Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2011; 56: 112–121
REVIEW
doi: 10.1111/j.1834-7819.2011.01312.x

Applied anatomy of the pterygomandibular space: improving

the success of inferior alveolar nerve blocks
JN Khoury,* S Mihailidis,* M Ghabriel,  G Townsend*
*School of Dentistry, The University of Adelaide, South Australia.
 Discipline of Anatomy and Pathology, School of Medical Sciences, The University of Adelaide, South Australia.

ABSTRACT
A thorough knowledge of the anatomy of the pterygomandibular space is essential for the successful administration of the
inferior alveolar nerve block. In addition to the inferior alveolar and lingual nerves, other structures in this space are of
particular significance for local anaesthesia, including the inferior alveolar vessels, the sphenomandibular ligament and the
interpterygoid fascia. These structures can all potentially have an impact on the effectiveness of local anaesthesia in this area.
Greater understanding of the nature and extent of variation in intraoral landmarks and underlying structures should lead to
improved success rates, and provide safer and more effective anaesthesia. The direct technique for the inferior alveolar nerve
block is used frequently by most clinicians in Australia and this review evaluates its anatomical rationale and provides
possible explanations for anaesthetic failures.
Keywords: Inferior alveolar nerve block, dental anaesthesia, mandibular nerve, sphenomandibular ligament, lingual nerve.
Abbreviations and acronyms: IAA = inferior alveolar artery; IAN = inferior alveolar nerve; IANB = inferior alveolar nerve block;
IAV = inferior alveolar vein; LN = lingual nerve; PVP = pterygoid venous plexus.
(Accepted for publication 6 September 2010.)

INTRODUCTION Scope of the review

The inferior alveolar nerve block (IANB) is widely used
in dental clinical practice and, considering its impor-
tance for mandibular anaesthesia, it is essential that the
anatomical rationale for this technique is well under-
stood. The relationships of structures in the pterygo-
mandibular space have significant bearing on the
effectiveness of the IANB, as well as its safety. Failure
of mandibular anaesthesia and associated safety con-
cerns are common problems,1 with as many as 20% of
IANBs reported to result in ineffective anaesthesia.2 It
has been suggested that many of these failures are
associated with vascular damage and ⁄ or variations in
the anatomical pattern of the relevant nerves and
surrounding fibrous tissue. This review examines pub-
lished research concerning the location, size and overall
relationships of structures in the pterygomandibular
space, and highlights the need for clinicians to have a
thorough understanding of the relevant anatomy so that
IANBs can be delivered as safely and as effectively as
possible. It builds on the excellent description of the
applied anatomy of the pterygomandibular space by
Barker and Davies,3 as well as a series of published
papers by Shields.4–6
112
The literature selected for this review has been limited
to work published in English from the 20th century
onwards. Standard anatomical textbooks as well as
keyword searches using the online PubMed database
have been used. PubMed search terms included most
anatomical terms relating to anatomy of the pterygo-
mandibular space, as well as local mandibular anaes-
thesia and its possible complications. Further relevant
papers were identified by examination of the reference
lists of the useful articles found. The aims of this review
are to summarize and critically evaluate the existing
literature on what is currently known about the
contents and relationships of structures in the pterygo-
mandibular space, including the inferior alveolar nerve
(IAN), vein and artery and the sphenomandibular
ligament.
General anatomy of the pterygomandibular space
The pterygomandibular space is a small fascial-lined cleft
containing mostly loose areolar tissue.5 It is bounded
medially and inferiorly by the medial pterygoid muscle7
and laterally by the medial surface of the mandibular
ª 2011 Australian Dental Association

Fig 1. Diagrammatic representation of a transverse section of the
right mandibular ramus at the level at which an IANB would be given.
(M = masseter; R = ramus; IAN = inferior alveolar nerve; IAV =
inferior alveolar vein; IAA = inferior alveolar artery; SML =
sphenomandibular ligament; MP = medial pterygoid muscle; LN =
lingual nerve; B = buccinator; PMR = pterygomandibular raphe;
SCM = superior constrictor muscle; P = parotid gland; TT = tendon
of temporalis; L = lingula). The needle is shown passing through the
buccinator muscle, B, and into the pterygomandibular space where it
is directed to an area of bone just superior to the lingula, L. The IAN,
IAV and IAA are wrapped together by a fibrous sheath, in a
neurovascular bundle, which occupies a spooned-out depression on
the medial surface of the ramus. The LN is located anterior and medial
to the IAN.
ramus. Posteriorly, parotid glandular tissue curves
medially around the back of the mandibular ramus
to form a posterior border, while anteriorly the bucci-
nator and superior constrictor muscles come together
to form a fibrous junction, the pterygomandibular
raphe. Of particular importance to local anaesthesia,
the pterygomandibular space contains the IAN,
artery and vein, the lingual nerve (LN), the nerve to
mylohyoid, the sphenomandibular ligament and fascia
(Fig 1).
Direct technique for the inferior alveolar nerve block
and its anatomical rationale
Numerous techniques have been suggested to obtain
mandibular anaesthesia. The direct approach, also
known as the direct thrust technique, remains one of
the most commonly used.1 In addition to this tech-
nique, other alternatives for anaesthetizing the IAN
include the indirect technique,8 the anterior injection
technique,9 the Gow-Gates method10 and the Akinosi-
Vazirani closed-mouth block approach.11,12 This re-
view will concentrate on the direct IANB, which is the
most frequently used technique in many parts of the
world, including Australia.
The direct IANB technique involves the insertion of a
needle into the pterygomandibular space by piercing the
ª 2011 Australian Dental Association
Applied anatomy of the pterygomandibular space
buccinator muscle. Once in the pterygomandibular
space, the aim of the technique is to deposit local
anaesthetic solution at a level just superior to the tip of
the lingula (Figs 1 and 2). Diffusion of local anaesthetic
solution from the needle tip to the IAN anaesthetizes the
nerve just prior to it entering the mandibular foramen.
The lingual nerve lies medial and anterior to the IAN
and it can be anaesthetized during an IANB. This is
achieved by withdrawing the needle and swinging the
barrel of the syringe toward the dental midline.
Several intraoral landmarks can be used to guide the
clinician when administering an IANB. Firstly, when
the mouth is wide open, the pterygotemporal depres-
sion represents the injection site. It is situated between
the raised ridge of mucosa overlying the pterygoman-
dibular raphe medially and the mucosa that overlies the
anterior border of the mandibular ramus laterally.
The intraoral landmark laterally is the ridge produced
by the tendon of temporalis and the medial landmark is
referred to as the pterygomandibular fold (Fig 3). The
level at which the needle should reach the bone just
superior to the lingula is indicated by the maximum
concavity on the anterior surface of the mandibular
ramus, an area known as the coronoid notch.1 An
alternate guideline for determining the correct height of
Fig 2. Photograph of a skull with simulated maximum opening of the
mouth. A string has been attached to indicate where the pterygo-
mandibular raphe would normally be located. This structure attaches
to the pterygoid hamulus superiorly and descends to the inner aspect
of the mandible near the most posterior molar. The pterygomandib-
ular fold refers to the fold of mucosal tissue that overlies the
pterygomandibular raphe and the needle should always be inserted
lateral to the fold. The barrel of the syringe usually needs to be
positioned over the contralateral premolars so that the needle tip can
contact bone just superior to the lingula at the appropriate depth of
needle insertion, approximately 20–25 mm in adults. The thumb or
another finger can be used to palpate the coronoid notch, as seen in the
photograph, to assist in establishing the correct height of needle
insertion. (L = lingula; PMR = pterygomandibular raphe;
H = pterygoid hamulus; CN = coronoid notch.)
113
JN Khoury et al.
Fig 3. Intraoral photograph of the right side of the oral cavity
showing key anatomical landmarks observed when giving an IANB.
The site for needle penetration is the pterygotemporal depression,
which is outlined. The needle travels through the oral mucosa and
underlying buccinator muscle before entering the pterygomandibular
space. The height is at the level of the coronoid notch, the most
concave region on the anterior border of the mandibular ramus.
Approximate depth of needle penetration required in most adult
patients is about 20–25 mm. (CN = coronoid notch; PTD =
pterygotemporal depression; PMF = pterygomandibular fold.)
entry for the IANB includes inserting the needle
approximately 1 cm above the lower occlusal plane
when the mouth is fully open.13 Other landmarks
include locating a level midway between the upper and
lower dental arches when the mouth is wide open and
visualizing the apex of the buccal pad of fibrous tissue
that forms an apex close to the pterygomandibular
fold.3 The buccal pad is a submucosal fibrous band
separating the buccinator muscle from the overlying
oral mucosa3 and it should not be confused with the
buccal pad of fat which is an area of adipose tissue
between the buccinator muscle and masseter muscle.
The appropriate horizontal angulation of the
syringe to enable the needle to reach bone without
damaging nearby structures varies between individuals.
The degree of ramal flaring, morphology of the internal
oblique ridge, morphology of the lingula, dental arch
shape and alignment of teeth can influence horizontal
needle angulation. Generally, as a guide, the syringe
barrel should be over the premolars on the contralateral
side.5 This angulation can be modified if bone has not
been contacted by the needle tip at an appropriate
insertion depth of around 20–25 mm.14 Once the
correct needle position and angulation have been
determined, the needle is then withdrawn one or two
millimetres and aspiration performed before injection.
Figure 4 shows the appearance of key intraoral land-
marks for an IANB in different individuals. In addition
to intraoral landmarks, some authors have emphasized
the importance of extraoral landmarks in evaluating
114
ideal needle placement and angulation, such as the
degree of ramal flaring and the height and width of the
mandibular ramus.5
Specific anatomical features of the pterygomandibular
space
Anatomical information regarding the general contents
and relationships of structures in the pterygomandibu-
lar space is relatively consistent in the literature,
providing a basic framework upon which the clinician
can reflect when administering an IANB. However, the
reporting of more specific details about the anatomy of
the pterygomandibular space lacks consistency and can
be confusing due to varying terminology in texts and
publications. The following sections highlight the
extent of variation in descriptions in the literature.
Medial surface of the mandibular ramus
The surface anatomy of the pterygomandibular space
shows predictable patterns which can guide the clini-
cian when administering IANBs. The medial surface of
the mandibular ramus exhibits a number of relevant
features for determining the required depth of needle
insertion. As the inferior alveolar neurovascular bundle
approaches the mandibular foramen, it lies lateral to
the sphenomandibular ligament in the confines of a
spooned-out depression on the medial aspect of the
ramus, referred to as the sulcus colli (Fig 5).3 Superi-
orly, the sulcus colli begins as a shallow depression but
it becomes progressively more pronounced as it travels
inferiorly until it eventually leads into the mandibular
foramen. Just anterior to the sulcus colli, on the medial
aspect of the ramus, is a crest of thickened bone
(Fig 5).3
It has been suggested that the IAN lies along the
anterior border of the sulcus colli for at least 10 mm
above the lingula.15 However, no research has been
published to verify this. If the nerve does descend via
this path, it may be partially protected from oncoming
needles by a crest of thickened bone which bulges
anteriorly in front of the nerve. Considering that the
ideal level of injection is just superior to the lingula, this
crest of thickened bone is the structure that the needle
tip should contact before withdrawal and aspiration.
This would allow for deposition of local anaesthetic in
close proximity to the IAN, yet ensuring the safety of
important structures from iatrogenic trauma. The IAN
is also guarded anteriorly by the lingula as it nears the
mandibular foramen (Fig 5). The lingula is a projection
of bone to which the sphenomandibular ligament
attaches and this structure can provide some protection
to the IAN from oncoming needles.4 In contrast, the LN
is quite bare with no bony protection, exposing it to an
increased risk of direct contact during needle insertion
ª 2011 Australian Dental Association
 Applied anatomy of the pterygomandibular space

Fig 4. Four representative intraoral photographs of the right side of the oral cavity showing the key intraoral landmarks observed and palpated
when administering an IANB. (CN = coronoid notch; PTD = pterygotemporal depression; PMF = pterygomandibular fold.) The dotted line
indicates the location of the PTD and the curved outline represents the level of the CN, which is the most concave area on the anterior border of the
ramus. CN can be palpated to assist in establishing correct height of needle penetration.

due to its anteromedial position to the IAN. It also

tends to be stretched when the mouth is wide open.
These characteristics may explain why the LN is more
likely to experience neurosensory disturbances follow-
ing an IANB than the IAN.
The ability to precisely position the needle close to
the IAN during an IANB hinges on a number of factors
and is generally difficult to evaluate while performing
the procedure. Variations in mandibular size and
shape, relative position of the mandibular foramen to
the lingula and the required depth of soft tissue
penetration add to the uncertainty about whether the
needle is close enough to the IAN to achieve adequate
anaesthesia.16

Fig 5. Medial surface of the right mandibular ramus showing some
landmarks relevant to IANBs. A crest of thickened bone lies slightly
superior to the lingula and it represents the area where needle contact
should be made on insertion, as it lies close to the inferior alveolar
neurovascular bundle but minimizes the risk of damage to structures
in the bundle. Although needle contact with the lingula may produce
satisfactory anaesthesia, it is likely that needle withdrawal after initial
bony contact will cause local anaesthetic solution to be deposited
medial to the sphenomandibular ligament and, hence, reduce its
effectiveness. (CN = coronoid notch; Li = lingula; SC = sulcus colli;
GNM = groove for nerve to mylohyoid; CB = crest of thickened
bone; MN = mandibular notch.)
ª 2011 Australian Dental Association
Fascial relationships
The pterygomandibular space is a cleft, lined at its
anterior, posterior, superior, inferior and medial
boundaries by various fasciae.3 The medial wall of the
space is covered by the interpterygoid fascia (Fig 6)
which lies on the lateral surface of the medial pterygoid
muscle.4 This fascia has a complex shape as it attaches
superiorly to the base of the skull and lines the medial
surface of the lateral pterygoid muscle, then descends
onto the medial surface of the ramus, attaching to it just
superior to the insertion of the medial pterygoid
muscle.3 Posteriorly, the interpterygoid fascia bridges
the gap between the two pterygoid muscles, involving
attachment of the fascia to the entire posterior border
of the mandibular ramus all the way up to the level of
115
JN Khoury et al.

nature and structure of fascia within the region

represents a gap in current anatomical knowledge.
There is a very close relationship between the
sphenomandibular and stylomandibular ligaments and
the adjacent interpterygoid fascia, leading some to
suggest that the former may represent localized thick-
enings of the latter.3 Others have observed how the
sphenomandibular ligament can be separated in blunt
dissection from the adjacent fascia,18 leading them to
consider that they are separate structures, with the
interpterygoid fascia forming an intervening layer
between the sphenomandibular ligament and the
medial pterygoid muscle. To date, no histological
evaluation of these tissues has been published to
precisely specify the nature of this relationship.

Anatomy of the sphenomandibular ligament

The sphenomandibular ligament is a band of fibrous
tissue that connects the lingula on the mandible to the
spine of sphenoid on the skull base (Fig 7). The shape,
length, thickness and nature of attachment of this
ligament varies considerably between individuals. Garg
and Townsend18 dissected seven cadavers and found

Fig 6. Transverse section of the right mandibular ramus at the level of

the lingula showing the IAN located just behind the tip of the lingula,
anterior to the veins and artery. The thickening of the fibrous tissue
medial to the neurovascular bundle represents the sphenomandibular
ligament. During an IANB, the ideal position to deposit local
anaesthetic solution is just above the tip of the lingula, as it allows the
needle tip to be in close proximity to the nerve, without directly
contacting it and risking damage. (SML = sphenomandibular
ligament; IAN = inferior alveolar nerve; IAA = inferior alveolar
artery; IAV = inferior alveolar vein; L = lingula; IPF = interp-
terygoid fascia.)

the condylar neck.15 This fascia, sometimes referred to

as temporopterygoid fascia, becomes very thin anteri-
orly and forms the anterior boundary of the pterygo-
mandibular space by bridging the gap between the
anterior border of the medial pterygoid muscle and the
fascia overlying the tendinous insertions of the tempo-
ralis muscle. All these fascial linings closely adapt to the
structures that create the borders of the pterygoman-
dibular space (i.e. medial pterygoid muscle, parotid
gland). Their presence has been recognized as a
potential barrier to diffusion of local anaesthetic
Fig 7. Photograph of the pterygomandibular space on the left side
solution that is deposited outside this pouch-like from a medial view. The medial pterygoid muscle and tongue have
network, thus increasing the probability of inadequate been removed to expose the fibrous tissue that forms the
anaesthesia.3,9,17 sphenomandibular ligament and associated fascia. A needle has been
inserted through the buccinator muscle and into the pterygomandib-
The structure and attachments of fascia in the ular space to indicate where an IANB would be administered.
pterygomandibular space have been reported in numer- Note that the mouth is closed, which would not be the case when
ous publications but no methodology or sampling a direct IANB is given to a patient. (LN = lingual nerve; P = palate;
PH = pterygoid hamulus; LPP = lateral pterygoid plate; SML =
characteristics have been provided to indicate how sphenomandibular ligament; NM = nerve to mylohyoid; R = ramus;
such descriptions were generated. Hence, the true 36 = lower left first molar.)

116 ª 2011 Australian Dental Association


that the sphenomandibular ligament ranged in shape
from a thin band that descended for a short distance
from the spine of the sphenoid to a broad bi-concave
ligament with prominent insertions. Similarly, Shiozaki
et al.19 observed considerable variation in 40 Japanese
cadavers, with some sphenomandibular ligaments
attaching to the medial aspect of the mandibular ramus
anterior and posterior to the lingula, in addition to their
direct attachment to this structure.
Due to its density and shape, the sphenomandibular
ligament has the potential to impede diffusion of local
anaesthetic solution to the IAN if the tip of the needle is
placed too far medially in relation to the ligament.3
In vivo diffusion studies involving radiographic analysis
of local anaesthetics mixed with contrasting medium
have found that local anaesthetic solution diffuses
easily through the loose connective tissue of the
pterygomandibular space if it is introduced directly
into the space.9,17 However, deposition of local anaes-
thetic in a location where it is separated from the IAN
by the sphenomandibular ligament or other fibrous
tissue may impede diffusion. The direct IANB technique
has been illustrated and described as involving insertion
of the needle until it comes into contact with the
lingula. Some anatomical studies have found cases
where the ligament attaches to the superior border of
the lingula.18 This may increase the possibility that the
needle tip could arrive at a position that is medial to the
ligament, especially if bony contact of the needle tip is
at, medial or inferior to the apex of the lingula. In such
cases, diffusion of local anaesthetic would need to occur
through the ligament or around it to produce its desired
effect. To avoid this, it is recommended that the level of
needle contact with bone should be slightly superior to
the lingula.
Accessory innervation from the nerve to mylohyoid
The nerve to mylohyoid is primarily motor in nature,
but it may contain a sensory component that innervates
mandibular teeth20–23 which may be relevant when
attempting an IANB. As the posterior division of the
mandibular nerve descends and approaches the man-
dibular foramen, it gives off the nerve to mylohyoid
which often follows an antero-inferior course on the
medial aspect of the mandibular ramus.23 In some
cases, however, part of the course of this nerve may
involve an intra-osseous component.24,25 Anatomical
variabilities such as this, or variation in the height at
which the nerve to mylohyoid branches off the IAN,
may ultimately influence whether this nerve is anaes-
thetized during an IANB. This is relevant for local
anaesthesia as the nerve to mylohyoid can provide
accessory innervation to mandibular teeth.20–23,26 It has
also been reported to innervate the chin and tip of the
tongue in some individuals.27 Bennett and Townsend28
ª 2011 Australian Dental Association
Applied anatomy of the pterygomandibular space
when analysing six human cadavers reported that the
average distance between the mandibular foramen and
the branching point of the nerve to mylohyoid was
13.4 mm, ranging from 3.9 to 27.0 mm, while Wilson
et al.22 reported after observing 37 human cadavers an
average branching distance of 14.7 mm, ranging from
5.0 to 23.0 mm above the mandibular foramen.
The dental relevance of these observations is that the
greater the distance between the point at which
the nerve to mylohyoid branches off the IAN and the
location where the local anaesthetic solution is depos-
ited, the greater the likelihood that the nerve to
mylohyoid may not be fully anaesthetized, leading to
potential failure in achieving anaesthesia.
In addition to the height of the branching point, there
may be physical barriers that separate the nerve to
mylohyoid from the area where local anaesthetic
solution is deposited during an IANB. The nerve to
mylohyoid travels behind the sphenomandibular liga-
ment at its attachment to the lingula.18 Consequently,
the density and shape of this structure may prevent
effective diffusion of local anaesthetic during an IANB.
Similarly, if part of the course of the nerve to
mylohyoid is encompassed by bone, which has been
reported in the literature, then this will also act as a
potential barrier.29
Relationship of structures within the inferior alveolar
neurovascular bundle
Typically, major nerves and their branches are accom-
panied by an artery and vein. This is also true for the
nerves within the pterygomandibular space, such as the
IAN.30 Anatomical descriptions of the pterygomandib-
ular space have been published but accounts often
neglect to mention how the IAN and associated blood
vessels are arranged within their neurovascular bundle.
Of the few descriptions reported, a number of patterns
have been identified, but they lack consistency and in
some cases are directly conflicting. These reports also
do not provide a standardized height in the supero-
inferior plane at which these structural relationships
were analysed, leading to possible variations in the
descriptions as the IAN, inferior alveolar artery (IAA)
and inferior alveolar vein (IAV) arise from different
regions within the infratemporal fossa before converg-
ing inferiorly to form a neurovascular bundle.
The presence of an IAN, IAA and IAV are not
disputed, providing an important and essential neuro-
vascular supply to the mandibular teeth. The IAA arises
from the maxillary artery which branches off the
external carotid artery in the vicinity of the mandibular
condylar neck.3 As it travels inferiorly, it assumes a
path close to the IAN. The degree to which the IAA
transverses the pterygomandibular space from its origin
to its eventual path alongside the IAN depends on
117
JN Khoury et al.
whether the maxillary artery follows a path that is
superficial or deep to the lateral pterygoid muscle.
Independent of this, the IAV exits the mandibular
foramen, acting as a tributary to the pterygoid venous
plexus (PVP) which is closely associated with the lateral
pterygoid muscle. The specifics of exactly how each of
these structures (IAN, IAA and IAV) interact together
along their path toward the mandibular foramen have
not been described clearly. Barker and Davies3 sug-
gested that the IAN is relatively anterior while the
inferior alveolar vasculature is more posterior, with the
IAV being closest to the bone. Their explanation for
this arrangement relates to the path taken by these
structures from their origin superiorly to the mandib-
ular foramen inferiorly. For example, the IAN and
lingual nerves separate from each other on the deep
surface of the lateral pterygoid muscle where they each
enter the pterygomandibular space along the lateral
surface of the medial pterygoid muscle, and this is
relatively more anterior than where the IAV feeds into
the PVP.3 Similarly, Sicher and Dubrul8 and Murphy
and Grundy14 reported that the inferior alveolar
vasculature was generally placed more lateroposteriorly
and closer to the bone than the nerve, which was
always located more anteriorly. However, it is impor-
tant to note that neither of these publications provide
information on sampling methods or sample size.
There are numerous other reports that agree with the
observations of Murphy and Grundy,14 Barker and
Davies,3 and Sicher and Dubrul.8 However, when most
authors make reference to or illustrate the relationships
of the IAN, IAA and IAV, the inferior alveolar vessels
are coupled together.7,13,15,20,30–32 In each of these
examples, the IAN is always represented as being
anterior to the blood vessels. Hence, while these
descriptions may be consistent with earlier reports,
they are less specific and provide no details about how
such information was obtained.
In contrast to the preceding reports, there have been
other descriptions of different relationships between the
IAN, IAA and IAV. For example, Wadu et al.33
suggested that the course of the IAN was closer to the
mandible, with the artery and vein being placed more
medially. Cousins and Bridenbaugh34 similarly sug-
gested that the IAN was closer to the mandible and
lateral to the IAA and IAV. Another variation in the
description of this relationship was an observation by
Malamed1 that the IAA was positioned more anteriorly
compared with the IAN. Roda and Blanton,35 though
maintaining that the IAA and IAV are very close to the
bone when compared to the IAN, reported a number of
possible relationships with their respective frequencies.
Although no descriptions of methodology or sampling
characteristics are provided, their review article sug-
gested that the IAN was anterior to the blood vessels in
70% of cases while in 20% of cases, the IAN was
118
medial to the blood vessels. The blood vessels were
anterior to the IAN in 10% of cases. A more recent
study involving 56 specimens has demonstrated similar
findings, with the inferior alveolar blood vessels tending
to be posterior, posterolateral or posteromedial to the
IAN in most cases.36 Figure 6 shows an example of a
typical arrangement of the IAN and associated vessels.
Potential anatomical causes for failure of anaesthesia
Anaesthetic failures occur frequently with IANBs, even
with experienced clinicians. There are many reasons
why this may occur. The two major factors being poor
operator technique and anatomical variation.16 Other
potential reasons for anaesthetic failure include psy-
chological issues where patient fears and anxieties lead
to either exaggerated or imagined pain and discomfort,
or where acute localized infections within the pterygo-
mandibular space or distal branches of the IAN reduce
the effectiveness of local anaesthetic.37
Apart from the nerve to mylohyoid, other nerves may
also provide accessory innervation to mandibular teeth,
potentially leading to failure of anaesthesia. Barker and
Lockett38 observed canals in the rami of mandibles
which led to the apices of lower posterior molars,
particularly third molars. Ossenberg39 suggested that
sensory nerves, most likely branches of the long buccal
nerve, may travel through many of these retromolar
foramina. As the long buccal nerve arises from the
anterior division of the mandibular nerve, direct IANBs
will not anaesthetize these branches. In these situations,
a Gow-Gates block may be used as local anaesthetic is
deposited in a much higher location within the
pterygomandibular space, where anaesthesia of the
IAN, lingual nerve and buccal nerves can be obtained
with a single injection.1 Tong40 has also reported a case
of a patient who presented for removal of an impacted
lower molar in whom the great auricular nerve, a
branch of the cervical plexus, appeared to provide
additional innervation to the region around the angle of
the mandible.
Bifid mandibular canals have the potential to increase
the difficulty of achieving adequate anaesthesia using
the IANB technique.1,16 Embryologically, the develop-
ment of mandibular bone through intramembranous
ossification occurs around the IAN. Consequently,
alterations in the anatomy of this nerve and ⁄ or its
communications with other nerves will be reflected in
mandibular bony development.16 The prevalence of this
anatomical variation varies between 0.35%41 to almost
1% of the population.42 Usually diagnosed by a
panoramic radiograph, there are a number of different
patterns that may present. The type suggested to be the
most problematic for IANBs is where there are two
independent mandibular foramina with a portion of
the IAN entering both simultaneously.1 This form of
ª 2011 Australian Dental Association

variation is also known as a Type 4 bifid canal
according to the classification outlined by Langlais
et al.42
Mandibular prognathism is another anatomical var-
iation that can complicate IANBs. Prognathic mandibles
generally have a lingula that is positioned higher than
the coronoid notch, making it more difficult for the
operator to insert the needle at the correct height.15 The
difference in height between the lingula and coronoid
notch may be as much as 1 cm. In these cases, needle
insertion above normal is indicated.
The effects of needle deflection during insertion into
the pterygomandibular space have been suggested to
lead to reduced effectiveness of IANBs.43 The degree to
which a needle deflects relates to the density of the
medium through which it is inserted, the gauge of
the needle44 and the nature and degree of taper of the
needle’s bevel.1 Many studies to date have been
conducted to evaluate these effects in an attempt
to determine whether they are clinically significant.
In vitro studies have shown that needles have a
tendency to deflect toward the non-bevelled side during
insertion into media of homogenous density.44–46 This
has led some to suggest that the bevel should be
orientated away from the ramus to guide the needle
toward the bone on insertion, thus reducing the
likelihood of over-insertion of the needle.45 However,
in vivo research has found no significant differences
between the effectiveness of direct IANBs when admin-
istered with the bevel away from the ramus compared
with the bevel toward the bone.47 Anatomically, the
density of the tissue within the pterygomandibular
space is mostly loose areolar tissue, which lacks dense
fibrous elements.5 Hence, if an IANB is executed
correctly, it is likely that needle deflection would be
minimal, especially with needles of larger diameter.
More recently, a new technique of needle insertion
has been suggested which involves rotating the needle
while it is inserted.48 This is in an attempt to negate any
potential needle deflection by preventing the needle’s
bevel from being on any particular side for the duration
of needle insertion.48 In vitro research has indicated
that this method can reduce deflection.43 However, an
in vivo study has not shown this technique to be
clinically superior with respect to the level of anaesthe-
sia attained in individuals with irreversible pulpitis.49
Further research is required to more accurately assess
whether this technique has clinical advantages.
Failure of anaesthesia can prove challenging for the
clinician to understand. If an IANB has failed, it is
essential that the operator carefully evaluates his ⁄ her
technique as well as common anatomical variations to
determine what may have contributed to the problem.
If the cause(s) are not accurately identified, this may
lead to multiple IANBs that continue to fail. Not only
does this damage more tissue than necessary, placing
ª 2011 Australian Dental Association
Applied anatomy of the pterygomandibular space
the patient at increased risk of trismus, but it may
reduce patient confidence in the operator’s abilities and
reinforce negative stereotypes of oral health profession-
als.
Research methods and their relative usefulness
Gross dissection has been the most common method of
examining the pterygomandibular space and it provides
arguably the most useful insights into how soft tissue
structures relate to the osteology of the skull in three
dimensions. Anatomical studies of the sphenomandib-
ular ligament and relationships of the IAN to the IAA
and IAV(s) are often conducted in this way. Advantages
of gross dissection are that it allows for qualitative
analysis of how structures relate to each other as they
travel supero-inferiorly, anteroposteriorly and medio-
laterally. Clear weaknesses of this approach are that it
disturbs superficial structures in the area of interest, it
may distort the exact relationships of nerves and their
related blood vessels, it cannot be performed on living
subjects, and it does not lend itself to quantitative
analysis.
Transverse sectioning of anatomical material can also
be performed and provide useful data. Such transverse
sections can be viewed macroscopically or prepared for
histological interpretation. Advantages of this approach
are that it does not disturb the anatomical patterns in a
transverse plane, thus making it ideal for analysing the
relationships of the IAN to the IAA and IAV. Similarly,
if histological sections are prepared, they provide much
greater detail regarding the structures depicted, such as
the number of IAVs and the number of IAN fascicules
and the nature of connective tissues. Also, quantitative
analyses can be performed when anatomical material is
prepared using this method, such as determining precise
distances between specific structures. A disadvantage is
that this method does not provide a three-dimensional
view of structures.
Osteological features of the mandible have been
studied on numerous occasions using both qualitative
and quantitative approaches in various populations.
Although there are obvious limitations in what can be
extrapolated from osteological research, these studies
are powerful and involve large sample sizes, in some
cases over 300 specimens.13 As IANBs require recog-
nition of bony landmarks as part of the execution of the
technique, osteological studies can provide useful data
regarding how mandibular anaesthesia could be made
more effective. They also provide insights into why
IANBs may fail sometimes, such as due to nerves
travelling in accessory foramina.
Radiographic and computerized tomographic (CT)
methods have also been used to analyse the pterygo-
mandibular space.9,17 Radiographs involve a two-
dimensional representation of three-dimensional
119
JN Khoury et al.
structures, thus making them useful in identifying bony
relationships in a plane that is perpendicular to the
X-ray source. Panoramic radiographs have been used to
identify bifid inferior alveolar canals and these studies
are extensive, involving retrospective analysis of
thousands of radiographs.41 Radiographs have also
been used to follow the diffusion patterns of local
anaesthetic mixed with radiopaque contrasting media
when administered as IANBs.17 More recently, CT
imaging has been used to analyse the dynamics of local
anaesthetic diffusion.9 This research has included
acceptable sample sizes but more of these studies are
needed to add to what is currently known about
diffusion paths in the pterygomandibular space.
SUMMARY AND CLINICAL TIPS
Just as an understanding of the basic anatomy of the
pterygomandibular space promotes safe and effective
anaesthesia, improved knowledge about less explored
regions and relationships should make the administra-
tion of IANBs even safer and more effective. Consid-
ering that this is the main technique for achieving
mandibular anaesthesia in many parts of the world, it is
essential that clinicians are familiar with the relevant
anatomy and understand how anatomical variations
can lead to anaesthetic failures.
Based on this review of the anatomy of the pterygo-
mandibular space, three key points underpin the basis
of a successful IANB technique: (1) the rationale of the
direct IANB is based on being able to reliably position
the needle tip above the tip of the lingula by paying
attention to the entry point, the level of injection and
the angulation of the syringe. The entry point is the
pterygotemporal depression located between the
pterygomandibular fold medially and the coronoid
notch laterally. Placing a cotton bud onto the pterygo-
temporal depression can assist in defining this structure
as the tissue in this area is less dense than the structures
on either side; (2) the level of injection can be gauged
by palpating the coronoid notch, and also keeping the
needle parallel to and about 1 cm above the lower
occlusal plane. The syringe should be angulated over
the premolar teeth on the contralateral side, but
angulation will vary from patient to patient according
to various anatomical factors; and (3) bone should
always be contacted with a direct IANB at the
appropriate depth of approximately 20–25 mm. Fol-
lowing this, the needle should be withdrawn 1–2 mm
and aspiration performed prior to injection.
ACKNOWLEDGEMENTS
This review has arisen from research funded by the
Australian Dental Research Foundation. The assistance
of the Discipline of Anatomy and Pathology, The
120
University of Adelaide, and Victor Marino, School of
Dentistry, The University of Adelaide, is greatly appre-
ciated. The dissection shown in Fig 7 was performed by
Dr Zac Morse.
REFERENCES
1. Malamed S. Handbook of local anesthesia. 5th edn. St Louis:
Mosby, 2004.
2. Kaufman E, Weinstein P, Milogram P. Difficulties in achieving
local anesthesia. J Am Dent Assoc 1984;108:205–208.
3. Barker BC, Davies PL. The applied anatomy of the pterygo-
mandibular space. Br J Oral Surg 1972;10:43–55.
4. Shields PW. Mandibular anaesthesia. Aust Dent J 1970;15:428–
432.
5. Shields PW. Further observations on mandibular anaesthesia.
Aust Dent J 1977;22:334–337.
6. Shields PW. Local anaesthesia and applied anatomy. Aust Dent J
1986;31:319–325.
7. Huelke D. Selected dissections of the facial regions for advanced
dental students. 6th edn. Ann Arbor: Overbeck Co, 1973.
8. Sicher H, DuBrul EL. Oral anatomy. 6th edn. St Louis: CV
Mosby Company, 1975.
9. Takasugi Y, Furuya H, Moriya K, Okamoto Y. Clinical evalua-
tion of inferior alveolar nerve block by injection into the
pterygomandibular space anterior to the mandibular foramen.
Anesth Prog 2000;47:125–129.
10. Gow-Gates G. Mandibular conduction anesthesia: a new tech-
nique using extra-oral landmarks. Oral Surg 1973;36:321–328.
11. Akinosi JO. A new approach to the mandibular nerve block. Br J
Oral Surg 1977;15:83–87.
12. Vazirani SJ. Closed mouth mandibular nerve block: a new tech-
nique. Dent Dig 1960;66:10–13.
13. Bremer G. Measurements of special significance in connection
with anesthesia of the inferior alveolar nerve. Oral Surg Oral Med
Oral Pathol 1952;5:966–988.
14. Murphy T, Grundy E. The inferior alveolar neurovascular bundle
at the mandibular foramen. Dent Pract Dent Rec 1969;20:41–48.
15. Jorgensen N, Hayden J. Premedication, local and general anes-
thesia in dentistry. Philadelphia: Lea & Febiger, 1967.
16. Lew K, Townsend G. Failure to obtain adequate anaesthesia
associated with a bifid mandibular canal: a case report. Aust Dent
J 2006;51:86–90.
17. Berns J, Sadove M. Mandibular block injection: a method of
study using an injected radiopaque material. J Am Dent Assoc
1962;65:735–745.
18. Garg A, Townsend G. Anatomical variation of the sphenoman-
dibular ligament. Aust Endod J 2001;27:22–24.
19. Shiozaki H, Abe S, Tsumori N, Shiozaki K, Kaneko Y, Ichinohe
T. Macroscopic anatomy of the sphenomandibular ligament re-
lated to the inferior alveolar nerve block. Cranio 2007;25:160–
165.
20. Sicher H. The anatomy of mandibular anesthesia. J Am Dent
Assoc 1946;33:1541–1557.
21. Frommer J, Mele F, Monroe C. The possible role of the
mylohyoid nerve in mandibular posterior tooth sensation. J Am
Dent Assoc 1972;85:113–117.
22. Wilson S, Johns P, Fuller PM. The inferior alveolar and my-
lohyoid nerves: an anatomic study and relationship to local
anesthesia of the anterior mandibular teeth. J Am Dent Assoc
1984;108:350–352.
23. Stein P, Brueckner J, Milliner M. Sensory innervation of man-
dibular teeth by the nerve to the mylohyoid: implications in local
anesthesia. Clin Anat 2007;20:591–595.
ª 2011 Australian Dental Association

24. Arensburg B, Nathan H. Anatomical observations on the
mylohyoid groove, and the course of the mylohyoid nerve and
vessels. J Oral Surg 1979;37:93–96.
25. Jidoi K, Nara T, Dodo Y. Bony bridging of the mylohyoid groove
of the human mandible. Anthrop Sci 2000;108:345–370.
26. Madeira MC, Percinoto C, das Gracas M, Silva M. Clinical sig-
nificance of supplementary innervation of the lower incisor teeth:
a dissection study of the mylohyoid nerve. Oral Surg Oral Med
Oral Pathol 1978;46:608–614.
27. Tier G, Rees R, Rood J. The sensory nerve supply to the tongue: a
clinical reappraisal. Br Dent J 1984;157:354–357.
28. Bennett S, Townsend G. Distribution of the mylohyoid nerve:
anatomical variability and clinical implications. Aust Endod J
2001;27:109–111.
29. Barker BC. Anatomy of the hard and soft tissues of the oral
cavity. Ann Aust Coll Dent Surg 1969;2:22–38.
30. Harn SD, Durham T. Anatomical variations and clinical impli-
cations of the artery to the lingual nerve. Clin Anat 2003;16:294–
299.
31. Harn SD, Shackelford L. Further evaluation of the superficial and
deep tendons of the human temporalis muscle. Anat Rec
1982;202:537–548.
32. Marks RB, Carlton DM, McDonald S. Management of a broken
needle in the pterygomandibular space: report of case. J Am Dent
Assoc 1984;109:263–264.
33. Wadu SG, Penhall B, Townsend GC. Morphological variability of
the human inferior alveolar nerve. Clin Anat 1997;10:82–87.
34. Cousins M, Bridenbaugh P. Neural blockade in clinical anesthesia
and management of pain. 3rd edn. Philadelphia: Lippincott-
Raven, 1998.
35. Roda RS, Blanton PL. The anatomy of local anesthesia. Quin-
tessence Int 1994;25:27–38.
36. Khoury J, Mihailidis S, Ghabriel M, Townsend G. Anatomi-
cal relationships within the human pterygomandibular
space: relevance to local anesthesia. Clin Anat 2010;23:936–
944.
37. Meechan J. How to overcome failed anaesthesia. Br Dent J
1999;186:15–20.
38. Barker BC, Lockett BC. Multiple canals in the rami of a
mandible. Oral Surg Oral Med Oral Pathol 1972;34:384–
389.
ª 2011 Australian Dental Association
Applied anatomy of the pterygomandibular space
39. Ossenberg NS. Retromolar foramen of the human mandible. Am
J Phys Anthropol 1987;73:119–128.
40. Tong DC. The great auricular nerve: a case report and review of
anatomy. N Z Dent J 2000;96:57.
41. Sanchis J, Peñarrocha M, Soler F. Bifid mandibular canal. J Oral
Maxillofac Surg 2003;61:422–424.
42. Langlais R, Broadus RJ, Glass B. Bifid mandibular canals
in panoramic radiographs. J Am Dent Assoc 1985;110:923–926.
43. Hochman MN, Friedman MJ. In vitro study of needle deflection:
a linear insertion technique versus a bidirectional rotation inser-
tion technique. Quintessence Int 2000;31:33–39.
44. Robison SF, Mayhew RB, Cowan RD, Hawley RJ. Comparative
study of deflection characteristics and fragility of 25-, 27-, and
30-gauge short dental needles. J Am Dent Assoc 1984;109:920–
924.
45. Davidson MJ. Bevel-oriented mandibular injections: needle
deflection can be beneficial. Gen Dent 1989;37:410–412.
46. Jeske AH, Boshart BF. Deflection of conventional versus
nondeflecting dental needles in vitro. Anesth Prog 1985;32:62–64.
47. Steinkruger G, Nusstein J, Reader A, Beck M, Weaver J. The
significance of needle bevel orientation in achieving a successful
inferior alveolar nerve block. J Am Dent Assoc 2006;137:1685–
1691.
48. Hochman MN, Friedman MJ. An in vitro study of needle force
penetration comparing a standard linear insertion to the new
bidirectional rotation insertion technique. Quintessence Int
2001;32:789–796.
49. Kennedy S, Reader A, Nusstein J, Beck M, Weaver J. The sig-
nificance of needle deflection in success of the inferior alveolar
nerve block in patients with irreversible pulpitis. J Endod
2003;29:630–633.
Address for correspondence:
Professor Grant C Townsend
School of Dentistry
The University of Adelaide
Adelaide SA 5005
Email: grant.townsend@adelaide.edu.au
121