CLINICAL SCIENCE
Utilization of the Neutral Zone Technique
for a Maxillofacial Patient
Alvin G. Wee, BDS, MS,1 Roger B. Cwynar, DMD,2 and Ansgar C. Cheng, BDS, MS3
The use of a neutral zone technique to fabricate a more stable complete mandibular denture for
a maxillofacial patient is presented. The technique incorporates an altered sequence from
traditional denture fabrication, resulting in a shortened treatment period.
J Prosthod 2000;9:2-7. Copyright r 2000 by The American College of Prosthodontists.
INDEX WORDS: complete denture, dental prosthesis, edentulism
T O MAXIMIZE the stability and retention of
mandibular dentures, previous reports1-3 have
recommended that posterior denture teeth be posi-
tioned directly over the crest of the edentulous ridge.
This relationship of the teeth and alveolar ridge is
important for the stability of the denture in func-
tion.1-3 Although this tooth position may be desirable
when adequate alveolar ridge height is available,
such a position may not be suitable for severely
resorbed ridges because of a lateral shift in the
orientation of the ridge crest. This horizontal discrep-
ancy between original tooth position and resorbed
ridge crest, coupled with an increased vertical dis-
tance between occlusal table and tissue support, can
lead to denture instability. Successful denture treat-
ment in situations like this can become increasingly
dependent on the position of the denture teeth and
the external contours of the dentures. It is for these
patients that the neutral zone concept4-12 becomes
increasingly significant.
The importance of the polished denture surface
for retention and stability has been well advo-
cated.13-22 Fish first exposed the dental profession to
1Assistant Professor, Section of Restorative Dentistry, Prosthodontics and
Endodontics, The Ohio State University, Columbus, OH.
2Staff Prosthodontist, VA Pittsburgh Healthcare System, and Associate
Professor, Department of Prosthodontics, University of Pittsburgh, Pitts-
burgh, PA.
3Head, Maxillofacial Prosthetics, Ontario Cancer Institute–Princess
Margaret Hospital, Toronto, Ontario, Canada.
Accepted December 17, 1999.
Presented in part at the 1999 Carl O. Boucher Prosthodontic Conference
in Columbus, OH.
Correspondence to: Dr. Alvin G. Wee, Section of Restorative Dentistry,
Prosthodontics and Endodontics, The Ohio State University, 305 West 12th
Avenue, Columbus, OH 43210-1241. E-mail: Wee.12@osu.edu
Copyright r 2000 by The American College of Prosthodontists
1059-941X/00/0901-0002$5.00/0
doi: 10.1053/jd.2000.5936
2 Journal of Prosthodontics, Vol 9, No 1 (March), 2000: pp 2-7
the concept of neutral zone for complete denture
treatment in 1933.4 Several authors since that time
have contributed to the development of the neutral
zone concept.5-10,12 The neutral zone is defined as the
potential space surrounding the mandibular denture
between the lips, cheeks, and the tongue. In theory, it
is that area or position where the forces between the
tongue and cheeks or lips are equal.23
Whereas leverage during function is of primary
concern for the conventional ‘‘teeth over ridge’’
concept, muscular forces during function are consid-
ered more crucial for the neutral zone concept.24
Advocates of the neutral zone do not ignore the
resulting, less favorable leverage, but assume that it
is counterbalanced by the controlling actions of
cheeks, lips, and tongue, especially for resorbed
alveolar ridges.4-10,12
A criticism of the technique is that many advo-
cates of the neutral zone concept have made sugges-
tions based on empirical evidence. One of the first
clinical studies dedicated to this topic was by Strom-
berg and Hickey in 1965.11 Despite criticism of their
research design,16 this study was an initial step
towards clinical, evidence-based evaluation of the
neutral zone technique.
Two clinical studies have shed light on the advan-
tages of using the neutral zone technique. Cinefluoro-
graphic studies by Sheppard25 have shown that the
muscles reseat the complete denture during func-
tion. In a clinical study, Fahmy and Kharat5 evalu-
ated patients’ chewing efficiency and satisfaction for
complete dentures made with either a conventional
or neutral zone technique. Patients had better chew-
ing efficiency when wearing conventional dentures;
however, patients could not detect any difference in
masticatory performance between their convention-
ally fabricated dentures and neutral zone dentures.
Patients did report greater comfort and improved
 March 2000, Volume 9, Number 1
speech clarity with the dentures fabricated using the
neutral zone technique compared with their conven-
tionally prepared dentures. These studies suggest
that the neutral zone strategy for denture fabrication
may be helpful in certain edentulous situations.
The purpose of this article is to present the use of
the neutral zone technique for the fabrication of a
complete mandibular denture for a maxillofacial
patient with a continuity mandibular defect and
severely resorbed ridges.
Clinical Report
A 65-year-old white man was referred from the
Department of Otolaryngology to the Dental Maxil-
lofacial Unit at the Veteran’s Affairs Medical Center
in Pittsburgh, PA. The patient presented with a
history of squamous cell carcinoma in the left man-
dibular molar area and tumor removal that resulted
in a healed, continuity defect. Before the surgery, the
patient had been wearing complete maxillary and
mandibular dentures for the last 20 years. The
patient did not wear his previous mandibular denture
after surgery.
Procedure
Consultation Appointment and Treatment
Planning Considerations
The patient’s chief complaint was that he could not wear
his previous dentures after the surgery and desired new
denture treatment. A detailed examination was com-
pleted, and his previous dentures were evaluated for
retention and stability. Extra-oral examination revealed
asymmetrical lip retraction with reduced excursion on the
left side of the face. This was not unexpected, given the
patient’s prior surgical history (ie, removal of tumor and
muscle in the left mandibular molar area). Intraorally, the
left mandibular region presented atypical anatomy with a
reduced retro-molar pad area. A low mandibular alveolar
ridge height was also evident (Fig 1).
The use of dental implants to achieve improved stability
and retention for this patient’s planned mandibular pros-
thesis was a recommended treatment modality.26,27 Unfor-
tunately, the patient did not meet appropriate criteria that
would allow him treatment with dental implants in the
federally funded institution where he was being treated.
Financial constraints also precluded implant rehabilitation
in private or academic settings. Because of his atypical
intra- and extra-oral anatomy, the neutral zone technique
was considered the best means to determine the most
stable position for the mandibular denture teeth.
With the patient’s permission, his previously overex-
3
tended mandibular denture was modified and relined with
a tissue conditioner (Lynol; Kerr, Romulus, MI). He was
then advised not to wear his dentures 2 days before the
final denture impressions.28
First Appointment
The final maxillary impression was made using Type
I impression compound (Red Compound, 132°C;
Kerr) with a nonperforated metal tray. The com-
pound impression was removed from the oral cavity,
and the borders were trimmed to a length 2 to 3 mm
short of the active sulcus. Border molding was per-
formed with a Type I impression compound (Green
Compound, 123°C; Kerr; Fig 2), and a final wash
impression was made with a silicone impression
material (Elasticone; Kerr). Impression wax (Iowa
Wax; Kerr) was used to make a functional impres-
sion of the posterior palatal seal. A slightly overex-
tended mandibular irreversible hydrocolloid impres-
sion was also made using a prefabricated impression
tray.
Laboratory Procedure
In the laboratory, the maxillary impression was
beaded and boxed. Both impressions were poured in
American Dental Association type III dental stone. A
close-fitting custom mandibular impression tray was
made from a light polymerization composite resin
(Triad; Dentsply, York, PA). The tray border was
fabricated 2 to 3 mm short of the active sulcus. Metal
loops for the retention of a compound rim were
incorporated (Fig 3). A maxillary occlusal wax rim
was formed over a record base made from clear
autopolymerizing polymethylmethacrylate resin
(Orthoresin; Dentsply, Milford, DE).
Second Appointment
The maxillary occlusal rim was adjusted for proper
esthetics, occlusal plane, phonetics, and support of
the upper lip. Appropriate lines (midline, canine
lines, smile line) were marked. A facebow record was
made.
The mandibular custom tray (Fig 3) was adjusted
intraorally to ensure that it was short of the active
sulcus. A Type I impression compound (Grey Com-
pound, 126°F; Kerr) was applied in the area of the
mandibular ridge on the acrylic resin tray. The
compound occlusal rim was reheated in the water
bath. Use of denture adhesive (Fixodent; Procter and
4 Neutral Zone Technique ● Wee, Cwynar, and Cheng
Figure 1. Patient’s mandibular edentulous ridge with
atypical edentulous anatomy on the left side.
Gamble, Cincinnati, OH) assisted in retaining the
mandibular tray in the patient’s mouth. The patient
followed a regimen of swallowing, sucking,5,8 and
saying ‘‘ah, ee, oh’’ aloud.17 This permitted the
muscles to engage and adjust the compound occlusal
rim intraorally. The patient was also instructed to
move his cheeks, lips, and tongue continuously to
assist in molding the compound material.6 The com-
pound was reheated in the water bath, and the
procedure was repeated to confirm the shape of the
neutral zone. Denture adhesive was removed from
the intaglio of the tray. The adjusted maxillary
Figure 2. Border molded maxillary compound impres-
sion.
Figure 3. Custom mandibular impression tray with reten-
tive components for the neutral zone technique.
occlusal rim was positioned on the maxillary arch,
and the occlusal portion of the rim was adjusted to
the correct vertical dimension of occlusion, with the
rims touching evenly (Fig 4). Simultaneous bilateral
anterior and posterior occlusal contacts in centric
relation were verified. The mandibular custom tray
was then border molded without altering the occlusal
relationship of the maxillary occlusal rim.
A closed mouth impression was made of the
mandibular arch with a silicone impression (Elasti-
con; Kerr). After adhesive was placed, impression
material was positioned in the tray, and the patient
was instructed to close gently against the opposing
rim. The mandibular impression was completed, and
an interocclusal record was made between the maxil-
lary occlusal rim and the mandibular compound
occlusal rim/border molded impression complex with
a polyvinylsiloxane occlusal registration material (Blu-
Figure 4. Maxillary wax occlusal rim and mandibular
compound occlusal rims in proper vertical dimension of
occlusion.
 March 2000, Volume 9, Number 1
Figure 5. Poured mandibular cast with compound rims
mounted against maxillary occlusal rim using polyvinylsilox-
ane occlusal registration material.
Mousse; Parkell, Farmingdale, NY). The shade and
shape of acrylic resin denture teeth were also chosen.
Zero degree posterior teeth were selected for mono-
plane occlusion in accordance with the neutrocentric
occlusal concept.29-31
The mandibular final impression was poured in
the laboratory, and the master cast was indexed (Fig
5). The maxillary and mandibular casts were mounted
in an articulator without removing the mandibular
impression tray from its cast (Fig 5). The mandibular
neutral zone rim was indexed with plaster placed on
the buccal and lingual surfaces (Fig 6). The indices
were removed once set. The anterior and posterior
maxillary denture teeth were initially positioned
against the mandibular occlusal rim. The compound
occlusal rim and impression tray were then removed
Figure 6. The shape of the mandibular compound rim
captured with buccal and lingual plaster indices.
5
Figure 7. Patient’s uneven smile at wax try-in appoint-
ment.
from the mandibular cast. A mandibular record base
was fabricated using Triad material. The record base
and plaster indices were positioned on the cast. The
inner surfaces of the plaster indices were lubricated
with petrolatum gel. Molten wax was poured within
the plaster matrix to form a wax rim on the record
base that was located in the neutral zone. The
mandibular denture teeth were then set within the
confines of the wax rim. Because of the patient’s
atypical anatomy and an uneven balance of muscular
forces influencing the neutral zone technique, an
asymmetry on the patient’s left side resulted in a
skewed placement of teeth in this area.
Third and Fourth Appointments
A clinical wax try-in (Fig 7) was completed. A clinical
remount was used to verify the interocclusal relation-
Figure 8. Completed mandibular denture intraorally.
Note slight underextension of the mandibular denture at
the left retromolar pad area. The left mandibular acrylic
resin teeth are also positioned slightly lingual to the crest of
the ridge. This resulted from the patient’s mandibular
defect and asymmetric balance of muscular forces and
their influence on the neutral zone technique.
6 Neutral Zone Technique ● Wee, Cwynar, and Cheng
ship. The dentures were then processed, and a new
laboratory and clinical remount were accomplished
to refine the occlusion.32 The dentures were polished
and delivered (Fig 8). The patient was recalled at 1
day, 1 week, and 6 months.
Discussion
The final mandibular prosthesis presented in this
article has a number of attributes that make it
unique relative to a conventional mandibular com-
plete denture. As observed in Fig 8, the final mandibu-
lar prosthesis appears slightly underextended on the
patient’s left retromolar pad area. This is caused by
previous tumor removal surgery in that region. An-
other unique feature is the more lingually placed left
mandibular denture teeth, as determined by the
neutral zone technique.
It is important to note that the technique pre-
sented here differs from that described by Beresin
and Schiesser.33 Only the mandibular denture is
modified for the neutral zone procedure, as pre-
sented. The neutral zone procedure is more benefi-
cial to the mandibular denture, because many other
factors favor the retention and stability of the maxil-
lary denture, when compared with the mandibular
denture.34-37
The planned sequence of this method of denture
construction also requires fewer fabrication appoint-
ments for the completion of the prosthesis, as com-
pared with traditional methods of denture fabrica-
tion.38 A disadvantage of this technique involves the
laboratory aspect. Increased laboratory time is neces-
sary, and the laboratory technician must be trained
to support this clinical procedure.
Conclusion
The use of the neutral zone concept for denture
fabrication has been advocated since the 1930s.
Altered treatment sequencing, using a modified
neutral zone technique for mandibular denture fabri-
cation, was presented for a maxillofacial patient. This
technique may provide a more stable and retentive
complete lower denture and a shorter treatment
time relative to conventional treatment for patients
with severely resorbed ridges and/or mandibular
defects.
Acknowledgment
The primary author would like to thank Dr. Robert L.
Schneider (University of Iowa) and Dr. Hussein S. Zaki
(University of Pittsburgh Medical Center) for initiating his
interest in the neutral zone technique. Dr. Alan B. Carr’s
(Ohio State University) review of the manuscript was also
appreciated.
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