Rehabilitation of an Ocular Defect Using a Custom Ocular Prosthesis in a Pediatric Patient

Akansha V Bansod¹, Sweta Pisulkar², Arushi Beri³, Seema Sathe⁴

^1-4Department of Prosthodontics and Crown & Bridge, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Medical Sciences (Deemed University), DMIHER, Wardha, Maharashtra, India

Corresponding Author: Akansha V Bansod, Department of Prosthodontics and Crown & Bridge, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Medical Sciences (Deemed University), DMIHER, Wardha, Maharashtra, India, Phone: +91 8208726715, e-mail: akanshabansod29@gmail.com

ABSTRACT

It is a well-known saying that the eyes are “windows to the soul.” The absence or loss of any facial part, particularly the vision, can lead to severe physical as well as emotional trauma. Losing any part of the face causes the patient societal, physical, and psychological anguish. An ocular prosthesis aims to improve social acceptance and boost self-confidence by restoring the facial appearance. A pediatric dental specialist should be a part of the maxillofacial prosthesis team since maxillofacial prosthetic rehabilitation in young children can be challenging, especially with the less cooperative ones. The following case report describes these challenges in relation to a 5-year-old boy who had his eye enucleated due to trauma. The purpose of the case was to provide custom-built, acrylic ocular prostheses in as comfortable and atraumatic manner as possible by the maxillofacial prosthetic team.

How to cite this article: Bansod AV, Pisulkar S, Beri A, et al. Rehabilitation of an Ocular Defect Using a Custom Ocular Prosthesis in a Pediatric Patient. Int J Clin Pediatr Dent 2024;17(4):479-482.

Source of support: Nil

Conflict of interest: None

Patient consent statement: The author(s) have obtained written informed consent from the patient’s parents/legal guardians for publication of the case report details and related images.

Keywords: Case report, Children, Maxillofacial prosthesis, Maxillofacial prosthodontist, Ocular prosthesis.

INTRODUCTION

The loss or absence of an eye not only physically disables the child, but it correspondingly has a long-term psychological impact on the patient. As the orbital sockets of pediatric patients are constantly growing, replacement of the eye at an early age is necessary.¹ As delay in rehabilitation may form the basis for asymmetrical growth of the face, the shape and the volume of the enucleated socket ought to be well-maintained. This can lead to significant esthetic issues in adulthood.²

There are varied techniques and materials for making ocular prostheses in the literature. It could either be a stock eye, a modified stock eye on the ocular defect, or a customized ocular prosthesis. Stock available eyes are less time-consuming but have a few drawbacks, such as compromised esthetics and unacceptable fit.³ Custom-made ocular prostheses provide better fitting and enhanced esthetics, but they are time-consuming and require expertise pertaining to the fabrication of the prosthesis and patience, considering the rehabilitation of the defect in a child. A stock eye prosthesis can be used as an interim prosthesis but should always be replaced by a custom-made prosthesis.⁴^,⁵ This case series demonstrates a simplified technique for fabricating custom ocular prostheses for pediatric patients that provides an esthetically pleasing result while remaining comfortable.

During the initial examination, the patient was uncooperative and aggressive. Positive reinforcement was used in a collaborative approach with the pediatric dentist to help the patient cooperate with the potentially traumatic procedure and cope with the psychological trauma. The maxillofacial team could work efficiently and meet the treatment objectives by allowing the patients to manage during this time-consuming and challenging procedure. Hence, a multidisciplinary approach combining the ophthalmologist, surgeon, maxillofacial prosthodontist, and pediatric dentist was beneficial for esthetic and stable outcomes for the patient.

CASE DESCRIPTION

A 5-year-old male patient reported to the prosthodontics outpatient department in need of left ocular prostheses. The patient provided a history of trauma to the left eye 2 months back in the left eye, for which he had to undergo enucleation of the contents of the orbit, resulting in the acquired ocular defect. He presented with an anophthalmic socket with complete healing, as shown in Figure 1.

Figs 1A and B: Preoperative photograph; (A) Preoperative photograph of a patient with an ocular defect on the left side; (B) Close-up view of the defect site

No signs of inflammation and tenderness were present; hence, we could proceed with rehabilitation of the defect with an ocular prosthesis. We opted for custom-made ocular prostheses to meet the esthetic demands. A preliminary impression was made with alginate, irreversible hydrocolloid impression material (Pyrax Accurax Impression Alginate), as seen in Figures 2 and 3.

Fig. 2: Preliminary impressions made with irreversible hydrocolloid impression material

Figs 3A and B: Customized tray attached to a syringe and final impression obtained; (A) Customized tray fabricated using clear acrylic resin and attached to a syringe; (B) Final Impression obtained in light body polyvinyl siloxane impression material

From the final impression obtained, a two-piece type III dental stone (Shivam Dental Stone Type III) cast was poured. After the stone had been set, the surface was treated with separating media (Dental Products of India, Mumbai). Then, another layer was added. For correct reorientation of the cast, markings in the form of grooves were made on all four sides. The melted wax was then poured into the mold cavity to create the wax design (Fig. 4A). The wax pattern was gently removed once it had hardened and cooled in cold water. The wax was suitably carved and contoured to simulate the missing eye. During try-in, the wax pattern was tested for fullness, size, retention, support, and comfort in the patient’s socket by performing functional movements. The patient suffered mild blepharospasm and was given a few minutes to get used to it. The patient was then asked to sit up straight and keep the head erect. Using a prefabricated eye shell, the size and color of the iris and cornea portion were chosen (Figs 4B to D). The wax pattern was modified to reflect the typical gaze position using an iris that coincided with the right eye. It was trimmed to the required size during the second try-in, which had been indicated on the shell beforehand. The iris position was validated using the grid approach by examining the iris point from a distance of roughly 9 ft in front.

Figs 4A to D: Wax pattern fabrication and iris positioning; (A) Melted wax was poured into the two-piece mold obtained on pouring the final impression; (B) Grid method was used to confirm the iris position by the operator; (C) Iris matching to simulate the right eye; (D) Iris embedded in the wax pattern for try-in

The wax pattern was tried on the patient, esthetics were reevaluated, and approval for final fabrication was obtained from the patient and his relatives (Fig. 5). The scleral shell’s surface was covered with a small coating of wax to make room for clear acrylic, which produced a lifelike effect. The wax pattern was flasked with dental stone (Fig. 6A). After setting, the wax pattern was removed and packed using a mixture of clear heat-cure acrylic resin (Dental Products of India, Mumbai) and heat-cure acrylic resin (Dental Products of India, Mumbai), whose color was initially matched to the scleral portion of the opposing eye. Additionally, fine red silk threads were added to the resin to mimic the veins in the orbit (Fig. 6B).

Fig. 5: Try-in of the wax pattern

Figs 6A to C: Laboratory steps in the fabrication of final prosthesis; (A) Flasking of the wax try-in using dental stone; (B) Packing of the final prosthesis with customization of sclera, fine red silk threads were added to the resin to mimic the veins in the orbit; (C) Finished and polished ocular prosthesis

Following curing, the prosthesis was finished and polished. The prosthesis’ rough edges were carefully trimmed. To give the prosthesis a naturally glossy surface, polishing burs, pumice, and buff were used in the polishing process (Fig. 6C). It was then placed within the patient’s eye. The patient was taught about the insertion and removal of the prosthesis, and instructions regarding care and hygiene were given. The patient was informed that the prosthesis could need to be repolished on a timely basis in the near future as shown in Figure 7.

Fig. 7: Ocular prosthesis insertion after finishing and polishing

DISCUSSION

The ocular prosthesis is a synthetic replacement for the anophthalmic socket. After the surgeon has enucleated the eye, a maxillofacial prosthodontist is a person who provides the patient with an artificial eye to alleviate the suffering of losing an eye.⁶ When the patient performs various movements, a properly constructed and well-made ocular prosthesis keeps its orientation. Though not functional, it is a very apt esthetic replacement for patients. It restores the self-confidence of the patient and prevents social embarrassment.⁷

This method outlines the creation of an ocular prosthesis using materials that are widely accessible and utilized often by maxillofacial prosthetists. The customized prosthesis ensures a good fit and a natural esthetic outcome. Allergic reactions have not been reported yet, despite treating several patients in India. In order to prevent conjunctival irritation, the prosthetic eye must be polished carefully under magnification and repeated at regular intervals during follow-up visits.⁸^,⁹

Several kinds of ocular prostheses/implants are currently available. Adult enucleation without orbital replacement therapy resulted in bone orbital collapse and impairment, and growth retardation in enucleated sockets leads to facial asymmetry.¹⁰ Without prompt replacement of progressively bigger orbital prostheses, children with an anophthalmic socket are at significant risk of developing craniofacial deformity. Yago and Furuta stated that craniofacial development is linked to definite functional demands. The interaction of the soft tissues and muscles of the eye, especially the orbital socket region, provides the necessary movement for proper bony development of the socket.¹¹ As a result, the prosthesis acts as a growth matrix, preventing anophthalmic socket collapse and thus promoting natural development, tissue stimulation and maintaining facial symmetry.¹² Bentley et al. suggested immediate replacement of the lost orbital volume after enucleation with stock ocular implants or conformers followed by customized ocular prosthesis.¹³ This way, the prosthesis will prevent the socket collapse and maintain the natural development of the face in pediatric patients.

CONCLUSION

The custom-made prosthesis outperformed the stock ocular prosthesis in terms of esthetic results. The technique used here is straightforward, simplified and inexpensive. Despite the patient’s inability to see with this prosthesis, it will increase their self-assurance in public. Pedodontists may need to broaden their parts to assist maxillofacial prosthodontists and other specialists who are treating young children. Future care of the pediatric population with complex medical needs may depend on an understanding of the associated challenges.

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