. Clips ( Nobel Pharma DCA 078, O- Quist) Ball attachments (Nobel Pharma ) Dalbo attachment ( Sjodings , Sweden) BAR AND RETENTIVE CLIPS INDIVIDUAL MAGNETS BALL ATTACHMENTS

117. Impression Techniques:

118. Before taking the impression the abutments and the surrounding tissues are inspected for the cleanliness and evidence of any infection. Once satisfied that the abutments are of suitable size and clean of debris, small neo-mini magnetic keeper are then screwed into the abutments, using a placing tool.

119. The area is then prepared as for normal impression techniques. Alginate is mixed and taking a 20 ml syringe, load sufficient alginate and proceed to inject this carefully all around the magnetic keepers and abutments. Following complete coverage of the abutment area, further alginate is added as normal so as to achieve a full impression. When set the impression is then removed. A separate set of keeper are thin screwed into brass abutment replicas.

120. The whole assembly is then placed carefully into the impression. When all the keepers and abutment replicas are in place, the impression is poured using a good quality stone plaster. If copings are placed before taking the impression, they must be kept stable during the impression procedure, as any movement can result in an inaccurate impression. There are two ways of achieving this stability. (1)The first method involves winding dental floss between the copings and then applying a self curing acrylic resin. When set the floss and acrylic form a rigid frame work, so that the copings are stabilized during the impression.  

121. In a second method a firm rubber base impression material is used. The two components are mixed and loaded into a 20 ml syringe, and then injected around the copings ensuring that the rubber base engages the undercuts on the copings. Undercuts are then prepared at the margins of the rubber base so as to provide retention for the alginate material. The alginate and plaster are then powered so as to completely cover that rubber base and area of tissue required. Care should be taken so as not to cover the top of that coping screw with plaster topping. When set, unscrew the copings and carefully lift away that impression. If the rubber base separates from the alginate, the two components should be carefully re-assembled. Brass abutment analogues are then screwed onto the coping and the whole impression is poured as normal. Once the working model has been obtained we can begin to construct the prosthesis.

122. Processing of prosthesis The mould cavity is prepared by coating the external tissue surface area with a thin coat of catalyzed uncolored silicone material Characterization colors are chosen and mixed with the silicone polymer and painted on the surface of the clear layer . Colored rayon fibers may be sprinkled into the mould to simulate microvasculature . After the mould surface is characterized by localize application of color, a base color mixture of the silicone material is prepared to fill the mould cavity . When a satisfactory base color has been mixed, the silicone catalyst is added, and air may be removed from the mixture by placing the container in a bell jar under vacuum

123. The colored catalyzed, air less silicone is then placed into the mould cavity, taking care to allow the liquid to flow into all the thin areas . The mould is then clamped and placed into a dry heat oven at the manufacturer prescribed polymerization time and temperature . Residual silicone may be left on the external surface of the mould to test for complete polymerization . After polymerization cycle is complete, the mould should be allowed to cool to room temperature before removing the completed prosthesis.

124. Complications in Fitting Anopthalmic Socket .. 1. Ptosis .. Drooping eye A) Pseudoptosis .. increase the volume of the prosthesis B) True ptosis Treatment.. 1) Surgical Correction 2) Upper aspect of corneal prominence is enlarged to raiselid ..Superior aspect of prosthesis is reduced to form shell or depression on to which lid may rest & fold.

125. 3) Extended shelf .. Holds upper eye lid at desired position 4) Crutch on spectacle.. Wire mounted on spectacle frame. Press eyelid tissue upward and backward

126. 2. Ectropion ( everted eyelid ) Wax pattern modified by extending a thin lower edge that will press downward upon the tarsus thus creating lower fornix. .. Remove resin from mid inferior margin...Add on medial and lateral aspects . Pressure directed in medial and lateral areas of the lid . This directs weight of the prosthesis . Giving a larger prosthesis. 3. Sagging lower eyelid 4. Narrow palpebral fissure..

127. 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. it is shown that such optical systems can be achieved using state-of-the-art micro-optics Systems. Duparré JW , Wippermann FC Bioinspir Biomim . 2006 Mar;1(1):R1-16. Epub 2006 Ap r 6 A compound eye is a visual organ found in arthropods such as insects and crustaceans. It may consist of thousands of ommatidia (photoreceptor units) that consist of a cornea, lens, and photoreceptor cells which distinguish brightness and color.

128. F uture Bionic Eye Prosthetic eye which connects to the brain function making it more realistic and better functional capabilities . Outside glasses – digital camera Inside glasses – eye movement sensor will direct the camera Side of glasses – digital processor and wireless transmitter Brain implant – small implant under the skull will receive wireless signals and directly stimulate the brain’s visual cortex

129. Summary & C onclusion “Nothing is as constant as change” This very much holds good for science, although prosthetic science evolved through ages there are still un explored thoughts which will exists as truth in future for the sole reason of betterment of humanity . The goal of any prosthetic treatment is to return the patient to society with a normal appearance and reasonable motility of the prosthetic eye. The disfigurement resulting from loss of eye can cause significant psychological, as well as social consequences. However with the advancement in ophthalmic surgery and ocular prosthesis, patient can be rehabilitated very effectively.

130. The maxillofacial Prosthodontist should provide prosthetic treatment to the best of his ability and should also consider psychological aspects and if necessary the help of other specialist should be taken into consideration. A commitment of follow-up for the clinical evaluation of implant tissues and the maintenance and periodic replacement of the facial prosthesis are a team responsibility and in the best interests of the patient.

131. R eferences Text book of Clinical maxillo facial prosthesis ; Thomas D.Taylor ; Quitessence publication 2006 Maxillofacial prosthetics handbook ; William Laney ;PSG Publication 1979 Ocular prosthesis : A Physiologic system Stephen O.Barlett , Dorsey J. Moore ; J Prosthet Dent 1973;29;4;450Ocular prosthesis Robert B. Welden and John V.Niranen ; J Prosthet Dent 1956;6;2;272

132. Modified ocular prosthesis impression technique .Robert L.Schneider ; J prosthet Dent 1986 ;55 ;4 ;482 Custom ocular prosthesis with dilating pupil.Joseph R.Cain ,Henry LaFuente J prosthet Dent 1983 ; 49 ;6 ;79Irritation of ocular tissue by irreversible hydrcolloids . James R.Moergeli ; J Prosthet Dent 1985 ; 54 ;2 ;286 Modified stock eye ocular prosthesis Taicher S. , Steinberg H.M.J Prosthet Dent 1985 ; 54 ; 1 ;95 Post insertion care of ocular prosthesis .G.R. Parr ; J Prosthet Dent 1983 ; 49 ;220 Digital imaging in the fabrication of ocular prostheses Ioli-Ioanna Artopoulou ; J Prosthet Dent 2006 ;95 ; 327

133. INTRODUCTION Thank You