Closed-eye orbital prosthesis: A clinical report Muhanad M. Hatamleh, BSc, MPhil, MSc, Dip, PhD, a Jason Watson, BMedSci, b and Dilip Srinivasan, MD c Nottingham University Hospital Trust, Nottingham, UK; King’s College Hospital, London, UK One of the most challenging prostheses to fabricate is an acceptable orbital prosthesis. Successful reconstruction of the complex missing tissues, the globe, muscle, skin, and bony elements requires time and high levels of practical skill. A good match to the contralateral nondefect side will help mask the underlying defect and give the patient confidence to return to normal, routine life. The contralateral eye opening will commonly dictate the eye opening of such a prosthesis, but because of the expressive nature of the eye and its high levels of mobility, this can be difficult to achieve. This clinical report presents a patient who had an extended orbital exenteration and right maxillectomy to remove a maxillary squamous cell carcinoma. An alternative approach to constructing an orbital prosthesis was undertaken with the eye closed. Compared to the normal method of fabrication, this process was less complex and quicker, made the prosthesis less “staring,” camouflaged the defect, and reduced the detection of the prosthesis because of movements in the remaining eye. The patient engaged in his routine daily life, which reinforced his self-esteem, confidence, and reintegration into the community. (J Prosthet Dent 2014;-:---) The crucial role of facial features in daily interpersonal relationships is readily appreciated. High value is placed upon personal attractiveness in most societies, and most people are sensitive to the effect they have on others. Changes in facial features are likely to be accompanied by various types of diffi- culties. 1-3 A patient’s self-perception, emotional stability, personality charac- teristics, and social circumstances appear to be the salient factors in dealing with maxillofacial defects and the rehabilitation process, 3 and, when esthetic and functional demands cannot be surgically fulfilled, a facial prosthesis is a practicable alternative. 4-6 Such a prosthesis can improve the patient’s appearance, enable early rehabilitation, shorten surgery and hospitalization time, lower treatment cost, and allow early psychosocial reintegration. 1,2,7,8 In 2007, of 1200 facial and body pros- theses fabricated in the UK, orbital prostheses ranked third (155 orbital). 8 Exenteration, or removal of the entire orbital contents (globe, muscle, fat, lids), is performed primarily to eradicate malignant orbital tumors. 9 Prostheses designed to cover the remaining defect and replace the missing tissues are commonly described as orbital prostheses. They can be retained by various methods from the anatomic undercuts left after surgery to medical adhesives or implants. In the majority of patients, satis- faction depends on how the prosthetic eye (and its components) resembles the contralateral site. 10-14 The patient will continuously compare the artificial prosthesis to the ocular component (iris and sclera), skin shape, texture, color, and the lids of the contralateral eye. The lids are highly complex and mobile and are important in adding not only anatomic contour but also personality and character specific to the patient. The shaping of the lids is fixed in the final stage of manufacture, so the final wax work has to capture many different “faces” of the patient. This is extraordinarily difficult to get right the first time. The following clinical report presents an unusual process for fabricating an orbital prosthesis while the subject keeps his or her eye closed. CLINICAL REPORT A 63-year-old man was referred to the reconstructive clinic at the Maxillo- facial Unit of Queens Medical Center in Nottingham, UK, for the fabrication of an orbital prosthesis. After being diag- nosed with a right maxillary squamous cell carcinoma, he underwent an extended right orbit exenteration that included part of the right cheek and a partial maxillectomy (Fig. 1A). The pa- tient had received no radiotherapy after his primary surgery, and the site had healed well with no complications. Af- ter his initial healing (3 months), he was referred to a local prosthetist with little experience at his district general hospital. After 8 months and multiple visits to the hospital, he was provided with a poor prosthesis that he described as being “staring” and “angry a Senior maxillofacial prosthetist, Maxillofacial Department, King’s College Hospital. b Consultant maxillofacial prosthetist, Maxillofacial Department, Queens Medical Centre, Nottingham University Hospital Trust. c Consultant maxillofacial surgeon, Maxillofacial Department, Queens Medical Centre, Nottingham University Hospital Trust. Hatamleh et al