THE NEUTRAL ZONE

INTRODUCTION
The goal of dentistry is for patients to keep all of their teeth
throughout their lives in health and comfort. If the teeth are lost despite all
efforts to save them, a restoration should be made in such a manner as to
function efficiently and comfortably in harmony with the muscles of the
stomatognathic system and the temperomandibular joints.
The stable position of the teeth represents an equilibrium of all the
forces acting on them. If that position of equilibrium namely the neutral
zone, is not found, the resulting dentition will not last long and will not be
esthetically pleasing and the patients use of functional efficiency,
maximum length of use and pleasing esthetics will not have been met.
To understand the stable position of teeth, the concept of neutral.
zone is important.
Neutral Zone is defined as that area in the mouth where, during
function, the forces of the tongue pressing outward are neutralised by the
forces of the cheeks and lips pressing inwards.

FORM AND FUNCTION :

In orthodontics and prosthodontics the basic principles of treatment
are identical. They revolve around the relationship between form and
function. Function determines form. Abnormal functions such as deviate
swallowing pattern, mouth breathing and thumb sucking, will modify or
dictate the form of the dental arches.
It is equally true that alteration of the form of a growing individual will alter
function. If the alteration of form is an improvement, there will be a
concomitant improvement in function. Ideally, both the function and form
should be corrected together for optimal results, and this correction should
take place before growth has ceased.
Prosthodontic treatment in complete dentures is also influenced by
the concept that form follows function. Complete dentures that are

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constructed by concepts that do not take into consideration the unique
functioning of the individual patients musculature are over looking this
basic law of physiology. .
If form is dictated by function, then in complete denture
construction, the operator must shape and form dentures to be in harmony
with function.
When the prosthodontist can establish that abnormal function exists
in the edentulous patient, then myofunctional therapy should be instituted
as an adjunct to prosthodontic treatment to establish normal function
(Plainfield, 1977). The alternative is for the prosthodontist not to alter
function, but rather to modify the form of the denture to fit the abnormal
function. This is accomplished by utilizing the neutral zone concept.
In all areas of dentistry, the ultimate problem in maintaining
the health of the stomatognathic system throughout life is one of
harmonious pressure distribution. The primary function of this system
is the application, distribution and dissipation of the pressure of the
bite and of the muscles of the lips, cheeks and tongue. To put it more
simply, the primary function of the stomatognathic system is
mastication.
The prosthodontist who is unaware of the effect of muscle function
will be faced with cases of prosthodontic relapse -unstable dentures.
The position of the teeth in space and even the size and
relationship of the jaws are in large measure controlled by the muscles,
both in repose and function. When natural teeth are lost, the shape and
position of their artificial replacements must be determined by these same
muscles, both in repose and function, if they are to .be functionally
successful.
The landmark work regarding the limiting effect on arch size was
done by Sidney Frederich.

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 THE NEUTRAL ZONE AND DENTURE SPACE
When all of the remaining natural teeth are removed; there exists within
the oral cavity a void that may be called the potential denture space. The
denture space is bounded by the maxilla and soft palate above, by the
mandible and floor of the mouth below, by the tongue, medially or
internally, and by the muscles and tissues of the lips and cheeks laterally
or externally. Within the denture space there is an area that has been
termed the neutral zone.
Weath (1970) has demonstrated that there is a difference in the
shape of the denture space and resultant arch form at rest as compared to
the denture space and arch form established by function.
The neutral zone is that area in the mouth where, during function,
the forces of the tongue pressing outward are neutralized by the forces of
the cheeks and lips pressing inward. Since these forces are developed
through muscles contraction during the various functions of chewing,
swallowing and speaking, they vary in magnitude and direction in different
individuals and in different periods of life. The way these forces are
directed against the dentures will either help to stabilize them or will tend
to dislodge them.

FACTORS AFFECTING THE NEUTRAL ZONE

Muscles and the neutral zone :
Neutral zone in complete dentures is in fact the zone previously
occupied by the natural teeth. The force that helped to position the natural
teeth in the dental arches can help to maintain the artificial teeth in their
places.
Dentures should occupy a position in the mouth where all the forces
during function are neutralized. Otherwise, denture stability will be
decreased proportionately to the difference in the amount of the opposing
forces.

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MUSCLES OF THE CHEEK
The outer limits of the neutral zone are determined by the perioral
musculature.

BUCCINATOR
The main determinant of length, strength and position of the perioral
musculature is the buccinator muscle. The buccinator is a thin, flat muscle
composed of three bands.
The combined width of the three bands covers the entire outer
surface of the dento alveolar structures, that is the teeth, alveolar process
and gingival tissues.
The upper and lower bands are continuous from side to side without
decussation. The middle band fibers decussate and joint into the fibers of
the orbicularis oris. Because the muscle fibers form a continuous band, the
size of the arch is limited by the length of the muscles when they are
contracted repetitiously. Regardless of the reason for variations in muscle
tonus in different patients, the strength of the contractile force, at the
length of the muscle during contraction, forces can inviolate outer limit for
arch size.
Problems of alignment occur when the size of the teeth are too
large to fit into the arch size dimension dictated by a constrictive perioral
musculature.
The effects of neutral zone confinement on the dentoalveolar
structures can also play a critical role as a determinant of facial profile. A
restrictive perioral musculature may prevent the dentoalveolar arches from
expanding to a normal alignment with the skeletal base.
Variations in length and strength of the three bands of the
buccinator can further affect the profile by controlling the axial inclination of
the anterior teeth, especially when combined with myriad variations of
tongue size and pressure.

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 In the natural dentition, when, the mouth is passive, the buccinator
is in contact with the buccal surfaces of the posterior teeth and with the
mucosa covering the alveolar process.
In function, as the buccinator contracts, the cheeks are pressed
against the teeth and alveolar process. During mastication, the buccinator
helps to place the food over the occlusal surfaces of the teeth in
coordination with the tongue, which positions the food over the teeth from
the lingual.
The common practice of centralization, or lingualization of
occlusion, prevents the buccinator from performing its proper function in
two ways. First, lingualization of occlusion creates a space between the
cheek and the teeth and the external surface of the denture, where food
tends to accumulate and it becomes more difficult for the cheek to place
the food back onto the occlusal surfaces of the teeth. Secondly, the space
resulting from lingualization prevents the buccinator from neutralizing the
lateral forces of the tongue during function.

MASSETER :
The masseter muscle has no influence on the neutral zone. It only
affects the distobuccal border of the denture.

MUSCLES OF THE LIPS

Orbicularis oris : To a great extent forms the lips. In function, as in
chewing, smiling and swallowing, it exerts force against the teeth and
denture flanges, which is counteracted by the tongue.

Canine muscle : This together with other muscles, pulls the lower lip up
and in sucking and swallowing helps to pull the lips forward, thus exerting
forces on the teeth and labial denture flange.
The greater zygomatic muscle pulls the angle of the, mouth upward
and backward.
The risorius muscle retracts the corner of the mouth.

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 The mentalis muscle turns the lower lip outward and in contracting
makes the lower labial vestibule shallow.
The triangular muscle contracts during sucking to exert pressure on
the teeth and the denture flanges.

The Modiolus : Because of the strength and variability of movement of the

area, the modiolus is extremely important in relation to the stability of the
lower denture. Unless the teeth and external surface of .the denture are
properly positioned and contoured by narrowing in the premolar area, the
modiolus may constantly unseat the lower denture.

MUSCLES OF THE TONGUE

The tongue is composed of intrinsic muscles that lie within the
tongue itself and extrinsic muscles that insert into the tongue.
The function of the extrinsic muscles the styloglossus,
palatoglossus, hyoglossus, and genioglossus - is to move the tongue into
various positions. The tongue is capable of many varied shapes and
positions during speech, mastication, and swallowing and in all of these
functions is in constant contact with the lingual surface of the teeth, the
lingual flange of the lower denture and the palatal surface of the upper
denture. Because of this contact, the tongue is a dominant factor in
establishing the neutral zone and therefore in the stability or .lack of
stability of the lower denture.
The common practice of lingualization is probably one of the
greatest influencing factors in lower denture instability, because it violates
the neutral zone and encroaches on the tongue space.

DENTURE SURFACES
The dental profession has always been concerned with equalizing
the vertical forces that are delivered by the occlusal surfaces of the teeth
and that are counteracted by the vault and the ridges. It has ignored the
importance of the horizontal forces exerted on the polished or external

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surface of the denture. Thus the dental profession has been concerned
mainly with two surfaces - the occlusal and the impression surfaces.
Sir Wilfred Fish in 1948 described a denture as having three
surfaces, with each surface playing an independent and important role in
the overall fit, stability and comfort of the denture.
The first surface, the impression surface, is that part of the denture
in contact with.the tissues and on which the denture rests and determines
retention of the denture,
The second surface, the occlusal surface is that area in contact with
the teeth, either natural or artificial, of the opposite jaw.
The stability of the denture when the teeth are in contact is
determined by the fit of the impression surface against the tissues and the
fit of the ooclusal surfaces against each other.
The third surface, the polished or external surface as termed by
Fish, is all the rest of the.denture that is not part of the other two surfaces.
It is mostly denture base material, but it consists also of those surfaces of
the teeth that are not contacting or articulating surfaces.
The buccal and lingual surfaces of the posterior teeth and the
labial and lingual surfaces of the lower anterior teeth are not part of the
occlusal surface but are part of the polished surface of the denture. The
upper anterior teeth actually belong to two surfaces, both the occlusal and
the polished surfaces. When the teeth are in contact , the lingual surfaces
of the upper anterior teeth are part of the occlusal surface. When the teeth
are apart, as in speaking as at rest, these surfaces are part of the polished
surface.
The external surface is in contact with, the cheeks, lips and tongue.
One can visualize that, based on a square unit of area, the external
surface is as large or larger than the impression and occlusal surfaces
combined, depending on the anatomic structures.

INFLUENCE OF FORCES ON DENTURE SURFACES

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 The more the ridge loss, the less the area of the denture base and
the less the influence the impression surface area will have on the stability
and retention of the denture. As the surface area of the impression surface
decreases and the external surface area increases, the development and
contour of the external surface becomes more critical. In other words,
where more of the ridge has been lost, the more the denture stability and
retention is dependent on the external surface than on the impression
surface. Many unstable lower dentures are caused by the external
surface .not being properly formed and the teeth not positioned in the
neutral zone.
The forces on the external surface are constantly changing in
magnitude and direction during swallowing, speaking and mastication. It is
only when the mouth is completely at rest, that the forces are constant.
If a person's teeth were in contact all the time, the external surface
would be relatively unimportant in denture stability. Conversely if a person
never brought his teeth into contact, the occlusal surface would be
relatively unimportant and the stability would be dependent on, the forces
on the external surface as transmitted to the impression surface.
The only time teeth are in contact is, during mastication and
swallowing. This means that .the patient will only make tooth contact
during normal function. But the lips, cheeks and tongue are constantly in
function. This stresses the significance of the horizontal forces exerted by
the lips, cheeks and tongue.
In order to construct dentures that function properly not only in
chewing but also in speaking and swallowing, we must develop the fit and
contour of the external surface of denture just as accurately and
meticulously as the fit and contour of the impression surface and the
occlusal surface.
To best illustrate this, let us examine a critical area of the lower
denture, the anterior segment. The force of the lower lip against the
anterior surface of the denture and the anterior teeth will cause the
denture to rise unless the teeth and flange are properly positioned and

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contoured. When the mouth is closed, the denture may remain stable.
However, as soon as the mouth opens, the denture comes under the
influence of forces on its external surface and anterior teeth. The lower lip
is like an elastic sand pressing against the anterior flange and teeth. The
wider the mouth is opened, the tighter the band.
The influence of the lip on the lower denture stability becomes more
critical as resorption of the ridge increases or as the patient becomes
older.
Lammie (1959) has shown that as the ridge resorbs, the ridge crest
falls below the origin of the mentalis muscle. As a result, the muscle
attachment folds over the alveolar ridge and comes to rest on the superior
surface of the crest. The result of this situation is a posterior positioning of
the neutral zone and with it the need to place the lower anterior teeth more
lingually than the position of the natural teeth.
In addition, as patients age, the lip instead of being averted as in
young individuals becomes thinner and inclines backward into the mouth.
To appreciate this, ask an older edentulous patient to open his mouth
without the denture in place and observe how the lower lip falls into the
mouth, many times covering the lower anterior ridge. It is obvious that if
we do not determine, the neutral zone, and as a result the teeth and
flanges are not properly positioned and contoured, the force as pressure
from the lower lip may constantly unseat the lower denture.
The lower posterior teeth are drastically affected by the position of
the tongue. If the lower posterior teeth are lingualized excessively, normal
tongue function will immediately unseat the denture. The tongue cannot
and should not be restricted by the position of the posterior teeth.

MUSCLE INFLUENCE ON THE DEVELOPMENT

OF THE DENTAL ARCHES
Teeth erupt into the mouth under the influence of muscular
environment. This environment which is created by the, forces between

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the tongue, cheeks and lips has a definite influence on the position of the
erupting teeth, the resultant arch form and occlusion.
However, the muscular forces alone do not always determine the
developing dental arch form. There is genetic factor which cannot be
overlooked. This internal factor, along with the local environmental forces,
combines their influences uniquely to determine the final arch form and
tooth position.
It would stand to reason that when the teeth are erupting into the
mouth during childhood and adolescence (2 - 14 year group) the muscular
activity and habits that develop will continue through life. Even after the
teeth are lost, the forces created by these habits and actions still persist
and will have a great influence on any complete or extensive partial
removable prosthesis that is placed into the mouth. It is therefore
extremely important that the teeth be placed in that part of the mouth and
with an arch form that falls within the area formed by muscular forces.
Our objective is to utilise the information on denture space and
muscle function so as to, position the teeth and the external surfaces of
the denture that the force the musculature exerts, instead of having a
negative influence, will favourably affect the dentures and tend to seat or
stabilize the dentures. This can be accomplished through awareness of
the neutral zone and by positioning the teeth and developing external
surfaces of the denture so that all the forces exerted are neutralized and
the denture is in a state of equilibrium.

DIRECTION OF FORCES
For the muscular forces to be of a stabilizing nature, the dentures
must be so constructed that they will receive these forces at the proper
angle. Dr. Fish (1948) described the cross section of stable dentures in the
molar area to be triangular in shape, with the tooth being the apex and the
denture periphery the base of a triangle.
A force exerted on an inclined plane may be broken down into two
components. One component acts in the direction parallel to the inclined

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plane. The other component, called normal force, acts perpendicularly to
the inclined plane. If the inclined planes of the external surface are
properly fashioned and the forces are of equal magnitude, the resultant
normal force will be in a seating direction. By the same token, if the
dentures are triangular but not properly located within the neutral zone, the
lateral force will be unequal and not provide the equilibrium necessary for
a stable denture. This will result either in the dislodgement of the denture
or unequal pressure on the ridge.

NEUTRALIZATION OF FORCES
The theory of the neutralization of forces that stabilize dentures and
the rationale involved was one of the major contributions made by
Dr.Russel Tench and his coworker, Dr.A.A.Cavalcarti.
The lips, cheeks and tongue in the passive and functioning state
exert forces on .the natural teeth. In the natural dentition, arch integrity and
tooth position are maintained when all the forces generated by the
musculature are neutralized. Any changes in the forces generated by the
musculature because of increased size, altered muscle function, or
abnormal habit patterns will upset the equilibrium and result in alteration of
tooth position and arch form.
If we accept the assumption that the teeth are positioned and
maintained in a neutral state by all the forces exerted against them by the
musculature, it seems reasonable that when the dentures are made, the
artificial teeth should be placed in the same relative position to the
musculature as the natural teeth. The term "relative position" rather than
exact position" is used because age, tonus, ridge resorption and other
factors may modify or alter the denture space and neutral zone so that the
artificial teeth, should not necessarily be in the exact same position as the
natural teeth.
If the teeth are placed too far lingually in the molar region, they will
encroach on the tongue space. Dr.Mayskens estimates that if the size of
the mandibular teeth are too large or if the posterior teeth are set 1 mm

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lingually, the tongue is deprived of approximately 1000 cubic mm of
functional space. This can force the tongue into an abnormal retracted
position.
In summary, 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 forces generated by the tongue
are neutralized by the forces generated by the lips and cheeks
Furthermore, denture stability is as much or more influenced by tooth
position and flange contour as by any other factors.
In other words, we should not be 'dogmatic and insist that the tooth
should always be placed over the crest of the ridge, or lingual to the ridge
or buccal to the ridge. Placement of the teeth should be detected by the
musculature and will vary for different patients.
A series of statements may give perspective to an evaluation of
neutral zone considerations.
1. The teeth and their alveolar process are the most adaptive part of the
masticatory system. They can be moved horizontally or vertically by
light forces.
2. There is a neutral zone within which muscular pressure against the
dentition and equalized from opposite directions. The entire arch form
falls within that zone of neutral pressure.
3. If irregularities of tooth position, alignment, or contour can be corrected
within the neutral zone, the prognosis for long term stability is good.
4. A problem occurs when the neutral zone is not where we want the
teeth to be.
5. A treatment decision then must allow determination of if and how we
can change the neutral zone to orient it, where we want the teeth to be.
Because the neutral zone can assume so many variations of form
from different types of confinement by the same musculature, any irregular
dental alignment or arch form should be evaluated in relation to the
directional pressure exerted by the tongue, the lips and the cheeks. It

12
should be determined why the dental arches are where they are, before it
can be determined if they can be altered. Several different arch
configurations may be possible without any changes in muscle lengths.

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 DETERMINATION OF THE NEUTRAL ZONE
DIAGNOSIS AND TREATMENT PLANNING
Success in complete denture prosthetics .is frequently dependent on
what is done prior to the construction of the dentures as much as or more
than on the skill and meticulous care utilized in the actual construction of
dentures.
Examination, diagnosis, and treatment planning for complete
dentures should be as meticulous and detailed as for any other branch of
dentistry.
After a proper examination and preparation of diagnostic casts we
go in for the treatment proper.

Reversed Sequence In Denture Construction

The usual sequence in complete denture prosthesis is to make
primary impressions, construct individual trays, make final impression and
then fabricate stabilized base plates on which occlusion rims are used to
establish vertical dimension and centric relation. With the neutral zone
approach to complete dentures, the procedure is reversed.
First, the bases are very carefully adjusted in the mouth to be sure
that they are not overextended and that they, are stable during mouth
opening, swallowing and speaking. Then modelling compound instead of
wax, is used to fabricate occlusion rims. These rims which are moulded by
muscle function, locate the patients neutral zone,. After tentative vertical
dimension and centric relation are `established, the final impressions are
made with a closed mouth procedure. Only then, when the final impression
is completed, are the vertical dimension and centric relation refined and
finalized.
It is, therefore, important to understand the rationale behind
reversal of the usual steps in complete denture construction.

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 DIAGNOSING THE LOWER DENTURE PROBLEM
The premise behind the rationale is that, in our thinking and
procedures, we should separate the denture base from that which rests on
the denture base - the body of the denture. With the neutral zone
approach, the impression surface is called the base and the polished
surface is called the 'body' of the denture.
Once the operator begins to think in terms of first creating a stable,
base and then placing on that base, teeth and flange contours that will not
unseat the denture base, the problem and its solution become apparent
and comparatively simple to solve.
We can best exemplify this crucial point by, tile following illustration.
All operators have had the experience of inserting a lower denture, and as
soon as it is seated, it begins to rise or actually pop up. As soon as the
patient opens the mouth or starts to speak the lower denture jumps up.
The first assumption made by most operators is that the denture base is
overextended, so they begin to reduce the denture borders. However,
interestingly enough, no matter how much the denture base is reduced, it
still pops up.
It is not unusual to end up with a denture base that is considerably
smaller than the size of the original denture base, but in which the lower
denture is still unstable and moves at the slightest sectional movement.
What we were not aware of was that possibly it was not the denture
base that was the cause for denture instability, but rather the body of the
denture, the tooth position, and the flange form that were placed on top of
the denture base.
There is no question that an inadequately extended denture base or
an inaccurate denture base can result in unstable dentures. Of course,
improper occlusion, that is incorrect centric relation, vertical dimension,
premature contacts. lack of balance in centric and eccentric relations and
cuspal interferences also will lead to an unstable denture. But there is a
third and equally important factor to be considered. The horizontal forces,

15
that are exerted by the muscles of .the lips, cheeks and tongue on the
teeth and the denture flanges.

EFFECT OF VERTICAL AND HORIZONTAL FORCES

Let us briefly analyze the forces to which dentures are subjected.
Essentially the forces are vertical, horizontal or a combination of the two.
The borders of the denture are affected by the forces from the
muscle attachments of the lips, cheeks and tongue and these forces are
essentially vertical. Denture bases that are overextended will readily be
dislodged by the vertical forces exerted on them. If the borders of the
dentures can be placed or fashioned so that the muscle attachments and
the peripheral tissue will not unseat them, one of the causes of denture
instability will be overcome.
The body of the denture consists of the external or polished surface
and the labial, buccal and lingual surfaces of the teeth and are affected
mainly by horizontal forces delivered by, the lips, cheeks, and tongue. If
the teeth and the body of the denture can be positioned within the denture
space so that functional movements of the lips, cheeks and tongue will not
unseat the denture, a second cause of denture instability can be removed.
The occlusal surfaces and incisal edges of the tooth on a denture
are subjected to vertical and horizontal forces both by the opposing teeth
and the bolus of food to be masticated. If the teeth can be so positioned
and placed that the occlusal forces exerted will be essentially vertical, the
third factor that leads to instability of the denture will be eliminated.
The forces that tend to unseat the denture were described. Our
objective is to fashion the three surfaces of the denture so that the forces
will not unseat the denture. We can now go a step further and think in
terms of constructing a denture in which the forces exerted will not unseat
the denture but rather will be harnessed so that they will tend to stabilize
the denture.

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 IDENTIFYING CAUSES OF INSTABILITY
Once the denture has been completed, it is frequently very difficult,
if not impossible, to evaluate which of the three factors described, or a11
of them, is accusing the instability of the denture. Is it caused by over
extension of the bases, improper tooth position, improper occlusion, or a
combination of these factors.
By dealing with one surface or one factor at a time before going to
the next, we can at all times be aware of which surface is creating the
problem. This is precisely what is done in the neutral zone approach to
complete dentures.
First, an acrylic base is constructed, with either processed or self
curing acrylic. If we insert the base into the mouth with nothing on it, and it
is not retentive or stable, we know that the instability is caused by
overextension of the borders of the base. At this stage, there is only one
factor to consider - the border of the base since the body and occlusion
have not ,as yet been constructed. What are the forces that will cause
instability of the base? They are the vertical forces of the muscles of the
lips and cheeks, and tongue. There is no other possible cause, since there
is nothing on the base. If we adjust that base until it is perfectly stable, so
that there is no interference or pull by the muscles to unseat it, we have
now achieved our first objective. Creating a stable base. If the finished
denture base is of the same outline or extension, we know then any
instability must be caused by some other factors.
If we now place on this stable base the body of the denture, be
it compound, wax or any other material that will later be replaced by the
teeth and the external surfaces of the denture and this base is no longer
stable; we know it is the body. that is at fault, not the base. In other words,
it is the horizontal forces exerted against the body of the denture by the
lips cheeks, and tongue that are creating the instability. If now, by empirical
methods adding or subtracting material - or by physiologic procedures -
molding the material - the body is repositioned so that the forces of the
lips, cheeks, and tongue do not unseat the base, we have created a stable

17
base and body. If in the final denture and the external 'surfaces are placed
in the same position as the body, they will not unseat the denture base.
We now have an upper and lower base-and body. If we instruct the
patient to bring the jaws together and the denture bases are dislodged, it
can only be caused by the occlusion and the occlusion should be
corrected.
By following the logical sequence just outlined, we know exactly
where the problem is and can correct or eliminate it.

CLINICAL AND LABORATORY PROCEDURES

After a thorough examination of the patient stock trays are selected
for the patient.
Primary impressions of the maxillary and mandibular ridges are
made with modelling compound. While making the impressions the patient
is asked to do the functional movements, including sucking and swallowing
movements.
There should be minimal displacement of tissues while making
impressions.
After acceptable impressions are made they are poured in plaster.

CONSTRUCTION OF THE ACRYLIC BASE

The acrylic base to be made in the neutral zone approach in
complete dentures has to serve two purposes. On this acrylic base,
occlusion rims will be constructed that will be formed and molded by the
patient to locate the individuals neutral zone and to establish a tentative
vertical dimension and centric relation. It's, second purpose is to serve as
a tray for the final. impression, which is obtained by a closed mouth
procedure. It is therefore extremely important that the primary impression
be carefully and meticulously developed so that the resultant tray be
accurate and stable.
Based on the denture border outline, the peripheral extension of the
tray is marked in pencil on the plaster casts. With a sharp instrument, a

18
groove approximately 1 mm deep is scribed on the pencil outline. This
results in a bonding on the tray that facilitates finishing the tray to the
proper extension. The casts are then thoroughly lubricated or treated with
a separating medium so that the tray material will not adhere to the casts.
Self cure acrylic resin is mixed and a tray of even thickness of
approx 7 mm is made. Before the material sets, the excess is trimmed
away. Wire loops made from paper clips are placed into the acrylic over
the crest of the ridge. These will be used as retention loops for the
modelling compound forming the neutral zone. When the acrylic is
completely set, it is removed from the cast and trimmed to the beaded line,
and the periphery is smoothed.

CREATING STABLE BASES

A stable base is one that will stay in place and not be dislodged
during normal function. The operator must adjust, trim, shorten, or add to
it, as necessary, until it will stay in place without moving when the patient
opens, closes, talks, smiles, laughs, and swallows.

TECHNIQUE
The stability of the base is tested by two methods. First, the base is
inserted into the mouth, and the operators index fingers are placed on the
base in the bicuspid area to firmly seat the base. If a squishing sound is
heard as the base is seated or if the base is seated then eases up or pops
up, it is unstable. The second method is to have the patient open wide,
purse the lips as in sucking, wet the lips, and speak normally. If the
operator observes the base move during these functional movements, or if
the patient is aware of movement, then the base is unstable.
Usually, lack of stability of the acrylic bases is attributable to over
extension and must be corrected. Occasionally, they are under extended
and have to be lengthened by the addition of cold cure acrylic.
There are two methods for locating the areas of overextension of
the base. One is by visual observation or eye balling. The other is by the

19
use of a disclosing, material to locate the area of over extension or
underextension.
Unless our objective of creating a stable base is achieved all future
steps in the procedure are compromised.

LOCATING THE NEUTRAL ZONE AND PLANE OF OCCLUSION

Materials :
Locating the neutral zone for the lower denture is one of the most
important factors in achieving stability of the lower denture. To locate the
neutral zone and form the body of the denture, if is necessary to use
materials that can be moulded by the horizontal forces of the tongue, lips
and cheeks.
Buchman, Gelb, Lott and Levin, and Russell have described the
use of waxes in locating the neutral zone.
Kline of France has advocated the use of self curing acrylic to form
a 'piezograph', which is his term for the registration of the neutral zone.
Health of England has, for experimental purposes used a gel that is
a polymer of dimethyl silocane filled with 17% calcium silicate.
Tench has suggested the use of modelling compound, which has
worked well. Korr's low fusing gray and green compound is best suited for
this purpose. It permits the patient to mold the compound into the neutral
zone with the least amount of time and effort.

MANIPULATION OF COMPOUND
To develop the body of the denture and register the neutral zone by
the use of modeling compound, there are three important factors to be
considered. First the compound must be very securely attached to the tray.
Secondly the compound must be thoroughly and uniformly softened for the
muscles to mold the material. Third, it must be hard enough so that it will
not flow and will maintain its shape as an occlusion rim until inserted into
the mouth for forming the neutral zone, The consistency of the compound
should be similar to that used when making a primary impression.

20
FIXING THE COMPOUND TO THE TRAY
A water bath, preheated to the proper temperature, is used to soften
the material, which is then kneaded and worked until it is uniformly soft.
The amount of compound required to make an occlusion rim is rolled into
the shape of a 'hot dog'. The tray is held in the left hand, and one end of
the compound is seared in the low flame of a bunsen burner so as to
avoid overheating. This end is placed on the tray at the left retromolar pad
and the compound is shaped and fitted onto the tray and is worked around
to, tyre right retromolar pad. Just before that compound is seated at this
end, it is also seared in the flame and there pressed against the tray. A
Hanau torch can then be used to heat and sear the compound so that it
will completely adhere to the tray. The compound is flamed and tempered
in the water bath. This keeps the compound soft so that it can be molded.
By repeated flaming, tempering, and shaping, one keeps the compound
soft while it is shaped into the form of an occlusion rim.

LOCATING THE NEUTRAL ZONE FOR THE LOWER ARCH

To locate the neutral zone for the lower arch, the patient's lips are
lubricated with petroleum jelly. The tray with the softened modeling
compound is rotated and carefully seated. Care must be used so that the
lips do not press against the compound until it is completely seated. The
patient is instructed to swallow and then purse the lips as in sucking. `
Most patients will swallow without any problem. However, some patients
will have difficulty in swallowing correctly. With these patients it is
necessary to practice before they can deliver a proper swallow on
command. The practice or instructional procedures is as follows :
1. Remove the compound rim from the mouth and instruct the patient to
swallow. If the patient swallows correctly several times, explain that this
is exactly what should be done when the material is put into the mouth.
If the patient does not swallow correctly, instruct the patient to keep the
lips together and swallow as if swallowing a bolus of food.

21
2. If difficulty still persists, place a few drops of water on the tongue by
means of a syringe to help the patient swallow.
3. Once the patient has swallowed correctly several times, resoften the
compound and proceed in locating the neutral zone.
It is important to instruct the patient to keep the lips together and
swallow. We should not tell the patient to close and swallow. By doing so,
the patient may overclose and press the compound into the maxillary
ridge, distorting the compound. If there are repeated impressions, of the
maxillary ridge onto the compound, the patient is either overclosing during
swallowing or too much compound has been used. Proper swallowing
actions will mold the compound rim into the neutral zone. Sufficient time is
allowed for the compound to harden and it is then removed from the mouth
and inspected.
If initially an excessive amount of compound is used, it will be
forced upward above the normal height of the occlusal plane and because
of excessive bulk of compound, the tongue, lips and cheeks will be unable
to mold the compound into a neutral zone of proper width. Therefore, any
excess compound above the usual height of the occlusal plane is removed
with a sharp knife and the compound is resoftened, placed back in the
mouth and the patient is instructed to suck and swallow. If additional
compound has been pushed up, it should be reduced and the procedure
repeated until the functions of swallowing and sucking no longer force the
compound to an excessive height.
In all cases, the compound will exhibit similar shapes and contours,
but there will be definite differences for each patient. The lingual surface of
the compound rim will be shaped to the contour necessary to avoid
interference with functional tongue movements. The anterior segment of
the compound rim may have a labial, straight or lingual inclination
depending on the tonus of the muscles in the lower lip and also the action
of the tongue during swallowing. The buccal surface will generally be
inclined to the lingual with a narrowing in the bicuspid area where the
modiolus functions. The lingual surface will be inclined to the buccal.

22
 Some neutral zones will be narrow, some will be wide because of
the size and action of the tongue. A deviate swallow will definitely force the
neutral zone to the labial.

ESTABLISHING THE 0CCLUSAL PLANE

In the natural dentition, the lower occlusal plane runs from the
incisal edges of the lower anterior teeth through the tips of the cusps of the
posterior teeth to a point approximately two thirds of the height of the
retromolar pad. To locate the occlusal plane, place the rim back into the
mouth and use a sharp pointed pencil to mark the commisures of the lip
and the height of the lower lip at rest. These three points are connected by
a line that is continued on each side to a point one half to two thirds the
height of the retromolar pad. The excess compound is trimmed to this line.
To further check the correctness of the height of the occlusal plane,
observe its relationship to the lateral borders of the tongue. With the
tongue at rest, the height of the occlusal plane should be 1-2 mm below
the greatest convexity of the lateral borders of the tongue. If necessary,
the compound rim can be, modified by reduction or addition.

TESTING THE STABILITY OF THE LOWER OCCLUSION RIM

The lower occlusion rims is placed back into the patients mouth and
checked for stability by having the patient open wide, wet the lips with the
tongue, count from 1 to 100, and say exaggerated "oh" "ahs" and "ees". If
these movements raise the rim, the lack of stability must be caused by a
improper molding of the compound, as the tray or base was proved to be
stable. So the lack of stability is because of the compound on the base
rather than the base itself. In such cases, the compound is resoftened and
the procedure is repeated until a stable rim is achieved.
The next procedure is to test the outer edge of the rim with the tip of
the index finger in the bicuspid and incisor regions. If pressure on the outer
edges causes the opposite side of the rim to lift up, then the rim must be
narrowed from the labial or buccal to where the vertical pressure will not

23
cause the rim to tilt. This will occur where there has been extensive ridge
resorption and where the residual ridge is narrow buccolingually and labio-
lingually. If this is not corrected and the teeth placed at this position, then
the vertical forces as in mastication will tilt the denture.
After the labial contour and curvature Of the occlusion rim have
been established and if the width of the anterior section is thicker than the
incisal edges of the anterior teeth, the occlusion rim should be narrowed
by trimming from the lingual.
The final test is to have the patient speak, swallow, wet the lips and
open wide without the rim moving or being dislodged. We have therefore
created a tray or base that is not dislodged by muscle function an have
placed on it a body that is also not displaced by muscle function.

LOCATING THE NEUTRAL ZONE FOR THE UPPER ARCH

The modeling compound is attached to the upper tray in the same
manner as for the lower. It is flamed, tempered and molded into the shape
of an occlusion rim and then inserted into the patient's mouth. The tray is
firmly seated, and with the operator's fingers out of the mouth, the patient
is instructed to suck and swallow.
The tray is removed after sufficient time for the compound to
harden. The contour and shape of the upper compound rims will all be
similar, but there will be variations in individual patients. The rims is
generally triangular in shape with, the palatal surface sloping bucally and
downward and the buccal surface sloping lingually and downward.
Variations will be seen in the width of the arch, the shape of the arch, and
the labial inclination of the anterior section of the compound rim.
The upper rim is placed back into the mouth and usually excess
compound will be seen extending below the relaxed upper lip. A line is
scribed about 2 mm below the upper lip at rest and the compound is
trimmed to this line. The excess in the posterior is cut away parallel to the
ridge. The upper rim is now tentatively completed and will be further

24
modified when determining vertical dimension acrd registering centric
relation.

VERTICAL DIMENSION :
Techniques
Dots are placed on the tip of the nose and most prominent part
of-the chin with an indelible marking pencil. The,patient is then instructed
to wet the lips, swallow and let the jaw rest in a relaxed position with the
lips barely touching. The distance between the dots is recorded by means
of calipers, The procedure is reported three or four times to determine if
the measurements are approximately the same. If they are, this position is
accepted as the rest vertical dimension.
Then lower occlusal rim is lubricated and inserted into the mouth.
The occlusal surface of the upper rim, which was adjusted approximately
2-3 mm longer than the upper lip line to allow for sufficient material is
softened by flaming and tempering. The upper rim is inserted and the
mandible is guided into terminal hinge position. When the lower rim
touches the softened compound of the upper rim, the operator's hand is
removed and the lower rim pressing into the upper rim will record the
vertical dimension and a tentative centric relation as dictated by the
neuromuscular function of swallowing.
The compound rims are removed from the mouth and carefully
examined. The hard lower rim will have made an indentation into the
softened upper rim, and the excess compound on the upper rim will have
extruded over the lower. The upper rim is then reinserted, and the length
of the upper lip is inscribed with pencil on the compound rim. The
compound is then trimmed to this line.
Both rims are placed back in the mouth and with the rims together
and lips gently touching, the distance between the dots on the nose and
chin are measured. The measurement should be atleast 2-4 mm than the
original measurement, which was the rest vertical dimension. If this is not

25
so, then the procedure is repeated until the interocclusal space of 2-4 mm
is obtained and this is verified by phonetics.
By comparing the vertical dimension of the old dentures and that of
the occlusion rims, we can see if we have made the changes 'necessary to
fulfill our objectives based on our diagnostic findings.

FINAL IMPRESSIONS
To achieve optimum success in complete denture prosthesis, the
dentures should be both retentive and stable. The retention of a denture is
mainly dependent on the accuracy of the impression and fit of the denture
base to the tissues.
Impression techniques can be either closed mouth or open mouth.
Both these can be incorporated into the neutral zone approach, but a
closed mouth technique is preferred.
In the past, closed mouth impression techniques wore used to
register the tissues in the position they would be during function. In order
for the impression material to be adapted to the tissues, some pressure
must be exerted. Our aim is to keep this pressure to .the minimum amount
necessary for proper adaptation.
The advantage, with the use of a closed mouth technique are :
- A more accurate functional molding of the borders can be obtained,
especially in the lower arch.
- By having the patient to close gently and swallow, there is more even
distribution of pressure and impression material with less likelihood of
excessive pressure in one area or another.

TECHNIQUE :
With the procedure to be described, two impression pastes of
contrasting colors are used. This is called a color-coded impression
procedure, the purpose of which is to locate areas of tissue displacement.
The impression trays and the two zinc oxide eugenol paste should be of
three different colors.

26
LOWER SECONDARY IMPRESSION :
The material is mixed and placed evenly over the lower tray and the
tray is placed carefully in the mouth. Slight pressure is applied with the
forefingers in the bicuspid area until the paste is seen to exude from the
tray around the peripheries.
The upper rim, which has been lubricated, is placed into the mouth,
and the patient is guided into a hinge closure and instructed not to exert
any pressure after light contact is made. After the initial contact, the patient
is directed to swallow and remain closed. In about 30 seconds, the patient
is asked to open and wet the corners of the mouth with the tongue, purse
the lips, such in as drawing through a straw and then close and swallow
again. At no time should excessive pressure be applied.
When material has set, the lower rim and tray are removed from the
mouth and inspected. If there are areas of the tray showing through the
impression material, it indicates areas of excessive pressure that will
cause tissue displacement. These areas are relieved to a minimum depth
of 0.5 mm. The impression material. covering the peripheris is cut away
with a sharp knife to prevent excessive pressure that will cause tissue
displacement. These areas are relieved to a minimum depth of 0.5 mm.
The impression material covering the peripheris is cut away with a sharp
knife to prevent excessive build up of the borders, which would result in
overextension when the corrective-impression is made.
The tray is now ready for a second impression. The material of
choice is Krex, which is white, soft, thin, free flowing and of a contrasting
color to the zinc oxide eugenol used. The Krex is mixed evenly and spread
over the entire tray and borders and the procedure as mentioned before is
repeated. After it is set the tray is removed and the impression is checked
for defects.
Upper impression : Prior to the making of the upper impression, several
holes are drilled in the ruage area. The zinc oxide impression paste is
mixed and placed over the tray and borders. The tray is carried into the

27
mouth and centered over the ridges. The anterior part of the tray is seated
with a light pressure to position it properly. With the fore finger applying
pressure in the molar area, the posterior part is seated until the material
starts to flow out from the posterior border.
The completed lower impression is inserted into the mouth and the
patient is guided into a hinge closure, avoiding excessive pressure. The
patient is instructed to swallow and remain closed. In 30 seconds the
patient is directed to open the mouth, move the jaw from side to side,
purse the lips as in sucking, bring the-upper lip down hard, and then
swallows and close without -pressure. When the material has set the tray
is removed and the impression is inspected for pressure areas.
If pressure areas are present, Krex is used for corrective impression
and the above procedure is carried out to get a corrected impression.

Centric relation
The centric relation is recorded with the same completed final
impression trays and compound rims.
After the vertical relation is rechecked and corrected for any
changes occuring after the final impression making the centric relation is
recorded by the check bite procedure or the nick and notch method.
After the centric relation is recorded a facebow recording is made.
After this the facebow assemblage, upper and lower final impressions, and
occlusion rims are now ready to be sent to the laboratory.
It should be noted that the neutral zone technique differs from
conventional impressions and registered vertical dimension and centric
relation as part of one procedure. This may be accomplished in one or
more appointments depending on the operators decision. If the operators
prefers several short appointments; the procedures can be divided as
follows , first appointment to stabilize bases; second appointment to locate
the upper and lower neutral zones, third appointment to determine
tentative vertical dimension and centric relation fourth appointment to

28
make a secondary impression and finalize vertical dimension and centric
relation.

LABORATORY PROCEDURES
After the face bow transfer is done on to the articulator, the .upper
tray with' the compound rims are removed and both the upper and lower
secondary impressions are boxed and casts are poured in stone. The
upper cast is then mounted onto the articulator. After the stone has set, the
face bow is removed from the articulator, and the lower occlusion rim and
model are severely sealed to the upper occlusion rim by means of wax.
The lower model is now attached to the lower bow of the articulator.

FABRICATION OF TONGUE, LIP AND CHEEK MATRICES

A great deal of time and effort has been spent thus for to locate, by
means of compound rims, the neutral zone for each individual patient. The
compound rims thus formed indicate within a given range where teeth
should be placed so that the denture will not be displaced during functional
movements. It is therefore necessary to record or make provision for the
preservation of the neural zone. By doing so, the technician will know
where to set the teeth, and the dentist can always recheck to be sure that
the teeth have been set within the neutral none. This is done .by making
matrices of the occlusion rims so that when the occlusion rims are
removed, a space remains within the matrices, which is the neutral zone.
The matrices may be made of plaster, stone or modeling compound.
Prior to construction of the matrices, the casts must be indexed so
that the matrices will fit back into their proper positions. Several circular
holes are made on the labial and buccal surfaces of the cast and .a cross
is made in the tongue area of the lower model.
With the lower occlusion rim in place, the lower model is lubricated
and stone is placed on the lingual portion of the model, forming an artificial
tongue, and on the labial and buccal of the lower model, completely
encasing the occlusion rim. These matrices are trimmed to the exact

29
height of the lower occlusal plane, which was established in the mouth.
This preserves the height of the lower occlusal plane. The same is done
for the upper model and occlusion rim.
After the stone is set, the labial and buccal matrices are split in the
middle to faciltate removal. When two occlusion rims are now removed,
the matrices can be placed back into position.
The space between the matrices on the lower rim represents the
neutral zone and indicates where the teeth should be positioned. The
matrices on the upper indicate the outer limits of the neutral zone. and
serve as a guide for positioning the upper anterior teeth.

SELECTION AND ARRANGEMENT OF ANTERIOR TEETH

The success or failure of dentures frequently hinges on how
successfully the operator has fulfilled the patient:, esthetic requirements. It
is extremely important to discuss facial appearance and esthetics with the
patient before one accepts the responsibility for the construction of
dentures.
The neutral zone developed by each individual patient is usually
not a narrow restricted area and therefore permits some latitude for
positioning of the anterior teeth to obtain adequate lip support for optimum
facial appearance. This is especially true, with the upper neutral zone,
since it is not nearly as critical for denture stability as is the lower neutral
zone.
After the shade, shape, size and tooth material are selected the
arrangement of the anterior teeth are done.

SELECTION AND POSITIONING OF POSTERIOR TEETH

With the neutral zone concept, either anatomic or non anatomic
forms can be used. The neutral zone only indicates the labiolingual or
buccolingual position of the teeth. The occlusal forms of the teeth to be
used are essentially the operator's choice.

30
 With the neutral. zone concept approach to complete dentures, a
posterior cross bite relationship is frequent. The action of the tongue in
swallowing frequently places. the lower posterior teeth more buccal to the
conventional position of the teeth over the crest of the lower ridge. During
the sucking action, the cheeks place the compound and therefore the
neutral zone over the crest of the upper alveolar ridge. The result 1, if we
follow the neutral zone concept, a posterior cross bite relationship results.
After selection of the proper size, occlusal morphology and material
of the posterior teeth to be used, we go in for the positioning or
arrangement of teeth. The following is a step by step sequence for
arrangement of anterior and posterior teeth
1) The lower anterior teeth are set to the height of the labial matrix
and to the labial limit of the neutral zone.
2) The upper anterior teeth are set against the labial limits of the
upper matrix.
3) The lower posterior teeth are set against- the tongue matrix and
against the template occlusally.
4) The upper posterior teeth are set, to the buccal limits of the
neutral zone.
5) The matrices are removed, and the upper bow of the articulator
is closed in order to evaluate the relationship of the upper and
lower posterior teeth.
6) The upper posterior teeth will have to be rearranged to assure
maximum contact with the lower posterior teeth.
7) The upper and lower posterior teeth are checked for the buccal
and lingual. relationship to each other.
8) In order to avoid an edge to edge relationship which might lead
to check biting, the lower posterior teeth may be moved buccally
within the neutral zone, resulting in a cross-bite relationship.

The author prefers using cuspless teeth. But the neutral zone
approach with cusp teeth is also successful.

31
 THE TRIAL DENTURE
The purpose of the trial denture is to check the following.
1) Stability and retention of the bases
2) Vertical dimension
3) Phonetics
4) Centric relation
5) Esthetics

After the verification and correction if needed of the above factors,

there is an extremely important step or procedure to be completed during
the trial denture try-in, namely the making of external impressions on the
labial, buccal and lingual surfaces of the dentures. These will determine
the thickness, contours and shape of the polished surfaces of the denture.
With conventional complete dentures, the technician or dentist empirically
waxes the external surface. By means of external impressions, a
physiologic molding is made so that the external surfaces are functionally
compatible with muscle action.
The trial denture acts as a tray to be used for the accurate
secondary impression for forming the contours of the external surface of
the denture.
The trial dentures are waxed up so that there is just enough wax to
hold the-tooth, in position.. If this is done, the trial dentures are ready for
the external impressions. If the trial dentures are waxed in the
conventional manner, the wax below and above the necks, of the teeth
and the periphery of the dentures must be scraped away prior to making
the impressions. The materials for the external impressions are either zinc
oxide eugenol base or one of the conditioning materials.
Both the upper and lower trial denture external impressions are
done in two steps, either the labiobucacal and than the lingual or palatal.,
or vice versa..

32
 The impression material is placed on the lingual surfaces of the
lower denture, between the necks of the teeth and the denture periphery.
The upper trial denture is placed in position, and the lower is then rotated
into the mouth, taking care not to wipe off any material on the lips. With the
lower trial denture in position, the patient is asked to close, purse the lips
as in sucking and swallow. This is repeated several times. After the
material has set, the trial dentures are removed from the mouth, and the
gross excess is cut away. The impression material is then placed on the
buccal and labial surfaces of the lower trial denture, and sucking and
swallowing motions are repeated, The same procedure is than followed for
the upper external impressions.
Usually interesting contours are developed on the lingual surface of
the lower denture and on the palatal, buccal and labial surfaces of the
upper. The impression on the lingual of the lower will frequently result in a
very large and extensive ledge in the anterior region. This should be
duplicated exactly in the processed denture. Experience has shown that
practically all patients do tolerate these contours, which rarely have to be
reduced. As a matter of fact, these ledges seem to help to retain the lower
denture. The tongue sits on these ledges and helps to keep the lower
denture in position.
Another important reason for using this procedure is that it tends to
minimise the accumulation of food on the external surface of the denture.
With the use of external impressions proper contours which eliminate or
minimize food accumulation, are developed. The external impression
tends to fill out the denture space, thus making it easier for the cheek to
push the food back onto the occlusal surfaces of the teeth. Finally, by
duplicating these impressions in the final denture, the operator has
reproduced functionally contoured external surfaces of the denture that will
aid immeasurably in the retention and stability of the dentures.

33
PREPARATION OF THE TRIAL DENTURE FOR INVESTING
The laboratory procedures for investing, packing and processing of
dentures when using the neutral zone technique is generally the same as
for conventional. dentures. However, because of the materials used for the
external impressions, it is necessary to be especially careful in some of the
procedures.
Great care must be taken to be sure that none of the external
impression material has flowed under the bases of the trial denture. This
would prevent the trial dentures from seating correctly on the model and
result in an incorrect occlusion. Any excess material present on the tissue
surface of the trial denture should be removed before the model is seated.
Sometimes it is necessary to flow little base plate wax into the
interproximal embrasures to create smooth conical papillae. Any voids or
rough areas in the external impressions are smoothed by the wax.
When conditioning material is used for the external impressions, a
layer of silastic 338 denture release is placed over the teeth on gingival
margins prior to investing. This facilities the separation of the investment
with minimal danger of fracture to the teeth and it will also result in a very
smooth finish to the interproximal embrasure.
When zinc oxide eugenol paste has been used for the external
impression, the flasks should not be allowed to remain in the boil-out tank
for more than 5 minutes, because the zinc oxide eugenol paste will liquefy
and attack the stone, resulting in a bleached appearance to the processed
acrylic.
After processing; the dentures and remount on the articulator.
Occlusal discrepancies are checked for with the template and carbon
paper. They are corrected, the dentures are finished, polished and
insertion is done.
A clinical remounting is done and the dentures are inserted and
checked for any discrepancies. The patient is given post insertion
instructions which are similar to that of conventional complete dentures.

34
 THE NEUTRAL ZONE AS APPLIED TO
PARTIAL DENTURES AND OVERDENTURES
The application of the neutral zone concept to extensive partial dentures
provides function, comfort, esthetics, preservation of the remaining ridge,
and also preservation of the remaining teeth.
The principal means to minimize harmful forces to the remaining
teeth is to obtain maximum stability of the partial denture base.
This is obtained by proper adaptation of the base and by eliminating
lateral or horizontal forces caused by the functional movements of the lips,
cheeks and tongue.
The application of the neutral zone concept adds a new dimension
to help enhance a the stability of the base.
After the metal frame work is obtained, it is polished and placed
over the master cast. A layer of auto cured acrylic is molded over the
frame work for securing the saddles in position.
The use of metal loops on the saddle will enhance retention of the
compound rim. The neutral zone is located and the occlusal plane
determined as mentioned before.
If the upper teeth are present, it will dictate the occlusal plane of the
lower.
The altered cast technique is used to make the final impression.
The altered master cast is poured and matrices are made to
preserve the neutral zone on the models.
The teeth are arranged and during the trial denture stage external
impressions are made.

METHODS FOR ALTERING THE NEUTRAL ZONE

The neutral zone may be altered in several ways, as follows
Orthodontics : By realigning the teeth for improved tolerance between
the tongue and the perioral musculature. One can most often improve it
without the need for lengthening muscle.

35
Elimination of noxious habits: Thumb sucking, lip biting, or forward
tongue posturing all tend to increase outward pressure against the perioral
musculature, thug moving the neutral zone accordingly. Elimination of
such habit patterns allows the perioral muscles to move the tooth back,
into harmony with normal tongue position. Success in changing. habit
patterns is often difficult or impossible if they involve long extending
tongue thrust patterns
Myofunctional therapy : If lip pressure can be increased by strengthening
the perioral musculature, the neutral zone will move accordingly. Any
change In muscle pressure will affect the neutral zone, but results are
often disappointing for long term effectiveness in mature adults.
Reduction of tongue size : Surgical reduction of tongue size will reduce
outward pressure and allow the perioral muscles to move the teeth
lingually in a new neutral. zone. For some reason this procedure has not
had popular acceptance:
Surgical lengthening of the buccinator band : It is used to reduce the
restrictive pressure that limits arch size. An increased thickness of labial
tissues over the roots of teeth, along with increased stability of the teeth
after arch expansion when restrictive muscle pressure is released, was
reported by Fredrick. It is usually done to lengthen the lower band of the
buccinator.

Procedure involves four steps,

1. Surgically cut through the mucosa with vertical incision.
2. Vertically, cut through the lower band of the buccinator muscle on each
side.
3. Suture only the mucosa leave the muscle segment unattached.
4. Add the pressure to increase the length of the muscle with a Frankel
type of appliance.

Scar tissue will fill in between the two anterior ends effectively
lengthening the perioral band around the arch.

36
Vestibuloplasty : Either alone or in combination with muscle lengthening
procedures should extend around the anterior arch to the bicuspid area.

CONCLUSION
In summary, 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 forces generated by the tongue are
neutralized by the forces generated by the lips arid cheeks. Furthermore,
denture stability is as much or more influenced by tooth position and
flange contour as to any other factor.
In other words, we should not be dogmatic and insist that the teeth
should always be placed over the crest of the ridge,or lingual to the ridge
or buccal to the ridge! Placement of the teeth should be dictated by the
musculature and will vary for different patients.
The neutral zone has. not been given enough importance, in the
literature, but as a determinant of occlusion it cannot be ignored.
Orthodontic, relapses, postoperative problems, unsuccessful periodontal
procedures and relapses with orthognathic surgery can be attributed to
neutral zone imbalance. Complete and partial denture failures are often
related to non compliance with neutral zone factors.
Regardless of the method of treatment, any part of the dentition out
of harmony with the neutral zone will result in instability, interference with
function, or some degree of discomfort or will bother the patient. Thus the
neutral zone must be evaluated as an important factor before one rates
any changes in arch form or alignment of teeth.

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