CLINICAL SCIENCE

Utilization of the Neutral Zone Technique

for a Maxillofacial Patient
Alvin G. Wee, BDS, MS,1 Roger B. Cwynar, DMD,2 and Ansgar C. Cheng, BDS, MS3

The use of a neutral zone technique to fabricate a more stable complete mandibular denture for
a maxillofacial patient is presented. The technique incorporates an altered sequence from
traditional denture fabrication, resulting in a shortened treatment period.
J Prosthod 2000;9:2-7. Copyright r 2000 by The American College of Prosthodontists.

INDEX WORDS: complete denture, dental prosthesis, edentulism

T O MAXIMIZE the stability and retention of

mandibular dentures, previous reports1-3 have
recommended that posterior denture teeth be posi-
the concept of neutral zone for complete denture
treatment in 1933.4 Several authors since that time
have contributed to the development of the neutral
tioned directly over the crest of the edentulous ridge. zone concept.5-10,12 The neutral zone is defined as the
This relationship of the teeth and alveolar ridge is potential space surrounding the mandibular denture
important for the stability of the denture in func- between the lips, cheeks, and the tongue. In theory, it
tion.1-3 Although this tooth position may be desirable is that area or position where the forces between the
when adequate alveolar ridge height is available, tongue and cheeks or lips are equal.23
such a position may not be suitable for severely Whereas leverage during function is of primary
resorbed ridges because of a lateral shift in the concern for the conventional ‘‘teeth over ridge’’
orientation of the ridge crest. This horizontal discrep- concept, muscular forces during function are consid-
ancy between original tooth position and resorbed ered more crucial for the neutral zone concept.24
ridge crest, coupled with an increased vertical dis- Advocates of the neutral zone do not ignore the
tance between occlusal table and tissue support, can resulting, less favorable leverage, but assume that it
lead to denture instability. Successful denture treat- is counterbalanced by the controlling actions of
ment in situations like this can become increasingly cheeks, lips, and tongue, especially for resorbed
dependent on the position of the denture teeth and alveolar ridges.4-10,12
the external contours of the dentures. It is for these A criticism of the technique is that many advo-
patients that the neutral zone concept4-12 becomes cates of the neutral zone concept have made sugges-
increasingly significant. tions based on empirical evidence. One of the first
The importance of the polished denture surface clinical studies dedicated to this topic was by Strom-
for retention and stability has been well advo- berg and Hickey in 1965.11 Despite criticism of their
cated.13-22 Fish first exposed the dental profession to research design,16 this study was an initial step
towards clinical, evidence-based evaluation of the
1Assistant Professor, Section of Restorative Dentistry, Prosthodontics and
neutral zone technique.
Endodontics, The Ohio State University, Columbus, OH.
Two clinical studies have shed light on the advan-
2Staff Prosthodontist, VA Pittsburgh Healthcare System, and Associate tages of using the neutral zone technique. Cinefluoro-
Professor, Department of Prosthodontics, University of Pittsburgh, Pitts- graphic studies by Sheppard25 have shown that the
burgh, PA. muscles reseat the complete denture during func-
3Head, Maxillofacial Prosthetics, Ontario Cancer Institute–Princess
tion. In a clinical study, Fahmy and Kharat5 evalu-
Margaret Hospital, Toronto, Ontario, Canada.
Accepted December 17, 1999.
ated patients’ chewing efficiency and satisfaction for
Presented in part at the 1999 Carl O. Boucher Prosthodontic Conference complete dentures made with either a conventional
in Columbus, OH. or neutral zone technique. Patients had better chew-
Correspondence to: Dr. Alvin G. Wee, Section of Restorative Dentistry, ing efficiency when wearing conventional dentures;
Prosthodontics and Endodontics, The Ohio State University, 305 West 12th however, patients could not detect any difference in
Avenue, Columbus, OH 43210-1241. E-mail: Wee.12@osu.edu
Copyright r 2000 by The American College of Prosthodontists
masticatory performance between their convention-
1059-941X/00/0901-0002$5.00/0 ally fabricated dentures and neutral zone dentures.
doi: 10.1053/jd.2000.5936 Patients did report greater comfort and improved

2 Journal of Prosthodontics, Vol 9, No 1 (March), 2000: pp 2-7

 March 2000, Volume 9, Number 1 3

speech clarity with the dentures fabricated using the tended mandibular denture was modified and relined with
neutral zone technique compared with their conven- a tissue conditioner (Lynol; Kerr, Romulus, MI). He was
tionally prepared dentures. These studies suggest then advised not to wear his dentures 2 days before the
that the neutral zone strategy for denture fabrication final denture impressions.28
may be helpful in certain edentulous situations.
The purpose of this article is to present the use of First Appointment
the neutral zone technique for the fabrication of a
complete mandibular denture for a maxillofacial The final maxillary impression was made using Type
patient with a continuity mandibular defect and I impression compound (Red Compound, 132°C;
severely resorbed ridges. Kerr) with a nonperforated metal tray. The com-
pound impression was removed from the oral cavity,
and the borders were trimmed to a length 2 to 3 mm
Clinical Report short of the active sulcus. Border molding was per-
formed with a Type I impression compound (Green
A 65-year-old white man was referred from the
Compound, 123°C; Kerr; Fig 2), and a final wash
Department of Otolaryngology to the Dental Maxil-
impression was made with a silicone impression
lofacial Unit at the Veteran’s Affairs Medical Center
material (Elasticone; Kerr). Impression wax (Iowa
in Pittsburgh, PA. The patient presented with a
Wax; Kerr) was used to make a functional impres-
history of squamous cell carcinoma in the left man-
sion of the posterior palatal seal. A slightly overex-
dibular molar area and tumor removal that resulted
tended mandibular irreversible hydrocolloid impres-
in a healed, continuity defect. Before the surgery, the
sion was also made using a prefabricated impression
patient had been wearing complete maxillary and
tray.
mandibular dentures for the last 20 years. The
patient did not wear his previous mandibular denture
after surgery. Laboratory Procedure
In the laboratory, the maxillary impression was
Procedure beaded and boxed. Both impressions were poured in
American Dental Association type III dental stone. A
Consultation Appointment and Treatment close-fitting custom mandibular impression tray was
Planning Considerations made from a light polymerization composite resin
The patient’s chief complaint was that he could not wear (Triad; Dentsply, York, PA). The tray border was
his previous dentures after the surgery and desired new fabricated 2 to 3 mm short of the active sulcus. Metal
denture treatment. A detailed examination was com- loops for the retention of a compound rim were
pleted, and his previous dentures were evaluated for incorporated (Fig 3). A maxillary occlusal wax rim
retention and stability. Extra-oral examination revealed was formed over a record base made from clear
asymmetrical lip retraction with reduced excursion on the autopolymerizing polymethylmethacrylate resin
left side of the face. This was not unexpected, given the (Orthoresin; Dentsply, Milford, DE).
patient’s prior surgical history (ie, removal of tumor and
muscle in the left mandibular molar area). Intraorally, the
left mandibular region presented atypical anatomy with a Second Appointment
reduced retro-molar pad area. A low mandibular alveolar
ridge height was also evident (Fig 1). The maxillary occlusal rim was adjusted for proper
The use of dental implants to achieve improved stability esthetics, occlusal plane, phonetics, and support of
and retention for this patient’s planned mandibular pros- the upper lip. Appropriate lines (midline, canine
thesis was a recommended treatment modality.26,27 Unfor- lines, smile line) were marked. A facebow record was
tunately, the patient did not meet appropriate criteria that made.
would allow him treatment with dental implants in the
The mandibular custom tray (Fig 3) was adjusted
federally funded institution where he was being treated.
Financial constraints also precluded implant rehabilitation
intraorally to ensure that it was short of the active
in private or academic settings. Because of his atypical sulcus. A Type I impression compound (Grey Com-
intra- and extra-oral anatomy, the neutral zone technique pound, 126°F; Kerr) was applied in the area of the
was considered the best means to determine the most mandibular ridge on the acrylic resin tray. The
stable position for the mandibular denture teeth. compound occlusal rim was reheated in the water
With the patient’s permission, his previously overex- bath. Use of denture adhesive (Fixodent; Procter and
4 Neutral Zone Technique ● Wee, Cwynar, and Cheng

Figure 1. Patient’s mandibular edentulous ridge with

atypical edentulous anatomy on the left side.

Gamble, Cincinnati, OH) assisted in retaining the

Figure 3. Custom mandibular impression tray with reten-
mandibular tray in the patient’s mouth. The patient tive components for the neutral zone technique.
followed a regimen of swallowing, sucking,5,8 and
saying ‘‘ah, ee, oh’’ aloud.17 This permitted the occlusal rim was positioned on the maxillary arch,
muscles to engage and adjust the compound occlusal and the occlusal portion of the rim was adjusted to
rim intraorally. The patient was also instructed to the correct vertical dimension of occlusion, with the
move his cheeks, lips, and tongue continuously to rims touching evenly (Fig 4). Simultaneous bilateral
assist in molding the compound material.6 The com- anterior and posterior occlusal contacts in centric
pound was reheated in the water bath, and the relation were verified. The mandibular custom tray
procedure was repeated to confirm the shape of the was then border molded without altering the occlusal
neutral zone. Denture adhesive was removed from relationship of the maxillary occlusal rim.
the intaglio of the tray. The adjusted maxillary A closed mouth impression was made of the
mandibular arch with a silicone impression (Elasti-
con; Kerr). After adhesive was placed, impression
material was positioned in the tray, and the patient
was instructed to close gently against the opposing
rim. The mandibular impression was completed, and
an interocclusal record was made between the maxil-
lary occlusal rim and the mandibular compound
occlusal rim/border molded impression complex with
a polyvinylsiloxane occlusal registration material (Blu-

Figure 4. Maxillary wax occlusal rim and mandibular

Figure 2. Border molded maxillary compound impres- compound occlusal rims in proper vertical dimension of
sion. occlusion.
 March 2000, Volume 9, Number 1 5

Figure 7. Patient’s uneven smile at wax try-in appoint-

ment.
Figure 5. Poured mandibular cast with compound rims
mounted against maxillary occlusal rim using polyvinylsilox- from the mandibular cast. A mandibular record base
ane occlusal registration material. was fabricated using Triad material. The record base
and plaster indices were positioned on the cast. The
Mousse; Parkell, Farmingdale, NY). The shade and inner surfaces of the plaster indices were lubricated
shape of acrylic resin denture teeth were also chosen. with petrolatum gel. Molten wax was poured within
Zero degree posterior teeth were selected for mono- the plaster matrix to form a wax rim on the record
plane occlusion in accordance with the neutrocentric base that was located in the neutral zone. The
occlusal concept.29-31 mandibular denture teeth were then set within the
The mandibular final impression was poured in confines of the wax rim. Because of the patient’s
the laboratory, and the master cast was indexed (Fig atypical anatomy and an uneven balance of muscular
5). The maxillary and mandibular casts were mounted forces influencing the neutral zone technique, an
in an articulator without removing the mandibular asymmetry on the patient’s left side resulted in a
impression tray from its cast (Fig 5). The mandibular skewed placement of teeth in this area.
neutral zone rim was indexed with plaster placed on
the buccal and lingual surfaces (Fig 6). The indices
Third and Fourth Appointments
were removed once set. The anterior and posterior
maxillary denture teeth were initially positioned A clinical wax try-in (Fig 7) was completed. A clinical
against the mandibular occlusal rim. The compound remount was used to verify the interocclusal relation-
occlusal rim and impression tray were then removed

Figure 8. Completed mandibular denture intraorally.

Note slight underextension of the mandibular denture at
the left retromolar pad area. The left mandibular acrylic
resin teeth are also positioned slightly lingual to the crest of
the ridge. This resulted from the patient’s mandibular
Figure 6. The shape of the mandibular compound rim defect and asymmetric balance of muscular forces and
captured with buccal and lingual plaster indices. their influence on the neutral zone technique.
6 Neutral Zone Technique ● Wee, Cwynar, and Cheng

ship. The dentures were then processed, and a new (University of Pittsburgh Medical Center) for initiating his
laboratory and clinical remount were accomplished interest in the neutral zone technique. Dr. Alan B. Carr’s
to refine the occlusion.32 The dentures were polished (Ohio State University) review of the manuscript was also
and delivered (Fig 8). The patient was recalled at 1 appreciated.
day, 1 week, and 6 months.

References
Discussion
1. Weinberg LA: Tooth position in relation to the denture base
The final mandibular prosthesis presented in this foundation. J Prosthet Dent 1958;8:398-405
article has a number of attributes that make it 2. Bolender CL, Smith DE: Diagnosis and management of
unique relative to a conventional mandibular com- inadequate denture prostheses, in Laney WR, Gibilisco JA
(eds): Diagnosis and Treatment in Prosthodontics. Philadel-
plete denture. As observed in Fig 8, the final mandibu-
phia, PA, Lea & Febiger, 1983, pp 279-282
lar prosthesis appears slightly underextended on the 3. Watt DM: Tooth positions on complete dentures. J Dent
patient’s left retromolar pad area. This is caused by 1978;6:147-160
previous tumor removal surgery in that region. An- 4. Fish EW: Using the muscles to stabilize the full lower denture.
other unique feature is the more lingually placed left J Am Dent Assoc 1933;20:2163-2169
5. Fahmy FM, Kharat DU: A study of the importance of the
mandibular denture teeth, as determined by the
neutral zone in complete dentures. J Prosthet Dent 1990;64:
neutral zone technique. 459-462
It is important to note that the technique pre- 6. Razek MK, Abdalla F: Two-dimensional study of the neutral
sented here differs from that described by Beresin zone at different occlusal vertical heights. J Prosthet Dent
and Schiesser.33 Only the mandibular denture is 1981;46:484-489
7. McDonald GT, Larsen HD: The neutral zone space: A clue to
modified for the neutral zone procedure, as pre-
denture stability. Gen Dent 1984;32:510-511
sented. The neutral zone procedure is more benefi- 8. Beresin VE, Schiesser FJ: The neutral zone in complete
cial to the mandibular denture, because many other dentures. J Prosthet Dent 1976;36:356-367
factors favor the retention and stability of the maxil- 9. Brill N, Tryde G, Cantor R: The dynamic nature of the lower
lary denture, when compared with the mandibular denture space. J Prosthet Dent 1965;15:401-418
10. Schiesser FJ: The neutral zone and polished surfaces in
denture.34-37
complete dentures. J Prosthet Dent 1964;14:854-865
The planned sequence of this method of denture 11. Stromberg WR, Hickey JC: Comparison of physiologically and
construction also requires fewer fabrication appoint- manually formed denture bases. J Prosthet Dent 1965;15:213-
ments for the completion of the prosthesis, as com- 226
pared with traditional methods of denture fabrica- 12. Raybin NH: The polished surface of complete dentures. J
Prosthet Dent 1963;13:236-239
tion.38 A disadvantage of this technique involves the
13. Kapur KK, Soman S: The effect of denture factors on
laboratory aspect. Increased laboratory time is neces- masticatory performance. Part II. Influence of the polished
sary, and the laboratory technician must be trained surface contour of denture base. J Prosthet Dent 1965;15:231-
to support this clinical procedure. 240
14. Landesman HM: A technique for the delivery of complete
dentures. J Prosthet Dent 1980;43:348-351
Conclusion 15. Levin B: Current concepts of lingual flange design. J Prosthet
Dent 1981;45:242-252
The use of the neutral zone concept for denture 16. Lott F: Discussion of ‘‘Comparison of physiologically and
fabrication has been advocated since the 1930s. manually formed denture bases.’’ J Prosthet Dent 1965;15:227-
Altered treatment sequencing, using a modified 228
neutral zone technique for mandibular denture fabri- 17. Lott F, Levin B: Flange technique: An anatomic and physi-
ologic approach to increase retention, function, comfort, and
cation, was presented for a maxillofacial patient. This
appearance of dentures. J Prosthet Dent 1966;16:394-412
technique may provide a more stable and retentive 18. Matthews E: The polished surfaces. Br Dent J 1961;111:407-
complete lower denture and a shorter treatment 411
time relative to conventional treatment for patients 19. McGee GF: Tooth placement and base contour in denture
with severely resorbed ridges and/or mandibular construction. J Prosthet Dent 1960;10:651-657
20. Pound E: Lost—Fine arts in the fallacy of the ridges. J Prosthet
defects.
Dent 1954;4:6-16
21. Shanahan TE: Stabilizing lower dentures on unfavorable
Acknowledgment ridges. J Prosthet Dent 1962;12:420-424
22. Starcke EN: The contours of polished surfaces of complete
The primary author would like to thank Dr. Robert L. dentures: A review of the literature. J Am Dent Assoc
Schneider (University of Iowa) and Dr. Hussein S. Zaki 1970;81:155-160
 March 2000, Volume 9, Number 1 7

23. The Academy of Prosthodontics: The Glossary of Prosthodon- 31. Gronas DG, Stout CJ: Lineal occlusion concepts for complete
tic Terms. J Prosthet Dent 1999;81:48-110 dentures. J Prosthet Dent 1974;32:122-129
24. Zarb GA, Bolender CL, Hickey JC, et al: Preliminary arrange- 32. Holt JE: Research on remounting procedures. J Prosthet Dent
ment of artificial teeth, in Zarb GA, Bolender CL, Hickey JC, 1977;38:338-341
et al (eds): Boucher’s Prosthodontic Treatment for Edentu- 33. Beresin VE, Schiesser FJ: The Neutral Zone in Complete and
lous Patients (ed 10). St Louis, MO, The C.V. Mosby Co, 1990, Partial Dentures (ed 2). St Louis, The C.V. Mosby Co, 1978
34. Jacobson TE, Krol AJ: A contemporary review of the factors
pp 363-364
involved in complete dentures. Part III: Support. J Prosthet
25. Sheppard IM: Denture base dislodgment during mastication. J Dent 1983;49:306-313
Prosthet Dent 1963;13:462-468 35. Jacobson TE, Krol AJ: A contemporary review of the factors
26. Adell R, Eriksson B, Lekholm U, et al: A long term follow up of involved in complete denture retention, stability, and support.
osseointegrated implants in the treatment of totally edentu- Part I: Retention. J Prosthet Dent 1983;49:5-15
lous jaws. Int J Oral Maxillofac Implants 1990;5:347-359 36. Jacobson TE, Krol AJ: A contemporary review of the factors
27. Lewis S: Implant-retained overdentures (Review). Compen- involved in complete dentures. Part II: Stability. J Prosthet
dium 1993;14:1270,1272,1274 Dent 1983;49:165-172
37. Zarb GA, Bolender CL, Hickey JC, et al: Biomechanics of the
28. Lytle RB: The management of abused oral tissues in complete
edentulous state, in Zarb GA, Bolender CL, Hickey JC (eds):
denture construction. J Prosthet Dent 1957;7:27-42
Boucher’s Prosthodontic Treatment for Edentulous Patient.
29. Kurth LE: The monoplane concept of occlusion. Dent Clin St Louis, MO, C.V. Mosby, 1990, pp 3-27
North Am 1962;6:199-209 38. Zarb GA, Bolender CL, Hickey JC, et al: Boucher’s Prosthodon-
30. De Van MM: The concept of neutrocentric occlusion as tic Treatment for Edentulous Patients. St Louis, C.V. Mosby,
related to denture stability. J Am Dent Assoc 1954;48:165-169 1990