Indian Journal of Dental Research, 23(3), 2012 407

CASE REPORT
Neutral zone and oral submucous fibrosis
Shaista Afroz, Sajjad Abdur Rahman
1
, Indresh Rajawat
2
, AK Verma
2
Received : 06-05-11
Review completed : 06-08-11
Accepted : 20-01-12
ABSTRACT
Oral submucous fibrosis is a premalignant condition in which rigidity of the lip, tongue, and
palate results in reduced mouth opening and tongue movement. Limited mouth opening,
mucosal rigidity, and reduced salivary flow makes prosthodontic procedures difficult in
these patients and affects the stability, retention, and the support of removable prostheses.
The burning sensation in the mouth that these patients experience reduces the tolerance to
prostheses. We report a case of oral submucous fibrosis where the conventional neutral zone
technique with certain modifications was utilized to rehabilitate a completely edentulous
patient with this condition.
Key words: Mucosal rigidity, neutral zone, oral submucous fibrosis
Department of Prosthodontics,
1
Department of Oral and
Maxillofacial Surgery, Dr Z A
Dental College, AMU Aligarh,
2
Department of Prosthodontics,
Career Post-Graduate Institute
of Dental Sciences, Lucknow,
India
Address for correspondence:
Dr Shaista Afroz
E-mail: shaista_afroz@yahoo.com
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DOI:
10.4103/0970-9290.102241
these patients. Mucosal rigidity and reduced salivary fow
adversely affects the stability, retention, and the support
of removable prosthesis and, in addition, the burning
sensation in the mouth that these patients characteristically
experience reduces the tolerance to the prosthesis.
CASE REPORT
A 55-year-old male presented with the chief complaint of
ill-ftting maxillary and mandibular complete dentures and a
burning sensation in the mouth. He gave history of betel nut
chewing for 25 years. Thickened dense fbrous bands with
blanching were observed on the buccal and labial mucosa,
anterior lingual vestibule, and the hard and soft palate.
Mouth opening was reduced and the inter-ridge space was
26 mm [Figure 1]. Based on these fndings a clinical diagnosis
of OSF was made.
Obtaining peripheral seal and placement of postpalatal
seal was diffcult because of the fbrosis and rigidity. There
was reduction in the potential cubicle space of the mouth.
The fbrous bands had resulted in a shallow vestibule and
reduction in maxillary and mandibular denture-bearing
areas. Decreased salivary fow resulted in poor retention and
contributed to the intolerance to the prostheses.
The patient was advised to discontinue the habit of betel
nut chewing; he was instructed in physiotherapy measures
(e.g., opening and closing of mouth with maximum
force); and he was prescribed multivitamin tablets and
topical corticosteroids. An artifcial salivary spray was also
prescribed to reduce the discomfort. The patient was offered
surgical correction of the fbrous bands but he refused.
Fabrication of complete dentures using the neutral zone
technique with some modifcations was planned.
Oral submucous fbrosis (OSF) is an insidious-onset chronic
disease that predominantly affects Indians and South-East
Asians.
[1]
Consumption of chillies areca nut, nutritional
defciency, genetic susceptibility, altered salivary constituents,
autoimmunity, and collagen disorders are the stated etiologic
factors. Rigidity of lip, tongue, and palate, leading to reduced
mouth opening and tongue movement, and intolerance
to spicy food are the major complaints of these patients.
[2]

Discontinuation of the consumption of etiologic agents is
an important preventive measure. Correction of nutritional
defciency is necessary. Local or systemic administration
of immunomodulatory drugs like glucocorticoids help by
preventing or suppressing infammatory reactions, thus
decreasing fbrosis by reducing fbroblastic proliferation
and collagen deposition. Physiotherapy measures, such as
opening and closing of mouth with maximum efforts and heat
therapy, and surgical correction are the various strategies
proposed for the management of reduced mouth opening
seen in this disease.
[3]
Limited mouth opening makes prosthodontic procedures
from the primary impression till insertion diffcult in
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408 Indian Journal of Dental Research, 23(3), 2012
Neutral zone and oral submucous fbrosis Afroz, et al.
Technique
After making primary impressions in irreversible
hydrocolloid impression material (Zelgan 2002,
Dentsply India Pvt. Limited), the fnal border molding
was done conventionally, using low-fusing impression
compound (DPI Pinnacle, Mumbai, India), and the fnal
impression was made with metallic oxide impression
paste (Septodont, Cidex, France). The posterior palatal
seal was established at the fnal impression stage, using
low-fusing impression compound.
[4]
The fluid wax
technique can also be used.
Maxillary bite rim was adjusted for lip support,
phonetics, and esthetics and the occlusion plane was
established.
On mandibular trial denture base impression compound
(Y-Dents, MDM Corporation, Delhi) was adapted in the
shape of the residual ridge. It was softened uniformly
in a warm water bath and inserted in the mouth. A cup
of warm water was given to the patient to sip and he
was instructed to sip and swallow several times. The
procedure was repeated till the correct recording of the
neutral zone was obtained [Figure 2].
[5]
The vertical dimension was recorded by reheating the
mandibular bite rim.
[6]
The patient was guided in centric
relation and instructed to swallow till both the rims
touched lightly. This procedure resulted in the creation
of an anterior stop. Excess material was trimmed. This
tentative vertical dimension was evaluated by other
techniques of recording vertical dimension, i.e., closest
speaking space, vertical relation at rest, overall facial
support, and the patient reported comfort. Centric
relation was recorded using bite registration paste (3M,
ESPE, Ramitec, Bangalore. India).
The maxillary cast was mounted by a facebow transfer
record, and the mandibular cast with the centric
relation record.
The addition-silicone putty (Aquasil, Dentsply,
Germany) was used to make neutral zone index. One
rope was molded into the tongue space and another
one on the labial and buccal surface of the neutral zone
record [Figure 3]. We ensured that it completely flled
in the tongue space, level with the occlusal plane, and
extended up to the posterior land area of the cast. After
polymerization, the index was checked on the cast
without record to ensure complete seating.
[7]
Semi-anatomic teeth (Lactodent, Pyrex Polychem,
Roorkee, India) were selected for this patient. Maxillary
and mandibular anterior teeth were arranged to satisfy
the esthetics and phonetics, and the mandibular
posterior teeth were arranged within the recorded
neutral zone, touching the lingual index and at the
level of recorded occlusal plane. The maxillary teeth
were arranged in maximum intercuspation with the
mandibular teeth.
Metallic oxide paste was used to develop a polished
surface contour [Figures 4 and 5]. Polyvinyl siloxane
light body can be used alternatively. To record the
facial aspect of the maxillary trial denture, the patient
was instructed to pucker his lips forward, smile
broadly, open the mouth, and move the mandible side
to side. The palatal surface was recorded by asking
the patient to sip, swallow, and produce fricative and
sibilant sounds.
[7]
Mandibular labial and buccal surfaces were recorded
by asking the patient to pucker his lips and move the
mandible side to side. Finally, the mandibular lingual
surface was recorded by asking the patient to sip and
swallow water several times, protrude the tongue and
touch the anterior palate, move the tongue from side
to side, and lick the upper and lower lips.
Investment, processing, laboratory remounting,
fnishing, and polishing were done conventionally.
The prosthesis was relined with permanent resilient
denture liner (GC Lab Technologies Inc, USA). For
this, 0.5 mm of the acrylic was removed from the tissue
surface and the borders. A closed-mouth impression
was taken with light body polyvinyl siloxane (Aquasil
Ultra LV). The denture was invested and the impression
material was replaced by permanent soft liner.
After processing, fnishing, and polishing, a clinical
remount was performed by a new centric record and
occlusal refning was done on the articulator.
After insertion, the patient was recalled for postinsertion
adjustment at 48 hours and then asked to come for
periodic checkup, initially at 1-month intervals to look
for any signs of intolerance to the prosthesis in the
form of redness and ulceration and, later, at 6-month
intervals for the maintenance of oral health.
DISCUSSION
In this case, the neutral zone technique as suggested by
Schiesser and Beresin, with modifcations, was utilized to
fabricate the complete denture prostheses.
[5]
Since in oral
SMF the rigidity of the tongue, lips, and cheeks occur due
to progressive fbrosis of their muscles, the available space
for denture teeth placement is altered; hence, utilization
of the neutral zone concept to achieve the coordination of
complete denture with the existing neuromuscular function
was benefcial in this case.
The neutral zone is that area where the outward forces
exerted by the tongue are neutralized by the inward forces
exerted by the cheeks and lips during various functions
such as chewing, swallowing, and speaking and while
making various facial expressions.
[5,8]
These forces may
vary in magnitude and direction in different areas of
the oral cavity, in different individuals, and at different
periods of the life. Different conditions may also alter
this potential space, for example, oral cancer (resulting
in mandibulectomy and glossectomy), oral SMF, trauma,
burns, etc.
[9,10]
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Indian Journal of Dental Research, 23(3), 2012 409
Neutral zone and oral submucous fbrosis Afroz, et al.
Figure 4: Polished surface of the maxillary denture recorded using
metallic oxide paste.
Figure 5: Polished surface of the mandibular denture recorded using
metallic oxide paste.
During the prosthodontic rehabilitation phase, the most
diffcult step is the insertion of the loaded impression
tray and the fnal prostheses. Various modifcations in the
form of sectional impression trays with locking levers,
[11]

collapsible denture,
[12]
and sectional dentures
[13]
made in
fexible denture material are reported in the literature.
Most of these studies deal with fabrication of prostheses
for partially edentulous patients, where the presence of
teeth poses an additional problem. In this patient, the
inter-ridge space was reduced to 26 mm so the making
of impression of individual arch was not a problem. The
Figure 2: Neutral zone record in impression compound.
Figure 3: Neutral zone index in putty on the mandibular cast
Figure 1: Inter-ridge distance at the reduced mouth opening.
Figure 6: Patient with the fnal prosthesis.
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410 Indian Journal of Dental Research, 23(3), 2012
Neutral zone and oral submucous fbrosis Afroz, et al.
only diffculty was when both the rims were to be inserted
simultaneously. For that reason, the vertical dimension
was recorded simultaneously with the neutral zone
recording, with the mandibular bite rim made in softened
impression compound. Also, the fnal vertical dimension
was established at that reduced mouth opening so that the
insertion of the fnal denture was not a problem.
Because of the fbrosis of the muscles, the vertical relation
at rest and vertical relation at occlusion are expected to be
altered. In one study it was found that neutral zone changed
with change in vertical dimension, based on it decision was
taken to record the neutral zone and the vertical dimension
simultaneously.
[14]
Since the harmony between the polished denture surface
and the surrounding tissues during function is important,
it was recorded using metallic oxide impression paste after
the try-in.
Since the patient gave history of intolerance to prostheses,
relining the prostheses with a permanent soft liner was done
to provide a cushioning effect and thus increase patient
acceptance [Figure 6]. A similar technique can be used for
designing an implant-supported overdenture for better
neuromuscular adaptation by the patient.
CONCLUSION
In this patient, the conventional complete denture was
fabricated utilizing the neutral zone technique with
modifcations to meet with patients special requirements.
The patient was recalled periodically to check the tissue
response and the results have been satisfactory.
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How to cite this article: Afroz S, Rahman SA, Rajawat I, Verma AK. Neutral
zone and oral submucous fbrosis. Indian J Dent Res 2012;23:407-10.
Source of Support: Nil, Confict of Interest: None declared.
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