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The Ocular Impression: A Review of the Literatureand Presentation of an Alternate Technique

Mark F. Mathews, Rick M. Smith, Alan J. Sutton

and Ron HudsonJournal of prosthodontics 2000;9:210-216

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Introduction

Anatomy

History

The ocular impression: review of literature

An alternative technique

Removal and replacement

Post insertion care

Discussion

References3

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Introduction

Introduction

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Maxillofacial prosthetics is the art and science ofanatomic, functional, or cosmetic

reconstruction by means of non-living substitutes of those regions in the maxilla,

mandible, and face that are missing or defective because of surgical intervention,

trauma, pathology or developmental or congenital malformation.

The branch of prosthodontics concerned with the restoration and/or replacement of

the stomatognathic and craniofacial structures with prostheses that may or may not

be removed on a regular or elective basis. -GPT8

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Ocular prosthesis have been used for centuries to provide a

cosmetic replacement for enucleated or eviscerated eyes.

Goal of prosthetic treatment - Return the patient to society

with a normal appearance.

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Anatomy

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Orbit

Contents of orbit

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1. Eyeball

2. Fascia: Orbital and bulbar.

3. Muscles: Extra ocular muscles

4. Vessels: Ophthalmic artery, superior

and inferior ophthalmic Veins and

lymphatic's.

5. Nerves: Optic, occulomotor, trochlear,

abducent, branches of ophthalmic

nerve and sympathetic nerves.6. Lacrimal gland

7. Orbital fat.

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EXTRAOCULAR MUSCLES

Voluntary muscles

1. Four recti: (a) Superior rectus

(b) Inferior rectus(c) Medial rectus

(d) Lateral rectus.

2. Two obliqui: (a) Superior oblique and(b) Inferior oblique

3. Levator palpebrae superioris

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Limbus

Medial canthus

Pupil

IRIS ANATOMY

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CAUSE FO LOSS OF EYE

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CAUSE FOR LOSS OF EYE

congenitaldefect

irreparabletrauma tumor

a painful blindeye

sympatheticophthalmia

excision forhistological

confirmationof a suspected

diagnosis

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SURGICAL MANAGEMENT

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SURGICAL MANAGEMENT

3 approaches :

evisceration- surgical procedure wherein the intraocularcontents of the globe are removed, leaving the sclera,

Tenon's capsule, conjunctiva, extraocular muscles, and optic

nerve undisturbed; the cornea may be retained or excised.

enucleation-is the surgical removal of the globeand a portion of the optic nerve from the orbit.

exenteration- is the en bloc removal of the entireorbit, usually involving partial or total removal of

the eyelids, and is performed primarily foreradication of malignant orbital tumor 16

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SURGICAL REHABILITATION IS LIMITED BY :

Availability of tissue

Tissue contractures

Physical condition of patient

Very large defect

Compromised vascular supply to radiated tissue

bed

Advanced age of patient

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History

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Dating from very early times in Egypt

(i.e., the predynastic Period, before 3000 B.C.),

simple inlaid eyes, consisting usually of white shellbeads, have been found, and human figures

bearing such eyes are to be seen in the Cairo

museum.

Ambroise Pare (1510-1590), a Frenchman, was the

first to use both glass and porcelain eyes.

By 1835 artificial glass eyes were being produced

on a large sale in Germany, which continued as the

center of production.

International Ophthalmology Clinics: Winter 1970 - Volume 10 - Issue 4 - ppg713-719

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During the two world wars, the supply of glass eyes from Germany to

the United States was halted, and in 1943 the United States Army and

Navy both undertook research to find a substitute.

Attention was concentrated on plastics, and the development of an

acrylic eye resulted.

By 1945, the Army thousands of artificial plastic eyes were beingproduced.

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The Ocular Impression: A Review ofthe Literature and Presentation of

an Alternate Technique

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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,

The wax scleral blank technique.

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h i i / l i

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1.The Direct Impression/External Impression

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.

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2 I i Wi h S k O l T

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.

Most common impression technique

To help support the impression

material.

Also called as modified impression

method.

Perforations present in tray.

2. Impression With Stock Ocular Tray

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3 S k O l T M difi i

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.

Maloney - 3 channels were placed through the

superior edge of set of customized stock trays to

prevent air entrapment.

A raised ring around the stem prevents the eyelid

from blocking the channels.

Engelmeier -Casting a set of stock trays in

Ticonium to permit sterilization and reuse.

Sykes, Essop, and Veres - Use of modeling plastic

impression compound as an ocular tray

3.Stock Ocular Tray Modifications

Variations of the modified impression method

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4 I i With C t O l T

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.

Miller -A custom ocular tray is necessary in certain situations.

The anophthalmic socket could be highly irregular or stock trays may not be available.

Millers method involves attaching a solid suction rod to the patients existing

prosthesis, conformer, or wax shell and investing it in an alginate mold .

After the alginate sets, the prosthesis, conformer, or wax is removed and replaced with

clear acrylic resin.

Perforations are made in the resulting tray, and a tunnel is cut into the stem through

which impression material can be delivered.

An impression is made using injected alginate.

4.Impression With Custom Ocular Tray

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5 I i U i St k O l P th i

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.

Use of a stock ocular prosthesis as a tray to carry impression material.

Select an esthetic stock eye and reduce peripheral and posterior aspects.

Lined with a thin mix of ophthalmic alginate and inserted for the definitive impression.

The resulting impression is processed, providing a customized stock prosthesis.

5.Impression Using Stock Ocular Prosthesis

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6 O l P th i M difi ti

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.

Modification of an existing prosthesis to gain acceptable fit.

Trimming and polishing a stock prosthesis will sometimes achieve this goal.

Alternately, the stock prosthesis can be modified using alginate or soft wax, andthen invested and processed.

6.Ocular Prosthesis Modification

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Smith -Reline procedure for an existing prosthesis using a dental impression wax

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.

Smith Reline procedure for an existing prosthesis using a dental impression wax.

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Ow and Amrith- Use of a tissue conditioner as a reline material because of its

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.

Ow and Amrith Use of a tissue conditioner as a reline material because of its

biocompatibility and ease of manipulation.

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W S l l Bl k T h i

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Wax Scleral Blank Technique

Benson-Created a wax blank by adapting base plate wax around half of an

appropriately sized steel ball. The resultant pattern is smoothed, tried in, and

adjusted.

After the addition of an iris button, the pattern is invested and processed.

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Method of attaching the iris disk

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Method of attaching the iris disk

33Ref-Journal of Prosthodontics (2008) 223227

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Moore, Ostrowski, and King-an esthetic Iowa implant conformer for use during

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Moore, Ostrowski, and King an esthetic Iowa implant conformer for use during

healing.

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An alternative technique

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Disinfect and lightly lubricate the patients existing

prosthesis or conformer.

Fill a medicine cup with quick set stone

and invest the tissue side of the

prosthesis to the height of contour.

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When set, notch the edges of the stone cast. Mix a small amount of PVS

putty and adapt it over the top of the prosthesis and into the notched

indices.

Remove the putty cope, and cut a large, beveled sprue hole into its

center and a small vent to the side.

Remove the prosthesis from the mold , lubricate

the stone surface and replace the putty cope.

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Mix chemical-cure polymethylmethacrylate and pour it into the mold.

Place the assembly in a pressure pot for 20 minutes at 25 psi.

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Remove the acrylic resin tray, trim and thin as needed.

Perforate the approximate pupil location with a 3- 4mm diameter hole.

Place multiple perforations over the remainder of the surface.

Smooth and polish the custom tray .

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To fabricate the injection tube, unscrew

the tip of a 5-mL plastic syringe, and cut

approximately 7 mm from the end.

Roughen the sides of the tip and wedge

it into the pupil perforation hole.

Secure it with cyanoacrylate resin.

Repolish the tray, and check for rough

spots.

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Clean and disinfect the custom tray.

Try in the tray and check for overextension and proper orientation.

Attach the barrel of the 5-mL syringe to the injection tube.

Orient the tube with the numbers facing upward.

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Mix 3 teaspoons water to 1 tablespoon ophthalmic alginate

impression material , and back load the syringe.

Insert the plunger, seat the tray, and inject the alginate.

After the alginate impression material has set, remove and check

the impression for acceptability.

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A wax trial ocular prosthesis (blank) can be made chairside by using

the double alginate technique.

Suspend the impression in a small cup using a clothespin.

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Pour a new mix of irreversible hydrocolloid into the cup, surrounding

the impression.

When set, remove the alginate mold with impression from the cup.

Partially section the alginate mold, spread it, and retrieve the original

impression.

The different mixes of alginate will not adhere to each other.

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The second alginate impression becomes a mold to form the wax blank.

Replace the alginate mold in the cup, and pour ivory wax through the

sprue hole created by the syringe tip.

Upon cooling, remove the impression from the cup to retrieve the wax

blank.

Cut off the sprue, and shape and polish

the wax trial ocular prosthesis.

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Try in the wax trial prosthesis.

Assess fit, contour, and comfort.

Add the iris button to the pattern, then process.

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Post insertion care

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1. Adjusting to the prosthesis .

2. Period of wear .

3. Placed in water or contact lens soaking solution.

4. Never be allowed to dry otherwise it causes various layers to separate.

5. Maintain normal facial animation and to avoid habits designed to hide the

prosthesis.

6. Eye lubricants.

7. Polishing.

8. No contact with alcohol,spirits

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Removal & replacement

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The prosthesissometimes may get

dislodged , so thepatient must be able

to replace in itsposition to avoid any

embarrassment.

Hence it is essentialthat each patient be

trained in the method

of removal and thereplacement of the

prosthesis before the

patient leaves thedental office.

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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 .

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P ti t t l d d hi h d

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Patient must clean and dry his hand.

Looking in the mirror with chin down

Top edge of the prosthesis engagedunder 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.53

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Discussion

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CUSTOM OCULAR PROSTHESIS

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Advantages

Disadvantages

CUSTOM OCULAR PROSTHESIS

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A good impression

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References

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References1. Bartlett SO, Moore DJ: Ocular prosthesis: A physiologic system. J Prosthet Dent 1973;29:450-

459

2. International Ophthalmology Clinics: Winter 1970 - Volume 10 - Issue 4 - ppg 713-719

3. Schneider RL: Modified ocular prosthesis impression technique.J Prosthet Dent 1986;55:482-

485

4. Taicher S, Steinberg HM, Tubiana I, et al: Modified stockeye ocular prosthesis. J Prosthet

Dent 1985;54:95-98

5. Brown KE: Fabrication of an ocular prosthesis. J Prosthet Dent 1970;24:225-235

6. Dorrey J. Moore,John S. Ostrowski, and Lawrence M. King;A quasi-integrated custom ocular

prosthesis jpd oct 1974

7. Sykes LM: Custom made ocular prostheses: A clinical report. J Prosthet Dent 1996;75:1-3

8. Ocular prosthetics: Use of a tissue conditioner material to modify a stock ocular prosthesis R.

K. Ow ,and S. Amrith-218 222

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i i i h i f h

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Vision is the main aspect of the eyeProsthodontist cannot replace this aspect, but canRestore the most beautiful aspect next to god.

Thank you!