1anuary/Pebruary 2006 DentaIUpdate 2l

RemovabIeProsthodontics
Christopher D Lynch
Overcoming the Unstable
Mandibular Complete Denture:
The Neutral Zone |mpression
Technique
Abstract: This article describes a technique for improving the stability of mandibular complete dentures for patients who have a
diminished mandibular neutral zone. The technique involves making an impression which is shaped by the patient's oral musculature,
and which defines the shape and contour of the patient's neutral zone. A case report is presented in which the use of this technique is
described. |t is hoped that this article will increase the awareness of dental practitioners to the use of this technique.
CIinicaI ReIevance: The neutral zone impression technique is a useful technique when providing mandibular complete dentures. |ts use
can overcome some of the denture stability difficulties caused in some patients by a more powerful oral musculature, or in patients who
have poor or altered neuromuscular control.
Dent Update 2006, 33: 21-26
As a result of recent advances in dental
treatments and increased utilization of
dental services by the public, there has been
a fall in the prevalence of edentulousness.
l

This development has resulted in a dental
population who become edentulous later
in life (if at all), and in whom there may
be diminished neuromuscular control to
adapt to complete dentures.
2
Another
consequence of this advance in dental
profile in society is decreased exposure of
dental students and dental practitioners
to the challenges of complete denture
prosthodontics. One such challenge is the
unstable mandibular complete denture.
An unstable mandibular
complete denture may occur for a variety of
reasons:
|ncorrect extensions of buccal or lingual
flanges,
Poorly adapted fitting surface,
An atrophic mandibular ridge, or
An inappropriately contoured polished
surface.
3
Some patients have diminished
or altered neuromuscular control, such
as those who have Parkinson's disease, or
those who have had a stroke or surgical
resection. The focus of this paper is on
the mandibular complete denture that
fits well, and is properly extended, but is
still 'loose'. This problem is caused by poor
or inappropriate contour of the polished
surfaces or positioning of the teeth on the
mandibular complete denture.
Christopher D Lynch, 8DS, MPD PCS|,
Pegistrar in Pestorative Dentistry, and
P Finbarr AIIen, 8DS, MSc, PDS PCPS,
PhD, Department of Pestorative Dentistry,
National University of |reland, Cork,
|reland.
|t will be recalled that there is
a zone of 'minimal conflict'
3
between the
buccal and lingual musculature within
which a denture should optimally be
situated. This zone of 'minimal conflict' is
also referred to as the 'neutral zone'
4,5
or
'denture space'
2
(Pigure l). The polished
surfaces of a mandibular denture should be
contoured such that they do not encroach
on the lingual or buccal musculature during
function - to do so would result in a force
being applied to the denture that would
result in its displacement.
6
However, in
some patients, the extent of the neutral
zone may be limited. There has been much
focus in recent times on the 'transition' to
the edentulous state.
7
A poorly planned
transition characterized by uncontrolled
tooth extraction can lead to:
Lateral spreading of the tongue in the
posterior part of the mouth,
Lxcessive anterior resorption leading
P Finbarr AIIen
RemovabIeProsthodontics
22 DentaIUpdate 1anuary/Pebruary 2006
to increased prominence of the mentalis
muscle. |n such patients the size of the
neutral zone may be drastically reduced.
|n some patients, the shape
of the neutral zone is more 'bizarre', for
example following a surgical resection, a
stroke, scleroderma, or arising from other
natural causes such as a prominent mental
groove.
The purpose of this paper is
to describe an impression technique for
recording the neutral zone for mandibular
complete dentures. This technique has been
referred to in the past as the 'anthropoidal
pouch technique',
3
'muscle formed
mandibular denture technique',
8
or 'denture
form impression technique'.
9
CIinicaI report
A 55-year-old female patient was
referred to the Department of Pestorative
Dentistry, University Dental School and
Hospital, wilton, Cork, |reland for provision
of a mandibular complete denture (Pigure
2). The patient had been edentulous for l0
years and, while she had been able to wear
a maxillary prosthesis, was unable to wear a
mandibular complete denture. The patient
reported that the lack of a mandibular
prosthesis had a negative effect on her
quality of life, as she was conscious of her
speech and her ability to eat in public. On
examination of the patient, it was found
that she had microstomia, and maxillary
hypoplasia. Her maxillary complete denture
was well retained and, after discussion
with the patient, it was decided to retain
this prosthesis. On examination of the
mandibular denture bearing area, it was
noted that there had been lateral spreading
of the patient's tongue, and that the neutral
zone was diminished. |t was decided to
provide the patient with a mandibular
complete denture, utilizing a neutral zone
impression technique.
Treatment for this patient is
outlined under the heading of the various
clinical and laboratory visits:
CIinicaI visit 1
A primary impression was made
of the patient's edentulous ridge using a
plastic stock tray and alginate (Alginate:
Dentsply Ltd-UK, weybridge, Surrey, UK). The
plastic stock tray had been modified as a
result of the patient's microstomia (the ends
of the tray were removed).
Visit 1 (Iaboratory)
A primary model was poured
from this impression and an acrylic special
tray with 2 mm spacing was fabricated.
CIinicaI visit 2
The extensions of the
special tray were assessed intra-orally. A
secondary impression was made using
polyvinylsiloxane (Lxtrude: Kerr Corporation,
Pomulus, M|).
Visit 2 (Iaboratory)
A transparent heat-cured acrylic
baseplate was made on the master cast.
CIinicaI visit 3
The acrylic baseplate was
returned to the chairside and tried in
the mouth. The retention, stability and
extensions were assessed. The use of a
transparent material allowed visualization
of the adaptation of the baseplate to the
denture-bearing area. A wax block was
added to the baseplate, and a 'conventional'
occlusal registration visit took place. The
polished surfaces of the wax block were
contoured as close to the shape of the
neutral zone as possible (Pigure 3), and
the height of the wax block was ad|usted
to permit an acceptable occluso-vertical
dimension (OvD), ie the free-way space was
3 mm. The reason for making the baseplate
alone first was to permit an assessment
of its accuracy - a concern following the
difficulty in making a master impression. A
face-bow transfer and centric relation were
recorded.
Visit 3 (Iaboratory)
|n the laboratory, the maxillary
cast was mounted on a semi-ad|ustable
articulator (Denar Anamark Possae:
Teledyne water Pik Port Collins, Colorado,
USA) using the face-bow transfer. The
mandibular cast was located to the upper
at the correct OvD and in Centric Pelation
using the mandibular wax block. The wax
block was removed, and was replaced
with vertical wire loops, which were
attached to the transparent acrylic base.
These were carefully positioned within the
bucco-lingual dimension as defined by the
contours of the wax block, and conformed
to the same OvD as the height of the wax
block (Pigure 4).
Figure 1. Diagrammatic representation of the
'neutral zone'. Porces are applied to the denture
bases by the cheek and the tongue. Por optimal
stability and retention, complete dentures should
be situated in the 'neutral zone' where such forces
'cancel' each other. (Pigure drawn by Ms Catherine
MacGillycuddy and Pichard Taylor.)
Figure 2. Lxtra-oral photograph of the patient prior
to treatment. Note the limited mouth opening, and
'tightness' of oral musculature.
Figure 3. Mandibular occlusal rim shaped to an
approximate bucco-lingual dimension.
RemovabIeProsthodontics
24 DentaIUpdate 1anuary/Pebruary 2006
CIinicaI visit 4
At the chairside this appliance
was assessed to ensure the baseplate was
not overextended, and that the wire loops
were in the correct bucco-lingual position
(Pigure 5). The free-way space was assessed
to ensure that the height of the wire loops
was not different from the height of the wax
block. Tissue-conditioning material (Coe-
Soft: Pesilient Denture Liner, GC America
|nc, Alsip, |L, USA) was applied to the wire
loops (Pigure 6), and placed in the mouth.
The patient was instructed to carry out
simple oral movements, such as moving
her lips, cheeks and tongue, swallowing,
chewing, 'puffing' of cheeks, and 'sucking in'
of lips, whilst keeping the rims in occlusal
contact. This permitted the buccal and
lingual oral musculature to shape the
tissue-conditioning agent on the wire loops
to the contours of the neutral zone (Pigure
7a). The patient was left to perform these
actions for up to 30 minutes. After this time,
the baseplate and attached materials were
removed, disinfected in the normal way, and
returned to the laboratory (Pigure 7b).
Visit 4 (Iaboratory)
|n the laboratory, silicone
putty indices (Coltene Lab Putty: Coltene
whaledent GmbH, Konstanz, Germany) of
the baseplate and attached materials were
made (Pigure 8a, b). The tissue-conditioning
material and wire loops were removed and,
using the silicone putty indices, replaced
with prosthetic teeth (Pigure 9). The bucco-
lingual width of these teeth was determined
by the contour of the buccal and lingual
musculature recorded on the tissue-
conditioning material. As the stability of
the planned mandibular complete denture
was a concern, shallow-angled cusped
posterior prosthetic teeth were arranged
on a semi-ad|ustable articulator in balanced
articulation. As this patient had a Class |||
Skeletal 8ase, the lower anterior teeth were
retroclined to resemble a Class | incisor
relationship, however, it was not possible to
position these lingual to the contour made
by the tongue on the anterior section of the
tissue-conditioning agent. This was returned
to the chairside as a 'conventional' try-in
(Pigure l0).
Figure 4. Mandibular baseplate with vertical wire
loops attached.
Figure 5. |ntra-oral view of baseplate and wire
loops. Note the bucco-lingual location of these.
Figure 6. Application of tissue-conditioning agent
to the wire loops.
Figure 7. (a) |ntra-oral view of completed neutral zone impression. (b) Lxtra-oral view of completed
neutral zone impression.
a b
a b
Figure 8. (a, b) Putty indices applied to completed neutral zone impression.
Figure 9. Teeth set up for try-in using putty
indices.
1anuary/Pebruary 2006 DentaIUpdate 25
RemovabIeProsthodontics
CIinicaI visit 5
At the chairside 'try-in' took
place. The stability and retention of the
prosthesis was assessed and found to be
satisfactory. The patient was satisfied with
the appearance of the lower anterior teeth
(even though there was a 'reverse over|et').
The try-in was returned to the laboratory.
Visit 5 (Iaboratory)
The denture was processed in
the normal manner.
CIinicaI visit 6
The mandibular complete
denture was returned to the chairside and
was found to be satisfactory in terms of
stability, retention, aesthetics and occlusion
(Pigure ll).
At subsequent review
appointments the patient reported
satisfaction with the prosthesis.
Discussion
|t is often more clinically
challenging to provide a mandibular
complete denture than a maxillary one.
|t is even more so when there is altered
neuromuscular control, or when the neutral
zone has been altered as a result of surgical
resection, or where there are powerful
lingual or buccal muscles. while dental
implants are a possible treatment option in
this situation, there is a group of patients
who, for a variety of clinical or medical
reasons, are unsuited for dental implant
treatment. There are also some patients
who do not wish to have surgically invasive
procedures, such as the placement of dental
implants. The technique described provides
a useful way to overcome this difficulty. |t is
also indicated when a mandibular denture
is 'loose' but appears technically correct (ie
correctly extended and well adapted to the
denture-bearing areas). The clinician should
avoid attempting to correct this problem
by 're-lining' the denture. The instability is
not caused by poor fit, but inappropriate
contour of the polished surfaces. |t may
also be appreciated that, in patients where
the denture-bearing areas are less than
ideal (eg a markedly resorbed ridge), or
in patients with altered neutral zones as
a result of stroke or surgical resection,
polished surfaces that are contoured to
match the shape of the neutral zone will be
harnessed by the oral musculature and have
a positive effect on the retention of the
mandibular complete denture.
The use of wire loops and tissue-
conditioning agent to record the contours
of the neutral zone is a clinical preference
of the authors. Alternate descriptions in the
literature include: the use of acrylic pillars
instead of wire loops,
3,5
and the use of wax,
8

impression compound,
l0
chairside relining
materials,
9
or polyvinylsiloxane materials
9

to record the contours of the neutral zone.
whatever materials are used, it seems that
two factors cannot be overlooked:
The impression of the neutral zone
must be recorded at the occluso-vertical
dimension determined at a previous visit
using an occlusal rim, and
The material should be reasonably slow
setting to permit the oral musculature to
shape it to the appropriate contour and
dimensions.
The authors also advocate the
use of shallow-angled, cusped posterior
prosthetic teeth, and their arrangement on
a balanced articulation on a semi-ad|ustable
articulator to reduce eccentric tipping
forces affecting the prosthesis.
There are published studies
that support the use of the neutral zone
impression technique.
2,ll,l2,l3
|n a study of
Saudi Arabian patients, Pahmy and Kharat
found that a ma|ority of patients expressed
a preference for mandibular complete
dentures made using the neutral impression
technique rather than those made in
a 'conventional' manner.
ll
|n a similar
study in Sweden, 8arrenas and Odman
found that a ma|ority of patients again
expressed a preference for mandibular
complete dentures made using a neutral
zone impression.
l2
A study by Miller ETAL.
2

examined the forces necessary to dislodge a
mandibular complete denture. A larger force
was required to remove dentures made
using a neutral zone impression technique
than a conventional denture. Neill and
Glaysher
l3
examined the forces exerted
on complete dentures in which the teeth
were arranged using different methods.
These included the use of biometric guides
(where the teeth are arranged relative to
the vestige of lingual gingiva) and neutral
zone techniques. They concluded that, while
biometric guides are useful in conventional
complete denture cases, neutral zone
techniques are indicated where the
situation is less straightforward.
As mentioned previously, the
problem of a 'narrow' neutral zone may be a
consequence of a poorly planned transition
to the edentulous state. This problem can
be avoided if proper consideration is given
to this transition. Lxtraction of posterior
teeth should be accompanied with
provision of a removable partial denture,
where suitable, to prevent lateral spreading
of the tongue. Mandibular removable partial
dentures should be reviewed and ad|usted
where necessary to prevent excessive
anterior resorption, as this can lead to
increased prominence of the mentalis
muscle. The transition to edentulousness
should be carefully planned, and many
options are currently available to facilitate
this, such as overdentures and transitional
partial dentures.
7
ConcIusion
Management of an unstable
mandibular complete denture can often
be difficult and frustrating for both
clinician and patient. The neutral zone
impression technique is a useful way of
Figure 11. The completed denture.
Figure 10. Teeth set up for try-in on semi-
ad|ustable articulator. Note the retroclination of
the mandibular anterior teeth.
RemovabIeProsthodontics
26 DentaIUpdate 1anuary/Pebruary 2006
overcoming this problem. The technique is
also indicated when treating patients with
altered neutral zones as a result of stroke
or surgical resection. The role of planned
transition to the edentulous state cannot be
underestimated in avoiding this problem.
AcknowIedgement
The authors thank Ms Catherine
MacGillycuddy, MA, for her drawing of
Pigure l.
The authors thank Mr Tim Clark
and the staff of the 'Dentacast of Lxeter'
laboratory (PO 8ox 2l, l88 Cowick Poad,
Lxeter, LX2 98L, UK) for their technical
support in the case described.
References
l. Kelly M, Steele 1, Nuttall N, 8radnock G,
Morris 1, Nunn 1, Pine C, Pitts N,
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2. Miller wP, Moteith 8, Heath MP. The
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resistance to lifting forces. 'ERODONTOLOGY
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4REATMENTOFTHE%DENTULOUS0ATIENT 4th ed.
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8. walsh 1P, walsh T. Muscle-formed
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patients. *0ROSTHET$ENT 200l, 85: 62l-
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l2. 8arrenas L, Odman P. Myodynamic and
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ook Review
DentaI Hard 7issues and onding:
InterfaciaI Phenomena and ReIated
Properties. G Lliades, DC watts and T
Lliades, eds. Heidelberg: Springer-verlag
8erlin, 2005 (l98 pp. h/b, 77.00, LUP
99.95). |S8N 3-540-23408-X.
This book reviews bonding to
enamel, dentine or cementum and the
related adhesion mechanisms.
The first section is devoted
entirely to enamel bonding. The first
chapter reviews the literature concerning
bonding to enamel and discusses the role
of total-etch and self-etch adhesives, as
well as the interaction of glass ionomer-
based materials with enamel. There is
some overlap with the next chapter that is
devoted to bonding of resinous materials
to primary enamel. Chapter three looks at
the experimental models for evaluating
bond strength and identifies important
variables. Chapter four addresses bonding
with water-insensitive and water-
activated orthodontic adhesive resins. The
authors identify the effects accompanying
long term intra-oral ageing of bonded
restorations that may prevent meaningful
comparison with short-term bond
strength data. The widely quoted proposal
of a particular minimum 'threshold' bond
strength value for orthodontic bracket
retention is wisely re|ected.
Part two is divided into three
chapters which cover:
8onding to dentine smear layers,
)NSITU photo-polymerization, and
Polymerization-shrinkage phenomena
and bonding in prosthodontics with
cements.
The advantages of simplified
adhesive systems are weighed against
their shortcomings. A simple but
scientifically sound classification of
adhesives is proposed which categorizes
products by bonding mechanism rather
than by 'generation'. The succeeding
chapter covers the polymerization of
light-activated dental biomaterials
and the factors governing shrinkage
stress. The final chapter in this section
looks at prosthodontic luting cements
and proposes a classification based on
their mechanism of adhesion to tooth
structure.
The final section of the book
reviews the structural, compositional
and functional aspects of cementum and
discusses possible future approaches for
bonding to this unique substrate.
This well referenced
and beautifully illustrated concise text
contains a wealth of information for
anyone interested in researching the
sub|ect. As such it should be a welcome
addition to any dental library.
A C ShortaII
Reader in Restorative Dentistry
University of irmingham
SchooI of Dentistry