Ocular prosthesis 1

The eye was a symbol of life to the
ancient world, particularly in Egypt,
where bronze and precious stone eyes
were placed on the deceased.
 The Romans decorated statues with
artificial eyes made of silver.
history

 Ambrose Paré (1510-1590), 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.

 Enamel prostheses (1820s-1890s)
were attractive but were expensive
and not very durable.
 The introduction of cryolite glass,
made of arsenic oxide and cryolite
from sodium-aluminum fluoride
(Na6A2F12), produced a grayish-
white color suitable for a prosthetic
eye.German craftsmen are credited
with this invention in 1835.

 To make these glass eyes, a tube of glass was heated
on one end until the form of a ball was obtained.
Various colors of glass were used like paintbrushes to
imitate the natural color of the eye
 The glass art form flourished in France and Germany
where fabricating secrets were handed down from one
generation to the next.

 The town of Lausche, Germany, had a
particularly rich history in both decorative (doll
eyes, Christmas ornaments) and prosthetic arts.
 In the 19th century, German craftsmen
("ocularists") began to tour the United States
and other parts of the world, fabricated eyes
and fit them to patients.

 Stock eyes (or pre-made eyes)
were also utilized. An "eye
doctor" might keep hundreds of
glass stock eyes in cabinets, and
would fit patients with the best
eye right out of the drawer.

 In the United States, eyes continued to be made of
glass until the onset of World War II, when German
goods were limited and German glass blowers no
longer toured the United States.
 The United States military, along with a few private
practitioners, developed a technique of fabricating
prostheses using oil pigments and plastics. Since World
War II, plastic has become the preferred material for
the artificial eye in the United States.

 By the mid-1940s, glass eyes were
being replaced by plastic counterparts.
 In Virginia, this was led by Joseph
Galeski
(of Richmond, Virginia),
 Although American Optical and several
military hospitals started to experiment
and dispense plastic artificial eyes.

 An ocular implant replaces the lost
volume of the natural eye. The first
account of placing an implant in the
socket, following enucleation, was
in 1841.
 Implants have been made of many
different materials, shapes, and
types throughout the years. It also
helps the artificial eye to have some
degree of movement

Naval dental school (1940), tested the use of acrylic
resin in fabricating a custom ocular prosthesis. Unlike
a glass eye, an acrylic eye was easy to fit and adjust,
unbreakable, inert to ocular fluids, esthetical good,
longer lasting and easier to fabricate

Surgical procedures in the removal of an eye are
classified into three categories
Evisceration- Removal of the contents of the
globe, but leaving the sclera and sometimes
the cornea in place. Because the extra-ocular
muscles are left intact, good mobility of the
prosthesis is usually possible
Enucleation- Removal of the eyeball itself
Exenteration- Removal of the entire contents
of the orbit, including the extraocular muscles

Stock ocular prosthesis
 Stock acrylic resin eyes are supplied in three
basic shapes: oval, standard and three-
cornered.
 Each shape has three sizes: small, medium
and large, and they may be prepared for the
right or the left eye.

 The irises are produced in three basic colours:
brown, hazel and blue, and the individual
colours have been formulated so that they
have some elasticity and overlapping quality
in matching effects.
 The scleral colours are also varied.

 One basic size of iris (11.5 mm) is used, and it
has a pupil opening of 3.5 mm.
 Where possible, the stock eye should be
made to duplicate as closely as possible the
superior fit and aesthetics of the custom eye.

impressions
Dental impression materials such as impression
compound, dental waxes, irreversible
hydrocolloids ,tissue conditioners and
elastomeric materials have been successfully
used to register the topography of the eye
socket

Stock tray impression technique:
• An impression is made of the ocular defect using a
disposable syringe, stock ocular trays and irreversible
hydrocolloid.
•Stock acrylic resin impression trays available in
different sizes for ophthalmic impressions
•Trays have a hollow handle which accomodates an
impression syringe

 During the procedure ,the patient should
be seated in an upright position with the
head tilted backward at app 450
This
position allows the natural positioning of
the palpebrae and surrounding tissue
relative to the force of gravity.

 The tray should be placed into the defect to
determine the proper orientation and fit without
overextension.
 The tray is then removed and the impression
material is loaded in the syringe and sufficient
material is ejected to fill the concavity of the
tray.

 Ophthalmic irreversible hydroclloid is mixed in
a 30 ml medicine cup –app 5 ml of powder to 5
cc of room temp water.
 Alginate – warm ,runny mix
flow easily
not distort the fatty tissues in the socket

 The tray is reinserted and sufficient
material is injected to elevate the lid
contours similar to the normal side.
 once filled the patient is directed to move
their eyes both up and done.
 After the impression sets the assembly is
removed and examined for defects and
voids.

L. M. Sykes,Essop, Veres(J Prosthet Dent
1999;82:362-5.)
 described a procedure for fabricating acrylic
resin ocular custom-made conformers to
maintain socketsize and contour.
 These custom-made ocular conformers act
as an interim measure and as valuable
diagnostic indicators of problems
experienced by the patients..

 While stock conformers merely maintain
the socket size and prevent scar tissue
contractures, the custom-made conformers
can also be used to enlarge unfavorably
small sockets, stimulate eyelid movement,
aid hygiene, help the clinician develop the
final shape for the definitive prosthesis, and
reduce the amount of postinsertion
adjustments needed.

 If further surgery is needed to deepen the
socket bed or alter the eyelids, the socket is
enhanced by using the conformer as a
surgical stent to maintain the mucosal grafts
in position and support the fornices.

 Early settling and sinking occurs with most
patients, so that modifications to their
conformers are required to maintain an
esthetic appearance and adequate eyelid
support.

 These advantages and the ease of
fabrication make custom-made conformers
a viable initial treatment option in patients
with ocular defects

 The presence of the custom-made conformer
and its close approximation to the tissues in
the socket, stimulates the eyelid muscles to
move, thus,exercising them and preventing
disuse atrophy.
 Stock conformers lack a close fit and
therefore cannot stimulate eyelid movement

 Beumer et al advocated placing a plastic
stock conformer immediately into the socket
to fit the contours of the cavity and to fill the
depths of the fornices.
 These were to be left in place while healing
occurs to reduce edema and to maintain the
socket contours for the definitive prosthesis

 Anesthetize the socket with 1 or 2 drops of
topical anesthetic
 Select an ocular special tray of the
appropriate size and try it into the socket to
verify the fit.

 If the special tray is not available, a tray can
be fabricated at the chairside by heating a
small piece of modeling compound and
adapting it to the area around the eye or
around a small rubber ball.

 This should be kept as thin as possible [2 to 3
mm].)
 Place a small tube in the center of the
compound and lute it into position with sticky
wax.
 The addition of a few small holes in the wax
aids retention of the impression material.

 Hydrocolloid material is mixed to a runny
consistency by adding 1.5 parts warm water
to 1 part powder.
 Inject the hydrocolloid down the tube into
the socket under slight pressure while
supporting the tray in position, then allow the
impression to set.

 Remove the impression and use it to pour a 2-
piece split cast mold that is used to fabricate
the acrylic resin conformer.
 Once fabricated, the conformer can be fitted
immediately and adjusted at the chairside
where needed, thus not allowing time for the
socket to shrink and scar tissues to contract.

 Dismiss the patient with instructions to wear
the conformer continuously and only to be
removed for cleaning.
 Severe pain or discomfort must be reported
immediately to ensure that necessary
adjustments can be made.

 Once the clinician and patient are satisfied
with the size and conformity of the
conformer, and the socket is well healed and
dimensionally stable, a conventional,
definitive ocular prosthesis can be
manufactured.
 A duplicate of the modified conformer in wax
can be used as a template for the definitive
prosthesis

 Alginate impression material is expressed
into the defect using a disposable syringe.
 Next a perforated acrylic resin tray is loaded
and placed over the defect.
 The impression is first recovered from the
lower, shallower sulcus first, then rotated out
of the deeper, upper sulcus.
38
External tray impression technique(Taylor)

 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

Engelmier.R.L.Autoclavable custom made metal
impression trays to improve infection
control.JPD 1987;58:121-2
 Has suggested casting a set of stock trays in
ticonium which is a non precious,removable
partial denture alloy (Ticonium Co
,Albany,NY) which can be sterilized in an
autoclave for reuse
 The impression material of choice is
ophthalmic alginate(Ophthalmic Moldite)

Ow,Amrith.Use of a tissue conditioner
material to modify a stock ocular
prosthesis.JPD 1997;78:218-22
 Advocated the use of tissue conditioners as a
reline material because of its bio compatibilty
and ease of manipulation.
 Stock acrylic resin prosthesis is selected and
is modified by trimming its periphery to fit
the eye socket Visogel(Dentsply,England) is
added and inserted for 20 mins.

 Excess material is removed and the ocular
prosthesis is worn for 24-48 hrs
 If the esthetics and adaptation are acceptable
,the prosthesis is relined with heat cure resin.

Smith R M.Relining an ocular prosthesis-A
case report.JPD 1995;4:160-3
 Described a reline procedure for an existing
ocular prosthesis
 The ocular prosthesis is reduced in size until
it fit comfortably in the socket.
 Melted base plate wax is added to the
borders until the ocular prosthesis is
positioned properly

Borders of modified prosthesis are shaped
with baseplate wax until proper gaze is
establishcd

 The lid contours and gaze were assessed and
wax carved or added until the position of the
ocular prosthesis was satisfactory in all
dimensions

Ocular prosthesis in place after borders are
adjusted, and gaze is established.

 A thin layer of Korrecta wax No.4 is added to
the intaglio surface and the borders
 The prosthesis is then dipped into 123 0 F
water bath,inserted and left for 5 mins

Ocular prosthesis showing reline impression
made with Korecta-wax

 During this time, the patient was directed to
take the prosthesis through a full range of
motion.
 The ocular prosthesis was removed,
inspected for coverage, and wax added in
deficient areas or the excess removed as
indicated.

 The borders and intaglio surface were
covered completely by the Korecta-wax.
 If there were any show throughs, the
underlying surface was relieved and covered
with more wax.
 Again, the prosthesis was placed and worn
for 5 minutes

 Once the dimensions are corrected kept in
the patients eyes for 30 mins while he moved
it intermittently in all directions
 A laboratory reline procedure is then
performed .

Ocular prosthesis relined with Crystal Clear
acqlic resin.

Impression With Custom Ocular Tray
Miller 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.
Miller BJ: Custom ocular impression trays. J Facial
SomatoProsthet 1996;2:109-113

 Miller’s method involves attaching a solid
suction rod to the patient’s 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 delivered.
 An impression is made using injected alginate.

Mark F. Mathews, DDS, Rick M. Smith, DDS, Alan J. Sutton,
DDS,and Ron Hudson .The Ocular Impression: A Review of the
Literature and Presentation of an lternate Technique .JPD
December 2000, Volume 9, Number 4
1. The patient’s existing prosthesis or
conformer was disinfected and lightly
lubricated

2. Medicine cup was filled with
quick set stone (Whip-Mix Blue
Mounting Stone; Whip-
MixCorporation, Louisville,KY),
and the tissue side of the
prosthesis was invested till the
height of contour.

3. When set, the edges of the stone cast were notched. A
small amount of PVS putty (Reprosil Putty;
DentsplyInternational Inc, Milford, DE),was mixed and
was adapted over the top of the prosthesis and into the
notched indices.
Putty cope,was removed and a large, beveled sprue hole
was cut into its center and a small vent to the side.

4. The prosthesis were removed from the mold,
The stone surface was lubricated (Liquid Tin Foil
Substitute; Robert B.Scott, Inc, Tampa, FL), and
the putty cope was replaced.

5.Chemical-cure polymethylmethacrylate (Great Lakes Co,
Chicago, IL),was mixed and poured into the mold .The
assembly was placed in a pressure pot for 20 minutes at 25
psi.

6.The acrylic resin tray was removed, trimed and thined as
needed.
The tray was perforated approximate at pupil location with a
3- to 4-mm diameter hole.
Multiple perforations were placed over the remainder of the
surface.
The custom tray was then polished .

The tray was repolished, and checked for rough spots.
Tray was checked for overextension and proper orientation.
Now the barrel of the 5-mL syringe was attached to the
injection tube.

3 teaspoons water and 1 tablespoon of ophthalmic alginate
impression material was mixed(Robert B. Scott, Inc), and
back loaded in the syringe.
Tray was seated and the alginate was injected. After the
alginate impression material was set, the impression was
removed and was checked for for acceptability

 When set, the alginate mold was removed with
impression from the cup.The alginate mold was
partially sectioned,and the original 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. The alginate mold is poured in
the cup,with ivory wax (40/40 Ivory Wax; MDLDental
Products Inc, Seattle, WA) through the sprue hole
created by the syringe tip.

Upon cooling,the impression is removed from the cup to
retrieve the wax blan.The sprue is cut off, The wax trial
ocular prosthesis is shaped and polished.
Try in of the wax trial prosthesis is done to assess fit,
contour, and comfort. The iris button is added to the
pattern, and then it is processed.

Formulation of the cast
 Imp poured in
two sections
using a 30 ml
cup filled
halfway with
dental stone .

 D.stone is added to the post.surface of the
impression and then placed into the cup upto
the ant of the postr edge of the imp and
allowed to set .
 2 keyways are made ,1 each adjacent to the
region of the nasal and temporal canthus.

 Stone is coated with a seperating medium
[tin foil substitute] allowed to dry.
 Second half of the mold is poured with dental
stone leaving a funnel shaped hole around
the stem of the tray .

 The hole used as a funnel to fill the mold with
molten wax .
 After the d.stone has set ,2 halves of the mold
are separated and the imp material is
removed .

Wax pattern:
 The melted wax is then poured through the funnel
shaped hole and into the assembled mold.
 Soaking the mold in water for a few minutes prior
to filling it with molten wax will prevent the wax
from adhering to the stone.

 After the wax has cooled, the wax pattern is
recovered. Once the wax pattern has been
smoothed and polished, it is ready to be tried
in the eye socket.

To insert the wax pattern, the upper lid is lifted,
and the superior edge of the pattern is placed
behind the lid and gently pushed upward.

 While drawing the lower lid down, the inferior
border of the pattern is seated in the inferior
fornix, and then the lower lid is released. The
eye contours are checked. Pressure points
and areas of discomfort is noted and relieved

Iris position
 The iris should be bilaterally symmetrical;
therefore, accurate placement of the custom-
painted iris disk on the scleral wax pattern is
critical.
 The gaze and the position of the iris is
determined .

McArthur RD: Aids for positioning prosthetic eyes in
orbital
prosthesis. J Prosthet Dent 1977;37:320-326
 McArthur described methods for positioning
the artificial eye in the orbital prosthesis
using an ocular locator and fixed caliper.
 This determined the placement of the
prosthetic eye in the mediolateral and
supero-inferior planes.

Benson P: The fitting and fabrication of a custom
resin artificial
eye. J Prosthet Dent 1977;38:532-539
 Benson suggested a method for fabricating aBenson suggested a method for fabricating a
custom-made acrylic resin ocular prosthesiscustom-made acrylic resin ocular prosthesis
in which he determined the size and positionin which he determined the size and position
of the iris byof the iris by visual judgment.visual judgment. Because irisBecause iris
positioning is a technique-sensitivepositioning is a technique-sensitive
procedure, visual assessment alone may notprocedure, visual assessment alone may not
be accurate.be accurate.

Roberts.A.An instrumeny to achieve pupil alignment in
eye prosthesis.JPD 22;4:1969
 Roberts has suggested the use of aRoberts has suggested the use of a
pupillometerpupillometer for precise alignment of the pupilfor precise alignment of the pupil
in the eye prosthesis. Though the advocatedin the eye prosthesis. Though the advocated
method may be more precise, it may not bemethod may be more precise, it may not be
feasible to use the pupillometer in everyfeasible to use the pupillometer in every
clinical set-upclinical set-up


The iris should be bilaterally symmetrical;
therefore, accurate placement of the custom-
painted iris disk on the scleral wax pattern is
critical.

Satyabodh S. Guttal, Narendra P. Patil. A
Simple Method of Positioning the Iris Disk on
a
Custom-Made Ocular Prosthesis. A Clinical
Report.JOP ;17: (2008) 223–227
 The transparent graph grid was used in this
method to attach the iris disk.

 During the trial of the
scleral wax pattern,
certain guidelines were
marked on the patient’s
face with an indelible
pencil ,a vertical midline
was marked considering
the stable anatomical
landmarks and
prominent points on the
face

 The midline was marked passing through the
forehead crease, glabella, tip of the nose, and
chin.
 The distance from the right eye medial
canthus to the midline and left eye medial
canthus to the midline was measured.
 This distance standardized the midline
marking and was used to reposition the grid
template each time during the try-in visit.

 The patient was asked to
gaze straight at an object
kept 4 feet away.
 The operator then marked
the vertical lines
coinciding with the medial
and distal extremities of
the iris of natural eye.

 Similarly, the horizontal lines referring to the
center, inferior, and superior limits of the iris
were marked.
 The facial markings were transferred to the
grid template by placing it on the patient’s
face.

 Markings were also made on the transparent
grid template, on the X-axis from A through
H starting from the midline, and on the left
side A1 to H1; similarly, on the Y-axis from 1
through 7 and 11 to 71.
 The distance between each marking was 1
cm on both X and Y axes.

 These markings were transposed onto the
side of defect. This can be done either
directly on the patient’s face or on the facial
moulage
 The markings were transferred onto the
sculpted scleral wax pattern, and the iris
button attached to the wax pattern

 The method described in this article involves
a simple procedure for positioning the iris in a
prosthetic eye
 The accurate placement of the iris and pupil
component in the ocular prosthesis simulated
the conversational gaze

 Thus, the use of a transparent grid template
helped to accurately locate and position the
iris on the custom-made ocular prosthesis
rather than relying purely on the visual
assessment, the latter being subjective with
possible interobserver errors

Paper Iris Disk Technique
When the wax pattern is determined to
be appropriate, it is flasked and processed in
scleral resin. The scleral blank is then
finished, and it is polished using pumice and
acrylic resin polish

 The scleral blank is tried in and the middle of
the pupil is marked while the patient gazes
directly at the clinician.
 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.

 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
patient's iris.

 A good selection of colors for this purpose
includes ultra-marine 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.

Medial canthus
Pupil
IRIS ANATOMY

 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

 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.

 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

•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.

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.

BLACK IRIS DISK TECHNIQUE
 The natural eye is observed closely and the
diameter of the iris is estimated using a
millimeter measurement gauge or optical
scale.
 Ocular discs, which are used in the iris
painting, are available in half- mm sized
increments, ranging from 11 mm to 13 mm.
120

 They come in black or clear, and either with
or without pupil apertures.
 Clear corneal buttons are available in the
same sizes as the discs.
 The buttons can also be purchased with
pupils of various sizes already in place.

 The technique employed in painting the disk
produces a three-dimensional effect. oil pigments
are employed in this technique but are mixed with
a monomer-polymer syrup during the painting
process.
 This mixing procedure provides some degree of
translucency in the iris painting and permits rapid
drying of the pigments

 The basic eye color or background color is
observed along with the limbus color.
 The background color is applied to the disk
first, using brush strokes from the center
toward the periphery.

 After the background color is applied and
dried, a coat of the clear syrup is applied and
allowed to dry.
 Characteristic striations are applied over the
clear layer and allowed to dry. A second clear
layer is then applied and further
characterization accomplished

 After the second layer is dried, the limbus
color is matched around the periphery of the
disk and a third clear layer applied.
 The color around the pupil is applied over the
last clear layer and the final color evaluated
with the water interface.
 After a satisfactory color match has been
obtained, a final clear layer is applied and
allowed to stand for 15 minutes.

 A single droplet of the monomer-polymer
syrup is then placed in the center of the iris
disk and the lens button is gently placed and
centered.
 The positioning of the iris-lens assembly on
the wax scleral pattern is the most important
phase in fabrication of the prosthesis.

Fix the lens button to the scleral pattern in a
manner such that the apparent gaze of both
natural and artificial eyes is on the same
object, or parallel to one another and in the
same plane.

 The size of the lens assembly selected
should be large enough to include the limbus.
 The lens assembly is placed in a slight
depression in the scleral pattern, and a thin
layer of wax should be brought up over the
curvature of the lens assembly.

 This thin layer of wax will allow the opaque
white scleral acrylic resin to flow up over the
edge curvature of the lens assembly during
the packing procedure, forming a very thin,
translucent layer.

 The finished pattern is then invested in a
small two-piece brass flask.
 The resulting scleral blank is deflasked,
trimmed, and polished

 The position and gaze of the artificial eye is
again observed.
 The sclera is slightly roughened using
sandpaper disks in preparation for adding the
simulated vasculature.
 Rayon-thread fibrils are placed onto the
surface of the sclera using the monomer-
polymer syrup.

 The pattern and type of vessels ( tortuous,
straight, branched) of the opposite eye are
reproduced.
 The colors found in the sclera are usually
yellow and blue, or combinations of these.
Greens and browns can also be present.

 The scleral painting begins with the
application of a wash of yellow comparable to
that found on the patient's natural eye.
 Next, blue is added, which is usually located
inferior and superior to the iris.
 Finally, any characteristic details present in
the natural eye are added.

 Once complete, a coat of monomer and polymer
is applied to the sclera.
 The eye is now ready for the final processing, the
application of a layer of clear acrylic resin

The prosthesis is cleaned and placed in socket. The fit
of the artificial eye are evaluated and adjustments are
made as necessary.

Digital imaging in the fabrication of ocular
prostheses
Ioli-Ioanna Artopoulou, DDS, MS,a Patricia C.
Montgomery,b Peggy J. Wesley, CDA,c (J Prosthet Dent
2006;95:327-30.)
 Using digital imaging in the fabrication of the
ocular prostheses presents several
advantages compared to the conventional oil
paint and monopoly iris painting technique

 The digital image provides acceptable
esthetic results be cause it closely replicates
the patient’s iris with minimal color
adjustments and modifications.
 The described technique is simple, decreases
treatment time, and requires minimal artistic
skills, which are necessary in the iris painting
technique .

 However, special digital photography
equipment and settings, as well as computer
software that allows for image adjustments,
are required.

 Make an impression of the anophthalmic
socket with a stock acrylic resin tray designed
for ophthalmic impressions (Factor II Inc)
using the ophthalmic irreversible hydrocolloid
(J-603 Special Formula Alginate; Factor II Inc).

 Pour a master cast and fabricate a wax
pattern using baseplate wax (Truwax
Baseplate Wax; Dentsply Intl, York, Pa).

 Evaluate the wax pattern in the patient, and
evaluate and finalize the sculpting following
the eye socket contours and lids
configuration

 Make a digital photograph of the patient’s iris
using a digital camera (Canon EOS Digital
Rebel; Canon Inc, Tokyo, Japan) with a macro
lens (Canon Macro Lens EF 100 mm f/2.8
USM; Canon Inc) and a ring flash (Canon
Macro Ring Lite Flash MR-14EX; Canon Inc)
attached.
 Set the shutter speed to 125 seconds, the
aperture to F 16, and the sensitivity to ISO
640

 Evaluate the photograph and compare it to
the patient’s iris.
 Using graphics software (Photoshop
 7.0; Adobe Systems Inc, San Jose, Calif),
adjust for slight differences in color,
brightness, contrast, or hue, and format the
image.

 Print the final image on 20-lb white paper
with brightness87 (HP Office; Hewlett-
Packard, Palo Alto, Calif) using a laser printer
with a color-ink print cartridge

 Cover the paper iris with 3 light coats of
water-resistant spray (Workable Fixatif;
Krylon, Solon, Ohio) used for artwork, and
attach it to the ocular disk.
 Use monopoly syrup (J-305 Monopoly
Syrup;Factor II Inc) to position the ocular
button (Factor II Inc) on the iris, and paint
around the edges of the button and the disk
to achieve maximum seal

Ocular button positioned on paper iris
using monopoly syrup

Disk assembly attached to wax
pattern and ready for trial
insertion

 Attach the disk assembly to the wax pattern
and evaluate it in the patient.
 Process the selected scleral acrylic resin at
the same temperatures, using the procedure
previously described for the conventional
technique

 After characterization is added, reprocess the
ocular prosthesis with clear acrylic (Factor II
Inc) using the previously described
temperatures.
 Pumice and polish the completed eye and
insert it

COMPLICATIONS IN FITTNG
ANOPHTHALMIC SOCKET
Ptosis: Superior eyelid ptosis is a frequent problem in
the restoration of an anophthalmic patient.
Pseudoptosis is due to the loss of volume between
the implant and the lids after removal of the eye.

 If the physiological function of the eyelids is
intact, correction of Pseudoptosis is achieved
by increasing the volume of the prosthesis in
the socket.
 This condition usually occurs whenever a
small, poorly fitted prostheses is used.

 A simple technique of correcting
Pseudoptosis is to make a larger prosthesis
that will thrust forward and separate the
eyelids

Persistent ptosis requires modification of the
ocular prosthesis to correct for a deficient levator
muscle, which causes the upper eyelid to droop..

 Attempts aimed at increasing the size of the
ocular prosthesis, as seen in Pseudoptosis,
will not correct the problem in persistent
ptosis.
 The tension on the superior lid forces the
larger prosthesis downward, thus depressing
the lower eyelid, deflecting the gaze
downward and creating patient discomfort

A thin transparent shelf can be made across the
front surface of the eye to hold the upper eyelid
at the desired open position. The shelf is 3 to 4
mm wide and is placed along the upper limbus.

 This modification of the prosthesis works well
for ptosis caused by a superiorly migrated,
large, spherical implant with limited socket
space between the implant and the upper
eyelid.
 The major drawback to the shelf is that eye
cannot blink or close. The weight of the upper
eyelid and the action of the orbicularis muscle
may press the eye downward.

This may be corrected by adding material to the
inferior tissue surface of the prosthesis to contour it
backward and upward. The surface above the shelf
can be reduced to decrease the weight of the
prosthesis and to create space for a tight upper
eyelid.

Ectropion: -
Inferior displacement of the implant can lead to
the loss of the inferior fornix and cause ectropion
of the lower lid. Patients have difficulty with
retention of the prosthesis, since it has a
tendency to slip down and out over the everted
lower lid.

 This is rectified by extending a thin lower
edge that will press downward upon the
tarsus, and rotate it into a more vertical
plane, thus creating a lower fornix.

 The lower edge should be rounded and at
least 1 mm in thickness so it will not cut into
the socket.
 The lower fornix will deepen within minutes
of modification, and insertion of the
prosthesis and retention will improve

Sagging lower eyelid: The weight of the
prosthesis, and the contraction force of the
upper eyelid on the prosthesis can cause a
downward displacement of the lower eyelid,
causing it to droop.

Degenerative disease may also weaken the lower
eyelid, causing it to droop. By removing resin from
the mid inferior margin of the prosthesis, downward
pressure against the middle of the lower fornix is
relieved.

 Wax is added to extend the nasal and
temporal aspects of the inferior margin to
create pressure in the medial and lateral
areas of the lid.
 This directs the weight of the prosthesis
where the lower eyelid is strongest, near the
palpebral ligaments. These modifications tilt
the tarsus of the lower eyelid favorably so
that the eyelid margin is elevated.

Ocular implants are classified as
1. Integrated
2. Semi - integrated
3. Non-integrated
and
1. Buried or
2. Non-buried

 Integrated implants are designed to improve
prosthesis motility by coupling to the overlying
prosthesis. Implants is exposed through the
conjunctiva to be directly coupled to the
prosthesis with a peg, pin, screw or other
method.

Semi-integrated ocular implants consist of an
acrylic resin implant with 4 protruding mounds on
the anterior surface. These acrylic resin mounds
on the implant protrude against the encapsulating
tissue. When an ocular prosthesis is made, a
counter contour to the implant is formed on the
posterior surface of the prosthesis.
Nonintegrated implant This is done by placing a
hollow or solid acrylic resin sphere ranging from 10
to 22mm in diameter.

The placement of an orbital implant into an
enucleated socket was first described by
Frost in 1886

 Soil described an improved surgical method
of placing the orbital implant deep within the
muscle cone, and buried beneath the
posterior layer of Tenon’s capsule, following
the enucleation of the eye .

 The optic nerve and its associated vessels are
severed and tied close to the posterior wall of
the capsule. The implant is placed and the
posterior portion of Tenon’s capsule is closed
over the implant providing the first layer of
closure.

 Next, the anterior portion of Tenon’s capsule
and conjunctiva are then closed to form the
second and third layers over the implant. The
horizontal rectus muscles are then attached
to the medial and lateral fornix.

 It is the movement of the fomix in the
enucleated socket that provides the motility
to the artificial eye. For example, as a person
looks up. the inferior fomix shortens, the
superior fornix deepens and the prosthesis
revolves upward

 By utilizing the posterior layer of Tenon’s
capsule,a larger implant can be placed deep
within the muscle cone decreasing the
incidence of implant migration and reducing
the tension on the anterior Tenon’s capsule
sutures.

 The larger implant reduces the volume deficit
in the superior and inferior sulcus. preventing
enophthalmos which can be produced by
smaller implants.
 Postoperative complications may develop
during the first weeks following surgery.

 Early extrusion of the implant may occur
secondary to orbital hematoma formation
and infection, traumatic manipulation of the
tissues, or placement of too large an implant.
thus creating excess tension on Tenon’s
capsule

 The technique of wrapping the orbital
implant with fresh or preserved scleral tissue
is thought to be a deterrent for extrusion and
migration of the implant and it is a technique
used quite frequently with enucleation
 After enucleation. a plastic conformer and
corticosieroid antibiotic ointment is placed in
the socket.

 The conformer should fit the contour of the
socket and fill the depths of the fomices.
 The conformer should not be removed by the
patient, and should be unnecessary, as it is
designed with drainage holes to allow mucoid
discharge to escape and for insertion of
postoperative medication.

 The plastic conformer is left in place for 4 to 6
weeks to reduce edema and maintain the
socket contours for the prosthetic eye.
 Following healing of the anophthalmic
socket, a stock or custom eye should be
placed temporarily for cosmetic and
psychological reasons.

CRITERIA FOR SUCCESS OF CRANIOFACIAL
OSSEOINTEGRATED IMPLANTS
According to “Swedish council on
Technology assessment in Health care”.
The criteria for success is as follows.
 Implants are immobile as verified by clinical
examination.
 No prolonged symptoms, such as pain,
infection, tactile disorders or nerve damage
should be present in connection with the
implants.

 Penetrated soft tissue should be free from
irritation in at least 85% of regular out patient
postoperative checks.
 At least 95% of the temporal bone implants
and at least 75% of other extraoral implants
should be functional after 5 years.

The orbital defect
 The ideal defect is circumscribed fully by
bony orbital rim. The eyebrow should be
intact. The soft tissue defining the defect
should be thin and immobile. The surface
with in the defect may be lined with a skin
graft or even a free tissue flap.

 An orbital defect may be the result of a
congential anomaly (facial cleft), trauma
(gunshot wound, road traffic accident) or
surgery. Even with the advent of
microscovascular surgery and free tissue
transfers, surgical reconstruction alone
cannot fully restore this area. Prosthetic
rehabilitation is needed.

 If the defect is more extensive, bone and
softissue grafting should be considered to
restore missing portions of the orbital rim,
zygoma, or temporal or midface regions
before implant placement. The surgical
restoration of contour can contribute to a less
extensive prosthesis.

Implant Placement
 Implants are commonly placed in the orbital
rim most often superiorly and laterally.
 Placement in the inferior rim is desirable if
the shape of the defect and access permit.

 This improves the stability and retention of
prosthesis.
 In larger defects extending beyond the orbital
rim, implants can be placed in the zygoma or
maxilla.
 Evan a single implant can help stabilize and
retain a prosthesis.

Surgical Positioner
 Actual placement of the implants is guided by
a surgical positioner.
 This is an acrylic resin prototype of the
prosthesis that is used intraoperatively.
 It indicates the ideal position for implant
placement.

It also serves as guide for selection of the
retentive mechanism and later as a time
saving reference for the shape of the
prosthesis.

The surgical positioner also helps determine if
preprosthetic surgery is needed before
implant placement. Most often, the lateral
superior aspect of the orbital rim needs
reduction to place an implant at the location
and remain with in guidelines of the
positioner .

 Implant angulation should be parallel to the
frontal plane of the face or be inward slightly.
 A protrusive angulation can interfere with
positioner contour and require compromise
of the ideal shape of the prosthesis.

 At the same time implant should not be over-
angulated inward because prosthetic access
for fabrication of retentive mechanism can be
hampered.
 This is true especially in smaller shallow
defects when a soft-tissue flap has been used
to close the opening of the defect.

Abutment selection and retention
systems
 The shortest abutment that protrudes to 1 to
2 mm above the level of skin should be
selected at second-stage surgery.
 This can minimize stress to the implant and
still allow for hygiene and prosthetic access.
 A shorter abutment takes up less space in
conjunction with the retentive mechanisms.

 At second-stage surgery, the gauze strip
surgical dressing should be wrapped carefully
around the abutments and under the healing
caps so that close adaptation of skin to the
abutment and underlying bone is achieved.

 Rubenstein reported that orbital prostheses
were fabricated with a wider variety of
attachments than any other type of bone-
anchored facial prosthesis :
bar clips,
magnets,
ball studs or a combination of
types.

Bar-clip systems yield the highest retentive
forces.
 good retention for large defects, especially
when there are implants in only the superior
orbital rim.
 When implants are splinted together by the
bar, loading can be shared among them.

 This type of system permits retention and
support beyond the actual position of
implant.
 At least two implants must be used for this
system, but three or more spread in a slight
arch are preferred to control and distribute
forces

 Because the mechanism takes up more space
than individual magnets, care must be taken
that the bar does not interfere with the ideal
position of the ocular prosthesis.

 REQUIREMENTS of the bar system so as not
to stress the implants.

 Impression making and bar construction can
be difficult, especially if the implants are
excessively divergent (more than 350
) or
widely distributed around the orbital defect.
Asymmetric withdrawl of the prosthesis can
result in amplification of loads to the
implants.

 Some divergence of implants is desirable to
offer stability of the prosthesis against
horizontal forces

Use is limited:
 when the implants are divergent, and they
can introduce forces that are not along the
axis of the implants.
 Like the bar-clip system, a prosthesis with
ball attachments can be more difficult for the
patient to place than one with magnetic
attachment.

No retention system is ideal for all situations;
each case must be evaluated to select the
optimal one

PROSTHETIC TECHNIQUES:
I) Fabrication of the ocular prosthesis:
Ocular prosthesis is made in conjunction with
the surgical positioner because its shape and
position relate to the overall shape of the
orbital prosthesis.

 A stock eye piece can be used. However,
custom fabrication yields the best aesthetic
results.
 A pyramidal index of acrylic resin is
incorporated on to the back surface of the
eyepiece to aid in registering its position in
the wax prototype and for subsequent mold
making.

II) Impression making:
Impression making for an orbital prosthesis
varies depending on the anatomic
configuration of the orbital defect, location of
implants and type of retention system
selected

 If individual magnets are used for
retention, the MAGNACAPs are threaded
into the abutments, and the transfer magnets
are placed on them. These can be connected
with autopolymerising resin to stablize them
in impression.

 The impression can be made using
irreversible hydrocolloid, a silicone rubber .
The impression should include the entire
midface to provide adequate references and
landmarks for accurate sculpting

 Orientation lines are marked on the patient
indelible pencil and will be transferred to the
cast to aid this process. After removal of the
impression and disinfection, LAB-
ANALOGUE CAPS are placed against the
transfer magnets and the impression is
poured in dental stone.

III Design and Fabrication of resin plate
The resin plate retains the retentive
components in a rigid base and provides
stability for the prosthesis. In most cases, it
should be as small as possible so as not to
interfere with the placement of the ocular
prosthesis

 Magnets are placed on the lab-analogue caps
on the cast.
 Wax is used to block out the defect and the
abutments

 The resin engages this area to help retain the
magnets in the plate. The area is bordered
with boxing wax, and clear autopolymerising
acrylic resin is poured over the area, covering
the magnets and engaging the retentive rim.
The thickness should be minimal and uniform
to control distortion

A sprinkle on method can be used to apply the
resin to better control the thickness of the
plate. Alternatively, colourless urethane
dimethacrylate visible light cure resin can be
used to fabricate the plate. It is cured initially
on the cast with a handheld light and then
placed in the curing unit to complete curing.

 The processed plate is shaped not to interfere
with the ideal contour of the prosthesis. It is
adjusted on cast and then tried on the
patient. Complete engagement of retentive
elements should be verified

IV Sculpting the wax prototype:
This is where art takes over from science. To
achieve a life like orbital prosthesis, attention
to anatomy and surface detail is important.
Input from the patient and family members is
encouraged during this process.

 To begin the sculpting process, the ocular
prosthesis is attached to resin plate with soft
utility wax while both are on the mastercast,
using the orientation lines as a guide. When
the prosthesis is transferred to the patient,
depth, position, and gaze are evaluated
relative to natural eye.

V Mold making:
A three – piece mold of white improved dental
stone is made : tissue side, eyepiece and
outer surface.

 Once the wax prototype is completed, its
outline is marked on the cast with indelible
pencil .
 An impression of the defect extending
beyond the margins of the prosthesis is made
with duplicating silicone elastomer and resin
forced with plaster backing.

 The periphery of this impression is poured in
stone so that the center of the defect is left
open. Registration keys are placed in the
tissue side of the mold.

 Lab-analogues of magnetic caps are placed
on the magnets with in the resin plate.

 The wax prototype is seated back on the cast
by using the transferred pencil line as guide
for orientation, and the margins are sealed.
 Skin surface detail can be refined at this time

Stone is poured into the back of the wax
prototype through the opening of the cast .

 Once set, wax spacers to facilitate later mold
seperation are placed in the first piece of the
mold, a seperator is applied to the stone
surface, paper tape or wax is used to box the
mold, and the top portion or outer surface of
the mold is poured .

 Once the stone has set, the mold is
separated and the eyepiece and resin plate
are removed. The mold is cleaned with
boiling water and detergent to remove all
wax residue

 Before casting the prosthesis, silicone
elastomer is used to make a mold of the outer
surface of the resin plate while it is in place of
on the tissue side of the mold.
 The impression material should be applied
with a syringe around the edges to capture
the ledge on the tissue side of the plate.

 Then a two piece silicone mold is of the
eyepiece and this is poured in stone. This
stone reproduction is used in the mold in
place of resin eyepiece during processing to
protect it from damage. These steps allow
the resin plate and prosthesis to be remade
without the patient and the prosthesis
present, when a replacement prosthesis is
necessary.

Maintenance of Prosthesis
 To maintain the health of the implants
and surrounding soft tissue and to preserve
the prosthesis and retention mechanism.
 Bone anchored facial prosthesis does require
more care on the patient’s part and closer
professional follow-up than one retained with
adhesive.

HOME CARE AFTER ABUTMENT
CONNECTION
 Follow up management actually begins once
the abutments have been placed. After the
initial healing period and once a surgical
dressing is no longer needed, the patient
should be instructed to clean this area on a
daily basis

 The purpose is to remove cellular material on
the skin or abutment, which can come from
the interface of the epithelium and abutment.
 This is performed with a soft, end tuft
nylon bristle toothbrush, an interproximal
dental brush or a cotton swab. To facilitate
cleaning the area should be moistened first
with an even mixture of hydrogen peroxide
and water to soften any dried debris

 When checking abutment tightness, an
abutment clamp should be placed on the
abutment body to provide countertorque so
that undue force is not placed on the
implant.If the abutment loosens, complete
seating should be verified before
retightening. This is done with an abutment
holder.

HOME CARE AFTER PROSTHESIS
PLACEMENT
 On the day that the prosthesis is given to the
patient, adequate time should be allotted for
instructions on placing and removing the
prosthesis as well as proper maintenance of
the prosthesis, abutments, and surrounding
skin areas. This information should be
written and given to the patient, and all steps
should be demonstrated.

 patient should be careful when removing the
prosthesis so that the thin margins do not
tear and the silicone rubber does not separate
from the resin plate

 At night, the prosthesis should be removed
and cleaned. The patients should wash their
hands first to decrease chances of soiling the
prosthesis during handling. All surfaces of
the prosthesis should be cleaned gently with
a soft, nylon-bristle toothbrush and mild soap
and water

 The prosthesis should be patted dry with a
towel and placed in a covered container.
 A denture cup or similar type of covered
container can be used.

 Should be stored away from extreme heat or
direct sunlight, which can cause degradation
and discolouration of the prosthetic material.
 The prosthesis should not be worn during
sleep so that air can circulate around the
abutments to help maintain skin health

conclusion
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.

 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.

 Sophistication in the surgical and prosthetic
reconstruction of structural and functional
defects in the craniomaxillofacial region
improves the final rehabilitation results, if
carefully planned, unbiased rehabilitation
regimens are established

 Bone anchored implant retention offers
patients who wear facial prosthesis increased
security, especially with large defects or
where the prosthesis rests on highly mobile
tissues. Perspiration and vigorous physical
activity will not affect the retention of bone-
anchored prosthesis.

 Independence from reliance on adhesives for
retention frees the patient from tedious task
of applying and removing adhesive at each
application and removal of prosthesis. It
prolongs the life of prosthesis, because the
edges are not subjected to excessive
handling.




The implant team must develop a co-
ordinated treatment plan that is delivered in
an efficient manner. As much attention
should be paid to the fitting and care of soft
tissues as to issues of hardware articulation
and registration.

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.

 Textbook of Medical Physiology –
GUYTON AND HALL
 Review of Medical Physiology -
WILLAM F. GANONG
 Medical Physiology –
CHAUDHARY
REFERENCES

 Clinical Maxillofacial Prosthetics -
THOMAS D. TAYLOR
 Maxillo Facial Rehabilitation – Prosthodontic
and surgical consideration
JOHN BEUMER
 Prosthetic rehabilitation-Keith.F.Thomas

 L. M. Sykes,Essop, Veres(J Prosthet
Dent 1999;82:362-5.)
 Engelmier.R.L.Autoclavable custom made
metal impression trays to improve
infection control.JPD 1987;58:121-2
 Ow,Amrith.Use of a tissue conditioner
material to modify a stock ocular
prosthesis.JPD 1997;78:218-22

 Smith R M.Relining an ocular
prosthesis-A case report.JPD
1995;4:160-3
 Miller BJ: Custom ocular impression
trays. J Facial SomatoProsthet
1996;2:109-113
 Mark F. Mathews, DDS, Rick M. Smith,
DDS, Alan J. Sutton, DDS,and Ron
Hudson .The Ocular Impression: A
Review of the Literature and
Presentation of an lternate
Technique .JPD December 2000, Volume
9, Number 4

 McArthur RD: Aids for positioning
prosthetic eyes in orbital
prosthesis. J Prosthet Dent 1977;37:320-
326
 Benson P: The fitting and fabrication of a
custom resin artificial
eye. J Prosthet Dent 1977;38:532-539
 Roberts.A.An instrumeny to achieve pupil
alignment in eye prosthesis.JPD 22;4:1969

 Satyabodh S. Guttal, Narendra P. Patil. A
Simple Method of Positioning the Iris Disk on a
Custom-Made Ocular Prosthesis. A Clinical
Report.JOP ;17: (2008) 223–227
 Digital imaging in the fabrication of ocular
prostheses
Ioli-Ioanna Artopoulou, DDS, MS,a Patricia
C. Montgomery,b Peggy J. Wesley, CDA,c
(J Prosthet Dent 2006;95:327-30.)

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