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Case Report
Pandey et al. WORLD JOURNAL OF PHARMACEUTICAL
World Journal of Pharmaceutical and Medical Research
AND MEDICAL RESEARCH ISSN 2455-3301
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NEUTRAL ZONE, A BOON FOR EDENTULOUS MANDIBULAR ATROPHIC RIDGES:

A CASE REPORT

Dr.Kaushik Kumar Pandey,1* Dr. Pratibha Katiyar,2 Dr. Abhishek Gaur,3 Dr. Krishna Deo,4 Dr. Manish Sahu,5
Dr. Farah Khan6
1
MDS, Senior Lecturer, Department of Prosthodontics, Career Post graduate Institute of Dental Sciences & Hospital,
Lucknow, Uttar Pradesh.
2
MDS, Reader, Department of Prosthodontics, Career Post Graduate institute of Dental Sciences & Hospital, Lucknow,
Uttar Pradesh.
3
MDS, Reader, Department of Prosthodontics, Career Post Graduate Institute of Dental Sciences & Hospital, Lucknow,
Uttar Pradesh.
4
MDS, Senior Lecturer, Department of Prosthodontics, Career Post Graduate Institute of Dental Sciences & Hospital,
Lucknow, Uttar Pradesh.
5
PG Student, JRIII, Department of Orthodontics and Dentofacial Orthopaedics, Career Post Graduate Institute of Dental
Sciences & Hospital, Lucknow, Uttar Pradesh.
6
Senior Lecturer, Department of Prosthodontics, Career Post graduate Institute of dental sciences & Hospital, Lucknow,
Uttar Pradesh.

*Corresponding Author: Dr. Kaushik Kumar Pandey

Senior Lecturer, Department of Prosthodontics, Career Post Graduate Institute of Dental Sciences, Lucknow, Uttar Pradesh, India.

Article Received on 10/06/2016 Article Revised on 01/07/2016 Article Accepted on 22/07/2016

ABSTRACT
Retention stability support esthetics and phonetics are the prime requisites for the complete denture prosthesis. In
severely resorbed mandibular ridge patients; the neutral zone technique should be done as an alternative approach.
Neutral zone technique balances the force of tongue and cheek musculature which results a stable mandibular
denture and denture is not displaced during functional movement like chewing, swallowing, speech etc. This case
report describes a unique approach for recording neutral zone technique in atrophic ridges.

KEYWORDS: Resorbed mandibular ridge, Neutral zone, Stability.

INTRODUCTION the tongue pressing outward are neutralised by the forces

of the cheeks and lips pressing inwards. The neutral zone
Management of highly resorbed ridges has always posed
technique is boon for resorbed mandibular ridge patients.
a challenge to the prosthodontist for years. Fabricating a
stable mandibular denture in resorbed ridge cases is the
The aim of the Neutral zone is to set the teeth in a
main concern for prosthodontist. In case of atrophic
denture in the area where the net resultant force exerted
ridges, Dental implants may provide stabilization of
on the denture is zero. If the denture is not in harmony
complete dentures, but every case is not indicated for
with the neutral zone, it will result in instability,
implants.[1]
interference with function and give discomfort to the
patient. The muscles affecting the neutral zone are
When it is not possible to provide implants on the
muscles of cheek which include buccinator and masseter,
grounds of medical risks, economic limitations or
muscles of lips which includes orbicularis oris and
patient’s attitudes, an alternative technique should be
caninus and muscles of tongue.[2]
thought.
As the residual alveolar ridge of mandible resorb at a
The stable position of the teeth represents equilibrium of
greater rate than the maxilla and has less residual ridge
all the forces acting on them. If that position of
for retention and support.[3] The lower denture commonly
equilibrium namely the neutral zone, is not found, the
presents the most difficulties with pain and looseness as
resulting dentition will not last long and will not be
the most common complain. Sir Wilfred Fish in 1931
esthetically pleasing and the patients use of functional
first described the influence of the polished surface on
efficiency, maximum length of use and pleasing esthetics
retention and stability. He also described how dentures
will not have been met. Neutral Zone is defined as that
area in the mouth where, during function, the forces of

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Pandey et al.
should be constructed in the ‘dead space’, which later
termed as the Neutral Zone.[4]
CLINICAL CASE REPORT
A 70 year old female patient was reported to the
department of Prosthodontics, career post graduate
institute of dental sciences and hospital, Lucknow for
the complain of difficulty in mastication. She had been
edentulous since 8 yrs without any prosthesis. After
intraoral examination it was diagnosed that patient had
complete edentulous maxillary and mandibular ridge. the
maxillary residual ridge was favorable, but the
mandibular residual ridge was unfavorable due to
resorption(Fig. 1a, 1b). First of all implant supported
prosthesis was advised to the patient as treatment option
but it was not accepted by the patient due cost and
surgical intervention so it was discarded.
Second treatment option was given to the patient as
maxillary conventional and mandibular complete denture
with neutral zone technique and it was accepted by the
patient.
Fig. 1a: maxillary edentulous ridge.
Fig 1b: mandibular atrophic edentulous ridge
Fig. 2a, 2b): Showing wire fin incorporated mandibular record base on cast and inside patient’s mouth.
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Treatment Steps
Primary impression of the maxillary edentulous residual
ridge was made with modelling plastic compound
impression material. The primary impression of
mandibular ridge was made with McCord’s technique.
Maxillary and mandibular primary casts were prepared
for maxillary and mandibular arch. The custom trays
were fabricated with self cure resin over the both primary
casts keeping the borders 2mm short of the sulcus.
The border molding was done with green stick
impression compound and the secondary impressions
were made with zinc oxide eugenol impression material.
The master casts were poured in tupe III gyspsum
product (dental stone). On maxillary master cast one and
on Mandibular master cast two temporary denture bases
were prepared in self cure resin. Wax occlusal rims were
made on maxillary and mandibular denture base. Jaw
relation and articulation was done.
On second mandibular denture base elevated fins
projecting upward towards maxillary arch were attached
(Fig 2a). Height of the fins were kept up to the maxillary
occlusal rim on articulator so that it could be in
accordance with the recorded vertical height of jaw
relation .These help in the retention of tissue conditioner
during recording of neutral zone.
The face-bow transfer and centric jaw relation was
recorded and casts were mounted on semi-adjustable
articulator.
Recording of Neutral Zone
The mandibular record base with wire fins were
evaluated intra-orally for their fit and was very carefully
adjusted in mouth to be sure that it was not overextended
and remained stable during opening, swallowing and
speaking (Fig. 2b). Then the tissue conditioner material
was mixed and loaded over the wire loops on buccal and
lingual aspects of fins of mandibular denture base and
inserted in mouth. The Patient was asked to perform the
usual movements, which included swallowing, sucking
of the lips, pronouncing the vowels, which helped in
recording the neutral zone space (Fig. 3a, 3b, 3c, 3d).
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Fig. 3a, 3b, 3c, 3d: showing different movement for recording neutral zone.

Plaster Index and Neutral Zone Record Rim
After recording neutral zone, plaster index was made.
Separating media was applied on master cast before
making plaster index surrounding neutral zone record.
Plaster index was cut with saw in three parts as to
remove tissue conditioner neutral zone record. Then the
tissue conditioning material and the adapted wire loops
were removed from the mandibular record base. This
record base was placed on mandibular master cast and
pieces of plaster index were reassembled on mandibular
master cast with elastic bands (Fig 4a, 4b, 4c). Now an
empty space (neutral zone space) was evident within the
plaster indices (Fig 4d). Next molten wax was made to
flow in this empty neutral zone space, in order to create
rim for arranging the mandibular teeth in the neutral zone
(Fig 5a, 5b). First mandibular teeth setting was done
according to neutral zone record. Later maxillary teeth
were arranged according to mandibular teeth. It was took
care during teeth arrangement that the wax contours were
preserved in case of mandibular denture as derived from
neutral zone technique and no additional wax was added
on denture flanges.[5]

Fig. 4a): Showing neutral zone recorded mandibular record base with tissue conditioner.
(Fig. 4b-4d): Showing plasters indices.

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Pandey et al.
Fig 5a) Showing occlusion rim made by neutral zone
technique.
Fig 5b) Teeth setting verified on neutral zone index.
Try-in was done, in order to evaluate the stability,
esthetics and occlusion intra-orally and satisfactory
results were seen. Then the dentures were processed with
heat cured acrylic. Lab remounting was done to check
any processing occlusal error and corrected. Before
denture insertion Finishing and polishing was done.[6]
Again retention, stability, support, esthetics and
phonetics were evaluated in patient’s mouth (Fig. 6a).
Post denture insertion instructions were given to the
patient. Patient was recalled after 24 hours and results
were found satisfactory and patient also expressed
satisfaction with the dentures (Fig 6b).
Fig 6a): Denture in occlusion inside patient’s mouth.
Fig 6b): Satisfied patient after denture insertion.
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DISCUSSION
Neutral zone is a noble technique which helps in
recording the relationship of perioral tissue with intra
oral tissues and thus provides us a space where all the
forces are in equilibrium. When teeth are arranged in this
zone, the stability of complete denture gets enhanced.[2, 4,
7, 8]
Various materials had been recommended for recording
neutral zone viz. low fusing temperature compound,
mouth temperature waxes, soft tissue conditioner etc. In
this case report tissue conditioner was used because it
provides least resistance to the tissue and gets molded
easily. Wire loops were attached to the support the
material during recording of neutral zone.[9]
The neutral zone philosophy is based on 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 and at the same
time where the force generated by the tongue are
neutralized by the force generated by the cheeks and lips.
Orthodontic relapses, postoperative problems,
unsuccessful periodontal procedures and replaces with
orthognathic surgery can be attributed to neutral zone
imbalance.[10]
Stability, the most important property of the complete
Denture may get hampered in certain situations such as
resorbed residual ridge, partial jaw resection, damaged
neuro-muscular control etc. These conditions demand a
critical evaluation and perpetual treatment planning
which not only preserve the remaining tissue but also
enhances the functional efficiency of the complete
denture.
Thus, by recording neutral zone, in this case proved
beneficial as it enhanced stability of the prosthesis as
well as gained patient satisfaction.
CONCLUSION
Thus neutral zone technique is bone for increasing the
stability of mandibular denture in poor ridge cases. In
this case report we have opted a simple and effective
method to record neutral zone for severely atrophic
ridges.
REFERENCES
1. Gahan MJ, Wansley AD.The neutral zone
impression revisited. Br Dent J., 2005; 198(5):
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2. Cantor R, Curtis TA. Prosthetic management of
edentulous mandibulectomy patients. Part II.
Clinical procedures. J Prosthet Dent., 1971; 25:
546-55.
3. Lymph CD, Allen PF. Overcoming the unstable
mandibular complete denture: The neutral zone
impression technique. Dental update., 2006; Jan-Feb
33(1); 21-2, 24-6.
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4. Alfano SG, Leupold RJ. Using neutral zone to

obtain maxillomandibular relationship records for
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