The neutral zone As each tooth erupts into position within its respective arch, it is guided into a narrow zone located between horizontally directed forces. ‘The outward pressure of the tongue versus the inward pressure of the perioral musculature defines the neutral zone (Fig. 6-1). The zone of neutrality between these opposing forces i positioned where outward pressure from the tongue is equal to the inward pressure from the buccinator—orbicularis oris band of mus- cle (Fig. 6-2), The neutral zone determines the position of each tooth and establishes the di mensions of the entire arch, including the shape and position of the alveolar processes. In effect, the boundaries of the neutral zone form a matrix for the dental arches. Any at tempt to move any part of the dental arch, in- cluding the alveolar structures outside the neutral zone, will result in increased pressure against the part that intrudes. There is no oc- clusal scheme that can stabilize teeth if they are in an unbalanced relationship with muscu. lar forces against them. The neutral zone has not been given enough importance in the literature, but as a determinant of occlusion it cannot be ignored. Understanding of the neutral zone would make it readily apparent why so many orthodontic results do not remain stable. It also explains why many postrestorative problems occur and. even why some periodontal procedures are unsuccessful. Relapses with orthognathic sur. gery can almost always be explained by neutral 2 zone imbalance. And complete or partial den- ture failures are often related to noncompli- ance with neutral zone factors, Regardless of the method of treatment, any Part of the dentition out of harmony with the neutral zone will result in instability, interfer- ence with function, or some degree of discom- fort or will bother the patient. Thus the neutral zone must be evaluated as an important factor before one makes any changes in arch form or alignment of teeth. The landmark work regarding the limiting effect. on arch was done by Sidney Frederick.' He showed that the perioral mus. culature was erroneously described in the ma: jority of anatomy texts. He also observed the effects of muscle pressure against the dentoal- veolar structures in hundreds of patients, His findings are important to every phase of dental treatment that deals with arch contour or tooth alignment, Understanding of the neutral zone is incomplete without knowledge of Fred- erick’s contributions regarding the perioral musculature. ‘The outer limits of the neutral zone are de: termined by the perioral musculature. The main determinant of length, strength, and posi- tion of the perioral musculature is the buccina tor muscle (Figs. 6-3 and 6-4). The buccinator a flat, thin muscle composed of three bands. ‘The upper band has a wide bony origin that starts at the base of the alveolar process abo the first molar and extends distally on the skel-‘The neutral zone 73 Fig. 6-1. The outward pressure of the tongue versus the inward pressure of the three bands of the buceinator mus dle determine where the corridor of neutral pressure is positioned. As the teeth erupt, they are directed into pos tion horizontally by these opposing forces. The size of the tongue and the strength of the perioral muscles influence the position of this neutral zone, as does any habit pattern that alfeets tongue oF lip pressures. Fig. 6-2. A, The upper band of the buccinator extends around the arch from origin to origin, and even though it becomes part of the orbicularis oris muscle, itis effectively one band of muscle. Thus it influ ences the dimensions of the arch to the limits of its repetitive contracted length. ‘The tongue is pos tured in direct opposition. B, ‘The lower band of the buccinator is often a strong band that, like the upper band, extends from origin to origin. If tongue size and posture is normal, it has the effect of re ing the inward force to form the neutral zone in between the opposing pressures. Notice how the buccinator origin extends from the external oblique line around the posterior teeth onto the internal ‘oblique fine. At this molar position the widest, strongest part of the tongue resists the strongest part of the buccinator.74 Evaluation, diagnosis, and treatment of occlusal problems Fig. 6-3. Origin of the three bands of the buceis Origin ot raphe U Upper bony origin or muscle. See text for description, (After Frederick, S: The buccinator, orbicularis oris complex, Manual prepared for Florida Prosthodontic Seminar, 1987.) Suspensor levator ‘ot raphe depressor Fig. 6-4. The three bands of the buceinator. See text for description. (After KAAS Bony origin ZB Buccinator SEZ idle band — | jz S | = lower bond Bony origin Suspensor depressor sdetick, S: The buccina- tor, orbicularis oris complex, Manual prepared for Florida Prosthadontic Seminar, 1987.) etal base above the alveolar process to the su- ture between the maxilla and palatine bone. From that bone, the line extends down to the lower surface of the pyramidal process of the palatine bone and continues on a short liga. ment to the tip of the pterygoid hamulus. The lower band also has a wide bony origin that starts at the skeletal base below the alveo- lar process at the first molar. It extends back and up along the external oblique line wher then crosses over behind the last molar at the lower end of the retromolar fossa and pro- ceeds onto the internal oblique line. Its bony. origin stops where the middle band starts at the end of the internal oblique line. The middle band fibers originate from the pterygomandibular raphe, a ligament that ex- tends from the tip of the pterygoid hamulusdown to the posterior extremity of the internal oblique line on the mandible. This middle band does not have a bony origin like the up- er and lower bands, and because of its soft o- igin, it cannot exert the strength of contraction that the upper and lower bands can apply to their underlying structures. The combined width of the three bands covers the entire outer surface of the dentoal- yeolar structures, that is, the teeth, alveolar process, and gingival tissues (Fig, 6-5), The upper and lower bands are continuous from side to side without decussation. The middle band fibers decussate and join into the fibers of the orbicularis oris, Because the mus- cle fibers form a continuous band from origin to origin, the size of the arch is limited by the length of the muscles when they are con- tracted repetitiously. The tonus of the buccin: tor-orbicularis oris muscle band may very well be controlled by the central nervous sys tem, but regardless of the reason for variations in ‘muscle tonus in different patients, the strength of that contractile force, at the length Of the muscle band during contraction, forms an inviolate outer limit for arch size Problems of alignment occur when the size Of the teeth are too large to fit into the arch- size dimension dictated by a constrictive peri- oral musculature. The effects of neutral zone confinement on the dentoalveolar structures can also play a ritical role as a determinant of facial profile. A Festrictive perioral musculature may prevent the dentoalveolar arches from expanding to a normal alignment with the skeletal base. Thus mandibular skeletal growth may extend the chin point forward while the dental arches are festricted by the band of muscles that prevent them from growing commensurately with their skeletal base (Fig, 6-6), Variations in length and strength of the three bands of the buccinator can further af- fect the profile by controlling the axial inclina. tions of the anterior teeth, especially when combined with the myriad variations of tongue size and pressure. Other factors, such as the size of the mouth, must also be evaluated when a change in arch size is being contemplated. A very small orifice is far more restrictive than a large broad open ing that exposes the dentition all the way around to the molars. A series of statements may give perspective ‘The neutral zone 75, Fig. 6-5. The combined width of the three bands of the buccinator cover both the teeth and the alveolar pro: cesses. The size of the orifice is also an important factor in regard 0 the limiting effect of the perioral musculature ‘The smaller the orifice, the stronger is the limiting effcet ‘on arch size and incisor inclination, Fig. 6-6. The combination of buceinator position and strength relates to tongue postion and sirength to deter: mine the inclination of the incisors. A strong lower band may limit arch size of the dentoalveolar process while the skeletal bone below it continues to grow, forming a button chin. Ifa strong lower band is placed low, it presses the roots back A strong tongue ean simultaneously press the crown forward. Various combinations in position and Strength of the three bands versus differences in tong size and position can produce a varity of incisor inctina tions.76 Evaluation, diagnosis, and treatment of occlusal problems to an evaluation of neutral zone consider- ations: 1. The teeth and their alveolar process are the most adaptive part of the masticatory system. They can be moved horizontally or vertically by light forces 2. There is a neutral zone within which muscular pressure against the dentition is equalized from opposite directions. ‘The entire arch form falls within that zone of neutral pressure 3. If irres ies of tooth position, align- ment, or contour can be corrected within the neutral zone, the prognosis for long-term stability is good. i. A problem occurs when the neutral zone is not where we want the teeth to be. 5. A treatment decision then must allow de- termination of if and how we can change the neutral zone to orient it where we want the teeth to be Because the neutral zone can assume so ‘many variations of form from different types of confinement by the same musculature, any ir- regular dental alignment or arch form should be evaluated in relation to the directional pres sures exerted by the tongue, the lips, and the cheeks. It should be determined why the den- tal arches are where they are before it can be determined if they can be altered. Several dif ferent arch configurations may be possible without any changes in muscle lengths. RELATING MALOCCLUSION TO THE NEUTRAL ZONE The high-vaulted, constricted maxillary arch good illustration of how aberrant pressure relate to the configuration of the dentoalveolar arches, It also serves as an example of the ind/-cffect influence by muscle pressures, explaining both why the problem occurs and how it can be treated. In the case of a patient with a high, narrow vault the maxillary arch is, squeezed inwardly by buccinator muscle pres: sure that is unopposed by outward tongue pressure. ‘The reason for the lack of outward tongue pressure against the posterior arch segments is, a forward tongue posture that possibly devel: oped as the effect of an inadequate airway space. With enlarged tonsils or adenoids, there is no room for the posterior width of the tongue in its normal position, and so it must be postured forward to provide an airway. cause: Fig. 6-7. An airway problem often results in a forward tongue posture in the growing child. ‘The forward tongue thrust moves the wide part of the tongue forward out of the vault. This changes the direction and position of tongue pressure against the posterior teeth and reduces resistance to the inward force ‘of the buccinator muscle. The result is a collapsed posterior arch. Simultaneously, the forward tongue position moves the anterior segment forward ‘The forward tongue posture causes two ¢ fects, It pushes the anterior teeth forward, and it evacuates its normal space up in the vault, thus eliminating the outward tongue pressure as resistance to buccinator pressure against the posterior teeth (Fig. 6-7). The narrowing of the arch form in back also permits a lengthen- ing of the arch forward, without altering the length of the perioral musculature. The arch configuration is determined by the Pressures exerted against the dentoalveolar structures during eruption of the teeth, and ‘even though the airway space may be enlarged during growth, permitting a more posterior tongue posture, the narrowed space between the posterior segments will not permit a nor- mal tongue position up in the vault. Thus the arch malformation will persist along with an aberrant neutral zone. One can correct both the narrow arch and the anterior disharmony by changing the neu- tral zone orthodontically. Expansion of the dentoalveolar arch width at the posterior seg- ments creates room for the tongue to fit up into the vault where it can then direct out- ward pressure against the posterior teeth to re- sist the inward buccinator pressure (Fig. 6-8).cinator. As the posterior arch width is expanded, the perioral band of muscle pulls back on the ante- rior teeth thus allowing for correction of the pointed protrusion in the anterior segment (Fig. 6-9). The corrected arch form can then be quite stable because the widened vault not only permits normalized outward tongue pres- sure against the posterior tecth, but it also re- duces the forward pressure against the anterior teeth as the tongue is allowed to posture back into the widened vault space. The combination of firmer perioral muscle pressure against the anterior teeth versus lessened forward tongue ‘The neutral zone 77 Fig. 6-8. Expansion of the arch permits the tongue to ft up in the vault and into a position whereby it can resist the inward force of the buccinators. When the tongue #s permitted to drop back, the forward pressure against the antcrior tecth is reduced, allowing them to be repos tioned back into better alignment. Fig. 6-9. A, The arch form that results from an airway problem because of the forward tongue thrust. ‘The linear dimension of the perioral muscle bands is limited to its contraction length, but it can be altered in shape. This arch form resulted from a malposed neutral zone. B, Expansion of arch width can result in a stable arch form by altering the neutral zone position ‘The wider arch form also accommodates the tongue in the vault to resist the inward forces of the buc our altering the linear dimension. pressure results in a changed neutral zone po- sition that is consistent with the corrected arch form. ‘The above correction also alters the direc- tion of lip pressures against the upper anterior teeth. When the upper anterior segment is pro- truded, the lower lip tucks in against their lin. gual and incisal edges with forwardly directed pressure (Fig. 6-10). Correction of the overjet alters the neutral zone by allowing the lower lip to pass in front of the labial surfaces and thus reverse the lip pressure to hold the teeth in the improved alignment (Fig, 6-11).78 Evaluation, diagnosis, and treatment of occlusal problems Fig. 6-10. Analysis of any malocclusion should include analysis of the neutral zone that contributed to ‘the malrelationship to sce if the neutral zone can be changed. Diagnostic casts, A, tell only part of the story, Observation of lip postion in relation to the anterior teeth, By is essential. When the lower lip has insufficient linear dimension to posture in front of the upper incisors, t takes a position behind them and contributes further to the malposition, C. Fig. 6-11. Repositioning the anterior teeth back, A, makes it possible for the lower lip to bypass the "upper incisors to form a proper lip seal, B. This in tum postures the lips to resist the forward tongue pressure, C, which is also reduced by the expansion of the arch width at the posterior segments.— Determining the neutral zone clinically In dentulous patients the position and angu: lation of the teeth is the best indicator of the current neutral zone position if the teeth ap: pear to be stable. The strength and position of the three bands of the buccinator can be determined by observation of the location and contour of the line of demarcation where the bound-down Bingiva separates from the underlying bone. The upper border of the lower band of the buccinator aligns with the lower border of the bound-down tissue on the labial surfaces of the mandible, and the lower border of the upper band of the buccinator relates to the upper border of bound-down tissue on the maxillary arch. The middle much weaker band and covers the teeth and the attached gingiva (Fig. 6-12), If the contour of the alveolar process is ob: served at the border of attached tissue, the strength and length of the buecinator band can be evaluated. A deep ledge indicates that strong band is exerting firm pressure against the underlying structures (Fig. 6-13). In some instances, the pressure is so great that there are deep indentations around the roots and the roots may be jammed back against the lingual plate. The labial bone around the roots may be thinner than normal. Depending on tongue The neutral zone 79 pressure variances against the crowns of the teeth, the incisors may be flared out at the in- cisal edges. If the lower band covers the incisal edges of the upper anterior teeth or there is an en larged mentalis muscle underlying the bucci nator—orbicularis oris complex, there will be a tendency to press back on the crowns of the upper teeth and verticalize their inclination. A strong lower band combined with a short upper lip results in even greater lingualized in clination of the upper incisors be lower lip must reach up further to seal during swallowing Clinically, the observation of a deep cleft and a button chin is a sign of a tight, strong neutral zone, which will almost always result in a vertical or lingual inclination of the rior teeth (Fig. 6-14). Observation of a deeply indented alveolar process can have a significant effect on diagno. sis and treatment selection on the posterior segments as well as the anterior teeth, A deep indentation indicates a strong band of muscle that should not be encroached on if it is possi ble to avoid it. Partial denture bases that ex- tend improperly into conflict with the muscle bands are easily dislodged by normal muscle function (Fig. 6-15) use the ante Fig. 6-12. Normal, stable neutral zone showing demarcation of upper and lower bands of the buccina: tor. Lower border of the upper band aligns with the upper border of attached gingiva. Upper border of the lower band aligns with the lower border of attached gingiva, Middle band. covers atta Height of the bands is altered during lip seal ched tissue.80 Evaluation, diagnosis, and treatment of occlusal problems Fig. 6-13. Notice the effect of a strong lower band on the alveolar process. A deep ledge with fairly sharp indentation indicates strong pressure against the dentoalveolar process. Expansion of the arch into such pressure would be unstable Fig. 6-14. A decp cleft and button chin is a sign of a tight neutral zone that is limited by a strong perioral musculature. This combination almost always results in lingually inclined upper incisors. The lingual inclination is needed to permit the lower lip to close to a seal without interference from the "upper incisal edges. This is a stable relationship as long as holding contacts are present.The neutral zone 81 Fig. 6-15. Example of a partial denture base that interferes with strong lower band of the bucc A. Notice how the base extends helow the ledge line that indicates the upper edge of the buccinator band, B. Many prosthetic failures can be traced to interference with the neutral zone. This patient com. plained of constant dislodgment. Determining the posterior neutral zone Unless posterior teeth have been recently moved or restored, they will be in their cur rent neutral-zone relationship. Teeth will never spontaneously move either vertically or horizontally out of newt muscle pressures change tion, the teeth will change position to accom: modate, Thus any tooth that has remained in a stable position is in neutral-zone harmony ‘This position should be carefully evaluated in relation to muscle forces before one makes any decision to alter shape or position Inclination and alignment of second and third molars are particularly subjected to the strongest pressures from the widest part of the tongue versus the most unyielding part of the buccinator muscle near its origin. Attempts at uprighting or perfecting alignment in this seg- ment are often unsuccessful because the neu: tral zone does not conform to the textbook norm. Pretreatment observation can be very enlightening regarding the location of the neu: tral zone, and if realignment can take place within that established zone, the prognosis for stability will be excellent. In replacement of teeth on posterior eden: tulous ridges, there are no teeth to indicate the neutral zone location, but one can pre cisely determine it by allowing the muscula- ture to form a moldable material during swal- lowing. The procedure is described in Fig. 6-16. Observation of several neutral-zone record- ings is a convincing exercise that is highly rec- ommended. One will notice the consistency in the width of the recorded neutral zones, and it, will be apparent that it relates to the normal width of natural teeth. It will also be apparent, that even in mouths that have been without posterior teeth for extended time periods, the outward tongue pressure is still resisted by in- ward buccinator pressure that is sufficiently strong to position the neutral zone in ably normal alignment over the ridge. This re peated finding raises doubt about the popular belief that the tongue expands when teeth are lost. reason- ‘The effectiveness of some functional appli ances is based on blocking the pressure from one side of the neutral zone. By placing a shield on the check side to prevent inward pressure, tongue forces then move the tecth toward the check. Regardless of the method of creating teeth will move toward the one can see that the unopposed uneven pressur82 Evaluation, diagnosis, and treatment of occlusal problems Fig. 6-16. The neutral zone for an edentulous ridge can be formed in moldable compound during swallowing. Notice how the tongue pressure has formed the lingual contour. Pressure from the bucci nator forms the buccal conten ind defines the neutral 2one where the posterior teeth should be placed. B, A lower denture in harmony with the neutral zone is stabilized as much by the tongue and cheek musculature as itis by the adaptatio achieved, there are no dislodging a the ridge. When both vertical and horizontal harmony isnegative side of imbalanced forces and away from the side with stronger pressure. The long- term effectiveness of functional appliances ultimately related to the balance of pressures at the completion of treatment. If the parts of the system can be related to the variety of spa- cial accommodations that must conform to the length of muscles and the bulk of the tongue, the results of treatment can be predicted more accurately Determining the neutral zone for anterior teeth Because the neutral zone is determined by the functional relationship of the tongue ver- sus the perioral musculature, locating an un- known neutral zone starts by observation of the positional relationships of these structures during specific functions. There are several dif ferent functions that require rather precise me- chanical interrelationships between the teeth, the tongue, and the lips in order to perform the function correctly. The value of under- standing how these interrelationships work mechanically is that it provides known ref ence points for determining how the teeth st interrelate in order for correct function and_ anatomic harmony are almost always coincidental Phonetic methods can be used with a high degree of accuracy because the shaping of sounds results from such approximation of up- per and lower teeth with cach other, with the lips, and with the tongue. The near contact of structures that constrict the airflow into partic ular sound forms can also be used as guidelines for incisal edge position and the entire incisal plane. The lip closure path can be used to de termine labial contours, and methods for de- termining the anterior guidance can direct the contouring of the upper lingual surfaces. When all these functional relationships are correct, the teeth will be in harmony with the neutral zone. The methods for determining all the neces. sary anterior relationships are described in de: tail in Chapters 16 to 18 = Methods for altering the neutral zone The neutral zone may be altered in several s, as follows. Orthodontics. By realigning the teeth for improved balance between the tongue and the w The neutral zone 83 perioral musculature, one can most often im- Prove it without the need for lengthening mus- cle. Elimination of noxious habits. Thumb- sucking, lip-biting, or forward tongue-pos- turing all tend to increase outward pressure against the perioral musculature, thus moving, the neutral zone accordingly. Elimination of such habit patterns allows the perioral muscles to move the teeth back into harmony with normal tongue position. It should be noted however that success in changing habit pat terns is often difficult or impossible if they in- volve long-standing tongue-thrust patterns. Myofunctional therapy. \f lip pressure can be increased by strenthening the perioral musculature, the neutral zone will move ac cordingly. Any change in muscle pressure will affect the neutral zone, but results are often disappointing for longterm effectiveness in mature adults, Reduction of tongue size. Surgical reduc- tion of tongue size will reduce outward pres: sure and allow the perioral muscles to move the teeth lingually into a new neutral zone. For some reason this procedure has not had popu- lar acceptance. Surgical lengthening of the buccinator band. Surgical lengthening of the buccinator band can be used to reduce restrictive pres- sure that limits arch size. Frederick has re- ported increased thickness of labial ti over the roots of teeth, along with increased stability of the teeth after arch expansion when, restrictive muscle pressure is released. It is usually done to lengthen the lower band of the buccinator. ‘The procedure involves four steps: 1. Surgically cut through the mucosa with a vertical incision, 2. Vertically cut through the lower band of the buccinator muscle on each side. 3. Suture the mucosa only. Leave the mus: cle segments unattached. 4. Add lip pressure to increase the length of muscle with a Frankel type of appliances Scar tissue will fill in between the two cut ends effectively lengthening the perioral band around the arch Vestibuloplasty. A vestibuloplasty either alone or in combination with the muscle. lengthening procedures appears to cause a re- duction of perioral pressure. It should extend ues84 — Evaluation, diagnos around the anterior arch to the bicuspid area. More study is needed to evaluate the full ef: fect of the surgical approach. However clinical results appear to be beneficial in reducing the thinning out and clefting of labial tissues when arches are expanded beyond the normal boundaries of a tight neutral zone. Neutral zone considerations in orthognathic surgery Surgical advancements tend to relapse if the advanced section causes extension of any con- nected muscle or interferes with the length of the perioral musculature. Modern surgical techniques all consider muscle relationships and cither move the muscle origin or insertion to compensate for the change in position of the skeletal part. . and treatment of occlusal problems REFERENCE, 1. Frederick, S: The buccinator, orbicularis oris complex. Manual prepared for Florida Prosthodontic § 198 SUGGESTED READINGS Beresin, V.f., and Scheesser, FJ: The neutral zone in com: plete dentures, J. Prosthet. Dent. 36:356, 1976, Fish, EW. An analysis of the stabilizing factors in full den- ure construction, Br. Dent. J. 52:559, 1951 Frederick, S: The buccinator muscle and alveolar process Unpublished article, Lafayette, La. Goldspink, G. Sarcomere length during post natal growth of mammalian muscle fibers, J. Cell Sci. 3:59, 1968. Singer, CPs The depth of the mandibular antegonial noteh 4 an indicator of mandibular growth potential, Am. J Orthod. 89:528, 1986. (Abstraet.) Weis, W., and Killen, B. An analysis of the patterns of cor- relations between the size of the masticatory muscles and shape of the facial skeleton, J. Oral Rehabil. 12:530, 1985. (Abstract.)