University of Baghdad/College of Dentistry

Department of Prosthodontic

Neutral zone concept and its technique

at impression stage

‫نبأ علي عبد الرضا‬

5th Grade
Group -E1-

‫ غزوان الكناني‬.‫ د‬: ‫الدكتور المشرف‬

 Introduction
The neutral zone is the potential space between the lips and checks on one
side and tongue on the other, in which natural or artificial teeth are subjected to
equal opposing forces from the surrounding musculature. It is also known as dead
zone, stable zone, zone of minimal conflict, zone of equilibrium, zone of least
interference, biometric denture space, denture space and potential denture space.
Many patients experience severe limitation of mouth opening after
mandibulectomy. The limitation of opening may, in fact, become more severe as
fibrosis progresses during normal healing. Because sufficient mouth opening is
required for making impressions, a common problem during dental treatment for
such patients is the insertion and removal of the stock impression tray. Several
techniques have been described for taking impressions of such patients. Neutral
zone impression technique designed to obtain maxillary and mandibular
impressions together, in 1 stage, for the purpose of constructing denture prosthesis
for a mandibular defect patient for whom the insertion of the fabricated impression
trays was impossible due to severe limitation of mouth opening.

Muscles involved
The muscles of the lower lips, cheeks and tongue are major displacing factors for
mandibular denture instability. The major muscles involved are:
1. Buccinator
The buccinator plays a major role in determining the neutral zone and extends from
the pterygomandibular raphe anteriorly, and converges with the other muscles, at
the modiolus. The main function of this muscle is to position food on the occlusal
surfaces of the teeth during mastication, in coordination with the tongue.
2. Modiolus
The group of muscles converging at the angle of the mouth is known as modiolus.
These are the orbicularis oris buccinator, risorius, zygomaticus major, and the

[1]
levator and depressor anguli oris. It plays a vital role in positioning of the premolar
teeth and establishing the contour of the polished denture surface in that region.
3. Orbicularis oris and mentalis
The movement of the lip and the tongue helps in determining the position of the
mandibular anterior teeth. If the teeth are positioned too labially, lip contraction
would cause posterior displacement of the denture. In highly resorbed ridges, the
mentalis muscle may displace the neutral zone lingually.
4. Tongue
The tongue is in constant contact with the mandibular denture at rest and function,
and is composed of a powerful group of intrinsic and extrinsic muscles. If the teeth
are positioned lingually, they will encroach the tongue space and the denture will
be displaced during function. Appropriately contoured polished surface of denture
is also important for normal tongue movement.
Objectives of Neutral zone Techniques:
1. Rehabilitation of complete denture patient.
2. Achieve maximum prosthesis stability, comfort, and function.
3. Arrange the denture teeth and contour the complete denture polished surfaces.
4. Minimize the ongoing diminution of the residual alveolar ridges.
Indication:
 Atrophic mandibular ridge.
 Denture fabrication undertaken after a long period of edentulousness leading to
tongue/cheeks/ lips partially occupying the usual denture space.
 Enlarged tongue, e.g. Down syndrome.
 Abnormal anatomy, e.g. hemimandibulectomy.
Advantages:
1. Improved stability and retention
2. Posterior teeth will be correctly positioned allowing sufficient tongue space
3. Reduced food trapping adjacent to the molar teeth

[2]
4. Good aesthetics due to facial support.
5. When implant overdenture therapy is not the treatment option, the neutral zone
technique is of great help.
The procedure for registering the neutral zone at impression stage:
A modeling plastic impression compound occlusal rim should be fabricated prior
to the record appointment to accomplish the procedure in a timely manner.
1) The mandibular record base with the modeling plastic impression compound
occlusal rim is immersed in a warm water bath set at temperature of 140°F (Fig 1a)

a b
Figure 1: (a) Modeling plastic impression compound occlusal rim immersed in a warm water bath set at
140 °F; (b) compound rim uniformly softened upon removal from the water bath.

2) Once the modeling plastic impression compound is uniformly softened (Fig. 1b)
the mandibular record base with the occlusal rim is removed from the water bath
and quickly placed in the patient’s mouth (Fig. 2).

Figure 2: Uniformly softened modeling plastic impression compound occlusal rim inserted in the patient’s
mouth.

A maxillary record base is not used for this procedure because eliminating the
maxillary record base eliminates the compressive forces that may arise during the
recording of the neutral zone.

[3]
3) The patient is given a cup of warm water and is asked to swallow, then sip warm
water and swallow again (Fig. 3).

Figure 3: Patient given a cup of warm water to sip (left) and then asked to swallow (right)

4) Sipping and swallowing procedures are repeated several times. The

thermoplastic rim is molded through the action of muscles of cheeks and lips
moving inward and the muscles of tongue moving outward (Fig. 4). As the heated
material cools and solidifies, the resulting volume of the modeling plastic
impression compound defines the neutral zone.

Figure 4: sipping warm water and swallowing (left) results in muscles of the cheeks and lips functioning
inward and muscles of the tongue expanding outward (center) thereby forming the neutral zone registration
(right).

5) The incisal length of the neutral zone record is compared with the patient’s
relaxed lower lip. The neutral zone record should be maintained at the same height
as the relaxed lower lip length when the lips are parted. If the record is longer than
the relaxed lower lip, a line is scribed at the level of the relaxed lower lip cooled
and adjusted with a sharp blade.
6) When the modeling plastic impression compound has hardened, the neutral zone
record is removed from the mouth and evaluated for accuracy (Fig. 5). If necessary,
the procedure is repeated to achieve a proper recording of the neutral zone area.

[4]
 a b

Figure 5: (a) Clinical image demonstrating the formed registration. (b) Neutral zone registration from
occlusal (left above) and lingual (right below) views.

7) Excess material may be trimmed with a sharp blade (Fig. 6). The molded
compound rim can be reinserted in the mouth for verification of contours.

Figure 6: Neutral zone registration trimmed with a

sharp blade.

8) Next the neutral zone record is seated on the mandibular definitive cast and
indexed lingual and facial matrices are developed around the neutral zone record
using laboratory putty (Fig. 7).

a b c d
Figure 7: (a) Grooves created on the lingual land area serve as indices – facial and lingual vestibular spaces
filled with vinyl polysiloxane impression material to facilitate complete seating of the completed indexes
during tooth setup; (b) indexed lingual matrix developed around the neutral zone record using laboratory
putty; (c) indexed facial matrix developed around the neutral zone record using laboratory putty; (d) neutral
space visible between the facial and the lingual indexes.

This short and simple procedure uses patients’ own physiological action and is
therefore very repeatable. Use of this technique provides an excellent road map for
optimally positioning the posterior prosthetic teeth in the mandibular denture.

[5]
References
1. Alfano SG, Leupold RJ. Using the neutral zone to obtain maxillomandibular
relationship records for complete denture patients. J Prosthet Dent, 2001; 85:
621-623.
2. Rangarajan V, Padmanabhan TV. Textbook of Prosthodontics-E Book. Elsevier
Health Sciences; 2017 Jul 11.
3. Srivastava V, Gupta NK, Tandan A, Kaira LS, Chopra D. The Neutral Zone:
Concept and Technique. J Orofac Res 2012; 2 (1): 42-47.
4. Aysha S, Shetty M, Kanji M. Utilizing the neutral zone: Concept and technique
for stabilizing complete denture–case report. Int J Oral Health Dent. 2015; 1:
201-3.
5. Cagna DR, Massad JJ, Schiesser FJ. The neutral zone revisited: from historical
concepts to modern application. The Journal of prosthetic dentistry. 2009 Jun 1;
101 (6): 405-12.
6. Massad JJ, Cagna DR, Goodacre CJ, Wicks RA, Ahuja S. Application of the
neutral zone in prosthodontics. Wiley Blackwell; 2017 Jun 6.

‫نبأ علي عبد الرضا‬

[6]