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| Smile Dental Journal | Volume 6, Issue 4 - 2011
Neutral Zone in Complete Dentures:
Systematic Analysis of Evidence and Technique
Ahmad A. Jumah, BDS(Hons), MSc/PhD (Clin) Student-Second year
Restorative Dentistry Department, Leeds Dental Institute, University of Leeds, UK
dnaahj@leeds.ac.uk
Peter J. Nixon, Senior Consultant in Restorative Dentistry, Leeds Dental Hospital,
Leeds Teaching Hospitals Trust (LTHT), England, UK
Analysis of functional forces
Understanding the unique and synergistic interplay
and complex movements of muscles of cheeks, lips
and tongue is the first step in construction of lower
CD that is stabilized rather than being dislodged by
movements of these structures.
11,12
Description of forces
applied to the lower CD purely on the basis of direction
is an oversimplification, yet, it is quite useful for better
understanding of the concept.
12
The outward forces are principally generated by the
tongue and lingual frenum into which, genioglossus
muscle is inserted. Teeth should be set and flanges should
be contoured in harmony with tongue size, position and
shape during rest and function. In rest position, the tongue
rests on lingual cusps of posterior teeth and lingual
flanges posteriorly and anteriorly. The tongue space
determined by position of teeth is far more important
during function. Setting teeth too lingualy will encroach
on this space and the tongue tends to dislodge denture
in function. The height of posterior teeth is of a great
importance in stability of lower CD as well. Having the
tongue resting on lingual cusps will reduce the horizontal
(outward) force and apply force with vertical (downward)
component which enhances stability and retention.
11
Inward forces are generated by cheeks resulting from
contraction of the buccinator muscle that pushes food
bullous on top of occlusal surfaces of posterior teeth.
Flanges contoured and teeth set too buccal are at
increased risk of being dislodged by the action of this
muscle. Anteriorly, lip muscles (mentalis and orbicularis
oris) are the source of inward forces generated during
speaking and swallowing. Contraction of these muscles
to attain seal during these activities can destabilize lower
CD with teeth and flanges placed too far labially. The
modiolus is a knot-like structure found in corners of the
Introduction
Stability of lower CDs is well recognized as a potentially
difficult treatment aim to achieve. Looseness and discomfort
are the most frequent complaints reported by patients and
they are quite often difficult to manage by dentists.
Neuromuscular control is said to be the key determinant
of stability of lower CD as the area available for support is
far less than maxillary support area. Size and position of
prosthetic teeth and the contours of polished surface have
a crucial role in lower CD stability as they are subjected to
destabilizing forces from the tongue, lips and cheeks if they
are placed in hindrance with function of these structures.
1
Throughout time, many concepts and theories emerged
to describe where prosthetic teeth of CD should
be positioned. Some of them adopted mechanical
principles,
2,3
others used biometric guides
4
and a minority
advocated mathematical formulas based on natural teeth
position and dimensions.
5
These dogmatic or arbitrary
approaches have been challenged and found insufficient,
in fact not only by rigorous research, but also by failure
to restore function, aesthetic and comfort in patients with
severely atrophic mandibular ridges (Class V Atwoods
6
),
patients with enlarged tongue and cases of marginal or
segmental mandibulectomy. To overcome such problem,
the neutral zone technique was advocated.
The neutral zone, zone of minimal conflict,
7
zone of
equilibrium,
8
potential denture space
9
and the dead
space
10
are all terms used to describe the potential area
where forces generated in an outward direction from the
tongue are being neutralized or balanced by the inward
forces generated by lips and cheeks during functional
activities. Setting teeth and contouring polished surface
of lower CD within this zone, makes the prosthesis less
subjected to dislodging forces and adds more to stability.
11

Abstract
Neutral zone technique is a physiologic and functional approach that is widely and concisely described as a treatment
modality for unstable lower complete denture cases. It serves as a guide of where to set teeth and how to contour the
polished surface of the denture to ensure optimal stability, retention, facial support and aesthetics. In patients with
compromised support and poor denture adaptability, this technique is considered as a valuable tool in the prosthodontists
armoury especially where dental implants are contraindicated or unfeasible. The aim of this article is to describe the concept
and technique of neutral zone, discuss rationale, indications and to evaluate this technique from evidence-based perspective.
Abbreviations: NZ: Neutral zone, CD: complete denture, VDO: Vertical dimension at occlusion.
Smile Dental Journal | Volume 6, Issue 4 - 2011|
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articulator. In the lab, the lower occlusal rim is removed
from baseplate and substituted with a baseplate with
acrylic pillars
29
in the premolar regions and/or wire
loops
13
on the remaining areas of the baseplate. The
pillars preserve the VDO recorded in bite registration
stage. It is essential the the pillars are relatively thin
bucco-lingually and are positioned directly over the
ridge. The base plate is then fitted in the patients mouth
and VDO and extensions are checked. Then impression
material such as compound
11
, plaster
22
, wax
30
, silicone
31
,
polyether
32
or tissue conditioner
13,33
is applied to the
baseplate and retained by the wire loops and/or acrylic
pillars. Before setting of material, patient is asked to
perform functional movement such as, licking lips,
swallowing, pronouncing some words or combination
of these. Care should be taken that the patient should
continue performing functional movements until the full
setting of material; otherwise material might flow back
and give inaccurate recording of the neutral zone. It is
useful if the chosen material has relatively long working
time to allow the required movements to be carried out
before the material becomes rigid. Also, it is worthwhile
to mention that it is better to perform the NZ record
while the upper occlusal rim or finished denture is fitted
in the patient mouth as it may help to control recording
material and prevent it from being displaced in a labio-
occlusal direction.
29
In the lab, the baseplate carrying recording material is
fitted on the master cast again and VDO is checked. A
putty or plaster index is made around the NZ record.
Placement of three orientation grooves is recommended
as these help in repositioning the index on the master cast.
Impression material is then removed and replaced
by wax; the use of the index will make sure that wax
replicates the neutral zone record. Subsequently, teeth
should be set and flanges contoured according to the
index that represents NZ.
NZ impression technique has various modifications, not
only in terms of materials used or retention provided by
baseplate, but also in terms of the functional movements
performed and refinement of the procedure. A further
more defined NZ record can also be achieved in try-in
stage. The wax below the teeth and covering the flanges
can be cut back and tissue conditioning material or
medium-bodied silicone applied. The patient is asked
again to perform functional movements. The dentures
are processed as usual. The same procedure has also
mouth where several muscles are inserted. Movement of
this structure narrows the space available for flanges and
teeth. The modiolus produces quite strong inward forces
in premolar region. Thus, contouring flanges in harmony
with its functional movement is essential.
11,12
Rationale
The rationale of using neutral zone technique is to
fabricate a lower CD that is optimally situated and in
harmony with the structures and forces discussed above.
By doing so, these forces are more likely to be stabilizing
rather than unseating.
11
The need for such a technique
that is based on physiologic concepts is significantly
increasing as emergence of several factors (discussed
below) render a high proportion of conventionally made
lower CDs unsatisfactory.
Increased access to dental care has led to patients losing
their teeth at a later stage of life.
13
Compounded by
increased life expectancy, this has led to the majority
of CD wearers to be elderly and has increased the
proportion of those who have poor neuromuscular
control, poor adaptive capacity, severely atrophic
ridges
14
and atypical denture support area as a result
of surgical interventions, poor planning for transition
from partially dentate to edentulous state,
15
untreated
edentulism for long period of time
,16,17
trauma or
systemic diseases. Occasionally, patients with one or
a combination of these conditions can be successfully
treated by CD constructed by conventional techniques.
11
Indications
In general, neutral zone technique is indicated when
stability and patients acceptance of lower CD are in
question. Searching the literature, this technique is
found to be used in the following clinical situations:
Severely atrophic mandibular ridge
12,13,18-22
(Atwoods V).
Patients with prominent and highly attached mentalis
muscle, lateral spreading of tongue as a result of poor
transition from dentate to edentulous state and severe
resorption.
13

Patients with diminished neuromuscular control such as
those with a history of stroke,
13
Parkinsons disease
13,23

or patients with impaired motor innervation to oral and
facial muscles as a result of brain surgery.
18
Patients with atypical shape or consistency of oral
and perioral structures. For example, patients who
have scleroderma,
13
marginal
21,24
or segmental
25,26
mandibulectomy and partial glossectomy.
27
NZ technique can be used to locate optimal position
for implants in cases of implant-supported or -retained
overdentures, which enhances the overall outcome of
treatment.
28
Clinical technique
Primary and secondary impressions are taken for
maxillary and mandibular denture bearing areas as in
standard complete denture treatment. Bite registration
is then performed as in conventional treatment. Master
casts with record blocks should be mounted on an
(Table 1) Materials Used for NZ Impression
Impression plaster
Impression waxes
Impression compound
Regular bodied silicone
Tissue conditioner
Polyether
Hard relining material
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| Smile Dental Journal | Volume 6, Issue 4 - 2011
ridge in patients who have been edentulous for less than
two years and significantly differs in those who were
edentulous for a period more than that.
16,17
Realizing the importance of the forces generated
by various oral structures on the teeth and polished
surfaces of CDs and their effect on the stability of CD
sheds light on the NZ technique.
1,10
It has been shown
that compromised retention, poor stability, phonetic
problems, inadequate facial support, inefficient
tongue posture/function and increased gagging are
all associated with functionally inappropriate setting of
denture teeth and physiologically inadequate contours
or volume of the denture base.
20
NZ technique has been criticized based on claims that
it is supported by empirical evidence. However, other
authors maintain that this is inaccurate as NZ technique
is based on significant clinical observations on the role
of destabilizing forces the muscles apply to CDs during
functional movements. Furthermore, the large number of
case reports accumulated in a short period of time and
clinical studies conducted by Stromberg & Hickey
36
and
Fahmy & Kharat
37
undermine this criticism and add to
the validity of NZ technique. Stromberg & Hickey
36
found
better patient adaptability to physiologically formed
denture bases when compared to conventional ones.
Fahmy & Kharat
37
found improved comfort and speech
clarity reported by patients upon wearing CD fabricated
using NZ technique when compared to conventional
CD. Moreover, Barrenas and Odman found less post
insertion problems and better patient acceptance in
NZ dentures when compared to conventional ones.
38

been described after insertion of the denture but using
hard relining material.
27,31
Discussion
Many approaches to set teeth have been advocated and
used in complete denture treatment.
20
However, there
is substantial debate on which of these provide optimal
position in the facio-lingual dimension and guarantee a
favourable outcome in terms of stability, facial support,
chewing efficiency, aesthetics and patient comfort. Some
of these approaches utilized biometric measurements and
location of relatively stable anatomical landmarks to set
teeth;
4
others relied on difference in resorption patterns
to set denture teeth where their natural predecessors
were thought to have been.
34
Some authors adopted a
mechanical concept and advocated setting teeth directly in
the centre of denture support area where the least amount
of leverage is present which in turn enhances the stability
of lower CD.
35
All of these approaches were and are still
being used and each of them proved to have advantages
and disadvantages when compared to others. Furthermore,
these approaches seem to work best when used with
patients who have; their oral and peri-oral musculature
unaltered for any reason, adequate neuromuscular control
and acceptable amount of residual ridge for support.
Unfortunately, the proportion of patients with these features
is dramatically decreasing and so the NZ concept has
become increasingly significant. These observations are
strongly supported by studies investigating the effect of
period of edentulism on position of neutral zone. It has
been found that NZ is closely related to the crest of residual
(Fig. 2) A: NZ impression taken with silicon. B: Putty index
adapted around master cast
(Table 2) Summary of clinical and laboratory stages of NZ
technique
Clinic 1: Upper & lower primary impressions using stock trays
Lab1: Casting primary models and construction of special trays
Clinic 2: Upper & lower secondary impressions
Lab 2: Casting master models and construction of record blocks
Clinic 3: Bite registration
Lab 3: Mounting master casts using CR record on semi-adjustable
or average value articulator. Removal of lower wax rim and fabrica-
tion of baseplate for NZ impression
Clinic 4: NZ impression
Lab 4: NZ impression record mounted on lower master cast, orien-
tation grooves placed on master cast, putty index adapted around
NZ record and impression material removed and poured in wax
Finally, setting of teeth completed
Clinic 5: Try-in stage. Afterwards, NZ impression refined by tissue
conditioner applied to lower try-in denture
Lab 5: Processing, finishing and polishing
Clinic 6: Insertion of finished dentures
(Fig. 1) NZ baseplate with
acrylic pillars and wire loop
(Table 3) Summary of NZ impression clinical technique
Baseplate with acrylic pillars and/or wire loop is fitted in patients
mouth and checked for proper extensions and VDO
Baseplate is coated by adhesive and loaded with regular bodied
silicone impression material
While the patient is setting upright and comfortable the baseplate is
inserted in patients mouth
Patient is then asked to swallow few time, moisten lips, use tongue to
clear buccal sulci, smile, grin and purse lips
Before final setting of material, patient is asked to read loudly a
vocal passage
Once set, NZ impression removed and inspected for deficiencies
which can be corrected by addition of impression material
Impression disinfected and sent to lab
Smile Dental Journal | Volume 6, Issue 4 - 2011|
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Recently, Raja and Saleem
19
published results of clinical
trial in which they compared patient acceptance of NZ
dentures and conventional dentures in 128 patients. The
authors concluded that there is no significant difference
in terms of patients acceptance between the two groups
as far as patients who have been edentulous for less
than two years are concerned. However, in patients who
have been edentulous for more than two years, better
results and patient acceptance were reported with NZ
dentures. Unfortunately, the aforementioned studies can
be criticized in terms of design or information about
blinding and randomization which affects the quality of
evidence taken from these studies.
The principle of the NZ concept has remained the
same since it has been first described by Beresin and
Schiesser. However, the technique has been subjected to
various modifications. Type of retention incorporated in
the baseplate (acrylic pillars or wire loops
13
), recording
materials used and further refinement to the initial
record are among the variations between clinicians.
The authors preference is to use combination of thin
acrylic pillars in premolar region connected by a wire
loop which maintains the VDO and provides maximum
retention at the same time. Medium or regular bodied
silicone impression material used along with adhesive
for the initial record that is refined in the try-in stage by
tissue conditioning material is the personal preference of
the authors for purposes of NZ recording.
(Fig. 4) Refined NZ record using tissue conditioner on try-in denture
(Fig. 3) Setting of teeth according to NZ record. Note the class II
arrangement of teeth
The effect of various functional movements patients
perform during recording NZ on the location and
dimensions of NZ has been investigated by Makzoumi
39
.
This investigation concluded that NZ recorded whilst
patients perform a phonetic exercise is significantly
narrower when compared with a NZ record produced
during swallowing. This finding may be of a clinical
significance from two perspectives; first, the author used
modelling compound for the swallowing and used tissue
conditioner for phonetic technique which may indicate
that one of these materials is less reliable than the other
in recording NZ. Second, dentures fabricated utilizing
one functional exercise to shape the NZ may be unstable
during other functions. The authors preference is to as
patients to perform multiple tasks including swallowing,
using the tongue to moisten lips and finishing with
reading a speech articulation passage loudly.
From biomechanical perspective, NZ technique has
one disadvantage as teeth may be set far from the
denture support area. For example, in a case of
excessive resorption of the anterior area of the mandible
accompanied by prominent and highly attached mentalis
muscle, this will shift the NZ more lingually away from
the crest of the ridge. This horizontal discrepancy can
increase the leverage forces on the denture and may
destabilize it.
21
However, there is an agreement that
these leverage forces are well counterbalanced by
favourable and seating forces resulting from optimal
placement of teeth and polished surfaces of denture
being in harmony with the tongue, lips and cheeks.
1,11,40
Conclusion
NZ concept is considered as exceptionally important
when considering treatment options for patients
complaining from unstable lower CD particularly
if implant treatment is not feasible. It aims to place
lower CD where forces generated by lips, cheeks and
tongue have a stabilizing rather than dislodging effect.
The principle technique used to record neutral zone
is extensively recorded; yet it needs to be backed up
with high quality clinical trials to push it further up on
the hierarchy of evidence. It is not a widely practiced
procedure while the proportion of patients that may
befit from is significant. This may be attributed to a lack
of experience and exposure to this technique during
undergraduate training and the associated increase in
chair time and laboratory costs.
Acknowledgement
The authors would like to acknowledge with gratitude Dr.
Brian Nattress for his continuous support and cheif dental
technician, Carol Scholfield, for the skilled lab work.
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