SQU Med J, May 2011, Vol. 11, Iss. 2, pp. 276-279, Epub. 15th May 11
Submitted 1st Dec 10
Revision ReQ. 12th Jan 11, Revision recd. 17th Jan 11
Accepted 15th Feb 11

Orbital eXenteration is a radical procedure consisting of removal of the orbital contents, including orbital fat, 
conjunctival sac, globe, and a part or whole of the 
eyelids1. Orbital defects are injurious to a person’s 
self-concept and sense of body image. Treatment 
should be provided as soon as possible to raise 
morale and ease the mind of the afflicted person. 

Orbital prostheses are made of silicone 
elastomers, acrylic resin, or a combination of 
these.2 Most maxillofacial elastomers perform well 
initially, but deterioration, associated with either 
degradation of mechanical properties or changes 
in appearance, commonly occurs subsequently.3-8 
This deterioration limits the service life of extraoral 
prostheses, and refabrication of these prostheses is 
time consuming, labour intensive, and costly.  

Moreover, extraoral prostheses are exposed 
to mucosa and skin secretions; subsequently, 
multilayer biofilm formation can occur on the 

silicone surfaces. Problems such as black stains 
on the surface of prostheses, offensive odours, 
and tissue infection can arise from microbial 
colonisation.9

Karakoca et al. reported a mean life span 
of 14.5 to 14.7 months for a patient’s first and 
second implant-retained extraoral prostheses, 
respectively. The primary reasons for making a 
new prosthesis were discoloration, tear of the 
prosthesis, and mechanical failures of the acrylic 
resin substructure or retentive elements.10 Jebreil 
reported that adhesive-retained orbital prostheses 
last for 6–9 months and need to be refabricated 
subsequently.11

Problems with silicone orbital prosthesis 
can be avoided by reconstructing the upper and
 lower eyelids surgically and then rehabilitating 
with custom-made ocular prostheses. 
This clinical report describes the management 
of a patient with an orbital defect by a 

Department of Prosthodontics, Government Dental College and Research Institute, Bangalore 560002, India.
*Corresponding Author email: dr_poojagarg@yahoo.com

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ABSTRACT: Reconstruction of an exenterated orbit remains a challenge. Orbital prostheses are nowadays are made 
of silicone elastomers. A major limitation with silicone orbital prostheses is their relatively short life span. This 
case report describes the treatment of a patient with an exenterated orbit using a combined surgical and prosthetic 
approach. The upper and lower eyelids were reconstructed surgically using a deltopectoral flap. A sectional eye 
prosthesis was made and placed in the modified bottle-neck shaped defect to restore the patient’s appearance and 
confidence.

Keywords: Exenteration; Ocular prosthesis; Maxillofacial prosthesis; Psychology; Silicone elastomers; Case report; 
India

Reconstruction of Exenterated Orbit using 
Combined Surgical and Prosthetic Approach

D R Prithviraj, Anish Gupta, Sumit Khare, *Pooja Garg, Malesh Pujari

CASE REPORT



D R Prithviraj, Anish Gupta, Sumit Khare, Pooja Garg and Malesh Pujari

Case Report | 277

combined surgical and prosthetic approach.

Case Report
A 24 year-old woman, who had undergone a 
right orbital exenteration for orbital meningioma, 
presented to the Department of Prosthodontics and 
Implantology, at the Government Dental College 
and Research Institute (GDCRI), Bangalore, India, 
for rehabilitation of an orbital defect [Figure 1]. It 
was decided to reconstruct the eyelids surgically 
in collaboration with the department of Plastic 
Surgery, Victoria Hospital, Bangalore. 

A deltopectoral flap from the second and third 
intercostal region was raised and then rotated into 
the exenterated orbit and sutured to the free skin 
margins. After 3 weeks, the pedicle was separated 
from the intercostal region. Four weeks later the 
flap was divided to construct the upper and lower 
eyelids. After 6 months, the patient presented to 
the Department with reconstructed upper and 
lower eyelids [Figure 2]. Although plastic surgery 
resulted in marked improvement, yet the resultant 
eyelids were thick, tense, and scarred. Moreover, 
the modified orbital defect was bottle-neck shaped.  
The palpebral aperture was 15 mm whereas the 
cavity inside was approximately 32 mm; hence, it 
was virtually impossible to fabricate a single piece 
eye prosthesis. This necessitated a unique treatment 
modality for the rehabilitation of the modified 
exenterated orbit. 

Separate impressions were made of the superior 
and inferior surfaces of the defect using irreversible 
hydrocolloid material (Hydrogum, Zhermack SpA, 
Italy). After that, irreversible hydrocolloid was 
injected directly into the remaining socket using 
an ocular impression tray. Multiple parts of the 
impression were assembled outside to pour a two-

piece dental stone cast. Three pieces of wax template 
were fabricated to be assembled in a specific 
spatial configuration in the reconstructed orbit 
and processed using heat cure acrylic (Trevalon, 
India). A notch was made in the middle piece for 
orientation of the fourth piece. After placing the 
multiple pieces of eye prosthesis in the modified 
orbit, an impression for the fourth piece was made 
according to the Allen and Webster technique.12 The 
irreversible hydrocolloid material was injected into 
the remaining socket through the attached hollow 
stem of the impression tray. 

Using this impression and a small plastic 
tumbler, an irreversible hydrocolloid mould was 
prepared, which was cut using a sharp blade to 
remove the impression. The mould space was 
subsequently filled with molten inlay wax. Once 
the wax was hard, it was removed from the mould, 
and the external surface was smoothed for a try-in 
on the patient’s face. The wax form and its corneal 
prominence were modified wherever necessary to 
duplicate the shape of the natural eye. After a try-in 
the wax template was processed using white acrylic. 
The acrylic shell was removed and trimmed for 
about 1–2mm on the external surface.  

During iris orientation patient was asked to gaze 
straight ahead. The distance from the pupil of the 
normal eye to the midline was used in establishing 
the horizontal position of the prosthetic pupil’s 
centre. Its vertical position was determined by the 
canthus relationships. Marked coordinates of the 
pupil were used to circumscribe the diameter of the 
iris. Iris and scleral painting were carried out using 
acrylic colors and mono-poly. As the palpebral 
aperture of the reconstructed eyelids was larger 
than that of the natural eye, it was camouflaged 
during scleral painting. Subsequently, using the 
same plaster mould, the eye shell was packed with 

Figure 1: Orbital defect following exenteration Figure 2: Reconstructed upper and lower eyelids 



Reconstruction of Exenterated Orbit using Combined Surgical and Prosthetic Approach

278 | SQU Medical Journal, May 2011, Volume 11, Issue 2 

transparent acrylic to give a natural appearance. 
Later, it was removed from the mould, trimmed, 
finished and polished. The prosthesis was placed 
into the ocular defect and critically evaluated 
[Figure 3]. Spectacles were used to camouflage the 
scarred tissue [Figure 4]. At the time of writing, the 
prosthesis had been in service for 9 months without 
complications. 

Discussion
This case report describes the treatment of a patient 
with exenterated orbit using a combined surgical 
and prosthetic approach. Upper and lower eyelids 
were reconstructed surgically using a deltopectoral 
flap from the second and third intercostal region to 
avoid the fabrication of a silicone prosthesis.

Silicones have been used for over 50 years 
in the field of maxillofacial prosthetics, with 
desirable material properties including flexibility, 
biocompatibility, ability to accept intrinsic and 
extrinsic colorants, chemical and physical inertness 
and mouldability.9,13 A major limitation with silicone 
orbital prostheses is their relatively short life span 
(on average 1.5 to 2 years). The main reasons for the 
refabrication of orbital prostheses are discoloration, 
problems with the attachment of the acrylic resin 
clip carrier to the silicone, rupture or deterioration 
of the silicone material and a poor fit. Moreover, 
meticulous hygiene is mandatory to prevent peri-
implant problems, including inflammation of the 
skin in the implant retained orbital prosthesis.14

The resultant eyelids were thick, tense, and 
scarred and the modified orbital defect was 
bottle-neck shaped. A sectional eye prosthesis 
was fabricated to overcome this limitation. The 
impression was made with irreversible hydrocolloid 
which helped in retrievability of the impression from 

undercut area. Heat cure polymethyl methacrylate 
was used for fabrication of the prosthesis which 
has better biocompatibility.4 Multiple pieces of eye 
prosthesis were fabricated to be assembled in a 
specific spatial configuration in the reconstructed 
exenterated orbit. The prosthesis, although static, 
helped restore the patient’s appearance and 
confidence. In the absence of recurrent orbital 
meningioma, this prosthesis can be a definitive 
treatment for the patient.

Conclusion
Reconstruction of the exenterated orbit remains a 
challenge. Patients in this situation can be treated 
by reconstructing the upper and lower eyelids 
surgically and then rehabilitation with custom-
made ocular prostheses. 

a c k n o w l e d g e m e n t

The authors would like to thank the patient for 
granting consent for her case and photographs to 
be published.

References
1. Perman KI, Baylis HI. Evisceration, enucleation and 

exenteration. Otolaryngol Clin North Am 1988; 
21:171–82. 

2. Kurunmaki H, Kantola R, Hatamleh MM, Watts DC, 
Vallittu PK. A fiber-reinforced composite prosthesis 
restoring a lateral midfacial defect:A clinical report. J 
Prosthet Dent 2008; 100:348–52.

3. Han Y, Kiat-amnuay S, Powers JM, Zhao Y. Effect 
of nano-oxide concentration on the mechanical 
properties of a maxillofacial silicone elastomer. J 
Prosthet Dent 2008; 100:465–73.

4. Dootz ER, Koran A 3rd, Craig RG. Physical properties 
of three maxillofacial materials as a function of 
accelerated aging. J Prosthet Dent 1994; 71:379–83.

Figure 3: Multiple unit eye prosthesis placed in 
reconstructed exenterated orbit

Figure 4: Spectacles used to camouflage the scarred 
tissue



D R Prithviraj, Anish Gupta, Sumit Khare, Pooja Garg and Malesh Pujari

Case Report | 279

5. Haug SP, Moore BK, Andres CJ. Color stability and 
colorant effect on maxillofacial elastomers. Part II: 
Weathering effect on physical properties. J Prosthet 
Dent 1999; 81:423–30.

6. Frangou MJ, Polyzois GL, Tarantili PA, Andreopoulos 
AG. Bonding of silicone extraoral elastomers to 
acrylic resin: The effect of primer composition. Eur 
J Prosthodont Restor Dent 2003; 11:115–8. 

7. Lemon JC, Chambers MS, Jacobsen ML, Powers JM. 
Color stability of facial prostheses. J Prosthet Dent 
1995; 74:613–8.

8. Polyzois GL, Tarantili PA, Frangou MJ, Andreopoulos 
AG. Physical properties of a silicone prosthetic 
elastomer stored in simulated skin secretions. J 
Prosthet Dent 2000; 83:572–7. 

9. Kiat-amnuay S, Johnston DA, Powers JM, Jacob RF. 
Color stability of dry earth pigmented maxillofacial 
silicone A-2186 subjected to microwave energy 
exposure. J Prosthodont 2005; 14:91–6.

10. Karakoca S, Aydin C, Yilmaz H, Bal BT. Retrospective 
study of treatment outcomes with implant-retained 
extraoral prostheses: Survival rates and prosthetic 
complications. J Prosthet Dent 2010; 103:118–126.

11. Jebreil K. Acceptability of orbital prostheses. J 
Prosthet Dent 1980; 43:82–5.

12. Allen L, Webster HE. Modified impression method 
of artificial eye fitting. Am J Ophthalmol 1969; 
67:189.

13. Jani RM, Schaaf NG. An evaluation of facial 
prostheses. J Prosthet Dent 1978; 39:546–50.

14. Anita V, Raghoebar GM, Oort RP, Vissink A. Fate of 
implant-retained craniofacial prostheses: Life span 
and aftercare.  Int J Oral Maxillofac Implants 2008; 
23:89–98.