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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 15  |  Issue : 2  |  Page : 312-316

Prosthetic rehabilitation of orbital defect owing to surgical management of rhabdomyosarcoma


Department of Prosthodontics, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra, India

Date of Submission14-Apr-2020
Date of Decision22-Apr-2020
Date of Acceptance30-Apr-2020
Date of Web Publication21-Dec-2020

Correspondence Address:
Dr. Sweta Kale Pisulkar
Sooraj Bhavan, Sai Mandir Road, Wardha - 442 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_118_20

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  Abstract 


Mutilation of any facial structure, especially eye, affects the health of the patient psychologically and functionally. “Its the right of every human being to appear like human” and hence facial prosthesis plays a major role in rehabilitation. Silicone among all materials used for facial prosthesis gives a life-like appearance and better marginal adaptation. This case report presents a straightforward technique for the rehabilitation of ocular defect owing to surgical management of rhabdomyosarcoma with silicone orbital prosthesis.

Keywords: Occular defect, orbital prosthesis, rhabdomyosarcoma, silicone prosthesis


How to cite this article:
Pisulkar SK, Dahihandekar C, Rajpurohit H, Mistry R. Prosthetic rehabilitation of orbital defect owing to surgical management of rhabdomyosarcoma. J Datta Meghe Inst Med Sci Univ 2020;15:312-6

How to cite this URL:
Pisulkar SK, Dahihandekar C, Rajpurohit H, Mistry R. Prosthetic rehabilitation of orbital defect owing to surgical management of rhabdomyosarcoma. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Jan 16];15:312-6. Available from: http://www.journaldmims.com/text.asp?2020/15/2/312/304236




  Introduction Top


The loss of any facial structure or tissue negatively impacts the patient's psychological, physical, social heath of the patient. It can be due to congenital defects, trauma including Road Traffic accidents with and without helmet,[1] disease or surgical intervention. Orbital and ocular prostheses in such patients act as a boon by providing a synthetic substitute to a missing eye as well as improve facial aesthetics and improves the overall health of the patient. According to GPT 9 “Orbital prosthesis can be defined as a maxillofacial prosthesis that artificially restores the eye, eyelids, and adjacent hard and soft tissues.”[2] This article describes a straightforward technique to fabricate a silicone orbital prosthesis.


  Case Report Top


A young female patient aged for every procedure consent form was obtained with the chief complaint of replacement of the orbital prosthesis and poor aesthetics. The patient was diagnosed with rhabdomyosaroma of the left eye about 21 years back for which she underwent evisceration of the orbit and its content. The patient did not receive any radiotherapy after the surgical treatment. The patient did not complain of pain or any kind of discomfort at the operated site [Figure 1] and [Figure 2].
Figure 1: Orbital defect

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Figure 2: Faulty prosthesis

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Procedure

The patient required an orbital prosthesis for her defect. Rehabilitation of the orbital defect has various options, and the final decision lies in the hands of the operator. Several factors are to be considered when formulating a treatment plan.

Patient factors like the age and the level of co-operation the patient can render are the far most important. The health of tissues should also be taken into consideration. The economic restraints of the patient also plays a major role as well as the technical skill acquired by the operator. Hence during the initial appointment, various modalities of the treatment were decided with the patient, and spectacle retained orbital prosthesis was finalized due to monetary constraints. There are certain steps[3] which are mandatory while constructing any orbital prosthesis:

  1. Obtaining a Facial Moulage– detailed examination of the defect and surrounding structure
  2. Finalizing the mode of retention– based on monetary constraints, age, and health of patient and condition of tissues involved in and around the defect
  3. Orientation of the planned prosthesis in facial harmony
  4. Assessing the trial prosthesis
  5. Selection of material for prosthesis and subsequent processing
  6. Shade selection, finishing, and polishing followed by insertion of the prosthesis.


Obtaining facial moulage

A facial moulage is mandatory for the proper examination and treatment planning of the prosthesis. Moreover an accurate facial moulage is obtained from an accurate impression, which is of utmost importance for a well-adapted orbital prosthesis. Plaster of paris, elastomers and irreversible hydrocolloids[3] are few materials which are mentioned in the literature for the impression procedure out of which irreversible hydrocolloid impression material was chosen owing to its ease of manipulation, faster setting, biocompatible, elastic with required dimensional stability along with accurate detail reproduction. For the fabrication of the facial moulage a full impression was recorded from forehead to chin region with right eye passively closed. For uninterrupted breathing, during the entire impression procedure, the nasal nares were blocked with cotton, and two rubber hollow tubes were placed in the corner of the mouths. The area was boxed on all the sides with boxing wax, and irreversible hydrocolloid material alginate was mixed homogenously and painted on the surface initially and poured. Due care was taken to keep the thickness of the impression material to a minimum to avoid compression of the tissues. Wet gauze was applied over the impression when the impression material was about to reach the final set. Dental stone was later mixed and poured over the gauze to stabilize the impression. Later on the facial moulage was prepared with type III dental stone and was used as the working model [Figure 3] and [Figure 4].
Figure 3: Impression from working

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Figure 4: Facial moulage

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Working cast fabrication

Once the study model was ready, another impression was recorded with irreversible hydrocolloid specifics of the site. The defect was boxed with boxing wax and the alginate was painted on the surface and later poured to maintain the minimum thickness carefully so as to relieve the tissues of the defect from the pressure. All the unrequired undercuts in the final working cast were blocked. The wax pattern was sculpted onto the working cast [Figure 5].
Figure 5: Working cast

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Mode of retention

Modes of retention for the facial prosthesis vary from using spectacle, resin bonded attachments, magnets to engaging tissue undercuts, and adhesives, including other extensive treatment options like using osseo-integrated implants. The prosthesis planned was with spectacles as a mode of retention due to the presence of natural undercuts and monetary constraints. Spectacles are cost-effective, are easy to use and have been proven successful.[3]

Orientation of the prosthesis

It is necessary to orient the prosthetic eye according to the facial harmony. Grid method for iris positioning was used to center the pupil and measure the dimensions of the iris on the right eye. These markings were transferred onto the moulage to help in the positioning of the ocular portion of the orbital prosthesis. A stock ocular prosthesis that closely matched the color, size, and shape of the iris and sclera of the normal eye was selected. It was embedded in the wax pattern.[4]

Assessing the trial prosthesis

The wax pattern, along with the embedded eye shell, was tried in the defect of the patient [Figure 6] and [Figure 7].
Figure 6: Final wax up

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Figure 7: Try in of prosthesis

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Shade selection, selection of material and processing

Among the various materials available for the fabrication of the prosthesis, silicone was selected owing to the better marginal adaptation and life-like appearance.[5] Room temperature vulcanizing medical-grade silicone material was finalized as the material for the final prosthesis. It was mixed with pigments according to the manufacturer's instructions to match the skin shade of the patient. After shade matching, silicone was packed into the mold and bench cured for 24 h. Following polymerization, the prosthesis was retrieved and finished. Artificial eyelashes which are available in the market were glued to the prosthesis with the help of cyanoacrylate and delivered to the patient [Figure 8], [Figure 9], [Figure 10], [Figure 11].
Figure 8: Mould space obtained after dewaxing

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Figure 9: Final prosthesis obtained

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Figure 10: Post insertion

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Figure 11: Spectacle to mask the margins of prosthesis

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  Discussion Top


The orbital prosthesis replaces not only the bulb of the eye but also the surrounding tissues. The fabrication of orbital prosthesis with silicone is done with the added advantage of better marginal adaptation and more tissue-like appearance. The various challenges which one faces during fabrication of orbital prosthesis are accurate impression recording, which would make an accurate working cast model, also the proper positioning of the iris for orientation with the facial harmony. Other factors are material choice and proper processing.

An evisceration is a removal of the eyes contents leaving the extraocular muscles intact, which was the surgical procedure carried out on the patient at the age of 3. When the patient visited the clinic, she was wearing a faulty prosthesis with poor esthetics, which not only caused discomfort but also diminished her self-esteem. A successful prosthesis helps the patient to elevate the comfort levels but also boosts up the self-belief.

For long term usage after care of the prosthesis is of utmost important. The most commonly faced problems are margin tear, discoloration, loss of retentive elements. The discoloration may be associated with daily wear, pollution, effect of cleansing agents etc., Topical antimicrobial agents are suggested, but for severe chronic reactions the abutment may need to be removed to allow the tissues to heal.

The use of imaging techniques like computed tomography, and magnetic resonance imaging has lead to significant improvement in the field of diagnosis and visualization. These techniques have enabled us to see the defect in three dimensions. With these modalities, surgical planning can be prosthetically driven. Virtual planning makes the treatment more accurate and predictable.[6]

Rapid prototyping uses digital data to construct a physical model. It is being used widely in maxillofacial prosthetics for fabricating accurate three dimensional models when compared with the conventional impression techniques.[6]


  Conclusion Top


As rightly said “Beauty is a greater recommendation than any letter of introduction.”[7] Loss of an eye can severely affect the person functionally and psychologically. In developing countries like India, the prosthesis made up of silicone adds cost benefits. Orbital prosthesis also improves the quality of life.[8] “she cannot see the world, but now she can definitely face the world.” and here lies the success of an accurate orbital prosthesis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Majumdar MR, Sune MP, Mohod P. Helmet-induced ocular trauma: A rare mechanism. J Datta Meghe Institute Med Sci Univ 2017;12:292-93.  Back to cited text no. 1
    
2.
Aidsman IK. Glossary of prosthodontic terms. Journal of Prosthetic Dentistry. 1977;38(1):66-109.  Back to cited text no. 2
    
3.
Bindhoo YA, Aruna U. Prosthetic rehabilitation of an orbital defect: A case report. The Journal of Indian Prosthodontic Society. 2011;11(4):258.  Back to cited text no. 3
    
4.
Wadhwa VN. Esthetic Rehabilitation of an Orbital Defect Secondary to Surgical Management of Rhabdomyosarcoma. Int J Experim Denatl Sci 2017;6:108-10.  Back to cited text no. 4
    
5.
Hanasono MM, Lee JC, Yang JS, Skoracki RJ, Reece GP, Esmaeli B. An algorithmic approach to reconstructive surgery and prosthetic rehabilitation after orbital exenteration. Plast Reconstr Surg 2009;123:98-105.  Back to cited text no. 5
    
6.
Binit S, Goveas R, Thaworanunta S. Rapid fabrication of silicone orbital prosthesis using conventional methods. Singapore Dent J 2014;35:83-6.  Back to cited text no. 6
    
7.
Pisulkar SK, Agrawal R, Belkhode V, Nimonkar S, Borle A, Godbole SR. Perception of buccal corridor space on smile aesthetics among specialty dentist and layperson. J Int Soc Prev Community Dent 2019;9:499-504.  Back to cited text no. 7
    
8.
Gondivkar SM, Bhowate RR, Gadbail AR, Sarode SC, Patil S. Quality of life and oral potentially malignant disorders: Critical appraisal and prospects. World J Clin Oncol 2018;9:56-9.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]



 

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