CLINICAL REPORT Closed-eye orbital prosthesis: A clinical report Muhanad M. Hatamleh, BSc, MPhil, MSc, Dip, PhD, a Jason Watson, BMedSci, b and Dilip Srinivasan, MD c The crucial role of facial features in daily interpersonal relationships is readily appre- ciated. High value is placed upon personal attractiveness in most societies, and most people are sensitive to the effect they have on others. Changes in facial features are likely to be accompanied by various types of difficulties. 1-3 A patient’s self-perception, emotional stability, personal- ity characteristics, and social circumstances appear to be the salient factors in dealing with maxillofacial defects and the rehabilitation pro- cess, 3 and, when esthetic and functional demands cannot be surgically fulfilled, a facial prosthesis is a practicable alternative. 4-6 Such a prosthesis can improve the patient’s appearance, enable early rehabilitation, shorten surgery and hospitalization time, lower treat- ment cost, and allow early psychosocial reintegra- tion. 1,2,7,8 In 2007, of 1200 facial and body prostheses fabricated in the UK, orbital prostheses ranked third (155 orbital). 8 Exenteration, or removal of the entire orbital contents (globe, muscle, fat, lids), is performed primarily to eradi- cate malignant orbital tumors. 9 Prostheses designed to cover the remaining defect and replace the missing tissues are commonly described as orbital prostheses. They can be retained by various methods from the anatomic undercuts left after surgery to medical adhesives or implants. In the majority of patients, satisfaction depends on how the prosthetic eye (and its components) resembles the contralateral site. 10-14 The patient will continuously compare the artificial prosthesis to the ocular component (iris and sclera), skin shape, texture, color, and the lids of the contralateral eye. The lids are highly complex and mobile and are important in adding not only anatomic contour but also personality and character specific to the patient. The shaping of the lids is fixed in the definitive stage of fabrication, so the definitive waxing has to cap- ture many different “faces” of the patient. This is extraordinarily difficult to get right the first time. The following clinical report presents an unusual process for fabricating an orbital prosthesis while the subject keeps his or her eye closed. CLINICAL REPORT A 63-year-old man was referred to the reconstructive clinic at the Maxillofacial Unit of Queens Medical Center in Nottingham, UK, for the fabrication of an orbital prosthesis. After being diagnosed with a right maxillary a Senior maxillofacial prosthetist, Maxillofacial Department, King’s College Hospital, London, UK. b Consultant maxillofacial prosthetist, Maxillofacial Department, Queens Medical Centre, Nottingham University Hospital Trust, Nottingham, UK. c Consultant maxillofacial surgeon, Maxillofacial Department, Queens Medical Centre, Nottingham University Hospital Trust, Nottingham, UK. ABSTRACT One of the most challenging prostheses to fabricate is an acceptable orbital prosthesis. Successful reconstruction of the complex missing tissues, the globe, muscle, skin, and bony elements requires time and high levels of practical skill. A good match to the contralateral nondefect side will help mask the underlying defect and give the patient confidence to return to normal, routine life. The contralateral eye opening will commonly dictate the eye opening of such a prosthesis, but because of the expressive nature of the eye and its high levels of mobility, this can be difficult to achieve. This clinical report presents a patient who had an extended orbital exenteration and right max- illectomy to remove a maxillary squamous cell carcinoma. An alternative approach to constructing an orbital prosthesis was undertaken with the eye closed. Compared to the normal method of fabrication, this process was less complex and quicker, made the prosthesis less “staring,” camouflaged the defect, and reduced the detection of the prosthesis because of movements in the remaining eye. The patient engaged in his routine daily life, which reinforced his self-esteem, confidence, and reintegration into the community. (J Prosthet Dent 2015;113:246-249) 246 THE JOURNAL OF PROSTHETIC DENTISTRY
Transcript
CLINICAL REPORT
aSenior maxibConsultant mcConsultant m
246
Closed-eye orbital prosthesis: A clinical report
Muhanad M. Hatamleh, BSc, MPhil, MSc, Dip, PhD,a Jason Watson, BMedSci,b and Dilip Srinivasan, MDc
ABSTRACTOne of the most challenging prostheses to fabricate is an acceptable orbital prosthesis. Successfulreconstruction of the complex missing tissues, the globe, muscle, skin, and bony elements requirestime and high levels of practical skill. A good match to the contralateral nondefect side will helpmask the underlying defect and give the patient confidence to return to normal, routine life. Thecontralateral eye opening will commonly dictate the eye opening of such a prosthesis, but becauseof the expressive nature of the eye and its high levels of mobility, this can be difficult to achieve.This clinical report presents a patient who had an extended orbital exenteration and right max-illectomy to remove a maxillary squamous cell carcinoma. An alternative approach to constructingan orbital prosthesis was undertaken with the eye closed. Compared to the normal method offabrication, this process was less complex and quicker, made the prosthesis less “staring,”camouflaged the defect, and reduced the detection of the prosthesis because of movements in theremaining eye. The patient engaged in his routine daily life, which reinforced his self-esteem,confidence, and reintegration into the community. (J Prosthet Dent 2015;113:246-249)
The crucial role of facialfeatures in daily interpersonalrelationships is readily appre-ciated. High value is placedupon personal attractivenessin most societies, and mostpeople are sensitive to theeffect they have on others.Changes in facial features arelikely to be accompanied byvarious types of difficulties.1-3
A patient’s self-perception,emotional stability, personal-ity characteristics, and social
circumstances appear to be the salient factors in dealingwith maxillofacial defects and the rehabilitation pro-cess,3 and, when esthetic and functional demandscannot be surgically fulfilled, a facial prosthesis is apracticable alternative.4-6 Such a prosthesis can improvethe patient’s appearance, enable early rehabilitation,shorten surgery and hospitalization time, lower treat-ment cost, and allow early psychosocial reintegra-tion.1,2,7,8 In 2007, of 1200 facial and body prosthesesfabricated in the UK, orbital prostheses ranked third(155 orbital).8
Exenteration, or removal of the entire orbital contents(globe, muscle, fat, lids), is performed primarily to eradi-cate malignant orbital tumors.9 Prostheses designed tocover the remaining defect and replace the missing tissuesare commonly described as orbital prostheses. They can beretained by various methods from the anatomic undercutsleft after surgery to medical adhesives or implants.
In the majority of patients, satisfaction depends onhow the prosthetic eye (and its components) resembles
llofacial prosthetist, Maxillofacial Department, King’s College Hospital, Londaxillofacial prosthetist, Maxillofacial Department, Queens Medical Centre,axillofacial surgeon, Maxillofacial Department, Queens Medical Centre, N
the contralateral site.10-14 The patient will continuouslycompare the artificial prosthesis to the ocular component(iris and sclera), skin shape, texture, color, and the lids ofthe contralateral eye. The lids are highly complex andmobile and are important in adding not only anatomiccontour but also personality and character specific to thepatient. The shaping of the lids is fixed in the definitivestage of fabrication, so the definitive waxing has to cap-ture many different “faces” of the patient. This isextraordinarily difficult to get right the first time. Thefollowing clinical report presents an unusual process forfabricating an orbital prosthesis while the subject keepshis or her eye closed.
CLINICAL REPORT
A 63-year-old man was referred to the reconstructiveclinic at the Maxillofacial Unit of Queens Medical Centerin Nottingham, UK, for the fabrication of an orbitalprosthesis. After being diagnosed with a right maxillary
on, UK.Nottingham University Hospital Trust, Nottingham, UK.ottingham University Hospital Trust, Nottingham, UK.
Figure 1. A, Patient presented with orbital defect extending into his right cheek. B, Silicone prosthesis fabricated. C, D, Prosthesis in situ.
March 2015 247
squamous cell carcinoma, he underwent an extendedright orbit exenteration that included part of the rightcheek and a partial maxillectomy (Fig. 1A). The patienthad received no radiotherapy after his primary surgery,and the site had healed well with no complications. Afterhis initial healing (3 months), he was referred to a localprosthetist with little experience at his district generalhospital. After 8 months and multiple visits to the hos-pital, he was provided with a poor prosthesis that he
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described as being “staring” and “angry looking.” Hewas unhappy and had immediately discarded theprosthesis.
At the initial consultation in our department, he wasdismissive of the possibility that his staring orbitalprosthesis could be improved. We discussed possiblealternative options, such as extended medical patchesand custom, vacuum-formed shields. He was not happywith these options and wanted a skinlike alternative.
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The idea began to form of a nonstaring orbit or a closedeye. He liked the idea, and we outlined the fabricationprocess for an adhesive-retained prosthesis.
The first parts of the process were carried outconventionally.15 His extensive nasal ethmoid sinuscomplex was packed to relieve the sensitive tissuespresent. An extended alginate impression (Hydrogum;Coltène/Whaledent) was made of his right and left sidesby following a closed impression technique. The im-pression was poured in hard dental stone (Crystacal R;British Gypsum), and then a wax prototype was fabri-cated based on this impression.
An advantage of this technique was that once a fewspecific landmarks such as facial planes, contralateralorbital closed fissure angles, and the canthus positionhad been identified, much of the sculptural carving couldbe carried out without the patient present. The cast of thecontralateral side had a detailed image of the closed eye.
The skin shade was recorded at the initial consulta-tion with a digital color system (SpectroMatch Ltd) asreported previously.6,16 Three color points were chosen torepresent the base color of the skin tone, the skin un-derneath the eye, and the eyelids. The color of the eye-lashes and eyebrow were also recorded by using naturalhair samples from the patient’s head. These were cut andretained.
The color formula of his skin tones was prepared andmixed from platinum-polymerized medical siliconeelastomer (M511 Cosmesil; Principality Medical). Thefirst wax sculpture was evaluated with the patient at thenext visit and required minimal adjustment, and thecolor match was checked for consistency. The wax wasflasked conventionally in a 2-part flask. The silicone waspacked and polymerized at 100�C for 1 hour. Oncebench cooled, the flask was opened, and the prosthesiswas finalized. The patient’s hair collected at the initialvisit was used to form eyelashes and an upper eyebrow.At the third visit, the prosthesis was fitted on the patientand external characterization was added (Fig. 1B). Thepatient expressed satisfaction with the definitive result,as it was less staring (Fig. 1C, D).
DISCUSSION
Eyes are generally the first features of the face to benoticed. A person in need of an ocular prosthesis mayhave lost or damaged his or her natural eye as a result oftrauma, malignancy, or congenital absence.15 Each ofthese etiologies leaves its own physical characteristicsand psychological traits; they can all be seen as traumaticoutcomes for the patient. For example, removal after adiagnosis of malignancy brings with it the constant fearof recurrence. Common to them all, however, is the socialstigma associated with facial abnormality. Persons with a
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facial abnormality may experience great psychologicaldisturbance, such as low self-esteem, depression,dissatisfaction with appearance, or low quality of life.17
Traumatic alterations to the face usually involve somechanges in the person’s sense of identity and attractive-ness. There is also uncertainty about how prosthetictreatment might improve or even make the defect moreobvious to others.
Facial prostheses can nominally improve a patient’sappearance and also provide much earlier rehabilitationthan more complex surgical options. The patient can getan early inspection of the affected area, manage bodyimage change at an early stage, and look after the defect,an important part of early psychosocial reintegration.
This treatment highlights the fragile nature of pros-thetic reconstructions. Nonliving material cannot expressthe underlying changes that are occurring. Orbital pros-theses differ from nasal or auricular prostheses in thesense that they must appear alive. The eye is expressive,is part of the character of the person, and transmits moodand feeling directly to others. How can this be accuratelycopied to reflect the ever-changing life of the patient?Trying to capture this mood at a sculpture sitting basedon a single gaze of a patient, mostly in the forward di-rection, is impossible,15 as this position becomes imme-diately invalid when the patient looks in a differentdirection.
When the eye is closed, the problems of expressionare immediately eliminated. The patient still had functionand movement of the left side. The lack of movement onthe right side resembled the aftereffects of a severe facialpalsy after a stroke.
At subsequent follow-ups, the patient supported theview that a closed eye was far less noticeable and morepublically acceptable than an eye that did not coincidewith the movement of the contralateral eye. The patientexpressed extreme satisfaction and was confident wearingit. Gaspare Tagliacozzi (1545-1599), an Italian surgeonwho became famous for his skill in reconstructive surgery,once stated, “We restore parts of the face which naturehas given but which fortune has taken away, not so muchthat they may delight the eyes, but that they may bring upthe spirit and help the mind of the afflicted.”
CONCLUSION
Orbital prostheses are challenging for both the practi-tioner and patient. Reproducing the expression, char-acter, and personality of the patient present in thecontralateral eye is almost impossible. This clinicaltreatment used an original approach of making a closedeye prosthesis that restored esthetics, simplified manu-facture, and provided a compromise that was acceptableto the patient.
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Noteworthy Abstracts of
Influence of sintering conditions on low-temp
Inokoshi M, Zhang F, DeMunck J, Minakuchi S, NaDent Mater 2014;30:669-78
The effect of sintering conditions and concomitant mon their low-temperature degradation (LTD) behav
Objectives. Therefore, their effect on LTD of dental ZrO2 c
Methods. Three commercial pre-sintered yttria-stabilized den(1450�C, 1550�C and 1650�C) applying three dwell times (1,performed on polished sample surfaces. LTD tests were perfoZrO2 on the exposed surface was measured by X-ray diffrac
Results. Higher sintering temperatures and elongated dwelllarger fraction of zirconia grains adopted a cubic crystal strucaining tetragonal grains. Both the larger grain sizes and the lomore susceptible to LTD. Overall, independent on the commat 1450�C for 1h combined good mechanical properties with
Significance. In general, increased sintering temperatures anddegradation of Y-TZP ceramics.
Reprinted with permission of the Academy of Dental Materi
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Corresponding author:Mr Jason WatsonQueens Medical Centre CampusNottingham University Hospital TrustNottingham, NG7 2UHUNITED KINGDOMEmail: [email protected]
icrostructure of dental zirconia (ZrO2) ceramicsior remains unclear.
eramics was investigated.
tal zirconia materials were sintered at three temperatures2 and 4h). Grain size measurements and LTD tests werermed at 134�C in an autoclave. The amount of monocliniction (XRD).
times increased the ZrO2 grain size. Simultaneously, ature, resulting in a decreased yttria content in the rem-wer average stabilizer content made the tetragonal grainsercial dental zirconia grade tested, the specimens sinteredthe best resistance to LTD.
times result in a higher sensitivity to low-temperature
