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Surgical considerations in the prosthetic treatment of ocular and orbital defects
Surgical considerations in the prosthetk ocular and orbital defects Gregory R. Parr, D. D.S.,* Barry M. Goldman, D.D.S.,
M.S.,**
treatment of
and Arthur
0. Rahn, D.D.S.***
Medical College of Georgia, School of Dentistry, Augusta, Ga.
0
rbital defects may be the result of trauma, infection, neoplastic disease, or congenital abnormalities. No surgical procedure permits the replacement of an eye following surgical removal. The high incidence of problems and the failure of the artificial eye to duplicate the appearance of the natural eye may lead some surgeons to avoid this procedure. Many orbital or ocular defects require some form of prosthetic restoration. Careful preoperative surgical and prosthetic planning using a team approach can greatly improve the success of the prosthesis. It is important that well-informed specialists prepare their patients surgically, physically, and psychologically for prosthetic rehabilitation on a routine basis. The purpose of this article is to discuss some significant considerations involved in the surgical planning for patients who are to receive postoperative ocular restorations.
Fig. 1. Evisceration defect, sag&al section. Spherical implant is in place inside remaining sclera. Cornea is intact. Broken lines indicate original diameter of globe. Scleral cover shell is in place.
EVISCERATION When removal of an eye is indicated, the surgeon should be encouraged to preserve as much of the orbital contents as possible. The surgical procedures involving the removal of the eye fall into three general categories-evisceration, enucleation, and exenteration. Evisceration involves the removal of the contents of the globe leaving in place the sclera and sometimes the cornea (Fig. 1). A 16 to 18 mm spherical implant is usually placed within the shell of remaining sclera. The size of this implant is critical, as an implant that is too large will put unnecessary tension on the sutures, possibly leading to extrusion. It may also cause an exophthalmic appearance and will definitely lead to fitting problems. An implant that is too small will require shrinkage of the
*Assistant Professor, Department of Prosthodontics. **.4ssociate Professor,Department of Prosthodontics. ***Professor
and Chairman,
THE JOURNAL
Department
OF PROSTHETIC
of Prosthodontics.
DENTISTRY
surrounding tissues, leading to socket distortions which might not be prosthetically correctable. The prosthesis best suited for the evisceration defect is the custom cosmetic cover shell or the scleral cover shell prosthesis. Since the eye wit1 remain close to its original size after the implant has been placed, this prosthesis will be very thin. A minimum of 1 mm thickness is required. An impression of the socket must be made to fabricate the custom shell. Great care must be taken when making this impression so that pain and cornea1 ulceration do not result due to malfit of the prosthesis, Close adaptation of the prosthesis usually results in excellent mobility; however, cosmetic results may be compromised since the iris may have to be painted on the outer curve of the thin shell prosthesis, leading to a lack of depth and a loss of vitality of appearance. While shell prostheses may be worn for long periods of time, a period of progressive wearing is frequently necessary to build up to a longer wearing period. If wearing problems cannot be overcome by careful prosthetic proce-
379
PARR, GOLDMAN,
AND
RAHN
Fig. 2. Enucleation defect, sagittal section. Spherical implant with muscles attached is in place. Broken lines indicate original diameter of globe and extraocular muscles. Ocular prosthesis is in place in socket.
Fig. 4. Severe superior sulcus deformity lack of implant.
associated with
Fig. 3. Spherical silicone implant which has migrated nasally and anteriorly creates several prosthetic complications.
dures, conversion of the evisceration to an enucleation may be necessary. While the decision regarding evisceration or a more extensive procedure rests with the surgeon, a comprehensive list of helpful suggestions has been presented by LeGrand’ for those interested in orienting surgical procedures for maximum cosmetic, esthetic results. The evisceration defect presents a situation where excellent cosmetics can be realized because the final anatomy is so close to normal. The scleral shell does not have to fill a sunken superior sulcus or compromise the eyelids with its weight. Skill and experience of the prosthetic specialist should be a major consid-
380
Fig. 5. Set of pressure conformers used to expand and shape severely contracted socket.
eration in presurgical planning, however, as these prostheses are more difficult to make and require more experience and closer tolerances.
ENUCLEATION Enucleation is the removal of the entire globe after the extraocular muscles and the optic nerve have been transected (Fig. 2). The enucleation patient
MARCH
1983
VOLUME
49
NUMBER
3
OCULAR
AND
ORBITAL
DEFECTS
Fig. 6. A, Patient with severe ptosis problem due to traumatic following successful prosthetic correction of ptosis problem. may present with numerous postsurgical complications which can be corrected either surgically or prosthetically. An ideal socket for the fitting of an ocular prosthesis should have (1) a well-placed implant with the extraocular muscle attached, (2) adequate superior and inferior fornices for positive retention of the prosthesis, (3) a palpebral fissure equal in size and shape to the fissure of the natural eye, (4) adequate anterior-posterior depth to the socket, (5) adequate support of the superior and inferior tarsal plates, (6) minimal scar tissue adhesions in the socket, (7) adequate mobility of the eyelids, and (8) some type of tissue irregularities in the depth of the socket for the positive adaptation of the prosthesis. Most surgeons will place an implant in Tenon’s capsule to fill the orbital defect and support the muscles and eyelids. Use of an implant permitting attachment of the extraocular muscles often enhances the mobility of the prosthesis, although some surgeons feel that suturing the extraocular muscles over the implant may increase the incidence of migration (Fig. 3). Failure of the surgeon to insert an implant may result in a sunken appearance to the orbit and a prosthesis with very little natural movement. These patients are difficult to fit and are less satisfied with the final result. There are patients who are not good candidates for an ocular implant. They
THE JOURNAL
OF PROSTHETIC
DENTISTRY
injury.
B, Same patient
include patients with severe scarring and patients with insufficient tissue to cover the implant. A detailed discussion of this problem was reported by Spivey et al.” Prosthetic correction of a sunken appearance due to lack of an implant (superior sulcus deformity) involves the addition of bulk to the anterior and superior surfaces of the prosthesis (Fig. 4). Such an addition may irnprove the cosmetic effect but may also sacrifice mobility and retention. Surgical insertion of an implant may be the only means of correcting the defect for maximum cosmetic effect and mobility. Implants which have migrated or partially extruded present several problems to the prosthetic specialist. Careful impression fitting and relief of heavy-contact sites provides the best mobility and cosmetic effect possible; however, surgical repair, especially in the case of the partially extruded implant, may be of great long-term advantage. It is recommended that the surgeon insert a conformer at the end of the operation or in the early postoperative period to prevent the contraction of the socket during healing and to accustom the patient to wearing a prosthesis. A contracted socket with inadequate superior and inferior fornices, with palpebral fissures of unequal size and shape, and with inadequate anteriorposteri-
381
PARR, GOLDMAN,
Fig. 7. A, Patient has partial prosthesis.
Fig. 8. Patient with exenteration with granulation tissue.
exenteration.
defect which is filling
or socket depth presents numerous fitting complications. Retention is a severe problem due to the inadequate fornices. Cosmetic results are severely compromised because the palpebral fissure may not be identical to the opposite side in size and shape. An iris of the correct size may completely fill the inadequate palpebral fissure, leaving no visible scleral area. The final prosthesis may be overly prominent, leading to inadequate lid closure, inadequate blink, inadequate fluid distribution, irritation, and discomfort. Prosthetic treatment of this problem involves the construction of sequentially larger pres-
382
B, Facial view. C, Completed
acrylic
AND
RAHN
resin
sure.conformers to expand and shape the contracted socket (Fig. 5). Such treatment is slow and requires many visits. While some patients may be treated successfully, the procedure may fail entirely, or the final result may not be long lasting. The most successful results are achieved in patients who require the least help. Surgery to enlarge the socket may be, in the long term, a better approach and should be considered if a short trial (2 to 4 weeks) with a pressure conformer proves unsuccessful. Ectropion and entropion of the eyelids can be due to lid relaxation following surgery or to surgical shortening of the eyelid skin. These conditions can be corrected prosthetically, if they are not too severe, by modification of the anterior and superior surfaces of the prosthesis. If they are severe, only surgery will help. The same is true of scar adhesion within the socket. Prosthetic success varies with the location and severity of the adhesion. When impression fitting and careful notching of the prosthesis cannot solve the problem with acceptable appearance and mobility, surgery is indicated. Ptosis is a common finding following enucleation surgery (Fig. 6, A). It may be due to accidental or surgical trauma, to volume loss in the orbit, to migration or malposition of an implant, or to pressure from a malfitted prosthesis.3 Ptosis of an iatrogenie nature may be due to an incorrectly positioned superior rectus muscle, to a levator muscle damaged
MARCH
19133
VOLUME
49
NUMBER
3
OCULAR
AND
ORBITAL
DEFECTS
Fig. 10. Inadequate recontouring of this orbit following exenteration will compromise esthetic placement of final prosthesis. of postoperative complications. Although many of these complications may be prosthetically corrected, careful presurgical consultation, and cosmetically oriented surgery is of great value. The most acceptable prosthesis is the one made for the ideal socket.
EXENTERATION Fig. 9. Preservation of right eyebrow would have contributed to esthetics of this final prosthesis. during dissection, or to surgical nerve damage. Such ptosis is usually permanent. Transient or temporary ptosis. due to hemorrhage or edema following surgery, resolve spontaneously with time. Additionally, Allen’ has reported on an intermittent type of ptosis which may vary from hour to hour and is probably not related to surgery. The prosthetic correction of ptosis is a “trial and error” procedure which requires both time and patience. It is often hard to predict how successful the correction will be. and results-even when acceptable-may be short lived due to normal changes in the socket and surrounding tissues. Meanwhile, the patient’s confidence becomes eroded while irritation and discomfort add to the frustrations of poor esthetics. Nevertheless, prosthetic ptosis correction is successful in many patients and should be attempted before surgery is considered (Fig. 6, B). Surgery may be the only option in severe ptosis, but should be delayed if there is a chance for a temporary ptosis situation to resolve spontaneously. ,4s a group, enucleations represent the largest number of patients treated and the greatest number
THE JOURNAL
OF PROSTHETlC
DENTISTRY
Exenteration is the removal of the entire contents of the orbit, including the extraocular muscle, The periosteum may or may not be maintained. This procedure is usually performed due to some form of malignant disease but may also be due to trauma, infection, or les#s aggressive disease processes. The eyelids may or may not be involved. When the eyelids are involved with the disease process, they must be removed during the surgical procedure. When the eyelids are not involved with the disease process, the surgeon has the following options: (1) leave the eyelids intact (partial exenteration) (Fig. 7, A and B), (2) preserve but split the eyelids. using the eyelid skin to cover the surgical defect at the orbital rim, or (3) remove the eyelids totally. As the size of the internal portion of the orbital defect increases, ,a point is reached where the surgeon should be discouraged from preserving the eyelids because the resultant large internal orbital defect will have a relatively small external opemng. Such a defect may lead to drainage and infection problems for the patient plus reconstruction problems for the prosthetic specialist. In most of these patients, it is impossible to construct a prosthesis which resides behind the eyelids. The defect is best treated by an external prosthesis lying totally outside of the eyelids. To avoid excessive prominence and an unsatisfactory appearance, these restorations must be very
383
PARR, GOLDMAN,
AND
RAHN
defect with exposed
Fig. 13. Patient whose defect has been allowed to partially fill with granulation tissue.
Fig. 12. Large exenteration defect has been covered by split-thickness skin graft and presents clean, dry surface for impression making.
Fig. 14. Eyeglasses with tinted lenses-add to esthetics of final prosthesis (same patient seen in Figs. 9 and 12).
thin. Acrylic resin is the material of choice as it is light in weight, durable, and can be well maintained. A consideration in patients whose eyelids are maintained may be to partially fill the orbital defect with a temporal muscle flap or to allow the defect to partially fill with granulation tissue before applying a skin graft (Fig. 8).” This process usually takes 2 to 3 months but may require as much as a year.6 Another procedure that may be used is the placement of an immediate implant, either preformed or custommade.‘. i These procedures will reduce the size of the internal portion of the orbital defect allowing a more ideal prosthetic restoration. If the eyelid skin is preserved to aid in coverage of the orbital opening, every effort should be made to ensure that the hair of the eyebrow is not pulled into the defect during healing and scar contracture. The presence of a normal eyebrow is a great aid in
achieving a more acceptable appearance with a prosthesis (Fig. 9). The presence of eyebrow hair at the prosthetic margin will interfere with the use of skin adhesives and will tend to lift the prosthesis away from the skin. If these procedures cannot be done, the eyelids should be removed and the lateral and superior bony walls of the orbit rounded to remove the knife-edge marginal bone (Fig. 10). The sharp edges will prove to be painful when a prosthetic restoration is placed against them. Adequate contouring of these walls may be necessary to allow for proper positioning of the prosthesis superiorly. If the disease process necessitates the removal of the inferior bony margin of the orbit, recreation of a firm inferior margin using a fascia lata graft or by some other means should be accomplished to prevent the lower margin from sagging postoperatively.
Fig. II. Crusted, moist exenteration bone along lateral margin (arrow).
384
MARCH
1983
VOLUME
49
NUMBER
3
OCULAR
AND
ORBITAL
DEFECTS
Exposed bone (Fig. 11, arrow) should be covered with a split-thickness skin graft to provide a firm, dry defect which is amenable to impression making, prosthesis support (Fig. 12) and the visualization of possible recurrent disease. Exenteration defects in some instances may be allowed to heal by secondary intent (Fig. 13). In these patients, careful presurgical consultation between the surgeon and the prosthetic specialist should be accomplished as adequate space must remain in the resultant defect to allow the prosthesis to be positioned superiorly and posteriorly enough for a good cosmetic appearance. Skin adhesives and the use of soft materials such as silicone rubber in natural undercuts serve to adequately retain the prosthesis in most instances. Orbital restorations can be quite natural in appearance, with margins hidden in normal skin folds or behind eyeglass rims. Tinted lenses and the use of cosmetics will also enhance esthetics by masking slight color differences between the patient’s skin and the prosthesis (Fig. 14). Careful preparation and counseling of the patient is necessary. Oribtal prostheses, while appearing natural, will not move; eyelids will not blink. Unrealistic expectations by the patient or his family must be evaluated and corrected to prevent psychologic reactions which may lead to rejection of the restoration.
CONCLUSION The goals of the surgeon and the prosthetic specialist regarding the prosthetic rehabilitation of the patient with an ocular or orbital defect are closely allied. The surgeon desires to render the patient free of disease and provide the basis for successful rehabilitation. The prosthetic specialist
THE JOURNAL
OF PROSTHETIC
DENTISTRY
desires to provllde prosthetic treatment IO the best of his ability. The problem of presurgical communication between the surgeon and the prosthetic specialist is a continuing one. The ocular prosthesis placed in an ideal socket can be both esthetic imd comfortable. Presurgical conferences between the involved specialists will help to resolve many- rehabilitative problems leading to more ideal restorative treatment. It is imperative that individuals involved either directly Norindirectly in prosthetrc rehabilitation be aware of the situations discussed here so that a more complete and successful service may be rendered to their patients. We would like to thank Mr. Lewis Hint+ drawings.
t:,~ providing: the
REFERENCES LeGrand, J. A.: Scleral cosmetic shells and lensrs. Int Ophthalmol Clin 10:773, 1970. 2. Spivey, B., Allen. L., and Burnes, C.: The Iowa enucleation implant: A iO.year evaluation of technique and rrsults Am J Ophthalmol 67: 171, 1969. 3. Guibor, P., and Cou$eman, H., editors: Problems and Treatment of Enucleation, Evisceration, Euposurr~ New York, 1974, Symposia Specialists, p 15. 4. Allen, I.., and Blodi, F. C.: A conoidai exentcration implant. Tram Am Acad Ophthalmol ?8:617. 1974 5. Reese. A. B.: Exenteration of the orbit with transplantation of the temporalis muscle. Am .J Ophthalmol 45:3&X 1958. 6. Fox, S. A.: Ophthalmic Plastic Surgery, eti .5. New \ork, 1976, Grune and Stratton Co.. p 562. 7. Gass,
Reprint
requests
to:
DR. GREGORY R. PAKK MEDICAL COLLEGE OF GEORGIA SCHOOL OF DENTISTRY
AUGUSTA,GA 30912
385
M.S.,**
treatment of
and Arthur
0. Rahn, D.D.S.***
Medical College of Georgia, School of Dentistry, Augusta, Ga.
0
rbital defects may be the result of trauma, infection, neoplastic disease, or congenital abnormalities. No surgical procedure permits the replacement of an eye following surgical removal. The high incidence of problems and the failure of the artificial eye to duplicate the appearance of the natural eye may lead some surgeons to avoid this procedure. Many orbital or ocular defects require some form of prosthetic restoration. Careful preoperative surgical and prosthetic planning using a team approach can greatly improve the success of the prosthesis. It is important that well-informed specialists prepare their patients surgically, physically, and psychologically for prosthetic rehabilitation on a routine basis. The purpose of this article is to discuss some significant considerations involved in the surgical planning for patients who are to receive postoperative ocular restorations.
Fig. 1. Evisceration defect, sag&al section. Spherical implant is in place inside remaining sclera. Cornea is intact. Broken lines indicate original diameter of globe. Scleral cover shell is in place.
EVISCERATION When removal of an eye is indicated, the surgeon should be encouraged to preserve as much of the orbital contents as possible. The surgical procedures involving the removal of the eye fall into three general categories-evisceration, enucleation, and exenteration. Evisceration involves the removal of the contents of the globe leaving in place the sclera and sometimes the cornea (Fig. 1). A 16 to 18 mm spherical implant is usually placed within the shell of remaining sclera. The size of this implant is critical, as an implant that is too large will put unnecessary tension on the sutures, possibly leading to extrusion. It may also cause an exophthalmic appearance and will definitely lead to fitting problems. An implant that is too small will require shrinkage of the
*Assistant Professor, Department of Prosthodontics. **.4ssociate Professor,Department of Prosthodontics. ***Professor
and Chairman,
THE JOURNAL
Department
OF PROSTHETIC
of Prosthodontics.
DENTISTRY
surrounding tissues, leading to socket distortions which might not be prosthetically correctable. The prosthesis best suited for the evisceration defect is the custom cosmetic cover shell or the scleral cover shell prosthesis. Since the eye wit1 remain close to its original size after the implant has been placed, this prosthesis will be very thin. A minimum of 1 mm thickness is required. An impression of the socket must be made to fabricate the custom shell. Great care must be taken when making this impression so that pain and cornea1 ulceration do not result due to malfit of the prosthesis, Close adaptation of the prosthesis usually results in excellent mobility; however, cosmetic results may be compromised since the iris may have to be painted on the outer curve of the thin shell prosthesis, leading to a lack of depth and a loss of vitality of appearance. While shell prostheses may be worn for long periods of time, a period of progressive wearing is frequently necessary to build up to a longer wearing period. If wearing problems cannot be overcome by careful prosthetic proce-
379
PARR, GOLDMAN,
AND
RAHN
Fig. 2. Enucleation defect, sagittal section. Spherical implant with muscles attached is in place. Broken lines indicate original diameter of globe and extraocular muscles. Ocular prosthesis is in place in socket.
Fig. 4. Severe superior sulcus deformity lack of implant.
associated with
Fig. 3. Spherical silicone implant which has migrated nasally and anteriorly creates several prosthetic complications.
dures, conversion of the evisceration to an enucleation may be necessary. While the decision regarding evisceration or a more extensive procedure rests with the surgeon, a comprehensive list of helpful suggestions has been presented by LeGrand’ for those interested in orienting surgical procedures for maximum cosmetic, esthetic results. The evisceration defect presents a situation where excellent cosmetics can be realized because the final anatomy is so close to normal. The scleral shell does not have to fill a sunken superior sulcus or compromise the eyelids with its weight. Skill and experience of the prosthetic specialist should be a major consid-
380
Fig. 5. Set of pressure conformers used to expand and shape severely contracted socket.
eration in presurgical planning, however, as these prostheses are more difficult to make and require more experience and closer tolerances.
ENUCLEATION Enucleation is the removal of the entire globe after the extraocular muscles and the optic nerve have been transected (Fig. 2). The enucleation patient
MARCH
1983
VOLUME
49
NUMBER
3
OCULAR
AND
ORBITAL
DEFECTS
Fig. 6. A, Patient with severe ptosis problem due to traumatic following successful prosthetic correction of ptosis problem. may present with numerous postsurgical complications which can be corrected either surgically or prosthetically. An ideal socket for the fitting of an ocular prosthesis should have (1) a well-placed implant with the extraocular muscle attached, (2) adequate superior and inferior fornices for positive retention of the prosthesis, (3) a palpebral fissure equal in size and shape to the fissure of the natural eye, (4) adequate anterior-posterior depth to the socket, (5) adequate support of the superior and inferior tarsal plates, (6) minimal scar tissue adhesions in the socket, (7) adequate mobility of the eyelids, and (8) some type of tissue irregularities in the depth of the socket for the positive adaptation of the prosthesis. Most surgeons will place an implant in Tenon’s capsule to fill the orbital defect and support the muscles and eyelids. Use of an implant permitting attachment of the extraocular muscles often enhances the mobility of the prosthesis, although some surgeons feel that suturing the extraocular muscles over the implant may increase the incidence of migration (Fig. 3). Failure of the surgeon to insert an implant may result in a sunken appearance to the orbit and a prosthesis with very little natural movement. These patients are difficult to fit and are less satisfied with the final result. There are patients who are not good candidates for an ocular implant. They
THE JOURNAL
OF PROSTHETIC
DENTISTRY
injury.
B, Same patient
include patients with severe scarring and patients with insufficient tissue to cover the implant. A detailed discussion of this problem was reported by Spivey et al.” Prosthetic correction of a sunken appearance due to lack of an implant (superior sulcus deformity) involves the addition of bulk to the anterior and superior surfaces of the prosthesis (Fig. 4). Such an addition may irnprove the cosmetic effect but may also sacrifice mobility and retention. Surgical insertion of an implant may be the only means of correcting the defect for maximum cosmetic effect and mobility. Implants which have migrated or partially extruded present several problems to the prosthetic specialist. Careful impression fitting and relief of heavy-contact sites provides the best mobility and cosmetic effect possible; however, surgical repair, especially in the case of the partially extruded implant, may be of great long-term advantage. It is recommended that the surgeon insert a conformer at the end of the operation or in the early postoperative period to prevent the contraction of the socket during healing and to accustom the patient to wearing a prosthesis. A contracted socket with inadequate superior and inferior fornices, with palpebral fissures of unequal size and shape, and with inadequate anteriorposteri-
381
PARR, GOLDMAN,
Fig. 7. A, Patient has partial prosthesis.
Fig. 8. Patient with exenteration with granulation tissue.
exenteration.
defect which is filling
or socket depth presents numerous fitting complications. Retention is a severe problem due to the inadequate fornices. Cosmetic results are severely compromised because the palpebral fissure may not be identical to the opposite side in size and shape. An iris of the correct size may completely fill the inadequate palpebral fissure, leaving no visible scleral area. The final prosthesis may be overly prominent, leading to inadequate lid closure, inadequate blink, inadequate fluid distribution, irritation, and discomfort. Prosthetic treatment of this problem involves the construction of sequentially larger pres-
382
B, Facial view. C, Completed
acrylic
AND
RAHN
resin
sure.conformers to expand and shape the contracted socket (Fig. 5). Such treatment is slow and requires many visits. While some patients may be treated successfully, the procedure may fail entirely, or the final result may not be long lasting. The most successful results are achieved in patients who require the least help. Surgery to enlarge the socket may be, in the long term, a better approach and should be considered if a short trial (2 to 4 weeks) with a pressure conformer proves unsuccessful. Ectropion and entropion of the eyelids can be due to lid relaxation following surgery or to surgical shortening of the eyelid skin. These conditions can be corrected prosthetically, if they are not too severe, by modification of the anterior and superior surfaces of the prosthesis. If they are severe, only surgery will help. The same is true of scar adhesion within the socket. Prosthetic success varies with the location and severity of the adhesion. When impression fitting and careful notching of the prosthesis cannot solve the problem with acceptable appearance and mobility, surgery is indicated. Ptosis is a common finding following enucleation surgery (Fig. 6, A). It may be due to accidental or surgical trauma, to volume loss in the orbit, to migration or malposition of an implant, or to pressure from a malfitted prosthesis.3 Ptosis of an iatrogenie nature may be due to an incorrectly positioned superior rectus muscle, to a levator muscle damaged
MARCH
19133
VOLUME
49
NUMBER
3
OCULAR
AND
ORBITAL
DEFECTS
Fig. 10. Inadequate recontouring of this orbit following exenteration will compromise esthetic placement of final prosthesis. of postoperative complications. Although many of these complications may be prosthetically corrected, careful presurgical consultation, and cosmetically oriented surgery is of great value. The most acceptable prosthesis is the one made for the ideal socket.
EXENTERATION Fig. 9. Preservation of right eyebrow would have contributed to esthetics of this final prosthesis. during dissection, or to surgical nerve damage. Such ptosis is usually permanent. Transient or temporary ptosis. due to hemorrhage or edema following surgery, resolve spontaneously with time. Additionally, Allen’ has reported on an intermittent type of ptosis which may vary from hour to hour and is probably not related to surgery. The prosthetic correction of ptosis is a “trial and error” procedure which requires both time and patience. It is often hard to predict how successful the correction will be. and results-even when acceptable-may be short lived due to normal changes in the socket and surrounding tissues. Meanwhile, the patient’s confidence becomes eroded while irritation and discomfort add to the frustrations of poor esthetics. Nevertheless, prosthetic ptosis correction is successful in many patients and should be attempted before surgery is considered (Fig. 6, B). Surgery may be the only option in severe ptosis, but should be delayed if there is a chance for a temporary ptosis situation to resolve spontaneously. ,4s a group, enucleations represent the largest number of patients treated and the greatest number
THE JOURNAL
OF PROSTHETlC
DENTISTRY
Exenteration is the removal of the entire contents of the orbit, including the extraocular muscle, The periosteum may or may not be maintained. This procedure is usually performed due to some form of malignant disease but may also be due to trauma, infection, or les#s aggressive disease processes. The eyelids may or may not be involved. When the eyelids are involved with the disease process, they must be removed during the surgical procedure. When the eyelids are not involved with the disease process, the surgeon has the following options: (1) leave the eyelids intact (partial exenteration) (Fig. 7, A and B), (2) preserve but split the eyelids. using the eyelid skin to cover the surgical defect at the orbital rim, or (3) remove the eyelids totally. As the size of the internal portion of the orbital defect increases, ,a point is reached where the surgeon should be discouraged from preserving the eyelids because the resultant large internal orbital defect will have a relatively small external opemng. Such a defect may lead to drainage and infection problems for the patient plus reconstruction problems for the prosthetic specialist. In most of these patients, it is impossible to construct a prosthesis which resides behind the eyelids. The defect is best treated by an external prosthesis lying totally outside of the eyelids. To avoid excessive prominence and an unsatisfactory appearance, these restorations must be very
383
PARR, GOLDMAN,
AND
RAHN
defect with exposed
Fig. 13. Patient whose defect has been allowed to partially fill with granulation tissue.
Fig. 12. Large exenteration defect has been covered by split-thickness skin graft and presents clean, dry surface for impression making.
Fig. 14. Eyeglasses with tinted lenses-add to esthetics of final prosthesis (same patient seen in Figs. 9 and 12).
thin. Acrylic resin is the material of choice as it is light in weight, durable, and can be well maintained. A consideration in patients whose eyelids are maintained may be to partially fill the orbital defect with a temporal muscle flap or to allow the defect to partially fill with granulation tissue before applying a skin graft (Fig. 8).” This process usually takes 2 to 3 months but may require as much as a year.6 Another procedure that may be used is the placement of an immediate implant, either preformed or custommade.‘. i These procedures will reduce the size of the internal portion of the orbital defect allowing a more ideal prosthetic restoration. If the eyelid skin is preserved to aid in coverage of the orbital opening, every effort should be made to ensure that the hair of the eyebrow is not pulled into the defect during healing and scar contracture. The presence of a normal eyebrow is a great aid in
achieving a more acceptable appearance with a prosthesis (Fig. 9). The presence of eyebrow hair at the prosthetic margin will interfere with the use of skin adhesives and will tend to lift the prosthesis away from the skin. If these procedures cannot be done, the eyelids should be removed and the lateral and superior bony walls of the orbit rounded to remove the knife-edge marginal bone (Fig. 10). The sharp edges will prove to be painful when a prosthetic restoration is placed against them. Adequate contouring of these walls may be necessary to allow for proper positioning of the prosthesis superiorly. If the disease process necessitates the removal of the inferior bony margin of the orbit, recreation of a firm inferior margin using a fascia lata graft or by some other means should be accomplished to prevent the lower margin from sagging postoperatively.
Fig. II. Crusted, moist exenteration bone along lateral margin (arrow).
384
MARCH
1983
VOLUME
49
NUMBER
3
OCULAR
AND
ORBITAL
DEFECTS
Exposed bone (Fig. 11, arrow) should be covered with a split-thickness skin graft to provide a firm, dry defect which is amenable to impression making, prosthesis support (Fig. 12) and the visualization of possible recurrent disease. Exenteration defects in some instances may be allowed to heal by secondary intent (Fig. 13). In these patients, careful presurgical consultation between the surgeon and the prosthetic specialist should be accomplished as adequate space must remain in the resultant defect to allow the prosthesis to be positioned superiorly and posteriorly enough for a good cosmetic appearance. Skin adhesives and the use of soft materials such as silicone rubber in natural undercuts serve to adequately retain the prosthesis in most instances. Orbital restorations can be quite natural in appearance, with margins hidden in normal skin folds or behind eyeglass rims. Tinted lenses and the use of cosmetics will also enhance esthetics by masking slight color differences between the patient’s skin and the prosthesis (Fig. 14). Careful preparation and counseling of the patient is necessary. Oribtal prostheses, while appearing natural, will not move; eyelids will not blink. Unrealistic expectations by the patient or his family must be evaluated and corrected to prevent psychologic reactions which may lead to rejection of the restoration.
CONCLUSION The goals of the surgeon and the prosthetic specialist regarding the prosthetic rehabilitation of the patient with an ocular or orbital defect are closely allied. The surgeon desires to render the patient free of disease and provide the basis for successful rehabilitation. The prosthetic specialist
THE JOURNAL
OF PROSTHETIC
DENTISTRY
desires to provllde prosthetic treatment IO the best of his ability. The problem of presurgical communication between the surgeon and the prosthetic specialist is a continuing one. The ocular prosthesis placed in an ideal socket can be both esthetic imd comfortable. Presurgical conferences between the involved specialists will help to resolve many- rehabilitative problems leading to more ideal restorative treatment. It is imperative that individuals involved either directly Norindirectly in prosthetrc rehabilitation be aware of the situations discussed here so that a more complete and successful service may be rendered to their patients. We would like to thank Mr. Lewis Hint+ drawings.
t:,~ providing: the
REFERENCES LeGrand, J. A.: Scleral cosmetic shells and lensrs. Int Ophthalmol Clin 10:773, 1970. 2. Spivey, B., Allen. L., and Burnes, C.: The Iowa enucleation implant: A iO.year evaluation of technique and rrsults Am J Ophthalmol 67: 171, 1969. 3. Guibor, P., and Cou$eman, H., editors: Problems and Treatment of Enucleation, Evisceration, Euposurr~ New York, 1974, Symposia Specialists, p 15. 4. Allen, I.., and Blodi, F. C.: A conoidai exentcration implant. Tram Am Acad Ophthalmol ?8:617. 1974 5. Reese. A. B.: Exenteration of the orbit with transplantation of the temporalis muscle. Am .J Ophthalmol 45:3&X 1958. 6. Fox, S. A.: Ophthalmic Plastic Surgery, eti .5. New \ork, 1976, Grune and Stratton Co.. p 562. 7. Gass,
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