Current status of the neutral zone: A

literature review
Amit Porwal, MDSa and Keiichi Sasaki DDS, PhDb
Pacific Dental College, Udaipur, India; Tohoku University
Graduate School of Dentistry, Sendai, Japan
Several studies have been published on the neutral zone regarding materials, techniques, and different prostheses;
however, the data are incongruent, and a literature review was necessary. This review summarizes the literature on the
neutral zone and identifies deficiencies suggesting future research. The English language peer-reviewed dental litera-
ture was reviewed from the period January 1, 1900 to June 30, 2011. Articles were searched in Medline (PubMed) and
Google scholar for the term “neutral zone” and were supplemented by a hand search in prosthodontic publications.
Deficiencies in the literature were found, including materials and techniques for recording the neutral zone, the com-
parison of different neutral zone dentures, and the effect of the period of edentulism on the neutral zone. (J Prosthet
Dent 2013;109:129-134)

Worldwide life expectancy at birth
was 67.2 years from 2005 through
2010.1 It has been estimated that, in-
ternationally, between 7% and 69% of
the adult population were completely
edentulous.2 However, by 2045 the
number of elderly in the world is likely
to surpass the number of children for
the first time in history.1
Elderly patients, especially those
who are long-time complete denture
wearers have advanced ridge atrophy
and atrophy of the musculature of the
cheeks and lips.3 Adaption to com-
plete dentures was less of a problem
in the past probably because new den-
ture wearers were younger.4 However,
currently people experience tooth loss
later in life, which makes it difficult
for them to develop the neuromus-
cular skills needed for the successful
wearing of dentures. The lack of these
neuromuscular skills makes denture
wearing on atrophic ridges difficult.5
Because of the progressive changes
that accompany edentulism,6,7 the func-
tional dynamics that define the oral cav-
ity,8 the loss of the patients’ capability
to adapt, and increased life expectancy9
have posed a challenge for the dentist
when restoring and rehabilitating the
oral cavity. After dental extraction,
alveolar bone may resorb until only
basal bone remains.10 Furthermore,
systemic diseases such as diabetes
mellitus, osteoporosis, osteosclero-
sis, and osteomalacia can exacerbate
the situation.11,12 Owing to this con-
tinued rise in treatment complexity,
other options have been suggested,
such as vestibular extension proce-
dures or implant-supported dentures.
Vestibuloplasty procedures are less
common because of involved surgical
intervention, pain and edema, infec-
tion, and transient paresthesia,11,13,14
whereas financial constraints and sys-
temic conditions limit the availability
of implants.15 Additionally, these sur-
geries may also eliminate the possibili-
ties for active muscular control of the
mandibular denture.16
Resorption of the residual ridges is
a continuous process17 and produces
a flat and sometimes concave founda-
tion. This has been called the difficult
lower jaw.16 Following this, character-
istic spaces forming the so-called den-
ture space develop in the oral cavity
of the edentulous patient. In edentu-
lous patients, support to the lips and
the cheeks is no longer available and
they tend to collapse into the oral cav-
ity. Simultaneously, the tongue will try
to expand into the space.18 Success in
treatment with complete dentures is
possible in such situations only if cer-
tain anatomic and physiologic facts
are considered.19
Regardless of the fabrication tech-
nique used, improper tooth arrange-
ment or physiologically unacceptable
denture base volume or contour re-
sult in poor prosthesis stability and
retention,8,16,20-23 compromised pho-
netics,24,25 inadequate facial tissue
support,25 inefficient tongue posture
and function,26 and hyperactive gag-
ging.27-30 To manage such difficult situ-
ations for the mandible, Fish in 193320
drew the attention of the profession
towards the cameo or polished sur-
faces of dentures. He highlighted the
importance of the muscular function
of the tongue, cheeks, and lips as be-
ing critical factors for denture stability.
When all natural teeth have been
lost, there exists within the oral cav-
ity a void which is the potential den-
ture space. A neutral zone is that area
in the potential denture space where
the forces of the tongue pressing out-
ward are neutralized by the forces of

The Japan Dental Association provided the fellowship which supported this research.

a
Reader, Department of Prosthetic Dentistry, Pacific Dental College and Hospital.
b
Dean, Professor, Tohoku University Graduate School of Dentistry, Division of Advanced Prosthetic Dentistry.
Porwal and Sasaki
130
the cheeks and lips pressing inward.31
According to the Glossary of Prosth-
odontic Terms (2005)32 the neutral
zone is “the potential space between
the lips and the cheeks on one side and
the tongue on the other; that area or
position where the forces between the
tongue and cheeks or lips are equal.”
Since these forces are developed
through muscular contraction during
the various functions of mastication,
speaking, and swallowing, they vary in
magnitude and direction in different
individuals.31,33 Therefore, if the pros-
thesis has not been placed in a space
defined by the musculature, the chanc-
es of the prosthesis failing increase.
In the literature, the neutral zone34,35
has been called the dead space,20 stable
zone,16 zone of least interference,36
zone of equilibrium,37 biometric den-
ture space,12 denture space,38,39 and
potential denture space.40 The tech-
nique for recording the same is well
documented and has been referred to
as the anthropoidal pouch technique,9
denture form impression technique,41
muscle formed mandibular denture
technique,42 piezograph technique,43
and border molding technique.44
The term neutral zone concept31
was coined by Beresin and Schiesser
in 1976. The authors suggested that
the denture teeth should be arranged
in the neutral zone. The neutral zone
philosophy is based on the con-
cept 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 where forces generated
by the tongue will be neutralized by
the forces generated by the lips and
cheeks. Thus, artificial teeth should
be arranged in the neutral zone for
denture stability. Positioning artifi-
cial teeth in the neutral zone achieves
2 objectives: teeth will not interfere
with the normal muscle function; and
the forces exerted by the musculature
against the denture are more favor-
able for stability and retention.
Various authors11,16,20,21,25,31 have
shown significance of the neutral zone
and have suggested that teeth must
The Journal of Prosthetic Dentistry
be positioned within this neutral zone
for optimum stability and retention of
the prosthesis. However, documenta-
tion of the techniques, materials, and
procedures for recording the same
is incoherent and scarce. Because of
the availability of newer materials,
the development of more sophisti-
cated techniques and an increase in
the older age group, an appropriate,
more evidence-based treatment is de-
sired. Therefore, the purpose of this
article was to summarize the existing
literature concerning the neutral zone
and to identify any gaps in the current
research to suggest areas for further
investigation.
A systematic review on this topic
was not possible as related articles were
few and of varied origins. Therefore,
a literature search was conducted for
peer reviewed dental articles published
in English and limited to humans for
“neutral zone”, from January 1, 1900
to June 30, 2011, in Medline (PubMed)
and Google scholar.
Articles retrieved from the elec-
tronic search were hand searched
for the relative references and the
cross references. The desired articles
were obtained manually from known
prosthodontic references such as The
Journal of Prosthetic Dentistry, the In-
ternational Journal of Prosthodontics,
and the Journal of Prosthodontics.
Articles that did not focus exclusively
on the neutral zone or techniques,
materials, or patients treated with this
technique were excluded from further
evaluation. The full text of all articles
identified through the electronic and
manual searches was reviewed and
assessed for suitability.
PubMed results showed 1158 ar-
ticles for neutral zone, but after ap-
plying the limitations, only 32 articles
remained. Of these only 25 relevant
articles were reviewed. Also, Google
scholar was searched for any other
relevant articles.
With the neutral-zone approach
the usual sequence for complete den-
ture fabrication is reversed. First the
individual trays are fabricated and
adjusted after trial insertion in the
Volume 109 Issue 2
mouth. This is followed by making oc-
clusal rims with modeling plastic im-
pression compound, which, in turn,
will be molded in the neutral zone by
muscle function. Later, a definitive
impression is made by using a closed
mouth procedure at a tentative oc-
clusal vertical dimension. After this
procedure, the occlusal vertical di-
mension and centric relation are de-
termined. The shape of the polished
cameo surface will determine whether
the muscular forces will stabilize or
dislodge the denture. Additionally,
this helps patients control their den-
tures even when the residual ridges
have atrophied and the fit is no longer
accurate.35 The proper position of the
teeth is not in the center of the ridge,
nor labial or buccal to it, but where
the cheek pressure and tongue pres-
sure balance each other.
Mahmoud et al45 found that the
residual ridge type (prominent ridges
and flat ridges) had no effect on the
neutral zone, suggesting that mus-
cular forces rather than the ridge it-
self were the determining factor. The
authors also demonstrated that the
width of the neutral zone is smallest
at the occlusal plane level (and in-
creases as it goes up and down) and
that as the occlusal vertical dimen-
sion increases, the width of the neu-
tral zone also increases and vice versa.
Techniques
The techniques most commonly
used for recording the neutral zone
were found to be swallowing 4,35,41,42,44-
57
and phonetics.5,32,46,49,51-53,55-60
However, other techniques such
as sipping water,46,49,51,56,57 lick-
ing,4,46,49 smiling,46,50,57 pursing the
lips,32,44,49,54 sucking, 32,42,47,48,52,53,55,57
masticating,48 mouth exercises (in-
cluding tongue movements, blow-
ing, protruding of the tongue, exer-
cise movements of the lips, cheek,
and tongue, facial expression, open-
ing and closing),19,32,41,42,45,54,55,57,59 and
whistling19,50 have also been reported.
To compare the outline form of
swallowing and the phonetic neu-
Porwal and Sasaki
February 2013 131
tral zone impression technique, a period of time by functional move- significantly with each impression
Makzoumé61 conducted a study in ments.58 A tissue-conditioning mate- material. It was concluded that the
which 1 method used phonetics and rial was preferred by many authors denture space was regulated by the
tissue conditioner to shape the neu- because of the ease of mixing, elec- volume of material and was located
tral zone and another used swallow- tive initial viscosity, and slow-setting slightly towards the buccal side from
ing and modeling plastic impression properties that enabled capture of the crest of the residual alveolar ridge.
compound. It was concluded that the movable tissue morphology in the However, the researchers included el-
the phonetic neutral zone appears to functional state. Moreover, this ma- derly participants and did not specify
be narrower posteriorly, thus limit- terial also allows for an incremental their denture experience or the length
ing premolar and molar positioning. molding procedure, which is important of their edentulism, nor were they able
Two factors would have resulted in in patients with focal neurological defi- to determine how many times the ma-
this situation: either the viscosity of cits and slow or false reactions to vari- terial should be added. Therefore, a
the modeling plastic impression com- ous commands.49,56 A disadvantage of proper technique for calculating the
pound was too great to be sufficiently this material is its relatively high cost.49 exact amount of material required to
molded by the buccinator or the ac- Light-polymerized acrylic resin provides record the neutral zone without in-
tivity of the muscles was increased sufficient working time and polishes to terfering with the functioning of the
in speaking. According to Lott and a high luster; however, irritation due to muscles needs to be established.
Levin,58 patients should be asked to the monomer may be a problem.44
read an interesting topic aloud and Whichever materials are used for Indexing Material
rapidly. This will cause the muscles recording the neutral zone, it seems
to be increasingly strained, and in- that 2 factors cannot be ignored: the Once the neutral zone has been re-
creased saliva secretion will result in neutral zone should be recorded at an corded, its position can be preserved with
more swallowing action. Also, it will established occlusal vertical dimen- the help of indexing material like plas-
reduce patient focus on the occlu- sion, and the material used for record- ter,31,41,46,53,50,58 silicone,41,44,46,48,49,51,56,57,60,64,65
sion rims, and more natural move- ing should be reasonably slow setting stone,4,19,55 or modeling plastic impression
ments of the muscles will be recorded. so that oral musculature shapes it into compound.31,35
However, the question remains which proper contour and dimension.48 A
technique should be used so that future comparative study could inves- Reproducibility
the dentures remain stable during all tigate the neutral zone as recorded by
functional activities? different materials such as modeling Studying the reproducibility of
plastic impression compound, silicone, the neutral zone, Karlsson and Hede-
Materials tissue conditioner, denture lining mate- gard59 compared the results of 2 op-
rials, and soft wax. erators using 1 impression material and
Tench et al33 were the first in this a spatula for application and concluded
field and have proposed modeling Volume of Material Required that there was no operator effect when
plastic impression compound as the making neutral zone impressions. They
material to be used for recording the Until now, the number of addi- also compared the results obtained by
neutral zone. Although this advice tions and the volume of impression 1 operator with 2 impression materials
is widely followed,31,35,47,50,51,53,61-64 materials required for recording the and 2 methods of application (spatula
other materials such as tissue con- neutral zone have not been clarified. versus injection) and reported signifi-
d i t i o n e r, 4 , 5 , 3 9 , 4 4 - 4 6 , 4 8 , 4 9 , 5 6 , 5 7 , 5 9 , 6 0 , 6 5 Heath39 demonstrated that record- cant differences among impressions
wax,19,42,52,55,58 zinc oxide eugenol im- ings of denture space morphology when different materials and differ-
pression material,35,42,64,66,67 silicone vary according to the volume of the ent application methods of the mate-
material,41,51,54,67,68 chairside relining material used. To address this volu- rial were used. The results confirm the
material,41,44,61 and acrylic resin60 are metric variable, a nonsetting gel - a variability of the neutral zone tech-
also described for this technique. polymer of dimethyl silicate filled with niques.59,69 These findings should, how-
These materials are either used for the 12% calcium silicate - was used on a ever, be considered carefully as sample
initial recording of the neutral zone or trial basis to estimate the optimal vol- size was limited, and interoperator and
at the evaluation appointment. ume of material required to record the intraoperator variability of experimen-
Modeling plastic impression com- denture space.4 Ikebe et al5 examined tal procedures were not assessed be-
pound, being a thermoplastic mate- the effect of incremental injections of cause 1 clinician made only 1 impres-
rial, is easy to manage and has the impression material on the resultant sion with each technique. Such studies
advantages of low cost and ease of denture space. For molar and premo- need to be done with more operators
availability, whereas wax is temporar- lar positions, the buccolingual widths using larger numbers of materials
ily stable and can be contoured over of the experimental analogs increased and different application techniques.
Porwal and Sasaki
132
Maxillofacial Prosthetics and
Implants
Recording the neutral zone be-
comes even more difficult when the
patient is not able to perform proper
functional movements of the cheek,
tongue, or lips because of disease or
trauma to the orofacial structures.
The use of dental implants to achieve
improved stability and retention for
the patient’s planned prosthesis is
a recommended method of treat-
ment.70,71 Implant-retained or sup-
ported overdentures also require an
appropriate polished cameo surface
to prevent harmful forces from acting
on the implant.72 Preparing diagnostic
and surgical templates by using the
neutral zone concept facilitates proper
placement of implants for complete
dentures54 or, after surgical recon-
struction of mandible, with implants.65
However patients may refuse treat-
ment with implants because of the
additional surgery and cost involved.
Such patients can be treated with the
neutral zone concept to improve es-
thetics, support of soft tissues, func-
tion, and improved articulation of
speech.73 Numerous articles have
been published which describe prosth-
odontic management with the neutral
zone technique for patients undergo-
ing mandibular surgical reconstruc-
tion,65,73 segmental mandibulectomy,74
brain surgery,57 marginal mandibulec-
tomy,64 maxillectomy,75,76 and partial
glossectomy44 and for those with se-
vere neurological disorders,56 Parkin-
son’s disease,60 and severely resorbed
residual ridge and mandibular conti-
nuity defects.53 These authors have all
used different materials for recording
the neutral zone but have not devised
any new recording techniques.
Comparative Studies
Several studies4,16,25,39,50,55,68,77 have
compared dentures fabricated by us-
ing neutral zone (myodynamic) and
conventional techniques, and it has
been observed that neutral zone den-
tures are functionally more stable
The Journal of Prosthetic Dentistry
than conventional dentures, increase
patient comfort and function, and
experience minimum postinsertion
problems.68 However, according to
Fahmy and Kharat,25 comfort and
speech performance were better with
the neutral zone dentures than with
conventional dentures, which showed
better mastication results. Raja et al63
showed that in those with longer pe-
riods of edentulism, neutral zone den-
tures had better assessment results
and success. These dentures have the
advantages of improved stability and
retention, sufficient tongue space,
reduced food trapping adjacent to
the molar teeth, and good esthetics
due to facial support.46 Cineradiogra-
phy has also revealed greater stability
during mastication for myodynamically
fabricated dentures.78 Research should
be done to compare larger samples of
dentures, and also to compare dentures
made with and without reversal of steps
to record the neutral zone.
Critically, Stromberg et al55 com-
pared similar dentures whose external
surfaces had been formed by manual
and physiologic procedures and found
that all patients preferred the manu-
ally formed dentures. The reason could
be that although both types of denture
were properly placed, the exaggerated
contours of the functionally formed den-
ture base caused a slight decrease in re-
tention because of the different degrees
of mouth opening used during the study.
It has been suggested47,63,79,80 that
long periods of edentulism modify
the position of the neutral zone and
that the duration of edentulism influ-
ences residual ridge resorption.81-85
Fahmy47 in 1992 concluded that the
longer the period of edentulism, the
more buccally or labially located was
the neutral zone. Lammie3 reported
that the direction of mandibular ridge
resorption allows the mentalis muscle
attachments to fold over the alveolar
ridge, which results in the posterior
positioning of the neutral zone. Fah-
my47 proposed that Lammie’s find-
ings were true only for patients who
were edentulous for less than 2 years.
However, another study by Raja et al63
Volume 109 Issue 2
in 2010 found that Lammie’s find-
ings were true for patients who were
edentulous for more than 2 years and
concluded that the neutral zone may
be shifted lingually in relation to the
alveolar ridge crest in patients with
prolonged edentulism. This was also
in agreement with a study by Demirel
and Oktemer,80 who suggested the
lingual placement of mandibular pre-
molars and molars. Lingual position-
ing of the neutral zone may result
because of facial changes due to age.
Prolonged periods of edentulism may
result in sagging of the facial muscu-
lature. In the mandibular molar area,
adjacent buccinator fibers run hori-
zontally downwards and forwards.
Edentulism eliminates the tooth and
alveolar bone support of the bucci-
nator fibers. Watt and MacGregor12
suggested shortening the buccina-
tor fibers in the absence of a dental
bulge. This may distort the facial cur-
tain, and, on contraction, the buc-
cinators will direct the forces further
lingually. Consequently, the neutral
zone may be placed more lingually
in the posterior segment.47 The study
done by Raja et al63 seems to be more
appropriate as the number of partici-
pants was greater, and the procedure
was standardized, and the accuracy
level of measurements was up to 0.05
mm. However, whether to place teeth
lingually or labially in relation to the
ridge crest remains unclear and re-
quires additional research.
Limitations to this review may have
influenced the outcome. Although the
electronic searches were supplemented
with manual searches with an attempt
made to include all the articles related
to the neutral zone, some articles might
have been omitted either because they
did not focus directly on the topic or
because of the filters applied.
In future studies, different materi-
als and quantity, application meth-
ods and techniques, number of oper-
ators, and varied edentulous periods
could be compared.
Porwal and Sasaki
February 2013
SUMMARY
Within the limitations of this re-
view, it is suggested that the neutral
zone technique for fabricating pros-
theses should be considered on a
more regular basis rather than as an
approach for complex treatments.
Reviewing the literature revealed few
articles which describe the most ap-
propriate use of materials and tech-
niques for recording the neutral zone,
and comparative data are still missing.
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Corresponding author:
Dr Amit Porwal
Pacific Dental College and Hospital
Udaipur, Rajasthan
INDIA
Fax: +91-294-2491508
E-mail: aporwal2000@gmail.com
Acknowledgments
The authors thank Dr Anurag Satpathy, Dr
Naveen Halemane, and Dr Santosh Nelogi for
assistance in the preparation and editing of
the manuscript.
Copyright © 2013 by the Editorial Council for
The Journal of Prosthetic Dentistry.
Porwal and Sasaki