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Lapsus 1
Lapsus 1
A CASE REPORT
E-mail: asrisastrawijaya@gmail.com.
Abstract
Introduction : Conventional complete denture therapy with severe residual ridge resorption
is challenging due to lack of denture retention, stability and difficulties in achieving optimum
denture bearing area. The surgical therapy can be an option for treatment on improving
denture support, retention and stability. Many elderly patients have compromised health and
are not feasible for surgical therapy. In such condition, clinicians have to deal with materials
and modified techniques for managing such problems. The neutral zone technique and
lingualized balanced occlusion concept are used to improve the denture retention and
stability. This technique and concept are not widely practiced due to lack of experience and
skills of dentists.
Case: A 90-year-old female complained about her unstable-lower-denture and unpleasant
profile. A modified neutral zone technique was performed to construct a new complete
denture. Case Management: Standard prosthodontic procedures were done in order to get
the vertical dimension of occlusion. Then, the neutral zone impression was performed by
using tissue conditioner. Functional movements were done during the impression to obtain
neutral zone. After 3 weeks of wearing the new complete denture, patient are fully adapted
and improved function of mastication, retention, stability and appearance. Discussion: .
Tissue conditioner was used because of its medium viscosity, repeatable and addible
properties, practical manipulation and economical. In order to reduce the residual ridge
resorption, lingualized balanced occlusion was designed for the new complete denture.
Conclusion: Neutral zone technique for complete denture construction successfully improves
stability, comfort and function for patient with severe mandibular ridge resorption.
Keywords : severe residual ridge, complete denture, neutral zone technique, lingualized
balance occlusion.
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Introduction technique is an important alternative
one tooth or the loss of all the teeth.1 The Residual ridge resorption is a
loss of teeth is caused by dental caries and physiologic changes following tooth
periodontal disease.2 The prevalency rate extraction or aging. The resorption process
Base 2013, the DMF-T score is 4,6% resorption consist of : functional factors
teeth.3 The high prevalency of tooth loss duration of denture-wearing, type and
increase the need of denture fabrication. including the shape, the height and the
Edentulism leads to a severe residual ridge quality of bone; biologic factors including
resorption have become a challenge for age, sex and hormonal imbalance;
ridge resorbtion with implant therapy is an of the denture’s base, type of prostheses,
optimum choice for denture fabrication. type and quanitity of artificial elements.
However, patient with compromised health Residual ridge resorption is the meticulous
treatment expenses and less of time for stability. The critical impact of the
with implant treatment. In such case the after tooth extraction. The average anterior
fabrication of denture with neutral zone ridge resorption in the edentulism is 9-10
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mm on mandible and 2,5-3 mm on occlusion is probably one of the greatest
Neutral zone is defined as potential zone and encroaches on the tounge space.
space between the lips, the cheecks and the The modiolus, located just distal to the
tounge, in that area where the forces are angle of the mouth, is the hub into which
equal. It is where the forces of the tounge all of the muscle of the lips and cheecks
pressing outward are neutralized by forces insert or pass through. Becuse of the
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of the cheecks and lips pressing inward strength and variability of movement of
(Fig.1). The dynamic muscle action affects the area, the modiolus is extremely
tooth position and contour of the flanges. important in relation to the stability of the
the dentures. The function of the muscles Wilfred Fish stated that denture has
influences the shape and the size of the three surfaces with each surface playing an
neutral zone and the position of the teeth important role in the over-all fit, stability
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originate from the square area of the
influence of the impression area will have Fig.2. Cross section of favorable and
denture. In other words, the denture The aim of neutral zone technique
stability and retention are more dependent is to construct a denture in muscle balance
contour and finish of the polished surface denture tooth arrangement. The advantages
has been mostly left to the discretion of a of neutral zone technique are improve
laboratory technician. The forces on the denture stability and retention, reposition
polished surface are constantly changing in the posterior teeth to allow sufficient
magnitude and direction during tounge space, reduce food trapping in the
only when the mouth is completely at rest good esthetics due to facial support.5,10
not only in chewing but also in speaking affecting denture stability is the occlusion.
and swallowing, the fit and contour of the The lingulized balanced occlusion (LBO) ,
accurately and meticulously as the fit and scheme, will reduce the ridge resorption in
contour of the impression surface and the mandible. The LBO concept first stated by
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(1971) and Murrel (1974) by using semi- Case Report
anatomic cusp (20°) for lower posterior A 90-year-old female, came to
teeth and grind the buccal cusp of upper Prosthodontic Clinic in Dental Hospital
posterior teeth (Fig.3). The buccal cusp of Faculty of Dentistry, University of
upper posterior teeth will be positioned ± Indonesia, with no systemic disease and in
0,5mm higher from the buccal cusp of a good medical history. Patient had worn
lower posterior teeth. her complete denture since 6 years ago.
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examination (Fig.6) showed good oral even surface shape. Mandibular posterior
hygiene; normal saliva and normal right-left and anterior residual ridge shape
consistency; normal tounge and normal is oval, with low height, low tissue
mobility; tounge is in Wright class I resistance and uneven surface shape. The
and edentulous both in maxilla and normal. The shape of palatum molle is
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denture and to reduce the occlusal load on transfered in to semi adjustable articulator.
the alveolar bone in the mandible even Then the upper and lower occlusal rim
impression was done to obtain a study space for impression material of the
model using irreversible hydrocoloid neutral zone technique. The neutral zone
(alginate) and edentulous perforated stock impression technique was done by using
impression using impression compound The tissue conditioner was injected into
(Houffman) was performed on the the entire surface of the upper and lower
mandibule due to the low alveolar ridge. occlusal rim and the patient instructed to
study model. In order to get a more sucking, swallowing and smiling (Fig.8).
detailed impression, the mucofunctional The impression of the neutral zone was
impression of the maxilla and mandible recorded by impression index using putty
were done by using green stick compound polyvinilsiloxanne. This index was used as
Japan) as border molding material. After reposition the teeth within the index area.
the working model was finished, occlusal The lingualized balanced occlusion
rims on the maxillary and mandibular arch concept were performed by recontouring
were constructed to determine the vertical the buccal cusp of the upper posterior teeth
dimension. Determining of vertical and the poosterior loewer teeth into the
dimension and recording with facebow semi-anatomic cusp . The wax denture was
transfer were done and the result were tried in into the patient before packing
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procedure for complete denture was done. on lower denture then followed by
The complete denture insertion was done occlusion and articulating examination.
by checking denture retention, examining The third control was done one week after
the adaptation of contact area between the the second control visit. Patient had no
impression surface of dentures and the complaints and satisfied with her new
control. On the second control, patient Fig.9 Left : Putty index of the neutral zone
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Lower: Previous denture.
Discussion
Fig. 10.Left: wearing previous denture. Right: done to get the vertical dimension of
using complete denture with the neutral zone occlusion. The neutral zone impression
technique. was performed using tissue conditioner.
movements.
Fig.11. Left: wearing previous complete
Condition of the previous lower
denture. Right: using complete denture with
complete denture was unstable, misfit and
the neutral zone technique
a decrease in the vertical dimension. That
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First method, the neutral zone impression movements, the usage of medium
occlusal rim before the final impression is optimum choice 5. Compared to previous
completed; the second method, the neutral method according to Beresin (1973) using
zone is registered with a special recording modelling compound and individual tray
base and maxillary wax rim at the selected with retentive looped are more
vertical dimension after final impression complicated, time consuming and rigid
occlusion (VDO); the last method, the patient’s cheeks and tounge.6
polished surface of the trial wax denture In order to obtain neutral zone,
was refined or relined with the impression functional movements like sucking,
impression activities. All the methods can Various functional movements have been
according to the clinician’s preference.5 The shape, size and position of the neutral
Tissue conditioner is used because zone can be vary individually due to the
area. The lower the viscousity is, the According to the putty index of the
better fine detail reproduction will be. neutral zone, the horisontal overlap of
Since elderly patient may not have anterior teeth of the new denture can be
sufficient muscle tone to push away the repositioned 5 mm anteriorly from the
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previous denture. This condition is needed occlusal loading received by the
to improve the labial support. mandibular ridge and the less the
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3. Penelitian B, Pengembangan, RI 7. Mete JJ. A Clinico-radiographic
Neuromuscular Incoordination : A
doi:10.7759/cureus.1189.
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Comparisons of Patient Satisfaction 12. Alam M, Joshi S, Joshi P. Shortened
2014;23:259-266.
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