J.

Adv Dental Research

All Right Res

CASE REPORT

Enhancement of stability for mandibular

complete denture prosthesis in atrophied
ridge with neutral zone technique A
case report
Viraj Patil* R B Hallikerimath** Shweta Magadum***
*M.D.S, Professor, **M.D.S, Professor, ***Post Graduate student, Department of Prosthodontics,
Maratha Mandals Nathajirao G. Halgekar Institute of Dental Sciences and Research Centre.
Belgaum. Karnataka, India. Email: drvirajpatil@gmail.com
Abstract:
The Neutral Zone technique is not a new but a very
valuable technique, it is an alternative approaches in
constructing stable complete denture in case of a
highly atrophic mandible. The main aim of the
Neutral zone technique is to construct denture in
muscle harmony, so that it does not get displaced
during the actions of the muscles surrounding as the
actions of swallowing, mastication, speech and so on.
Key wordsNeutral zone, Atrophic mandible.
Introduction:
The goal of dentistry is for patients to keep all
their teeth throughout their lives in health and comfort. If
the teeth are lost despite all efforts to save them, a
restoration should be made in such a manner as to
function efficiently and comfortably in harmony with the
muscles of the stomatognathic system and the
temporomandibular joints. With the increase in the life
expectancy of the population, the numbers of complex
complete denture cases also have been increasing. The
treatment for these complex complete denture cases
should be different from those of traditional complete
dentures. In case of Atrophic mandible, Dental implants
may provide stabilization of mandibular complete
dentures, but in cases when it is not possible to provide

implants on the grounds of medical risks, economic

limitations or patients attitudes, an alternative technique
should be thought1. The Neutral Zone Technique is an
alternative approach for these cases. The Neutral zone
technique is not new, but is one that is valuable yet not
practiced. The Neutral zone has been defined as the area
in the mouth where during function, the forces of the
tongue pressing outwards are neutralized by the forces of
the cheek and lips pressing inwards.
The aim of the Neutral zone is to construct a
denture in muscle balance. If the denture is out of
harmony with the neutral zone, it will result in instability,
interference with function or some degree of discomfort.
Thus neutral zone must be evaluated as an important
factor before aligning the teeth in complete denture or
partial denture. This is the zone where the natural
dentition exists. As the mandible atrophies at a greater
rate than the maxilla and has less residual ridge for
retention and support, the lower denture commonly
presents the most difficulties with pain and looseness
being the most common complaints. The Neutral zone
technique is most effective for patients who have had
numerous unstable and nonretentive lower complete
dentures. These patients usually have a highly atrophic
mandible and there has been difficulty in positioning the
teeth to produce a stable denture. The Neutral zone
approach has been used for patients who have had a
partial glossectomy, mandibular resections or motor nerve
damage to the tongue which have led to either atypical
movement or an unfavorable denture bearing area.
Background:
Sir Wilfred Fish in 1931 first described
the influence of the polished surface on retention and
stability. He also described how dentures should be
constructed in the dead space, which later became as the

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Neutral Zone1. Since then many techniques have been
described in the literature in an attempt to provide a
molding of the Neutral zone. These techniques involved
the use of soft, moldable material being placed in the
mouth and patients performing actions with their lips,
cheeks and tongue in order to capture actions with their
lips, cheek and tongue. These actions determine the tooth
position and shape of the polished surfaces. In highly
atrophic mandible muscular control over the denture is the
main retentive and stabilizing factor during function.
The denture shaped by the Neutral zone technique
will ensure that the muscular forces are working
more efficiently and in harmony.
Other advantages1--- Improved retention and stability
Posterior teeth will be correctly positioned
allowing sufficient tongue space.
Reduced food trapping adjacent to the molar
teeth
Good esthetics due to facial support.

The borders of the trays were molded

with green stick impression compound and the secondary
impressions were made with zinc oxide eugenol
impression material. The master casts were poured in
dental stone plaster.
In order to increase the
stability and retention of the record bases during
recording the neutral zone, the permanent bases were
prepared in heat cure resin on master casts. Wax occlusal
rims were made over the permanent record bases for
recording the jaw relations.
Clinical visit 3
During this visit face- bow transfer was
made (fig 1) and centric jaw relation was recorded on
semi-adjustable (Hanau Wide view) articulator. The
mandibular rim was completely removed and wire loops
were adapted over the permanent record base in
accordance with the recorded vertical height of jaw
relation (fig 2).

Factors affecting the neutral zone:

Muscles and the neutral zone: The actions of following
muscles affect.
Muscles of cheek:
Buccinator
Masseter
Muscles of lips:
Orbicularis oris
Caninus
Muscles of tongue
Clinical case report:
A 55 year old male patient was referred
to the department of prosthodontics for the provision of
complete denture. He had been edentulous since 7 yrs. He
was a denture wearer and was willing for a new set of
denture due to the reduced retention and repeated fracture
of the denture. On examination it was diagnosed that the
maxillary residual ridge was favourable, but the
mandibular residual ridge was unfavorable due to
resorption. Then it was decided to provide lower complete
denture, utilizing Neutral zone impression technique.
Clinical visit 1
At the first visit primary impression of
the maxillary and mandibular edentulous residual ridge
were made with modelling plastic compound impression
material. Soon after making primary impression, the
impression was poured in plaster of paris and primary
casts were prepared. The custom trays were fabricated
with self cure resin over the primary casts keeping the
borders 2mm short of the sulcus.
Clinical visit 2

Figure 1- Face-bow transfer

Clinical visit 4
The maxillary record base with wax occlusion rim and
mandibular record base with wire loops were evaluated
intra-orally for their fit (fig 3). The maxillary rim was left
in mouth in order to provide enough support to the facial
musculature during making neutral zone impression. Then
the tissue conditioning material (GC Corporation Tokyo.
Japan) was mixed and loaded over the wire loops on
buccal and lingual aspects and inserted in mouth and
patient was asked to perform the usual movements, which
included swallowing, sucking of the lips, pronouncing the
vowels, which helped in recording the neutral zone
space(fig 4).

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indices properly. Then the tissue conditioning material
and the adapted wire loops were removed from the
mandibular record base. Now an empty space (neutral
zone space) was evident within the plaster indices. Next
molten wax was made to flow in this empty neutral zone
space, in order to create rim for arranging the mandibular
teeth in the neutral zone. According to the neutral zone
space recorded, the mandibular teeth were arranged (fig6)
and in accordance with the mandibular teeth, maxillary
teeth arranged. The wax contours were preserved in case
of mandibular denture as derived from neutral zone
technique and no additional wax was added on denture
flanges.

Figure 2- Adaptation of wire loops in accordance with

obtained vertical dimension

Figure 5- Plaster index surrounding Neutral zone

impression

Figure 3- Evaluation of loops intra- orally

Next step was to make plaster
indices (fig 5) surrounding the neutral zone impression.
V shaped indexes were made on the mandibular cast, in
order to guide the placement and removal of the plaster

Figure 4- Recording
conditioner

neutral zone

with

tissue

Figure 6- Teeth arrangement in Neutral zone space

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Clinical visit 5
Try-in was done, in order to evaluate
the stability, esthetics and occlusion intra-orally and
satisfactory results were seen. Then the dentures were
processed with heat cured acrylic.
Clinical visit 6
Denture insertion (fig 7) was done
and again it was evaluated for stability, esthetics and
occlusion. Results were found satisfactory and patient
also was satisfied with the dentures.

Figure 7- Denture insertion

3.

David R, Cogna et al. The neutral zone revisited:

from historical concepts to modern application. J
Prosthet Dent 2009; 101(6):405-12.
4. Kokuto Y, Fukushimas et al. Arrangement of
artificial teeth in neutral zone after surgical
reconstruction of mandible: a clinical report. J
Prosthet Dent 2002; 88(2):125-7.
5. Alfano SG, Leupold RJ. Using neutral zone to
obtain maxillomandibular relationship records
for complete denture patients. J Prosthet Dent
2001; 85(6):621-23.
6. Victor E. Beresin et al. The neutral zone in
complete dentures. J Prosthet Dent 2006;
95(2):93-101.
7. Fahmy F M, Kharat D U. A study of the
importance of the neutral zone in complete
dentures. J Prosthet Dent 1990; 64(4): 459-62.
8. Cantor R, Curtis TA. Prosthetic management of
edentulous mandibulectomy patients. Part II.
Clinical procedures. J Prosthet Dent 1971;
25:546-55.
9. Frank J, Schiesser JR. The neutral zone and
polished surfaces in complete dentures. J
Prosthet Dent 1964; 14(5): 854-65.
10. Fahmi FM. The position of the neutral zone in
relation to the alveolar ridge. J Prosthet Dent
1992; 67: 805-9.

Conclusion:
Neutral zone technique is one of the best
alternative techniques in case of highly atrophied
mandibular residual ridge, but it is rarely used because of
the extra clinical step involved. The neutral zone
philosophy is based on the concept that for each
individual patient there exists within the denture space a
specific area where the function of the musculature will
not unseat the denture, and at the same time where the
forces generated by the tongue are neutralized by the
forces generated by the lips and cheeks. Orthodontic
relapses,
postoperative
problems,
unsuccessful
periodontal procedures and relapses with orthognathic
surgery can be attributed to neutral zone imbalance.
Complete and partial denture failures are often related to
non compliance with neutral zone factors. Thus the
neutral zone must be evaluated as an important factor
before one rates any changes in arch form or alignment of
teeth.
References:
1. Gahan MJ, Wansley AD.The neutral zone
impression revisited. Br Dent J 2005; 198(5):
269-72
2. Lymph CD, Allen PF. Overcoming the unstable
mandibular complete denture: The neutral zone
impression technique. Dental update 2006; JanFeb 33(1); 21-2, 24-6.

Source of Support: Nil

Conflict of Interest: Not Declared
Received: September 2010
Accepted: December 2010

Journal of Advanced Dental Research Vol II : Issue I: January, 2011

www.ispcd.org