NEUTRAL ZONE

J Prosthet Dent. 1976 Oct;36(4):356-67.

The neutral zone in complete dentures.
Beresin VE, Schiesser FJ
Classic Article
 DEFINITION

Neutral zone \noo΄tral, nyoo΄- zon\: the potential space between

the lips and 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. GPT 9

“The potential space between the lips and cheeks on one side and
tongue on the other. Natural or artificial teeth are subject to equal and
opposite forces in this zone from the surrounding
musculature.” Glossary of prosthodontic terms. J PROSTHET DENT 1977.
NEUTRAL ZONE
•According to author-
“The central thesis of the neutral zone approach to complete dentures is to
locate that area in the edentulous mouth where the teeth should be
positioned so that the forces exerted by muscles will tend to stabilize the
denture rather than unseat it.”

•In literature, Neutral Zone is not a new concept and has been mentioned on
and off by various authors using various terminologies:

Dead space, the Stable zone (Gerber 1954)

Zone of minimal conflict(Mathews 1961)

•It is thought to be the the ideal zone for placement of denture teeth for
maximum stability and retention
 MUSCLE FORCES IN THE DENTAL ARCH

•In the mouth of the child, the teeth erupt under the influence of a
muscular environment created by forces exerted by the tongue,
cheeks, and lips.

•The dental arch is formed by the muscle forces exerted on the teeth by
the tongue, lips, and cheeks.

Journal of interdisciplinary Dentistry, 2012

•Inherent genetic factor along with the muscular forces uniquely combine
their influences to determine the final arch form and tooth position.

•Generally, muscular activity and habits which develop’ during childhood

continue through life.

•After the teeth have been lost, muscle function and activity remain highly
individual and greatly influence any complete dentures that are placed.

• It is, therefore, extremely important that the denture teeth fall within the
area compatible with muscular forces.
 MUSCLE FORCES AND DENTURE STABILITY

Our objective, therefore, is to recognize and to utilize those forces

resulting from muscle function so that they will have a positive influence on
denture stability.

This can be accomplished only if we position the teeth and develop the
external surfaces of the denture so that all of the forces exerted are
neutralized and the denture maintains a state of equilibrium.
 DENTURE SURFACES

The dental profession has been concerned, in the main, with two surfaces--
the occlusal surface and the impression surface.

Sir Wilford Fish of England has described a denture as having three surfaces,
with each surface playing an independent and important role in the over-all
fit, stability, and comfort of the denture.

The third surface-as termed by Fish, “the polished surface”-is the rest of the
denture that is not part of the other two surfaces.
One can visualize that, per square unit of area, the polished surface can be as
large as or larger than impression and occlusal surfaces combined,depending
on anatomic structure.
 INFLUENCE OF FORCES ON DENTURE SURFACES

•The greater the ridge loss, the smaller the denture base area and the less
influence the impression surface area will have on the stability and retention of
the denture.

•Where more of the alveolar ridge has been lost, denture

stability and retention are more dependent on correct position of the teeth and
contour of the external surfaces of the dentures.

•When the occlusal surfaces of the teeth are not in contact, the stability of the
denture is determined by the fit of the impression surface and the direction and
magnitude of forces transmitted through the polished surfaces.
 REVERSED SEQUENCE IN DENTURE CONSTRUCTION

The usual sequence for complete denture:

•To make primary impressions

•Construct individual Custom trays

•Make final impressions

•Fabricate stabilized bases

The external polished surface of denture is nearly arbitrarily established by

the dentist
With the neutral-zone approach to complete dentures:

• Individual trays are constructed .

• These trays are very carefully adjusted in the mouth

•Modeling compound is used to fabricate occlusion rims.

•These rims, which are molded by muscle function,

locate the patient’s neutral zone.

• After a tentative vertical dimension and

centric relation have been established, the final impressions are made

Compound rims which located the neutral zone can be considered the
primary impression or the first procedure in developing the polished
surface of the denture.
 SUMMARY
•The neutral-zone philosophy is based upon the concept 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

•We should not be dogmatic and insist that teeth be placed over the crest of
the ridge.Teeth should be placed as dictated by the musculature.

•Positioning artificial teeth in the neutral zone achieves two objectives:

1.The teeth will not interfere with the normal muscle function, and second,
2. Forces exerted by the musculature against the dentures are more favorable
for stability and retention.
 STUDIES BY OTHER AUTHORS ON NEUTRAL ZONE

1. USING THE MUSCLES TO STABILIZE THE FULL LOWER DENTURE

By E. WILFRED FISH 1933

According to author:
“It is no exaggeration to say that the principal factor in stabilizing the full
lower denture is the modeling of that part of its surface which comes in
contact with the muscles of the cheeks, tongue and lips.”

“If we neglect the modeling of this polished surface,

it does not matter what articulator we use, or what impression technic, for it
will be a matter of luck as to whether we succeed in stabilizing the denture“
•This v shaped strap of muscle crosses the lower denture in the premolar
region, and, if the denture is at all wide here, will lift it up every time it
contracts; that is, at the moment when the buccinator is fixed to chew
food.

•We must, therefore, when fashioning a wide buccal flange in the molar
region, narrow the whole denture in abruptly as we approach the premolar
region, to escape these muscles which cross at the corner of the mouth.
2. THE DYNAMIC NATURE OF THE LOWER DENTURE SPACE
BRILL, TRYDE, CANTOR. J. Pros. Den. May-June, 1965

According to this author,

The musculature of the denture space is divided into two groups:
(1) those muscles which primarily dislocate the denture during activity, and
(2) those muscles that fix the denture by muscular pressure on its secondary
supporting surfaces
 VESTIBULAR DISLOCATING MUSCLES

A. Posterior extension of the inferior buccal part of the

denture space is determined by the action of the Masseter muscle . If an
impression is made of this region while the masseter muscle is relaxed, a
denture constructed from such an impression will tend to be displaced when
this muscle contracts.
B. Sicher and Tandler drew attention to the important fact that the origin of
the Mentalis muscle is located closer to the crest of the residual ridge than
the mucosal reflection in the alveololabial sulcus .
Consequently, the bottom of the sulcus is lifted when the mentalis muscle
contracts; and thereby, the depth and
space of the oral vestibule can be decreased considerably.
C. Incisive Labii Inferioris Muscle.
During contraction this muscle contributes
to the reduction of the denture space by raising the bottom of the
sulcus,quite similar to mentalis.
 LINGUAL DISLOCATING MUSCLES
A. Internal Pterygoid Muscle
Just as contraction of the masseter muscle determines the extension of a
denture in the lower, posterior, and buccal part of the denture space, the
internal pterygoid muscle determines the extension of a denture in the
lower posterior lingual part of the denture space.
B. Palatoglossus Muscle
Posterior lingual part of the denture space is further influenced by the
palatoglossus muscle.
During deglutition, the palatoglossus muscle reduces the lumen of the
isthmus fauces. By this action the mucosa covering the lower part of the
muscle is lifted superiorly, anteriorly, and medially.
When this mucle contracts, the terminating part of the alveololingual sulcus
will be included in this movement.
C. Mylohyoid Muscle.
The mylohyoid muscles form the floor of the oral cavity and are called the
oral diaphragm.
When both mylohyoid muscles contract, the floor of the oral cavity is lifted
and the tongue is pressed against the palate, decisively changing the denture
space. The alveololingual sulcus will be displaced upward, and the posterior
part of the sulcus will change from an almost vertical position to a nearly
horizontal one.
D. Pterygomandibular Raphe.

•The pterygomandibular raphe is covered by a fold of mucous membrane,

the plica pterygomandibularis.When the mouth is opened widely, the
pterygomandibular raphe is stretched, causing the plica to stand out like a
string between the pterygoid hamulus and the retromolar pad.
•Since the stretched raphe lifts the posterior part of the retromolar pad, and
denture that has been extended onto this structure

E. Tendon of the Genioglossus Muscle

•Lingually placed on the mandibular symphysis are bony processes, the

genial spines. Short but powerful tendons that run into the genioglossus
muscles arise from these processes .
• The peritendinous tissue of the tendon joins with, and is covered by, the
lingual frenum. When the apex of the tongue is lifted, the tendinous origins
of the genioglossus are capable of pressing on the borders of the lower
denture with a dislocating effect
 VESTIBULAR FIXING MUSCLES
A.The Buccinator muscle assists in positioning food between the teeth and
returning food that has escaped into the vestibular sulcus to the occlusal
table. Therefore, Strack calls the buccinator muscle an accessory muscle of
mastication.

B. Orbicularis Oris also aids in the same way as buccinator.

LINGUAL FIXING MUSCLES

Tongue muscles, when provided proper tongue space and relief of frenum
aids in retaining the denture
 INCLINATION OF POLISHED SURFACES

•The buccal flanges of the lower denture must slope inferiorly and
laterally, and the borders must be extended out beneath a fold of the
buccinator muscle very definitely in the molar region

• The lingual flanges must also definitely extend inferiorly and medially
below the anterior and lateral parts of the tongue, and as far posteriorly as
permitted by the range of action of the tongue and the internal pterygoid
muscle. With such a sublingual and mainly horizontal extension, the denture
will rest to a great extent on the soft tissues of the floor of the oral cavity.

•If, in the construction of “difficult” lower dentures, due consideration is

given to the dynamic nature of the denture space, it is easier to make
satisfactory lower dentures
3. A STUDY OF THE IMPORTANCE OF THE NEUTRAL ZONE IN
COMPLETE DENTURES
F. M. FAHMY, M.SC., AND D. U. KHARAT, M.D.S.
JournalProsthDent 1990

Study done to compare chewing efficacy and comfort level of

conventional denture vs Neutral Zone denture

MATERIAL AND METHODS

•Ten healthy edentulous patients visiting the Department
of Removable Prosthodontics, King Saud University, Riyadh, were
included in this study.

•Two sets of dentures were prepared for each patient, one by a

conventional method and another with the neutral. zone concept.

•OVD, tooth type, and cusp angle were the same for both dentures.
Masticatory Performance Test
Each sample of the test food consisted of 5 gm of peanuts.

The subjects were asked to chew peanuts for 15sec. Test samples were
collected.
Another set of test samples was collected when peanuts were almost ready
to be swallowed
The samples were passed through ten mesh sieve screen
Masticatory performance for 15 seconds and for the up to swallowing
cutoff was found to be better with the conventional dentures than with
the neutral zone dentures.
For the 15 seconds’ mastication with the conventional dentures
•Next the patients were asked to choose one set of dentures for regular use.

•Strangely, it was found that all ten patients selected the neutral zone dentures

• The most common criteria for selection as expressed

by the patients were: “the tongue feels at ease, the speaking is easy, the dentures
do not move in the mouth,and the dentures feel more secure.”

•Two patients expressed a better appearance of the cheeks, whereas none

commented on the mastication.

•When asked about mastication,the patients were satisfied with both dentures
and they could not indicate superiority of one set of dentures over
the other.
4. THE NEUTRAL ZONE IMPRESSION
REVISITED
M. J. GAHAN AND A. D. WALMSLEY

Primary impressions and secondary

impressions

•The primary impressions are taken in a

stock tray with a mucodisplacive material

•The lower secondary impression is taken in a

close-fitting special tray with a low viscosity
mucostatic such as a zinc oxide eugenol . Fig. 1 Secondary impression
with zinc oxide eugenol
•The borders must be moulded to represent
muscle activity, recording the functional
depth and width of the sulcus.
Jaw registration

•The wax record rims are constructed on heat

cured acrylic bases.

•Once the base plates have been

assessed and modified, jaw registration can be carried out.

• The upper rim should be carved to provide support for the musculature
labially and buccally

•.After establishing the correct incisal level, occlusal planes and palatal
contour — the lower rim is adjusted to the
correct occlusal vertical dimension (OVD).

•The laboratory can now articulate the rims on an average value articulator
and construct the upper wax tryin and lower base plate.
Lower Base Plate construction
•The wax is removed from the heat cured
base plate and a superstructure is constructed.

•The superstructure has two functions:

to provide even occlusal stops at the correct OVD
to provide support for the NZ impression material.

•Designs include self-cured pillars in the

premolar regions with a short vertical fin
between them or a light cured vertical fin
along the centre of the base plate.
Competency Stages for taking a neutral zone impression

• Ensure the patient in sat upright with the head supported.

• Assess the base plate — checking that it is stable and does not hinder muscular
function.
• Insert the upper wax try in - ensuring that the upper lip is supported, the
incisal and occlusal planes are correct and the functional width of the sulcus is
restored.
• Reinsert the base plate and modify the occlusal stops so that the correct OVD
is achieved.
• With the base plate out of the mouth, place the correct volume of a high
viscosity mix of tissue conditioner on the superstructure.
• Manipulate this to form an
approximate rim and insert the plate
into the mouth. The volume should
be controlled so that the sulci are not
distorted.
• Instruct the patient to perform
repeated actions:
- Swallow and take frequent sips of
water.
-Talk aloud, pronouncing the vowels
and count from 60 to 70.
-Smile, grin, lick their lips and purse
their lips.
• These actions will mould the
material by muscle activity.
• After 10 minutes, when the
impression has set, remove the plate
and proceed to the laboratory stage.
A summary of the neutral zone
laboratory stages
• Replace base plate on the working model.
• Cut locating grooves.
• Place plaster or silicone putty index around
the model and impression.
• Remove the NZ impression from the base
plate.
• Replace the index.
• Pour wax into the remaining space so that it
attached to the base plate.
• Set up the teeth following the index — the
posterior teeth may have to be trimmed.
• Rearticulate and assess the occlusion to
ensure that it is balanced in centric occlusion
and lateral excursions.

Wax try-in with the plaster

plaster index around the index (a) buccally and (b) lingually — note the
neutral zone impression locating grooves
CONCLUSION
The neutral zone is an alternative technique for the construction of lower
complete dentures on highly atrophic ridge

The aim of the neutral zone is to construct a denture in muscle balance, as

muscular control will be the main stabilising and retentive factor
during function.

The conventional dentures advocate placement of teeth on crest of the

alveolar ridge , while neutral zone says only the muscle forces can
determine the neutral tooth position.

Studies that have been conducted comparing neutral zone denture and
conventional denture, and different techniques of NZ.
 REFERENCES

•Porwal, A., & Sasaki, K. (2013). Current status of the neutral zone: A literature review.
The Journal of Prosthetic Dentistry, 109(2), 129–134

•Journal of Dental Sciences

Volume 8, Issue 4, December 2013, Pages 432-438
Neutral zone approach to denture fabrication for a severe mandibular ridge resorption
patient: Systematic review and modern technique
Yi-LinYeh Yu-HwaPan Ya-YiChen

•A study of the importance of the neutral zone in completedentures

F. M. Fahmy, M.Sc.,* and D. U. Kharat, M.D.S.**
King Saud University, College of Dentistry, Riyadh, Saudi Arabia
(J PROSTHET DENT 1990;64:469-62.)
•Brill, N.,Tryde, G., & Cantor, R. (1965).The dynamic nature of the lower denture
space.The Journal of Prosthetic Dentistry, 15(3), 401–418

•Makzoumé, J. E. (2004). Morphologic comparison of two neutral zone impression

techniques: A pilot study.The Journal of Prosthetic Dentistry, 92(6), 563–568

•Fish, E.W.: Principles of Full Denture Prosthesis, ed. 7, London, 1948, Staples Press,
Ltd.