Use of Modern Biomaterials in Ocular and Facial Prostheses
An absent eye, orbit, nose, ear, or even a large portion of the face, may be replicated with alloplastic external craniofacial prostheses. Absence of facial anatomy is due to congenital anomalies, trauma, or disease. Plastic surgery may not always yield the best result, considering the disease, health, and surgical risk of the patient. Patients may seek an anaplastologist, an individual dedicated to creating realistic anatomy in order to restore the form and function of the absent anatomy of the body and face. An ocularist specializes further by replicating only artificial eyes. Similarly a maxillofacial prosthodontist is one that specializes in restoring oral anatomy and function. Proper materials used in the fabrication of ocular and and facial prostheses are essential to patient satisfaction and improving the quality of life of individuals with facial differences.
Ocular implants for eviscerations and enucleations
When a patient is in need of an evisceration or enucleation, several implants have been used to replace the ocular contents within the tenon’s capsule such as polymethylmethacrylate (PMMA), hydroxyapatite, bio ceramic, and porous poly ethylene. An oculoplastic surgeon closes the tissue around the implant, inserts an healing conformer (an extruded thermoplastic PMMA shell shape), and allows 4-6 weeks of healing to occur prior to fitting of an artificial eye.
History of artificial eyes
The first prosthetic eyes were fabricated in ancient Egypt with clay, wax, or plaster, with crystal, quartz, or ivory with enamel as the irides, although there is no evidence of their use while living[Kelly]. In 2006, a mummy near Zabol, Iran was discovered with a prosthetic eye made of bitumen paste and secured externally to the orbit with a golden thread, dating approximately 4,800 years ago[Moghadasi].
The famous French surgeon Ambroise Paré described artificial eyes made of metal, presumably gold and silver, used within the lids or externally[Gibson]. In 1752, a German surgeon Laurent Heister wrote a book with recommendations for artificial eye wearers. He recommended the use of glass, rather than metal, due to being smoother and more tear compatible.
Artificial eyes made with glass began in Venice around 1579[Kelly]. Venetians maintained a monopoly on glass eyes until crystal became more broadly used throughout Europe. Notable is a French artificial glass eye maker by the name of August Boissenneau, who began as early as 1820 to teach and publish several books on artificial eyes. He is given credit for coining the term “Ocularist” and sold many stock artificial eyes to the Americas[Boissenneau]. Around 1835, a family of glass blowers began making artificial eyes with cryolite, a lower temperature mineral discovered in a mine near Lauscha in central eastern Germany[Danz]. The Mueller family became very well known for fabricating eyes and selling cryolite and metal oxides used for different pigments. Laushca became the epicenter of artificial eyes for training and supplies. Several Germans from Laushca emigrated to the United States in the 1800s and early 1900s and brought with them the skills of making artificial eyes. It is also worth noting that several Germanic speaking countries continue to make artificial eyes of cryolite glass, including descendents of the Muller family still located in Lauscha, Germany.
In the early 1900s, an early form of cellulose plastic was used to make artificial eyes and facial prostheses but didn’t prove to be successful[Bulbulian].
As the war was brewing in Germany prior to World War II, many American importers of cryolite glass and stock eyes foresaw supply issues. Just a decade earlier, Polymethylmethacrylate (PMMA), more commonly known as acrylic, was invented and sold under several different trade names. Dentists began using acrylic for artificial teeth. In 1939 Fritz Jardon, a dental technician, shared an office with some ocularists and began to make artificial eyes. He was hired by one of the predominant ocularist shops at the time to develop artificial eyes with PMMA[Danz]. He even experimented with embedding color photographs in the plastic to replicate the iris, something that ocularists still struggle to do today, although a few are successful[Zoltie]. When World War II erupted and the cryolite supply from Germany dwindled, ocularists and dental technicians quickly innovated with this new plastic material, filing several U.S. patents over the next ten years[Danz]. Fabrication techniques with PMMA continue to develop even until today as this is the most commonly used material for artificial eyes throughout the world.
Polydimethylsiloxane (PDMS), commonly known as silicone, was invented in 1943 by Dow Corning and was used in plastic surgery as early as the 1950s, and facial prosthetics in the 1960s[Roberts]. While silicone is predominantly used for fabricating facial prostheses to be applied externally to soft tissues, it was not used clinically until approximately 2005. Only a handful of ocularists and anaplastologists offer silicone eye prosthetics. Silicone could be an ideal material for its biocompatibility, flexibility, and workability.
Computer Aided Design (CAD) began in the 1990s and has flourished in the 2010s as patents on 3D printing have expired. Several people have created 3D printed artificial eyes[Moorsfield, Salazar]. 3D printers in 2022 are able to print in any Pantone™ color as well as clear[Salazar]. The challenge of color matching with 3D printing remains significant, stemming from the difficulties of adequately color matching using photographs. Questions with biocompatibility remain for ocular prostheses due to the proprietary formulations of 3D printed resins. Development of 3D printed materials is happening very fast and new materials are bound to come in a few short years.
Oculo-palpebral (orbital) prostheses for exenteration
An external facial prosthesis for orbital exenterations is called an orbital prosthesis when solely involving the soft tissue of the orbit. An upper facial prostheses restores the orbit in addition to portions of the frontal or zygomatic bones. A hemi-facial prosthesis restores the orbit in addition to portions of the nose or maxillary bone. Orbital, upperfacial, and hemi-facial external prostheses will all be referred to as orbital prostheses in this chapter.[Kesting, Sophie] Orbital exenterations include the removal of the globe, extraocular muscles, adipose tissue, and the optic nerve to the optic foramen[Tyers, Nassab]. Orbital exenterations are predominantly for oncological treatment. Occasionally, trauma or infection result in not just the loss of the eye but the surrounding tissue as well.
External orbital prostheses were first documented by Ambroise Paré, a prominent French barber surgeon known for conceptualizing and inventing not only surgical techniques and instruments, but prosthetics as well. In the mid 1500’s, Paré conceptualized many prosthetic devices including legs, noses, and eyes. The hypoblephara eye prosthesis that Paré conceptualized, had a wire that wrapped around the head and positioned the prosthetic eye on top of the atrophic eye. [Conroy, Snyder] Before this, prosthetic eyes were used in the Middle East and Egypt and made from clay, wood, ivory, wax, glass, leather, and metals.[Enoch, Popp, Wilson, Reisberg, Clarke]. In 1894, facial prostheses were made of a hard, black, opaque rubber material called Vulcanite which was invented for car tires.[Tetamore] After the turn of the century, a gelatin glycerin formula was individualized and given to each patient with a metal mold. Patients would cast their own prosthesis each week. It is unknown how common this was and how it was attached to the skin. Several metals such as silver, copper, aluminum, gold and tin were used to make prostheses.[Bulbulian] Metal prostheses were made by taking a life cast of the patient, shaping wax to fill the absent anatomy, then using an electroplating process to deposit dissolved metal cations onto the surface of the wax with an electrical current. An American artist named Anna Coleman Ladd drew a lot of attention to this process when she used her artistic skills with the American Red Cross and fabricated approximately 185 metal masks for French soldiers wounded in World War I in Paris.[Alexander, Archives, Kazanjian, Defosses] (FIGURE 7 of French soldier).
Rigid plastics such phenolic and cellulose plastics, polymethylmethacrylate (commonly known as acrylic), and vinyl and styrene plastics were exciting new materials in the early twentieth century because of their translucent qualities. Simultaneously, flexible but less durable materials such as latex and plasticized polyvinyl chloride (commonly known as plastisol in screen printing shirts).[Bulbulian] By the mid 1900’s, most facial prostheses were made with polymethylmethacrylate, rubber latex, and plasticized polyvinyl chloride. In the 1940’s, a super elastic and translucent material called polydimethylsiloxane, commonly known as silicone rubber, was invented. In the 1960’s, surgeons were using silicone rubbers as subdermal implants to augment the face and prosthetists started using them for facial prosthetics.[Wainstock, Cantor] Silicones evolved to have incredible elongation and tear properties since the 1940’s. Silicone rubber is the predominant material for facial prostheses today but there are some prosthetists that make prostheses with acrylic plastic because silicones may not be accessible in all areas of the world and silicones are not as durable (FIGURE 8).
Advances in Fabrication Techniques and Biocompatible Materials
Thermoplastic polyurethanes have great elongation and tear properties and could also be used if fabrication methods evolve with three dimensional printing. The commercialization and open source nature of three dimensional printing has lowered the cost and facilitated the fabrication of custom shapes with thermoplastic materials. Soon prosthetists will have many more materials and methods for fabricating facial prosthetics.
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