J.

Adv Dental Research All Right Res

CASE REPORT

Enhancement of stability for mandibular complete denture prosthesis in atrophied ridge with neutral zone technique A case report
Viraj Patil* R B Hallikerimath** Shweta Magadum***
*M.D.S, Professor, **M.D.S, Professor, ***Post Graduate student, Department of Prosthodontics, Maratha Mandals Nathajirao G. Halgekar Institute of Dental Sciences and Research Centre. Belgaum. Karnataka, India. Email: drvirajpatil@gmail.com
Abstract: The Neutral Zone technique is not a new but a very valuable technique, it is an alternative approaches in constructing stable complete denture in case of a highly atrophic mandible. The main aim of the Neutral zone technique is to construct denture in muscle harmony, so that it does not get displaced during the actions of the muscles surrounding as the actions of swallowing, mastication, speech and so on. Key wordsNeutral zone, Atrophic mandible. Introduction: The goal of dentistry is for patients to keep all 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 temporomandibular joints. With the increase in the life expectancy of the population, the numbers of complex complete denture cases also have been increasing. The treatment for these complex complete denture cases should be different from those of traditional complete dentures. In case of Atrophic mandible, Dental implants may provide stabilization of mandibular complete dentures, but in cases when it is not possible to provide implants on the grounds of medical risks, economic limitations or patients attitudes, an alternative technique should be thought1. The Neutral Zone Technique is an alternative approach for these cases. The Neutral zone technique is not new, but is one that is valuable yet not practiced. The Neutral zone has been defined as the area in the mouth where during function, the forces of the tongue pressing outwards are neutralized by the forces of the cheek and lips pressing inwards. The aim of the Neutral zone is to construct a denture in muscle balance. If the denture is out of harmony with the neutral zone, it will result in instability, interference with function or some degree of discomfort. Thus neutral zone must be evaluated as an important factor before aligning the teeth in complete denture or partial denture. This is the zone where the natural dentition exists. As the mandible atrophies at a greater rate than the maxilla and has less residual ridge for retention and support, the lower denture commonly presents the most difficulties with pain and looseness being the most common complaints. The Neutral zone technique is most effective for patients who have had numerous unstable and nonretentive lower complete dentures. These patients usually have a highly atrophic mandible and there has been difficulty in positioning the teeth to produce a stable denture. The Neutral zone approach has been used for patients who have had a partial glossectomy, mandibular resections or motor nerve damage to the tongue which have led to either atypical movement or an unfavorable denture bearing area. Background: Sir Wilfred Fish in 1931 first described the influence of the polished surface on retention and stability. He also described how dentures should be constructed in the dead space, which later became as the

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Neutral Zone1. Since then many techniques have been described in the literature in an attempt to provide a molding of the Neutral zone. These techniques involved the use of soft, moldable material being placed in the mouth and patients performing actions with their lips, cheeks and tongue in order to capture actions with their lips, cheek and tongue. These actions determine the tooth position and shape of the polished surfaces. In highly atrophic mandible muscular control over the denture is the main retentive and stabilizing factor during function. The denture shaped by the Neutral zone technique will ensure that the muscular forces are working more efficiently and in harmony. Other advantages1--- Improved retention and stability Posterior teeth will be correctly positioned allowing sufficient tongue space. Reduced food trapping adjacent to the molar teeth Good esthetics due to facial support. Factors affecting the neutral zone: Muscles and the neutral zone: The actions of following muscles affect. Muscles of cheek: Buccinator Masseter Muscles of lips: Orbicularis oris Caninus Muscles of tongue Clinical case report: A 55 year old male patient was referred to the department of prosthodontics for the provision of complete denture. He had been edentulous since 7 yrs. He was a denture wearer and was willing for a new set of denture due to the reduced retention and repeated fracture of the denture. On examination it was diagnosed that the maxillary residual ridge was favourable, but the mandibular residual ridge was unfavorable due to resorption. Then it was decided to provide lower complete denture, utilizing Neutral zone impression technique. Clinical visit 1 At the first visit primary impression of the maxillary and mandibular edentulous residual ridge were made with modelling plastic compound impression material. Soon after making primary impression, the impression was poured in plaster of paris and primary casts were prepared. The custom trays were fabricated with self cure resin over the primary casts keeping the borders 2mm short of the sulcus. Clinical visit 2 The borders of the trays were molded with green stick impression compound and the secondary impressions were made with zinc oxide eugenol impression material. The master casts were poured in dental stone plaster. In order to increase the stability and retention of the record bases during recording the neutral zone, the permanent bases were prepared in heat cure resin on master casts. Wax occlusal rims were made over the permanent record bases for recording the jaw relations. Clinical visit 3 During this visit face- bow transfer was made (fig 1) and centric jaw relation was recorded on semi-adjustable (Hanau Wide view) articulator. The mandibular rim was completely removed and wire loops were adapted over the permanent record base in accordance with the recorded vertical height of jaw relation (fig 2).

Figure 1- Face-bow transfer Clinical visit 4 The maxillary record base with wax occlusion rim and mandibular record base with wire loops were evaluated intra-orally for their fit (fig 3). The maxillary rim was left in mouth in order to provide enough support to the facial musculature during making neutral zone impression. Then the tissue conditioning material (GC Corporation Tokyo. Japan) was mixed and loaded over the wire loops on buccal and lingual aspects and inserted in mouth and patient was asked to perform the usual movements, which included swallowing, sucking of the lips, pronouncing the vowels, which helped in recording the neutral zone space(fig 4).

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indices properly. Then the tissue conditioning material and the adapted wire loops were removed from the mandibular record base. Now an empty space (neutral zone space) was evident within the plaster indices. Next molten wax was made to flow in this empty neutral zone space, in order to create rim for arranging the mandibular teeth in the neutral zone. According to the neutral zone space recorded, the mandibular teeth were arranged (fig6) and in accordance with the mandibular teeth, maxillary teeth arranged. The wax contours were preserved in case of mandibular denture as derived from neutral zone technique and no additional wax was added on denture flanges.

Figure 2- Adaptation of wire loops in accordance with obtained vertical dimension

Figure 5- Plaster index surrounding Neutral zone impression

Figure 3- Evaluation of loops intra- orally Next step was to make plaster indices (fig 5) surrounding the neutral zone impression. V shaped indexes were made on the mandibular cast, in order to guide the placement and removal of the plaster

Figure 4- Recording conditioner

neutral zone with tissue

Figure 6- Teeth arrangement in Neutral zone space

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Clinical visit 5 Try-in was done, in order to evaluate the stability, esthetics and occlusion intra-orally and satisfactory results were seen. Then the dentures were processed with heat cured acrylic. Clinical visit 6 Denture insertion (fig 7) was done and again it was evaluated for stability, esthetics and occlusion. Results were found satisfactory and patient also was satisfied with the dentures. 3. David R, Cogna et al. The neutral zone revisited: from historical concepts to modern application. J Prosthet Dent 2009; 101(6):405-12. 4. Kokuto Y, Fukushimas et al. Arrangement of artificial teeth in neutral zone after surgical reconstruction of mandible: a clinical report. J Prosthet Dent 2002; 88(2):125-7. 5. Alfano SG, Leupold RJ. Using neutral zone to obtain maxillomandibular relationship records for complete denture patients. J Prosthet Dent 2001; 85(6):621-23. 6. Victor E. Beresin et al. The neutral zone in complete dentures. J Prosthet Dent 2006; 95(2):93-101. 7. Fahmy F M, Kharat D U. A study of the importance of the neutral zone in complete dentures. J Prosthet Dent 1990; 64(4): 459-62. 8. Cantor R, Curtis TA. Prosthetic management of edentulous mandibulectomy patients. Part II. Clinical procedures. J Prosthet Dent 1971; 25:546-55. 9. Frank J, Schiesser JR. The neutral zone and polished surfaces in complete dentures. J Prosthet Dent 1964; 14(5): 854-65. 10. Fahmi FM. The position of the neutral zone in relation to the alveolar ridge. J Prosthet Dent 1992; 67: 805-9.

Figure 7- Denture insertion Conclusion: Neutral zone technique is one of the best alternative techniques in case of highly atrophied mandibular residual ridge, but it is rarely used because of the extra clinical step involved. 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. 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. Thus the neutral zone must be evaluated as an important factor before one rates any changes in arch form or alignment of teeth. References: 1. Gahan MJ, Wansley AD.The neutral zone impression revisited. Br Dent J 2005; 198(5): 269-72 2. Lymph CD, Allen PF. Overcoming the unstable mandibular complete denture: The neutral zone impression technique. Dental update 2006; JanFeb 33(1); 21-2, 24-6.

Source of Support: Nil Conflict of Interest: Not Declared Received: September 2010 Accepted: December 2010

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