Morphologic comparison of two neutral zone impression techniques: A pilot study

, DDSa Joseph E. Makzoume School of Dentistry, St-Joseph University, Beirut, Lebanon Statement of problem. Several studies have compared dentures fabricated using neutral zone and
conventional techniques. However, studies comparing swallowing and phonetic techniques for assessing the location and shape of the neutral zone could not be identied in the literature. Purpose. The purpose of this pilot study was to compare the outline form of the phonetic and swallowing neutral zone impression techniques for the same subjects. Material and methods. Nine denture wearers with advanced mandibular ridge resorption were included in this study. For each subject 2 trays were prepared in autopolymerizing acrylic resin. One method used phonetics and tissue conditioner to shape the neutral zone; the second method used swallowing and modeling plastic impression compound. The resulting neutral zone impressions were leveled to the same occlusal height by gently grinding the occlusal surface on sandpaper until it corresponded with landmarks (corners of the mouth, two thirds of the height of the retromolar pads, bilaterally) noted on the cast. The impression was inverted onto graph paper, and the contour was outlined with a lead pencil. One impression was made for each subject, for each technique. The buccal contours of both neutral zones coincided at the median line. The maximum distance between the zones was measured in a buccolingual direction in the anterior, premolar, and molar regions bilaterally. When the location of the phonetic neutral zone in relation compared to the swallowing neutral zone was buccally oriented, a plus score was given. When the phonetic neutral zone was lingually located, a minus score was given. When the 2 lines coincided, a score of 0 was given. Measurements were made from direct readings on the graph paper. Statistical analysis was performed using the Sign test (a=.05). Results. Signicant differences were noted buccally in the left molar (P=.031) and right molar (P=.003) regions and also in the left and right premolar regions (P=.007), where the swallowing neutral zone was found to be located buccal to the phonetic neutral zone. Signicant differences were also noted lingually, in the right premolar region (P=.015), where the swallowing neutral zone was found to be located lingual to the phonetic neutral zone. There was no signicant difference between the techniques for the anterior region. Conclusion. Within the limits of this study, the phonetic neutral zone appears to be narrower posteriorly compared to the swallowing neutral zone, thus limiting premolar and molar positioning. (J Prosthet Dent 2004;92:563-8.)

CLINICAL IMPLICATIONS
A denture fabricated with a mandibular impression made using a phonetic technique to determine that the neutral zone will be narrower in the posterior region than a denture using a swallowing technique to establish the neutral zone.

he neutral zone is dened as the potential space between the lips and cheeks on 1 side, and the tongue on the other; that area or position where the forces between the tongue and cheeks or lips are equal.1 This zone is referred to by various names, including the dead space2 and zone of minimal conict.3 Knowledge of the neutral zone concept may be advantageous when fabricating complete dentures. Incorrect tooth placement and arbitrary shaping of the polished surfaces

Private practice and Master Assistant, Post-Graduate Prosthodontics, Department of Removable Prosthodontics.

may have an adverse effect on the success of the prosthesis. This is particularly true for patients with reduced mandibular residual ridges, yielding at or concave foundations due to severe bone resorption. A number of techniques relying on function to develop the shape of the neutral zone and polished surface of mandibular dentures have been described.4-6 The concept considers the actions of the tongue, lips, cheeks, and oor of the mouth during a specic oral function, to push the soft material into a position where buccolingual forces are neutralized. Many materials have been suggested for shaping the neutral zone: modeling plastic impression compound,5 soft wax,7 a polymer of dimethyl siloxane
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lled with calcium silicate,8 silicone,9 and tissue conditioners and resilient lining materials.10,11 Many techniques have been suggested using the previously described materials in conjunction with movements including sucking,12 grinning and whistling,7 and pursing the lips.13 The swallowing/modeling plastic impression compound technique14 located the neutral zone, using swallowing as the principle modeling function. Considering that a person swallows up to 2400 times per day,15 and considering also that during the entire swallowing sequence teeth come into contact for less than 1 second,16 it may be concluded that less than 40 minutes of tooth-to-tooth contact occurs per day during function. Speech is also another important part of daily oral activities. During speaking, the mouth is moderately opened, pressures of different magnitude and direction are generated, and forces are produced with a greater horizontal than vertical component acting on the dentures. Furthermore, although speaking causes upward movements of the oor of the mouth similar to swallowing, these movements are not as constant as those found in swallowing.17 Thus, the phonation/tissue conditioner technique uses phonation to develop a mandibular impression.8,13,14 Many studies have analyzed the neutral zone13,18,19 and neutral zone dentures as compared with dentures made using conventional techniques in the edentulous patient.8,9,12,20 It has been shown that neutral zone dentures are functionally more stable than conventional dentures.6,8,9,12 However, the author could not identify studies comparing the swallowing and the phonetic techniques for assessing the location and shape of the neutral zone reported in the literature. The purpose of this study was to compare the outline form of the phonetic and swallowing neutral zone impression techniques on the same subjects.

sions of the borders. Borders were trimmed, and the trays were reevaluated intraorally for stability by the clinician and conrmed by the subject, after opening the mouth wide, wetting the lips with the tongue, swallowing, and speaking. One of the trays was used to shape resilient lining material (Functional Impression Tissue Toner; Kerr Corp) using phonation. Swallowing was used to shape modeling plastic impression compound (Green Impression Compound Type 1; Kerr Corp) on the second tray, constructed with wire loops to retain the modeling material. None of the subjects wore a maxillary denture during impression procedures. The resulting impressions were leveled to the same occlusal height by gently grinding the occlusal surface on sandpaper until it corresponded with landmarks noted on the cast. The contours of both impressions were outlined on graph paper and compared. The recording of the phonetic neutral zone was always performed before that of the swallowing neutral zone, and an impression was made for each subject using each technique.

The phonetic technique

The molding of the phonetic neutral zone (PNZ) was developed progressively. One lateral segment was molded rst (right or left), then the other lateral segment; and, nally, the anterior segment. The custom tray was seated on the edentulous ridge, and 5 mL of tissue-conditioning material mixed in a 1:1 ratio were injected with a syringe on the right lateral segment of the tray after the tongue was moved aside with a mirror. The subject was asked to pronounce the phoneme SIS 5 times followed by the phoneme SO once. Both sounds had to be pronounced clearly, loudly, and vigorously to induce sufcient muscle contraction. This phonetic sequence was repeated until the material had polymerized. The tray was removed from the mouth, and excess tissue-conditioning material extending anterior to the premolar area was removed with scissors. The tray was reinserted intraorally, and the same procedure was repeated to mold the left lateral segment of the PNZ. Then the right lateral segment that was molded initially was removed from the tray and remolded because the rst impression was not considered reliable due to the fact that the rst contact of the tongue with the soft material might be constrained, as the tongue would try to avoid this initial contact. Finally, the tray was reinserted and molding of the PNZ was completed by injecting material in the anterior region and having the subject pronounce successively the phonemes DE, TE, ME, PE, SE vigorously, until the polymerization of the material was complete. During the molding of each segment, whenever the subject swallowed or spoke sounds other than the phonemes, the material was removed and the segment was remolded. The occlusal plane was then located according to the height of the lower lip at rest anteriorly, the
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MATERIAL AND METHODS

After institutional review board approval, 9 healthy edentulous subjects who wore complete dentures for at least 2 years were included in this study. Ages ranged between 73 and 83 years, with a mean of 79 years. Requirements for selection were advanced mandibular ridge resorption (Class V, Atwood)21 and absence of clinical temporomandibular joint symptoms. During preliminary evaluation, none of the subjects showed signs of phonetic problems with their existing dentures. Clinical assessment showed no abnormal swallowing habits. All procedures were performed by a single clinician. A preliminary mandibular cast was made for each subject using an irreversible hydrocolloid (Aroma Fine Dust Free; GC Europe, Leuven, Belgium) impression. Two custom impression trays were then prepared in autopolymerizing acrylic resin (Formatray; Kerr Corp, Orange, Calif), placed intraorally, and evaluated for overexten564

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commissures laterally, and to a point located approximately two thirds of the height of the retromolar pad posteriorly. Excess tissue-conditioning material was removed with scissors. For research purposes, the impression was processed to replace the soft material with an autopolymerizing acrylic resin (Formatray, Kerr Corp). Using sandpaper (size 150#2/0; Greatwall Mould Co Ltd, Shenzhen, China), the occlusal surface of the resulting impression was leveled. The buccal and lingual median lines were determined intraorally according to the sagittal midface line and recorded rst on the PNZ impression, and then on the subsequent cast (Fig. 1). The PNZ impression was inverted onto graph paper, and the contour was outlined as a dashed line with a lead pencil.

The swallowing technique

Modeling plastic impression compound (Green Impression Compound Type 1; Kerr Corp) was softened in a preheated water bath (Petra Electric, Burgau, Germany) at 57C.5 Water temperature was controlled with a thermometer. The soft material was adapted to the tray and formed into the shape of an occlusion rim. Two and a half cakes of compound were used for each subject. The modeling compound was reheated for 2 minutes in the water bath, and the tray was carefully placed in the subjects mouth without distorting the rim. The subjects were instructed to swallow and then purse the lips as in sucking, several times. To make swallowing easier, 1 mL of warm water was injected intraorally before each swallow. After the material cooled, the tray was removed from the mouth and excess compound forced to an excessive height was trimmed away with a knife. The procedure was repeated as many times as necessary to perfect the impression according to the swallowing neutral zone (SNZ) technique. Impression was deemed satisfactory when 2 successive impressions produced similar shapes. The occlusal plane was then located as previously mentioned so that SNZ and PNZ impressions had the same occlusal height. Using sandpaper (size 150#2/0; Greatwall Mould Co Ltd), the occlusal surface of the molded compound rim was leveled. The tray was repositioned on the cast, and the median line was recorded on the compound, ensuring that the PNZ and SNZ impressions used the same median line. The SNZ impression was then inverted onto graph paper and placed on top of the PNZ impression outline in a way such that the buccal contours of both impressions coincided with the median line. The SNZ impression contours were outlined with the same lead pencil as a solid line. The position of the canine, determined clinically, was noted. From the position of the canine to the rearmost limit of the drawing, the distance was divided into 3 segments: the rearmost two thirds was the molar region, and the anterior-most one third was considered to be the premolar region.
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Fig. 1. Same cast and same median line for both neutral zone impressions for 1 subject. Top: phonation/tissue conditioner technique. Bottom: swallowing/modeling plastic impression compound technique.

The relationship between the buccal and the lingual contours was examined and measured in a buccolingual direction. The outlines were compared by measuring the maximum distance between them in the anterior, premolar, and molar regions on the left and right sides. When the location of the PNZ outline compared with the SNZ outline was buccally oriented, a plus score was assigned. For lingual location of the PNZ outline in relation to the SNZ outline, a minus score was assigned. When the 2 lines coincided, a score of zero was assigned. Measurements were made 3 times directly from the graph paper. The values refer to the maximum distance between the contours. As differences between the outlines were not all entirely lingual or entirely buccal, the 1/2 sign was assigned considering the direction at the point of maximum difference. The data were analyzed using the Sign test (a=.05).

RESULTS
The positions of the PNZ impressions with respect to the SNZ impressions for the buccal contours and the
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Fig. 2. Tracings of phonetic neutral zone and swallowing neutral zone for 9 subjects. Solid line represents swallowing neutral zone. Dashed line represents phonetic neutral zone.

Table I. Buccal position of phonetic neutral zone in relation to swallowing neutral zone in different locations
No. of subjects Left molar Left premolar Left anterior Right anterior Right premolar Right molar

Table II. Lingual position of phonetic neutral zone in relation to swallowing neutral zone in different locations
No. of subjects Left molar Left premolar Left anterior Right anterior Right premolar Right molar

1 2 3 4 5 6 7 8 9 Total Mean SD

21 21 21 0 21.5 0 20.5 0 20.5 25.5 20.6 0.55

22 21 20.5 21 0 21 22.5 21 21.5 210.5 21.1 0.75

0 0 20.5 0 0 0 21 0 20.5 22 20.2 0.36

20.5 0 21.5 0 0 0 0 0 0 22 20.2 0.51

22 21 21.5 21.5 0 21 21 21 21 210 21.1 0.55

22 21.5 22 21.5 23 21 21.5 21.5 20.5 214.5 21.6 0.70

1 2 3 4 5 6 7 8 9 Total Mean SD

21 22 0.5 20.5 0.5 0.5 0.5 21.5 21 24 20.4 0.98

20.5 1 22 0 0 0.5 0.5 0 20.5 21 20.1 0.86

21 0 20.5 21 0 1.5 0 0.5 21 21.5 20.1 0.83

21 0.5 20.5 20.5 0.5 1 0.5 1 20.5 1 0.1 0.74

1 1 0 1 1 1 0.5 0.5 0 6 0.6 0.43

0 20.5 1 0 0 1 1 21 0.5 2 0.2 0.71

SD, Standard deviation. Measurements in mm. Score of 0 indicates PNZ coincides with SNZ; 1 score indicates PNZ is buccal with respect to SNZ; 2 score indicates PNZ is lingual to SNZ.

SD, Standard deviation. Measurements in mm. Score of 0 indicates PNZ coincides with SNZ; 1 score indicates PNZ is buccal with respect to SNZ; 2 score indicates PNZ is lingual to SNZ.

lingual contours in different locations are summarized in Tables I and II. When data from the anterior, premolar, and molar regions were pooled, buccally, PNZ impression contours coincided with SNZ impression contours in 18 locations (33.33%). PNZ impression contours were located lingually in 36 locations (66.66%). No buccal location of the PNZ contours with respect to the SNZ contours was noted. Lingually, PNZ impression contours coincided with SNZ impression contours in 11 locations (20.37%). PNZ impression contours were
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located lingually in 18 locations (33.33%), and buccally in 25 locations (46.29%). When compared by segment, buccally, statistical analysis showed signicant differences in the left molar (P=.031) and right molar regions (P=.003) and also in the left and right premolar regions (P=.007) where the SNZ was found to be located buccal to the PNZ. Lingually, statistical analysis showed signicant differences in the right premolar region (P=.015) where the SNZ was located lingual to the PNZ. No signicant
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differences were noted when analyzing the anterior region, on both sides of the median line, since the number of subjects with different scores was small. However, in 13 locations (72.22%) the SNZ coincided with the PNZ, and in only 5 locations (27.78%) was the PNZ lingually located.

DISCUSSION
This investigation was not designed to determine which of the 2 impression materials is better for reproduction, nor whether swallowing or speaking is a better modeling function. The sole objective was to assess whether there was a signicant difference in outline of the impressions made with the 2 methods. Statistical analysis of the buccal contours of both PNZ and SNZ indicated consistent differences in the left and right molar regions. The SNZ in the most posterior locations was found to be located buccally (Table I). Two factors may be responsible for this observation. Either the compound was too viscous a material to be sufciently molded by the buccinator, or buccinator activity was increased in speaking. Whichever is true, the question is raised as to whether the SNZ denture on an advancedresorbed residual ridge would be in equilibrium during speech. The opposite question may also be raised as to whether a PNZ denture on an advanced-resorbed ridge would be stable during swallowing. Signicant differences were also noted in the left and right premolar region. The PNZ was found to be located lingually (Table I). Accordingly, teeth may be positioned more lingually, thus offering less lip and cheek support. If a neutral zone technique is indicated for a patient with a reduced alveolar ridge, it may be difcult to support the patients lips if this is required to improve facial esthetics. It is interesting to note that in the premolar region, the PNZ buccal curves appeared more clearly dened compared to SNZ curves (Fig. 2). The narrowness of contour in this section is caused by the contraction of the zygomatic, caninus, and triangularis muscles, which meet at the modiolus.2 Therefore, the corners of the mouth in speaking, when present with a resorbed residual ridge, may lift the SNZ denture up or move it laterally. Lingually, the only signicant difference was noted in the right premolar region where the SNZ was found to be located lingually (Table II). Whenever the width of the neutral zone in this lateral section is not thick enough to allow reduction from the lingual, tongue thrusting during speech may displace the SNZ denture, especially in the edentulous patient with advanced ridge resorption. Studying the reproducibility of the neutral zone, Karlsson and Hedegard18 compared the results of 2 operators using 1 impression material (Coe-Comfort; Coe Laboratories Inc, Chicago, Ill) and a spatula for applicaDECEMBER 2004

tion. The authors noted that the neutral zone could be reproduced with only limited variation and was within the range of clinical acceptability and concluded that there was no operator effect when making neutral zone impressions. These authors also compared the results obtained by 1 operator with 2 impression materials and 2 methods of application. The authors reported signicant differences among impressions when using different materials (Coe-Comfort versus Bio-Soft; B. L. Dental Co Inc, New York, NY) and different application methods of the material (spatula versus injection). In the present study, 2 modeling techniques and 2 materials were used. The results conrm the variability of the neutral zone techniques.13,18 These ndings should, however, be considered carefully as sample size was limited, and interoperator and intraoperator variabilities of experimental procedures were not assessed, since 1 clinician made only 1 impression of each technique. Since the PNZ impression was always made prior to the SNZ impression, bias may have been introduced as the subject and/or the operator could be more comfortable or precise in making the second impression. Ideally, the choice of the rst impression technique should have been randomized. Furthermore, more elaborate techniques could be developed to obtain similar occlusal plane for both techniques and to improve tracing technique. Further research is required to compare the functional potential of mandibular dentures made using the swallowing/modeling plastic impression compound technique and the phonation/tissue conditioner technique.

CONCLUSIONS
Within the limitations of this study, the ndings indicated that the location of the neutral zone was not the same with the swallowing/modeling plastic impression compound technique and the phonation/tissue conditioner technique. However, statistical signicance does not necessarily imply clinical signicance, and the results yielded by these 2 techniques may be clinically acceptable. In general, the PNZ technique resulted in impressions where the neutral zone appeared to be narrower as the buccal surface was located more lingual compared to the SNZ technique.
The author wishes to thank Dr Sheldon Winkler for his invaluable advice in this study, Drs Frank Schiesser and Pierre Klein for their for his statistical assistance, and encouragement, Mr Fouad Nakhle Dr Hani Ounsi for his help in editing the manuscript.

REFERENCES
1. Glossary of prosthodontic terms. 7th ed. J Prosthet Dent 1999;81:86. 2. Fish EW. Using the muscles to stabilize the full lower denture. J Am Dent Assoc 1933;20:2163-9. 3. Matthews E. The polished surfaces. Br Dent J 1961;5:407-11. 4. Raybin NH. The polished surface of complete dentures. J Prosthet Dent 1963;13:236-9.

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5. Schiesser FJ. The neutral zone and polished surfaces in complete dentures. J Prosthet Dent 1964;14:854-65. 6. Beresin VE, Schiesser FJ. The neutral zone in complete dentures. J Prosthet Dent 1976;36:356-67. 7. Lott F, Levin B. Flange technique: an anatomic and physiologic approach to increased retention, function, comfort and appearance of dentures. J Prosthet Dent 1966;16:394-413. 8. Miller WP, Monteith B, Heath MR. The effect of variation of the lingual shape of mandibular complete dentures on lingual resistance to lifting forces. Gerodontology 1998;15:113-9. 9. Barrenas L, Odman P. Myodynamic and conventional construction of complete dentures: a comparative study of comfort and function. J Oral Rehabil 1989;16:457-65. 10. Ohkubo C, Hanatini S, Hosoi T, Mizuno Y. Neutral zone approach for denture fabrication for a partial glossectomy patient: a clinical report. J Prosthet Dent 2000;84:390-3. 11. Kokubo Y, Fukushima S, Sato J, Seto K. Arrangement of articial teeth in the neutral zone after surgical reconstruction of the mandible: a clinical report. J Prosthet Dent 2002;88:125-7. 12. Fahmy FM, Kharat DU. A study of the importance of the neutral zone in complete dentures. J Prosthet Dent 1990;64:459-62. 13. Neill DJ, Glaysher JK. Identifying the denture space. J Oral Rehabil 1982; 9:259-77. 14. Beresin VE, Schiesser FJ. The neutral zone in complete and partial dentures. 2nd ed. St Louis: Mosby; 1978. p. 73-86. 15. Lear CS, Flanagan JB Jr, Moorrees CF. The frequency of deglutition in man. Arch Oral Biol 1965;10:83-100. 16. Eibling DE, Cavo JW Jr. Dysphagia. In: Calhoun K, Eibling DE, Wax MK. Expert guide to otolaryngology. Philadelphia: American College of Physicians; 2001. p. 282.

17. Shelton RL Jr, Bosma JF, Sheets BV. Tongue, hyoid and larynx displacement in swallow and phonation. J Applied Phys 1960;15:283-8. 18. Karlsson S, Hedegard B. A study of the reproducibility of the functional denture space with a dynamic impression technique. J Prosthet Dent 1979;41:21-5. 19. Fahmi FM. The position of the neutral zone in relation to the alveolar ridge. J Prosthet Dent 1992;67:805-9. 20. Stromberg WR, Hickey JC. Comparison of physiologically and manually formed denture bases. J Prosthet Dent 1965;15:213-30. 21. Atwood DA. The problem of reduction of residual ridges. In: Winkler S. Essentials of complete denture prosthodontics. 2nd ed. St. Louis: Mosby Year Book; 1988. p. 22-38. Reprint requests to: DR JOSEPH E. MAKZOUME BADARO, 25 I. MEDAWAR STREET BADARO CENTER BEIRUT 2058-7007 LEBANON FAX: 00961-1-380530 E-MAIL: makzoume@inco.com.lb 0022-3913/$30.00 Copyright 2004 by The Editorial Council of The Journal of Prosthetic Dentistry

doi:10.1016/j.prosdent.2004.09.010

Noteworthy Abstracts of the Current Literature

Cytotoxicity of denture base resins: Effect of water bath and microwave postpolymerization heat treatments Jorge JH, Giampaolo ET, Vergani CE, Machado AL, Pavarina AC, Carlos IZ. Int J Prosthodont 2004;17:340-4.

Purpose: This study compared the effect of two postpolymerization heat treatments on the cytotoxicity of three denture base resins on L929 cells using 3H-thymidine incorporation and MTT assays. Materials and Methods: Sample disks of Lucitone 550, QC 20, and Acron MC resins were fabricated under aseptic conditions and stored in distilled water at 37C for 48 hours. Specimens were then divided into three groups: (1) heat treated in microwave oven for 3 minutes at 500 W; (2) heat treated in water bath at 55C for 60 minutes; and (3) no heat treatment. Eluates were prepared by placing three disks into a sterile glass vial with 9 mL of Eagles medium and incubating at 37C for 24 hours. The cytotoxic effect from the eluates was evaluated using the 3H-thymidine incorporation and MTT assays, which reect DNA synthesis levels and cell metabolism, respectively. Results: The components leached from the resins were cytotoxic to L929 cells when 3H-thymidine incorporation assay was employed. In contrast, eluates from all resins revealed noncytotoxic effects as measured by MTT assay. For both MTT assay and 3H-thymidine incorporation, the heat treatments did not decrease the cytotoxicity of the materials tested. Conclusion: Resins were graded by 3H-thymidine incorporation assay as slightly cytotoxic and by MTT assay as noncytotoxic. Cytotoxicity of the denture base materials was not inuenced by microwave or water bath heat treatment.Reprinted with permission of Quintessence Publishing.

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