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Prosthetic restoration of orbital defects
of orbital dekts Ark Shifman, D.M.D.,* Memorial
Alan C. Levin, B.D.S.,** Magda Levy,***
and James B. Leplay, D.D.S.****
Hospital for Cancer and Allied Diseases, New York, N. Y.
T
he restoration of orbital defects presents a challenge in maxillofacial prosthetics. Careful positioning of the ocular portion of the orbital prosthesis is one of the requirements for a successful esthetic result. A change of this position, which may occur during fabrication or may be due to distortion of the prosthetic housing or loss of retention of the prosthesis, may result in an unsatisfactory appearance. A prosthesis should be fabricated which is rigid enough to retain the ocular portion in position, and yet be flexible enough to engage some undercuts to aid retention. A technique for the fabrication of orbital prostheses used in Memorial Hospital, New York, is described. The procedure uses improved RTV silicone material? filled with RTV silicone foam.$
TECHNlQUE 1. The defect is examined for the presence of undercuts (Fig. 1). 2. A facial moulage is made with irreversible hydrocolloid and plaster of Paris reinforcement according to the accepted procedure,’ blocking out extreme undercuts. 3. A thin layer of autopolymerizing acrylic resin is poured onto the tissue surface of the moulageZ before casting a base in artificial stone to provide an improved surface on the cast. 4. To determine the accuracy of the cast, a wax template is adapted to the cast and tried on the patient. 5. The cast is modified by eliminating extreme *Formerly resident, maxillofacial prosthetics; presently at Chaim Sheba Medical Center, Tel Hashomer, Israel. maxillofacial prosthetics; presently at **Formerly resident, College of Dentistry, University of Florida, Gainesville, Fla. ***Facial prosthetist, Dental Service. ****Chief, Dental Service. tMDX 4-4210 Elastomer, Dow Corning Corp., Midland, Mich. $Silastic S-5370 RTV Foam, Dow Corning Corp., Midland, Mich.
0022-3913/79/l
10543 + 04$00.40/O Q 1979 The C. V. Mosby Co
Fig.
1.
Surgical defect.
undercuts and smoothing out the base of the defect. Two vent holes are drilled through the deepest portion of the defect area on the cast to the exterior to facilitate the injection of silicone foam at a later stage (Fig. 2). 6. The prosthesis is sculptured in wax and checked for fit and contour on the patient. 7. The wax pattern is finished on the cast by overlapping the margins of the defect with a thin layer of wax extending about 1 cm beyond the margins. 8. A pyramid-shaped index in cold-cure acrylic resin is attached to the cornea1 area of the ocular prosthesis for position stability during processing (Fig. 3). 9. The wax pattern is invested and eliminated in the accepted manner.
THE JOURNAL
OF PROSTHETIC
DFNTISTRY
543
SHIFMAN
ET AL
Fig. 2. A cast of the face with two vent holes through the deepest portion of the defect.
Fig. 4. Injection of silicone foam through vent hole.
Fig. 3. Acrylic resin design index attached to comeal area of ocular prosthesis. 10. Silicone material is prepared by mixing MDX 4-4210 base,* 10% curing agent, and 10% RTV silicone fluid.*3 It is intrinsically colored to the patient’s basic skin tone. The mixture is vacuumed and allowed to stand for 3 hours. 11. The cast and counter mold are preheated to 85“ C and coated with silicone separating medium? on all surfaces. A thin layer of the silicone reinforced with nylon mesh4 is applied to the surface of the cast and counter mold, which is then closed using a C-clamp for stability. It is cured in a dry-heat oven at 85” to 90°C for 1 hour. *Dow Corning Corp., Midland, Mich. tomnilube Spray, Omnidental Corp., Chicago, Ill.
544
12. The mold is bench cooled and RTV Silicone Foam* is prepared and immediately injected with a large plastic syringe into one of the holes while the other hole is left open for venting. Curing is at room temperature for 20 minutes (Fig. 4). 13. The mold is opened and the prosthesis removed. The projections left by the injection and vent holes are trimmed down below the surface and sealed with Medical Adhesive Type A.? The prosthetic eye with the acrylic resin pyramid extension attached is removed from the prosthesis and duplicated in autopolymerizing acrylic resin for future record (Fig. 5). The pyramid is then carefully removed and the cornea1 area repolished. 14. The prosthesis is tried on the patient and the extensions checked in order to finish the borders on normal skin tissue beyond the margins of the defect (Fig.6). 15. Extrinsic coloring is carried out by painting the surface of the prosthesis with Medical Adhesive *Silastic S-5370 RTV Foam, Dow Corning Mich. tDow Corning Corp., Midland, Mich.
NOVEMBER
1979
VOLUME
Corp., Midland,
42
NUMBER
5
ORBITAL
PROSTHESIS
Fig. 5. Duplicated future record.
ocular prosthesis with an index for a
Fig. 6. Side view extension.
of prosthesis
showing
a thin edge
Type A* diluted with xylene and mixed with dry earth pigments.? This sets within a few minutes at 90” c. 16. The patient is instructed in the use and care of the prosthesis. Epithane-3 Adhesivet is used on the margins of the defect only if necessary for additional retention and sealing (Fig. 7). DISCUSSION The method presented in this article has been found to be acceptable to most patients treated. The technique utilizes undercuts in the defect and the elasticity of the material primarily for retention. The prosthesis is light yet rigid enough to retain its form *Dow Corning Corp., Midland, Mich. I’M. Grumbacher, Inc., New York, N. Y. $Daro Products, Inc., Butler. Wis.
THE JOURNAL
OF PROSTHETIC
DENTISTRY
Fig. 7. A, The completed prosthesis. B, The completed prosthesis in place.
and not collapse. The thin layer of overlap of the prosthesis onto normal skin tissue increases the surface area of contact. It is in these areas that the adhesive is used to seal the margins of the prosthesis to the skin, particularly the movable regions of the skin. The MDX silicone material* has a greater edge strength than other silicone materials,” and when reinforced with nylon mesh it displays adequate edge ‘MDX
4-4210 Elastomer, Dow Corning Corp., Midland,
Mich.
545
SHIFMAN
strength to extend it in thin sections. The extensions of the thin sections mask the borders of the prosthesis and blend the movement of the face into the prosthesis. Use of a mild adhesive which does not irritate the tissues or damage the prosthesis is possible, as it acts as a sealant and not a major source of retention. REFERENCES 1. Bulbulian, A. H.: Facial Prosthetics. Springfield, Charles C Thomas, Publisher, pp 77-85.
The effect of age and removable disease L Rissin, J. E. House, H. H. Chauncey,
1973,
ET AL
2.
Pflughoeft, F. A., and Shearer, H. H.: Fabrication of a plastic facial moulage. J PROSTHETDENT 25:267, 1971. 3. Moore, D. J., Glaser, Z. R., Tabacco, M. J., and Linebaugh, M. G.: Evaluation of polymeric materials for maxillofacial prosthetics. J PROSTHET DENT 38:319, 1977. 4. Ranter, J. D.: The use of RTV silicones in maxillofacial prosthetics. J PROSTHET DENT 24:646, 1970. Reprint requeststo: ALAN C. LEVIN, B.D.S. COLLEGE OF DEN&TRY UNIVERSITY OF FLORIDA GAINESVILLE, FLA. 32610
partial dentures on gingivitis
and periodontal
and E. R. Loftus
V. A. Outpatient Clinic, Boston, Mass.
Reports exist indicating the detrimental effects of removable partial dentures upon the abutment teeth, their supporting periodontal structures, and the edentulous alveolar bone. A comprehensive “Dental Longitudinal Study” located at the V. A. Outpatient Clinic, Boston, employed over 1200 normal healthy males to evaluate interrelationships between aging, types of prosthetic replacement, and factors associated with periodontal disease. For the present analysis 694 non-smokers were selected; 563 wore no prosthesis and 131 wore a removable partial denture. Certain periodontal disease variables, plaque, gingival inflammation, calculus, pocket depth, bone loss and tooth
Reprinted from the Journal of Dental Research [57 (Special Issue A), 1978 (Abst No. 1073)] with editor.
permission
of the author
and the
mobility were scored utilizing standard methodologY. Analysis of variance indicated a statistically significant increase in plaque deposition, pocket depth, bone loss, mobile teeth as well as higher age in persons with a removable partial denture. Stepwise multiple regression analysis indicated the relative importance of independent variables (plaque, calculus, denture status, and age) in predicting their effect upon each of the dependent variables (gingivitis, pocket depth, bone loss, and mobility). For gingivitis the most important independent variable was calculus, followed by plaque, age, and denture status. The most important independent variable affecting periodontal breakdown is calculus followed by denture status, plaque, and age. From the data it is apparent that the presence of a removable partial denture has a significant detrimental effect upon the periodontium; more than plaque and age and second only to calculus.
NOVEMBER
1979
VOLUME
42
NUMBER
5
Alan C. Levin, B.D.S.,** Magda Levy,***
and James B. Leplay, D.D.S.****
Hospital for Cancer and Allied Diseases, New York, N. Y.
T
he restoration of orbital defects presents a challenge in maxillofacial prosthetics. Careful positioning of the ocular portion of the orbital prosthesis is one of the requirements for a successful esthetic result. A change of this position, which may occur during fabrication or may be due to distortion of the prosthetic housing or loss of retention of the prosthesis, may result in an unsatisfactory appearance. A prosthesis should be fabricated which is rigid enough to retain the ocular portion in position, and yet be flexible enough to engage some undercuts to aid retention. A technique for the fabrication of orbital prostheses used in Memorial Hospital, New York, is described. The procedure uses improved RTV silicone material? filled with RTV silicone foam.$
TECHNlQUE 1. The defect is examined for the presence of undercuts (Fig. 1). 2. A facial moulage is made with irreversible hydrocolloid and plaster of Paris reinforcement according to the accepted procedure,’ blocking out extreme undercuts. 3. A thin layer of autopolymerizing acrylic resin is poured onto the tissue surface of the moulageZ before casting a base in artificial stone to provide an improved surface on the cast. 4. To determine the accuracy of the cast, a wax template is adapted to the cast and tried on the patient. 5. The cast is modified by eliminating extreme *Formerly resident, maxillofacial prosthetics; presently at Chaim Sheba Medical Center, Tel Hashomer, Israel. maxillofacial prosthetics; presently at **Formerly resident, College of Dentistry, University of Florida, Gainesville, Fla. ***Facial prosthetist, Dental Service. ****Chief, Dental Service. tMDX 4-4210 Elastomer, Dow Corning Corp., Midland, Mich. $Silastic S-5370 RTV Foam, Dow Corning Corp., Midland, Mich.
0022-3913/79/l
10543 + 04$00.40/O Q 1979 The C. V. Mosby Co
Fig.
1.
Surgical defect.
undercuts and smoothing out the base of the defect. Two vent holes are drilled through the deepest portion of the defect area on the cast to the exterior to facilitate the injection of silicone foam at a later stage (Fig. 2). 6. The prosthesis is sculptured in wax and checked for fit and contour on the patient. 7. The wax pattern is finished on the cast by overlapping the margins of the defect with a thin layer of wax extending about 1 cm beyond the margins. 8. A pyramid-shaped index in cold-cure acrylic resin is attached to the cornea1 area of the ocular prosthesis for position stability during processing (Fig. 3). 9. The wax pattern is invested and eliminated in the accepted manner.
THE JOURNAL
OF PROSTHETIC
DFNTISTRY
543
SHIFMAN
ET AL
Fig. 2. A cast of the face with two vent holes through the deepest portion of the defect.
Fig. 4. Injection of silicone foam through vent hole.
Fig. 3. Acrylic resin design index attached to comeal area of ocular prosthesis. 10. Silicone material is prepared by mixing MDX 4-4210 base,* 10% curing agent, and 10% RTV silicone fluid.*3 It is intrinsically colored to the patient’s basic skin tone. The mixture is vacuumed and allowed to stand for 3 hours. 11. The cast and counter mold are preheated to 85“ C and coated with silicone separating medium? on all surfaces. A thin layer of the silicone reinforced with nylon mesh4 is applied to the surface of the cast and counter mold, which is then closed using a C-clamp for stability. It is cured in a dry-heat oven at 85” to 90°C for 1 hour. *Dow Corning Corp., Midland, Mich. tomnilube Spray, Omnidental Corp., Chicago, Ill.
544
12. The mold is bench cooled and RTV Silicone Foam* is prepared and immediately injected with a large plastic syringe into one of the holes while the other hole is left open for venting. Curing is at room temperature for 20 minutes (Fig. 4). 13. The mold is opened and the prosthesis removed. The projections left by the injection and vent holes are trimmed down below the surface and sealed with Medical Adhesive Type A.? The prosthetic eye with the acrylic resin pyramid extension attached is removed from the prosthesis and duplicated in autopolymerizing acrylic resin for future record (Fig. 5). The pyramid is then carefully removed and the cornea1 area repolished. 14. The prosthesis is tried on the patient and the extensions checked in order to finish the borders on normal skin tissue beyond the margins of the defect (Fig.6). 15. Extrinsic coloring is carried out by painting the surface of the prosthesis with Medical Adhesive *Silastic S-5370 RTV Foam, Dow Corning Mich. tDow Corning Corp., Midland, Mich.
NOVEMBER
1979
VOLUME
Corp., Midland,
42
NUMBER
5
ORBITAL
PROSTHESIS
Fig. 5. Duplicated future record.
ocular prosthesis with an index for a
Fig. 6. Side view extension.
of prosthesis
showing
a thin edge
Type A* diluted with xylene and mixed with dry earth pigments.? This sets within a few minutes at 90” c. 16. The patient is instructed in the use and care of the prosthesis. Epithane-3 Adhesivet is used on the margins of the defect only if necessary for additional retention and sealing (Fig. 7). DISCUSSION The method presented in this article has been found to be acceptable to most patients treated. The technique utilizes undercuts in the defect and the elasticity of the material primarily for retention. The prosthesis is light yet rigid enough to retain its form *Dow Corning Corp., Midland, Mich. I’M. Grumbacher, Inc., New York, N. Y. $Daro Products, Inc., Butler. Wis.
THE JOURNAL
OF PROSTHETIC
DENTISTRY
Fig. 7. A, The completed prosthesis. B, The completed prosthesis in place.
and not collapse. The thin layer of overlap of the prosthesis onto normal skin tissue increases the surface area of contact. It is in these areas that the adhesive is used to seal the margins of the prosthesis to the skin, particularly the movable regions of the skin. The MDX silicone material* has a greater edge strength than other silicone materials,” and when reinforced with nylon mesh it displays adequate edge ‘MDX
4-4210 Elastomer, Dow Corning Corp., Midland,
Mich.
545
SHIFMAN
strength to extend it in thin sections. The extensions of the thin sections mask the borders of the prosthesis and blend the movement of the face into the prosthesis. Use of a mild adhesive which does not irritate the tissues or damage the prosthesis is possible, as it acts as a sealant and not a major source of retention. REFERENCES 1. Bulbulian, A. H.: Facial Prosthetics. Springfield, Charles C Thomas, Publisher, pp 77-85.
The effect of age and removable disease L Rissin, J. E. House, H. H. Chauncey,
1973,
ET AL
2.
Pflughoeft, F. A., and Shearer, H. H.: Fabrication of a plastic facial moulage. J PROSTHETDENT 25:267, 1971. 3. Moore, D. J., Glaser, Z. R., Tabacco, M. J., and Linebaugh, M. G.: Evaluation of polymeric materials for maxillofacial prosthetics. J PROSTHET DENT 38:319, 1977. 4. Ranter, J. D.: The use of RTV silicones in maxillofacial prosthetics. J PROSTHET DENT 24:646, 1970. Reprint requeststo: ALAN C. LEVIN, B.D.S. COLLEGE OF DEN&TRY UNIVERSITY OF FLORIDA GAINESVILLE, FLA. 32610
partial dentures on gingivitis
and periodontal
and E. R. Loftus
V. A. Outpatient Clinic, Boston, Mass.
Reports exist indicating the detrimental effects of removable partial dentures upon the abutment teeth, their supporting periodontal structures, and the edentulous alveolar bone. A comprehensive “Dental Longitudinal Study” located at the V. A. Outpatient Clinic, Boston, employed over 1200 normal healthy males to evaluate interrelationships between aging, types of prosthetic replacement, and factors associated with periodontal disease. For the present analysis 694 non-smokers were selected; 563 wore no prosthesis and 131 wore a removable partial denture. Certain periodontal disease variables, plaque, gingival inflammation, calculus, pocket depth, bone loss and tooth
Reprinted from the Journal of Dental Research [57 (Special Issue A), 1978 (Abst No. 1073)] with editor.
permission
of the author
and the
mobility were scored utilizing standard methodologY. Analysis of variance indicated a statistically significant increase in plaque deposition, pocket depth, bone loss, mobile teeth as well as higher age in persons with a removable partial denture. Stepwise multiple regression analysis indicated the relative importance of independent variables (plaque, calculus, denture status, and age) in predicting their effect upon each of the dependent variables (gingivitis, pocket depth, bone loss, and mobility). For gingivitis the most important independent variable was calculus, followed by plaque, age, and denture status. The most important independent variable affecting periodontal breakdown is calculus followed by denture status, plaque, and age. From the data it is apparent that the presence of a removable partial denture has a significant detrimental effect upon the periodontium; more than plaque and age and second only to calculus.
NOVEMBER
1979
VOLUME
42
NUMBER
5