orbital implants and prosthetics

1. ORBITAL IMPLANTS
DR. RESHMA PETER

2.  Anophthalmia-Absence of globe
 Defined as an orbit not containing an eye ball, but has orbital soft tissues
 usually acquired, rarely congenital
 The most common cause - enucleation of the globe

3. SURGICAL PROCEDURES IN THE REMOVAL OF AN EYE
Classified into three categories
Evisceration-
Removal of the contents of the
globe
leaves the sclera ,fat,EOM, and
other adjacent structures of the eye
intact and sometimes the cornea in
place.
Enucleation-
Removal of the eye
leaves EOM and remaining
orbital contents intact.
Exenteration
Removal of the entire
contents of the orbit
including EOM

4. Tenon's capsule-
 Thin membrane which envelops the eyeball from the optic nerve to the limbus
 Separates eyeball from the orbital fat
 Forms a socket in which it moves
 In front it adheres to the conjunctiva.
After enucleation orbital implant inserted to the Tenon's capsule in order
 to keep the orbital size
 to keep eye animation

5. Eye socket
Eyelids
Conjunctival fornices
Orbital structures(bony cavity and soft tissues)

6. Common causes requiring socket reconstruction
 Congenital (anophthalmia ,microphthalmia)
 Trauma
 Tumour
 scarring

7. Acquired anophthalmos
After enucleation/evisceration/exenteration

8. Ideal anophthalmic socket
1.A centrally placed, well-covered, buried implant of adequate volume, fabricated from
a bio-inert material
2. A socket lined with healthy conjunctiva and fornices deep enough to retain a
prosthesis and to permit horizontal and vertical movements of an artificial eye
3. Eyelids with normal position ,appearance and adequate tone to support a prosthesis
4. A supratarsal eyelid fold that is symmetric with that of the C/l eyelid

9. 5. Normal position of the eyelashes and eyelid margin
6. Good transmission of motility from the implant to the overlying prosthesis
7. A comfortable ocular prosthesis that looks similar to the sighted, contralateral
globe and in the same horizontal plane

10. Enucleation/evisceration
secondary implantation
surgery
Conformer is placed in
the conjunctival fornices
to maintain the
conjunctival space
conformer is replaced
with a custom-made
ocular prosthesis
typically fashioned 4–6
weeks
ORBITAL IMPLANT CONFORMER OCULAR PROSTHESIS

11. Orbital implant
typically placed at the time of
evisceration or enucleation
Ocular prosthesis
fitted subsequently

12. Anophthalmic surgery
Successful anophthalmic surgery is achieved when the anophthalmic patient obtains
 a painless, non-inflamed eye socket
 with adequate volume restoration
 an artificial eye that looks and moves almost as naturally as a normal eye
The optimal time to achieve the best functional and cosmetic result for the anophthalmic
patient is at the time of enucleation

13. Most socket reconstructive surgeries are required to address the following problems:
1. A volume deficit following loss of the globe
2. Contracture of the socket
3. Orbital implant exposure, extrusion, and malposition

14. History
 500 B.C.:Egyptians and Romans wore ocular prostheses
 1555 :Johannes Lange (Lowenberg, Germany) 1st to mention enucleation (or extirpation
as it was called then)
 1583 :George Bartisch 1st recorded description of
removal of an eye for treatment of severe ocular disease
(Extirpation)

15. • 1579 :Ambroise Pare described the 1st prosthesis which was made of metal and coated with
paint .
• 1841: O’Ferrall (Dublin) and Bonnet (Paris) established current enucleation technique
• 1817 :1st recorded evisceration by James Bear
• 1874: Noyes -1st to perform a routine evisceration procedure
•

16.  1884: P.H. Mules developed a unique technique for evisceration
 a milestone in ophthalmic surgery
 He inserted a hollow glass sphere (the “Mules” sphere) into the scleral cavity after removal
of the cornea and intraocular contents
Since then Sponge, rubber, paraffin, ivory, wool, cork, cartilage, fat, bone, Vitallium,
platinum, aluminum, silver, and gold were used as implant.

17. 1886:Frost 1st described the placement of an orbital implant into an enucleated socket
1820s-1890s :Enamel prostheses introduced ;expensive and not durable.
 1835 :Germans introduced cryolite glass
 made of arsenic oxide and cryolite from NaAlF
 grayish-white color suitable for a prosthetic eye
 a tube of glass was heated on one end until the form of a ball obtained.
 Various colors of glass used to imitate the natural eye color

18. • 19th century:German craftsmen ("ocularists") began to tour the US 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.

19.  After the onset of WW II, when German glass blowers no longer toured US,the US
and practitioners developed prostheses using oil pigments and plastics.
•1940 :Naval dental school used acrylic resin in
fabricating a custom ocular prosthesis.
The acrylic eye was
•easy to fit and adjust
•Unbreakable
• inert to ocular fluids
•aesthetical good
•longer lasting
•easier to fabricate

20. • 1950s:A variety of implant designs were tried with an attempt to indirectly couple the
implant to an overlying artificial eye by modifying the anterior surface of the implant as
as the posterior surface of the prosthesis.
• The Allen and subsequently the Iowa enucleation implants were buried integrated (
integrated”) implants.

21.  1950s and 1960s :Troutman, Uribe, Iliff - magnetic implants
 1987 :Universal implant
 1989:spherical implants made of silicone, glass, or polymethylmethacrylate (PMMA)
 mid- to late 1980s The introduction of coralline hydroxyapatite orbital implants in
enucleation, evisceration, or secondary orbital implant surgery
 Several other porous implant materials have since been introduced as alternatives (e.g.
synthetic hydroxyapatite, porous polyethylene, aluminum oxide).

23.  Anophthalmic implant: Material or substance used to replace an enucleated or eviscerated
globe
(e.g. polymethylmethacrylate, silicone,hydroxyapatite, aluminum oxide, porous polyethylene,
etc.)
 Porous implant: Refers to an implant with numerous interconnected pores or channels
throughout its structure that permit fibrovascular ingrowth
(e.g. hydroxyapatite, aluminum oxide, porous polyethylene)
 Nonporous implant: Refers to an implant that is solid and does not allow fibrovascular
ingrowth
(e.g. polymethylmethacrylate, silicone)

24.  Buried implant:
an implant that has been placed within the anophthalmic socket with an overlying closed,
smooth, uninterrupted conjunctival surface completely covering the anophthalmic implant
 Exposed implant:
an implant that does not have an overlying closed, smooth, uninterrupted surface completely
covering it.
An exposed implant is an unwanted complication postoperatively with any implant

25.  Integrated implant:
an implant that can be directly coupled to the overlying prosthetic eye with a peg system.
As there is a small break in the overlying conjunctiva through which the peg protrudes,
Sometimes known as a partially exposed integrated implant
 Non-integrated implant
An implant that has been placed within the anophthalmic socket that has no connection with
the overlying prosthetic eye.
There is a closed, smooth, uninterrupted conjunctival surface completely covering the
anophthalmic implant. Also known as a “buried non-integrated implant”

26. Peg:
A motility coupling post, made of titanium, which permits direct coupling of the implant
movement to an overlying prosthesis.
Pegs may be inserted within sleeves that are drilled into the anterior aspect of the implant.

27. Quasi-integrated implant
(buried integrated implant OR indirectly integrated implant)
An implant that has been placed within the anophthalmic socket with a
closed, uninterrupted conjunctival surface completely covering
an anophthalmic implant that has an irregular anterior surface,
allowing indirect coupling (“quasi-integration”) of implant to
overlying, modified prosthesis
(e.g., Allen, Iowa, Universal, MEDPOR Quad implants).
Recently designed magnetic coupling systems may also be classified as quasi-integrated .

28. Integrated implants
 designed to improve prosthesis motility by coupling to the overlying prosthesis.
 Implant is exposed through the conjunctiva
 directly coupled to the prosthesis with a peg, pin, screw or other method.

29. Semi-integrated ocular implants
• consist of an acrylic resin implant with 4 protruding mounds on the anterior
surface
• These acrylic resin mounds protrude against the encapsulating tissue
• The ocular prosthesis is made with a counter contour to the implant on the
posterior surface of the prosthesis.

30. Nonintegrated implant
done by placing a hollow or solid acrylic resin sphere ranging from 10 to 22mm in diameter.

32. Ideal orbital implant
 Maintain Natural Lid Shape : ability to receive a motility/support peg, to support the weight
of the artificial eye to prevent lower lid laxity and malposition over time .
 Light Weight
 Porosity: The implant must allow vascular orbital tissues to invade its structure to:
a) lock it into place and prevent migration
b) allow it to fight infections from within the implant via the vascular bed infiltrating the implant
c) support "healing from within" of any defect in the conjunctival-Tenon's closure

33.  True Integration The implant must be directly integrated (e.g., via a peg) with the artificial
eye to allow direct transfer of all available movement from the rectus muscles to the
artificial eye
 Natural Biocompatibility: the implant must be a natural material and readily accepted by
the tissues of the orbit to prevent "synthetic implant syndrome" i.e., pseudocapsule
formation around the implant. This pseudocapsule is the body's way of walling off a foreign
material
 Non toxic
 non allergic

34. Current Classification of Implants
porous or nonporous, and in either category, the implants are non-integrated, integrated,
or quasi-integrated
 Porous implants (hydroxyapatite, porous polyethylene, aluminum oxide)
 Nonporous implants (silicone,polymethylmethacrylate)
Quasi integrated (or indirectly integrated) implants may be porous or nonporous and,
because of their irregular anterior surface, are partially coupled to the overlying prosthetic
eye (e.g., Allen, Iowa, Universal, MEDPOR ® Quad implant).

35. Acrylic sphere
 Acrylic, or methylmethacrylate
 is the most basic implant
 best used in cases of trauma, such as a severe gunshot wound to the orbit
Silicone sphere
 similar to an acrylic implant but slightly more pliable.
Non porous inert spherical implants

36. Non porous inert spherical implants
Advantages
 Provide comfort and low rates of extrusion.
 Cost-effective choice in patients.
Disadvantages
 decreased motility and implant migration.

37. Porous Orbital Implants
Hydroxyapatite
 Perry (1985) introduced coralline (sea coral)(HA) spheres
 complex calcium phosphate
 regular and complete system of interconnecting pores ( 500-µm pore size )
 secure attachment of the extra ocular muscles
 The most suitable for peg–sleeve system.

38. Disadvantages of HA:
 Surface is abrasive
 conjonctival thinning
 Extrusion or exposure
 infection
 Pyogenic granuloma formation
 Costly
Synthetic HA implants
developed by FCI
Chinese HA
Brazilian HA
 Less expensive
 Poor porous structure

39. Synthetic porous polyethylene (MEDPOR)
 a porous type of plastic
 Less biocompatible than HA
 Well tolerated by orbital soft tissue
 The surface is nonabrasive so extrusion is rare.
 They may be used with or without a wrapping material
 extra ocular muscles can be sutured directly onto the implant

40.  available in spherical, egg, conical, and mounded shapes (MEDPOR ® Quad implant)
 The anterior surface can also be manufactured with a smooth, nonporous surface to prevent
abrasion of the overlying tissue (e.g., MEDPOR ® smooth surface tunnel implant – SST™.

41. Aluminum oxide (Al 2 O 3, Alumina, Bioceramic implant)
 porous, inert substance
 permit host fibrovascular ingrowth
 Human fibroblasts and osteoblasts proliferate more rapidly on aluminum oxide than HA
suggesting it is a more biocompatible substance than HA
 lightweight
 has a uniform pore structure and excellent pore interconnectivity
 The microcrystalline structure is smoother than the rough surfaced Bio-Eye
 A protein coating that forms after insertion prevents the implant from being recognized as
a foreign body This inert nature of these implants is a potentially critical advantage in
minimizing socket inflammation.
 Less expensive

42. Variety of Shapes
Mesh- Spherical eggshaped

43. Advantages of vicryl mesh wrap
 Facilitates entry into the orbit by decreasing drag on surrounding structures
 Allows suturing directly to implant
 Eliminates need for donor tissue
 No risk of disease transmission
 Eliminates second surgical site
 Absorbable
 Allows 360 degree entry of fibrovascular tissue (as opposed to entry through scleral
windows)

44. Non integrated Semi integrated
Fully integrated Expandable implants
IMPLANTS

45. Pegging
 Is an option of any of the porous implants, most commonly done with hydroxyapatite.
 It improves motility by allowing the pegged surface to fit into a corresponding groove in
the back of the prosthesis .
 can promote infection and lead to extrusion

48. Orbital Implant Selection in Adults
BETWEEN 15 AND 65 YEARS OLD
 porous implant -quasi-integrated implant such as the Universal (PMMA – mounded) or MEDPOR ® Quad
implant (mounded)
 A nonporous sphere (e.g., PMMA, silicone), wrapped, centered within the muscle cone, and attached to
each of the rectus muscles and inferior oblique muscle,
SEVENTH DECADE OR BEYOND
 A nonporous implant simply placed into the orbit, without a wrap and without connection to the rectus
muscles

49. Orbital Implant Selection in Children
LESS THAN 5 YEARS AGE
 wrapped nonporous sphere implant 16- or 18-mm diameter
 Exchange with porous and bigger size is possible
 autogenous dermis-fat grafts
5 TO 15 YEARS AGE
 nonporous implants, either a PMMA mounded implant (e.g. Universal) or a
wrapped sphere (e.g. PMMA, silicone).

50. 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.
 may be the result of a congential anomaly (facial cleft), trauma (gunshot wound, road
traffic accident) or surgery.

51.  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
missing portions of the orbital rim, zygoma, or temporal or midface regions before
placement.
 The surgical restoration of contour can contribute to a less extensive prosthesis.

52. 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.
 Even a single implant can help stabilize and retain a prosthesis.

53. 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.
 It 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 .

54.  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.

55.  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.

56. TECHNIQUE OF IMPLANT INSERTION
Soil described an improved surgical method of placing the orbital implant 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 deep within the muscle cone, and buried beneath the
posterior layer of Tenon’s capsule
 The posterior portion of Tenon’s capsule is closed over the implant providing the
first layer of closure.

57.  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 fornix 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

58.  By utilizing the posterior layer of Tenon’s capsule,a larger implant can be placed deep
within the muscle cone which
 decreases the incidence of implant migration
 reduces the tension on the anterior Tenon’s
capsule sutures
 reduces the volume deficit in the superior
and inferior sulcus preventing enophthalmos
which can be produced by smaller implants
Orbital Sphere Introducer

59.  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
 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

60.  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 fornices.
 The conformer should not be removed by the patient, as it is designed with drainage
holes
 to allow mucoid discharge to escape
 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 by stretching the fornices for the prosthetic eye.
SMALL MEDIUM LARGE
20mm 23mm 26mm

62. • Following healing of the anophthalmic socket, a stock or custom eye should be
placed temporarily for cosmetic and psychological reasons.
• Patient should be taught how to insert and remove the eye (devote separate time,
quiet room and a mirror)
• Patient should be encouraged to
minimize handling the artificial eye.
• Daily removal and cleaning is not
necessary.

63. Notch is superonasally

64.  Lubrication may improve comfort (no tap water! Ringers, Saline or Artificial
Tears may work well instead, packed in the eyedrops bottles)
 There is only one eye now.
 Encourage using the protective plastic glasses
 One artificial eye should serve for 6-8 years.
 Easily gets damaged while dropped down
 Advise annual check up.

65. Evaluating the socket of
anophthalmic patient:
1) Socket is fit or infmalmed?
2) Lower lid is healthy or lax?
3) Can the patient blink naturally?
4) Any lagophthalmos?
5) Are the fornices deep enough?
6) Giant papillae of upper tarsal conjunctiva?

66. Evaluating the prosthesis
1) Artificial eye is well centered?
2) Horizontal symmetry?
3) Equal prominence?
4) High gloss, wet shine?
5) Scratches, debris of the surface?
6) Moving naturally within 10-15 degrees?

67. Types of ocular prosthesis
 Spherical or oval
 Stock or custom made
 Porous or non porous
 Chemical make up
 Presence or absence of motility post.

69. impression of the
socket is taken
Once the impression
material sets to a firm
consistency, the shape
is copied into a wax
mold
prepared iris–cornea
piece is positioned on
the front surface of
the wax pattern.
mold is placed into
the socket and modifi
ed (reshaped) for
comfort and to
improve cosmesis
The wax shape is then translated (using additional
molds) into fine quality acrylic (from methyl
methacrylate resin), painted, cured, and polished.
Modified impression technique

70. Prosthesis

72. CRITERIA FOR SUCCESS OF CRANIOFACIAL OSSEOINTEGRATED
IMPLANTS
(According to “Swedish council on Technology assessment in Health
care”)
 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.

73. 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

74. II) Impression making:
Impression making for an orbital prosthesis varies depending on the anatomic
the orbital defect, location of implants and type of retention system selected
daily hygiene procedures should be performed by
the patient to maintain the health of the soft
stabilization of the soft tissue to ensure fit and
marginal adaptation of the prosthesis.
This allows time for adequate healing
Impression is made 8 – 12 weeks after
of the abutments.

75.  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

76.  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
the transfer magnets and the impression is poured in dental stone.

77. 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

78.  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

79. IV Sculpting the wax prototype:
 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
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.

80. One or more of the following are helpful in creating the wax
prototype
:
the patient
tissue
conforme
r
computeri
zed
images
Surgical
positioner
photograp
hs
measuring
devices
(boley and
contour
gauges,
calipers)

81. 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

82.  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

83.  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.

84. 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 require more care on the patient’s part and closer
professional follow-up than one retained with adhesive.

85. 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
 to remove cellular material on the skin or abutment, which can come from the
interface of the epithelium and abutment.

86.  This is performed with a soft, end tuft nylon bristle toothbrush, an interproximal dental
brush or a cotton swab.
 The area should be moistened first with an even mixture of H2O2 and H2O 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.

87. 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.
 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

88.  The prosthesis should be patted dry with a towel and placed in a covered container.
 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

89. Complications

90. Exposure and Extrusion of Implant
 Implant exposure may occur with any type of implant or at any time
 may lead to implant extrusion or explantation

91. Porous orbital implants have a lower incidence of implant exposure than traditional
nonporous implants
Predisposing factors 
1. closing the wound under tension
2. poor wound closure techniques
3. Infection
4. mechanical or inflammatory irritation from the speculated surface of the porous
implant
5. Delayed ingrowth of fibrovascular tissue with subsequent tissue breakdown

92. Preventive measures for implant exposure
 proper placement of the implant within the orbit
 two-layered closure of anterior Tenon’s capsule and conjunctiva
Treatment :
If few weeks,
 No infection
simple reclosure or with a patch graft (eg, Sclera, temporalis fascia)
 If infection is suspected
vigorous treatment with topical and systemic antibiotics
an extrusion and removal of the implant may be avoided.

93. beyond 4–6 months,
 If non porous 
The defect should not be closed
secondary orbital implant surgery should be arranged
 If porous,
exposure
<3mm >3mm
Treat conservatively
Wait 8 weeks for spontaneous closure
no
Close with scleral patch graft
surgical repair is indicated
Using sclera patch graft or
temporalis fascia patch graft

94. TREATMENT OF VOLUME DEFECIT

95. Dermis fat graft

97. TREATMENT OF LID LAXITY

98. Lax socket and inferior fornix shelving :
 results from shifting of tissues within the orbit
 With time there is involutional relaxation of the supporting tissues of the inferior eyelid
 the weight and pressure effect of the prosthesis  laxity of the lid  inability to retain the
prosthesis
Treatment
 Use prosthesis of optimal weight and size
 Lateral tarsal strip
 fornix formation sutures to increase the depth of inferior fornix

100. FORNIX DEEPENING SUTURES

102. Anophthalmic ptosis
 Inadequate implant size
 Migration of the orbital implant
 Poorly fit prosthesis
 Laxity of the fibrous connective tissue
 Orbit trauma from the original injury/surgery
 Senile dehiscence of the levator aponeurosis
 Frequent manipulation of the eyelids to insert and remove the artificial eye also stretches
the upper eyelid tissues  drooping eyelid.

103. Pseudoptosis
 Due to the loss of volume between the implant and the lids after removal of the eye.
 Occurs with a small, poorly fitted prostheses
 If the physiological function of the eyelids is intact, correction of pseudoptosis is achieved
by increasing the volume of the prosthesis in the socket.
 A simple technique of correcting pseudoptosis is to make a larger prosthesis that will
thrust forward and separate the eyelids

104. Treatment
 Small amounts of ptosis may be managed by modification of the prosthesis
 correction of socket volume deficiency should be considered prior to levator surgery
 Once the other factors contributing to ptosis in the anophthalmic socket have been
addressed tightening of the levator aponeurosis can be done

105. Treatment of enophthalmos :
 placement of a secondary orbital implant if no implant was placed at the time of primary
surgery
 Dermis fat graft (DFG) is an option in patients with associated surface contracture
 Orbital floor implants.
Autologous bone grafts
Non autologous medpor
Treatment of superior sulcal deformity
 implantation of fascia lata / sclera / bone / fat/ alloplastic material in upper eyelid

106. Anophthalmic ectropion
 Frequently associated with significant lower eyelid laxity
 A large or heavy prosthesis or frequent prosthesis removal may contribute to a stretching of
the medial and/or lateral canthal tendons
 Rotation of the orbital contents inferiorly and anteriorly contribute to a shallow inferior
fornix, tilt of the prosthesis, and lower eyelid ectropion

107. Treatment
 If the prosthesis is >5 years old, a new one may be required
 If the prosthesis is large then a thinner or lighter prosthesis may help correct the
malposition
 Tightening the lateral or medial canthal tendon may remedy the situation
 Correction of eyelid retraction by recession of IR/ grafting of mucus membrane tissue
inferior fornix

108. Contracted socket
 extensive loss of conjunctiva surface area
 deep scar formation
 shrinkage of orbital fat
 conjunctiva fornices contracture.
 the shrinkage and shortening of orbital tissues
 decrease in depth of fornices and orbital volume
 leading to inability to retain prosthesis.
Guibor has classified clinically contracted socket into 4 morphological types

109. Causes
Etiology related
・Alkali burns
・Radiation therapy
Surgery related
 Fibrosis from the initial injury
 Poor surgical techniques during previous surgeries -enucleation /evisceration with
extensive dissection of orbital tissue
 Excessive sacrifice of the conjunctiva and tenons capsule
 Traumatic dissection within the socket leading to scar tissue
 Multiple socket operations

110. Site related
 Poor vascular supply
 Severe ischemic ocular disease in the past
 Cicatrizing conjunctival diseases
 Chronic inflammation and infection
Implant and prosthesis related
 Implant migration
 Implant exposure
 Not wearing a conformer/prosthesis
 Ill fitting prosthesis

112. Grades of contracted sockets.
 The soft tissue sockets were divided into five grades for the sake of
convenience in management of contracted sockets.
Grade-0: Socket is lined with the healthy conjunctiva and has deep and well
formed fornices.

113. Grade-I: Shallow lower fornix or shelving of lower fornix
Here the lower fornix is converted into a downwards sloping shelf which pushes the lower lid down and out,
preventing retention of a artificial eye. shallow lower fornix and deep upper fornix resulting in upward migration of the
prosthesis

114. Grade-II: Socket is characterized by the loss of the
upper and lower fornices

115. Grade- III: Socket is characterized by the loss of
the upper, lower, medial and lateral fornices

116. Grade-IV: Socket is characterized by the loss of all
the fornices, and reduction of palpebral aperture
in horizontal and vertical dimensions

117. Grade-V: In some cases, there is recurrence of
contracture of the socket after repeated trial of
reconstruction

118. Aims of reconstruction
 To establish stable fornices by increasing the surface area by (hard palate ,oral
mucosal,skin graft) and if necessary by increasing size by orbital implant.
 The ocular prostheses should be light and take its support from infraorbital rim
not from the lids.

119. Surgical principle
 First : obtain adequate palpepral aperture size (canthoplasty may be needed in
grade3,4,5)
 Second : create adequate fornixes (lower,upper,lateral) insicion central in grade
2 while it can be at inferior position in grade 1.
 Third : perfect lining of the created fornix (hard palate ,oral mucosal,skin graft
,amniotic membrane)

120.  Fourth be sure that the fornix created supported by orbital bony rim to create
a stable and deep lower fornix, the lower edge of the graft should be sutured
to the inferior orbital bone rim using anchor sutures .
 Fifth: the conformer used during healing for about 6 weeks then ocular shell
prosthesis used there after.
 Sixth : central temporary tarsorrhaphy may be used.

122.  Bone anchored implant
 offers 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
 Independence from reliance on adhesives frees the patient from tedious task of applying
and removing adhesive at each application and removal of prosthesis.
 It prolongs the life of prosthesis, as the edges are not subjected to excessive handling
 Follow-up for the clinical evaluation of implant tissues and the maintenance and periodic
replacement of the facial prosthesis are a must

123. REFERENCES
 Clinical Maxillofacial Prosthetics-Thomas d. Taylor
 Maxillo Facial Rehabilitation – Prosthodontic and surgical consideration
-JOHN BEUMER
 Prosthetic rehabilitation-Keith.F.Thomas
 Ophthalmic and Plastic and Reconstructive Surgery

124. THANK YOU!!!