Indian Journal of Dental Research

CASE REPORT
Year
: 2018  |  Volume : 29  |  Issue : 6  |  Page : 840--843

Combination of skin flap and silicone prosthesis for rehabilitation of a large orbital defect: A case report


Nafij Bin Jamayet1, Ahmed Mushfiqur Rahman1, Md Minhaz Ul Islam Nizami1, Yanti Johari2, Adam Husein3,  
1 Maxillofacial Prosthetics, Prosthodontic Unit, School of Dental Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
2 Prosthodontic Unit, School of Dental Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
3 Dean, School of Dental Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia

Correspondence Address:
Dr. Nafij Bin Jamayet
School of Dental Sciences, Universiti Sains Malaysia, 16150 Kota Bharu, Kelantan
Malaysia

Abstract

Exenteration surgery greatly affects a person in terms of function, esthetics, and psychological trauma. In such cases, restoration by silicone orbital prosthesis is a well-accepted treatment option. However, this is a difficult task, necessitating personalized design of method for each patient. This case report describes the technique for fabrication of a silicone orbital prosthesis for a male patient with left orbital defect due to exenteration of a Grade 3 squamous cell carcinoma of the left eye and surrounding tissues. The patient was delivered with a satisfactory silicone orbital prosthesis having good retention and finish. Multidisciplinary management and team approach are crucial in providing precise and effective rehabilitation for improving the patient's quality of life and help them return to their normal social life.



How to cite this article:
Jamayet NB, Rahman AM, Nizami MU, Johari Y, Husein A. Combination of skin flap and silicone prosthesis for rehabilitation of a large orbital defect: A case report.Indian J Dent Res 2018;29:840-843


How to cite this URL:
Jamayet NB, Rahman AM, Nizami MU, Johari Y, Husein A. Combination of skin flap and silicone prosthesis for rehabilitation of a large orbital defect: A case report. Indian J Dent Res [serial online] 2018 [cited 2019 Sep 22 ];29:840-843
Available from: http://www.ijdr.in/text.asp?2018/29/6/840/248237


Full Text

 Introduction



Total orbital exenteration is a radical surgical procedure which typically involves removal of the entire orbital contents. Consequently, the patient suffers from a deep orbital deformity with devastating cosmetic and functional implications that require expensive and technically challenging oculoplastic intervention, not to mention the associated psychological effects. Orbital prosthesis offers an attractive and suitable alternative when esthetic and functional demands are beyond the capacity of local reconstructive efforts.[1],[2],[3],[4],[5] Ablative surgical procedure incurs major financial burden, and hence, the patient may seek a prosthetic treatment that is economical and long lasting. Therefore, selection of a reasonable maxillofacial prosthetic material is important for rehabilitating such patients. Since silicone elastomers have better marginal adaptation and lifelike appearance, it is now usually used for the fabrication of orbital prostheses.[4],[5],[6],[7],[8]

 Case Report



A 56-year-old male patient was referred to the Department of Maxillofacial Prosthetics, School of Dental Sciences, Universiti Sains Malaysia, for an orbital prosthesis. A history of exenteration of orbit was noted, which had been carried out due to eradication of a Grade 3 squamous cell carcinoma. It was a Stage 3 carcinoma which made the eradication more extensive. As a result, the defect after the surgery was quite huge that extended till the lower border of maxilla, and a skin flap was taken from the thigh to replace the majority part of the defect.

Procedure

Before the patient's referral to the maxillofacial prosthetic team, he had undergone an extensive surgery of excision of the carcinoma through extended total maxillectomy (external approach) with left eye orbital exenteration and partial removal of the left lamina papyracea floor and medial, anterior, and lateral wall of the left maxillary sinus followed by soft-tissue reconstruction of the left cheek with free myocutaneous anterolateral thigh flapAfter referral was complete, patient evaluation was done to determine the defect extension and size of the orbital prosthesis [Figure 1]Before taking impression, few preparations had to be made. Orientation marks were drawn on the supraorbital rim denoting nasal midline, medial canthus area, iris, lateral canthus in horizontal plane, and interpupillary line with a point on the nasal bridge of lateral canthus area. These lines will be detected in the impression and transferred onto the cast, providing orientation for wax sculpting [Figure 2] and [Figure 3]. Then, a boxing wax framework was prepared to hold the impression material in the desired area of the faceThe eyebrows were lubricated with petroleum jelly just before taking impression. Then, chair-side impression of the defect was taken with polyvinyl siloxane material with broken pieces of tongue blade as matrix for the impression material. Over that, regular set alginate was poured onto the boxed area and allowed to set. The completed facial moulage with polyvinyl siloxane incorporated into the alginate material was carefully removed [Figure 2]A working cast was fabricated by pouring the impression with Type III dental stone [Figure 3]Basic sculpting was done using wax. Then, a stock ocular prosthesis modified to match the patient's companion eye was incorporated in position into the wax with the help of the orientation marks on the cast, and try-in on the patient was done [Figure 3]Rest of the sculpting session was carried out in the presence of the patient restoring all deficient contours and the margin was adapted. The finalized sculpt was placed on the cast and the margin was sealed [Figure 3]Then, two-piece mold was fabricated and thoroughly dewaxed, dried, and made ready for silicone loadingRoom-temperature vulcanized silicone A 2000 (Factor II Inc., Lakeside, AZ, USA) was dispensed in a mixing pad, and intrinsic coloring pigments (Intrinsic coloring kit, Factor II Inc.) were added to obtain a base shade matching to that of the patient [Figure 4]The silicone was then packed into the stone mold and left for 72 h for complete polymerization as per the manufacturer's instructionThe excess flash was trimmed, and chair-side extrinsic staining was performed [Figure 4]Then, the final orbital prosthesis was ready and inserted by applying water-based adhesive onto the margins, and tissue undercuts were utilized to retain the prosthesis [Figure 4].{Figure 1}{Figure 2}{Figure 3}{Figure 4}

 Discussion



The significance of an orbital prosthesis with satisfactory esthetics and practical motility in rehabilitating the normal appearance in patients has been recognized as a viable treatment option for a long time.[4],[7],[9] The necessity for an artificial eye can sometimes be satisfied by stock ocular prosthesis that comes in various sizes, shapes, and colors. These stock ocular prostheses are comparatively inexpensive and they also facilitate quick supply of the orbital prosthesis. However, often a custom-made ocular prosthesis is recommended that has the advantage of better adaptation to the underlying tissues, increased agility of the prosthesis, improved facial contours, and enhanced esthetics. Nevertheless, a custom-made prosthesis is far more expensive than a stock ocular prosthesis and requires several time-consuming steps for its fabrication. Therefore, a modified stock ocular prosthesis in an orbital prosthesis is an excellent alternative which is relatively less expensive and easy to fabricate.[2],[3],[10] A precise alignment of the artificial eye is one of the foremost prerequisites for esthetic accomplishment of an orbital prosthesis. Facial measurements and several devices have been proposed for positioning the ocular portion of the orbital prosthesis.[11]

In this particular case, the defect was massive for an individual silicone orbital prosthesis to replace. One single large orbital prosthesis to cover the entire defect would have been overweight. Its weight would have dragged the prosthesis downward due to gravity and compromised the positioning and esthetics of the orbital prosthesis.[7],[9],[10] To avoid these complications, a skin flap was used from the thigh that extended from the lower border of the defect that coincides with the lower border of maxilla up to 3 mm below the orbital cavity. The introduction of the reconstructive flap made the maxillofacial prosthetic team to provide the patient with an ocular prosthesis which would have been more esthetic and was the first choice of rehabilitation instead of orbital prosthesis. Unfortunately, fabrication of ocular prosthesis was not possible due to the excruciating pain felt by the patient during impression taking owing to the positioning of suture of the flap.

Although the use of skin flap reduced the surface area for orbital prosthesis, it also introduced the risks of flap discrepancy and donor-site complications.[12],[13] Moreover, the skin flap posed few challenges in the fabrication procedure of the orbital prosthesis. Accurate preliminary impression taking became difficult due to the large extension of the flap. However, the complete facial moulage impression technique helped to overcome this problem. Another challenging aspect of this fabrication method was the coloration of the prosthesis. The color of the upper part of the prosthesis had to be matched with the skin tone of the forehead, whereas the lower part had to be related to the color of the flap. This dual-color shade of the prosthesis would have been much easier with digital imaging.[14] Unfortunately, manual imaging was done in this case. Nevertheless, the final extrinsic coloration achieved a shade that was acceptable by the patient.

 Conclusion



The rehabilitation of an orbital defect is a difficult task, and if plastic surgery cannot reconstruct the defect or is not desired or afforded by the patient, it can be rehabilitated by orbital prosthesis. However, multidisciplinary management and team approach are crucial in providing precise and effective rehabilitation for improving the patient's quality of life and help them return to their normal social life.

Acknowledgment

This case study was supported by USM short-term grant no: 304/PPSG/61313144.

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.

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