MANAGEMENT OF SEVERE MANDIBULAR RIDGE RESORPTION WITH

NEUTRAL ZONE TECHNIQUE AND LINGUALIZED BALANCED OCCLUSION -

A CASE REPORT

Asri D Sastrawijaya*, Muslita Indrasari**, Chaidar Masulili**.

*Post-Graduate Student of Prosthodontic, Faculty of Dentistry, University of Indonesia.

**Staff of Prosthodontic Departement, Faculty of Dentistry, University of Indonesia.

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.

1
Introduction technique is an important alternative

Edentulism is common in the treatment.

elderly . Edentulism is the loss of at least Residual Ridge Resorption

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

of dental and oral health problems in is chronic and irreversible. Atwood

Indonesia according to Riskesdas Data described some factors influencing ridge

Base 2013, the DMF-T score is 4,6% resorption consist of : functional factors

which the highest indicator is missing including denture-wearing history,

teeth.3 The high prevalency of tooth loss duration of denture-wearing, type and

due to physiologic changes intraorally fitness of prosthesis; anatomic factors

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;

clinician. Rehabilitation of the severe prosthethic factors including the condition

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

condition, age-factor corelation, limited- factor affecting denture retention and

treatment expenses and less of time for stability. The critical impact of the

treatment’s procedure is contraindicated resorption is in the first 6 until 12 months

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

2
mm on mandible and 2,5-3 mm on occlusion is probably one of the greatest

maxilla.4 influencing factors in lower denture

Neutral Zone and Muscles instability because it violates the neutral

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
5
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 muscle attachments and their position lower denture.6,7

and tonus influence the border extension of Neutralization of Forces

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

and flange contours. In function, as the and comfort.5,8

buccinator contracts, the cheecks are

pressed againts the teeth and alveolar

process. During mastication, the

buccinator plays very important role in

establishing the neutral zone by placing the

Fig.1.Neutralization of forces9
food over the occlusal surfaces of the teeth
The three surfaces consist of impression
in coordination with the tounge. The
surface, occlusal and polished surfaces.
common practice of lingualization of
The influences of forces on denture surface

3
originate from the square area of the

impression surfaces and the polished

surface. The greater the ridge loss, the

smaller the denture base area and the less

influence of the impression area will have Fig.2. Cross section of favorable and

on the stability and retention of the unfavorable lower ridge. 6

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

on the polished surface than on the through physiologically optimal denture

impression surface. The development, contours and physiologically appropriate

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

mastication, swallowing and speaking. It is posterior region of denture and provide

only when the mouth is completely at rest good esthetics due to facial support.5,10

that the forces are constant. In order to Lingualized balanced occlusion

construct dentures that function properly The other important factor

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) ,

polished surface have to be developed just considered as the appropriate occlusal

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

occlusal surface6 (Fig.2). Gysi (1921) and modified by Pound

4
(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.

Patient wanted a new denture in order to

improve her mastication and esthetic.

Fig.3. Arrangement of LBO and

lingualized resultant of forces.9

Thus, only palatal cusp of the upper

Fig.5.Extra oral photo
posterior teeth are in contact with the
Extra oral examination (Fig.5) showed
central fossa of the lower posterior teeth.
square and symmetrical face; convex facial
LBO will reduce the occlusal interference
profile; pupils and tragus are equally high;
so that the occlusal force on the lower
symmetrical nose and normal breathing;
denture will reduce. Furthermore, when
normal rima oris. Upper and lower lip:
denture in function, it will create a more
normal, thin and symmetrical. There is no
lingualize resultant of force to the ridge
abnormality in the left and right
crest to encourage lever stability to the
submandibular and sublingual lymphatic
lower denture.11
glands, normal temporomandibular joint

and muscles of mastication. Intra oral

5
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

position, gag reflex is low; healthy mucosa maxillary-mandibular arch relation is

and edentulous both in maxilla and normal. The shape of palatum molle is

mandible. House class 1.

Fig. 7. Radiograph examination showed severe

mandibular ridge resorption.

Fig.6. Intra oral of upper residual ridge and

lower residual ridge.

Diagnosis and Treatment Planning:
Radiographic examination showed a
The diagnosis for this patient is loss
severely mandibular ridge resorption.
of all teeth: 17,16,15,14,13,12,11, 21, 22,
There is a decrease in alveolar bone height
23, 24, 25, 26, 27, 37,36,35,34, 33, 32,31,
and density (Fig.7). No bad habits. The
41, 42, 43, 44, 45, 46, 47 requiring
maxillary posterior left, right and anterior
rehabilitation by maxillary and mandibular
vestibulum depth are moderate;
complete denture. Patient was planned to
mandibular posterior right-left and anterior
receive acrylic complete denture with
are low. Maxillary posterior right-left and
neutral zone impression technique and
anterior residual ridge shape is oval with
lingualized balanced occlusion to gain
medium height, low tissue resistance and
more retention and stability on lower

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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

more. were reduced approximately 3-4 mm in

At the first visit, preliminary buccolingual dimension in order to obtain

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

tray (Crown G-Japan). Muccocompressive tissue conditioner (Tokuyama soft liner).

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

Fabrication of individual tray was done on perform functional movement such as

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

(Peri compound border moulding a guidance for teeth arrangement on the

impression material, GC Corporation, articulator. Adjusment was done in order to

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

mucosa under the denture, and checking denture.

for balanced occlusion. The patient was a

instructed to wear the denture for the next

24 hours and to remove the denture when

eating. After 24 hours, patient had no

c
complaint about pain or unstable denture. Fig.8. Neutral zone impression technique

The occlusion and articulation were using tissue conditioner.

rechecked to ensure that the contacts in a

lingualized balanced occlusion. The

patient was then instructed to use the

denture for a soft meal, remove it during

sleep and follow the denture cleaning

instructions. The patient was scheduled to

have seond control, 3 days after the first

control. On the second control, patient Fig.9 Left : Putty index of the neutral zone

reported mild pain on anterior area of impression. Right: teeth arrangement

according to neutral zone putty index.

lower denture. Adaptation examination of

the mucosa showed there was small

pressured area of the intaglio surface.

Adjustment were done to reduce the pain

8
 Lower: Previous denture.

Discussion

In order to manage this case, the

standard prosthodontic procedures were

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.

The tissue conditioner was injected on the

entire surface of the upper and lower

occlusion rims after the determination of

VDO, then followed by functional

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

condition made the mandibular ridge

resorption more complicated and the

patient appearence became unpleasant.

Neutral zone impression technique

has various modification not only in terms

of impression materials used, but also in

terms of functional movements in order to

simplified the procedure for the clinicians.

A number of different neutral zone

impression methods have been suggested.

Fig.12. Upper : New denture insertion.

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First method, the neutral zone impression movements, the usage of medium

is made using impression compound as viscosity as the tissue conditioner is an

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

and determination of vertical dimension of enough for the compound to be molded by

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,

material in combination with functional smiling and swallowing were performed.

impression activities. All the methods can Various functional movements have been

be used individually or combined modified and reported on many reports.

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

of its medium viscosity, repeatable and differentiation of the impression material,

addible properties, practical manipulation functional movements, muscle tonucity,

and economical. Repeatable and addible vertical dimension, duration of edentulous

properties facilitate refining the detailed and post-extraction resorption.5

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

impression material while doing functional

10
previous denture. This condition is needed occlusal loading received by the

to improve the labial support. mandibular ridge and the less the

Bonwill suggested the teeth should resorption will be.

be adjusted to obtain balanced occlusion Conclusion

without interference. Occlussal harmony is The neutral zone concept and
important for patient comfort.11 lingualized balanced occlusion are an
Lingualized balanced occlusion reduce alternative treatment in fabricating
mandibular denture occlusal loading and complete denture of the severe mandibular
dislodging force and minimize mandibular ridge resorption. Combination of the two
ridge resorption. concept provide maximum adaption of the
The number of the posterior teeth were muscles of the lips, cheecks and tounge in
reduced according to the shortened-dental order to improve the denture retention and
arch (SDA) concept. SDA was firstly stability.
introduced by Kayser (1981), who
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