DSP2

Infratemporal fossa including mandibular nerve

(based on previous materials prepared by Prof Townsend)
Dr S Ranjitkar [BDS, BScDent(Hons), PhD]
Senior Lecturer

Adelaide Dental School

University of Adelaide

Labels
Artery = solid red
vein = solid sky blue
nerve: sensory = solid yellow and motor = dotted yellow
muscle = solid green
other structures (including outlines) = solid purple or brown
 Learning outcomes
Apply the knowledge of the anatomy of the infratemporal fossa to the two scenarios provided in Chapter 5 of
“Learning Anatomy applied to dentistry”.

Demonstrate the knowledge of various structures in the infratemporal fossa, including

- Venous system (pterygoid venous plexus and its associations with the cranial cavity, orbit and face)

- Arterial system (the branches of the maxillary artery, i.e. the “1st and 2nd parts of the maxillary artery” – note
the 3rd part extends into the pterygopalatine fossa and then to the nasal cavity, oral cavity and the orbit)

- Nervous system (the branches of the CN V(3), i.e. mandibular division of the trigeminal nerve; the
parasympathetic supply to the parotid salivary gland and the taste fibres from the lingual nerve)
[Note: sympathetic supply to the structures travel on arteries]

The applied anatomy of the pterygomandibular space –highly relevant to your local anaesthetic sessions

Demonstrate the knowledge of communications of the infratemporal fossa with the orbit, cranial cavity and face

Demonstrate the knowledge of the intraoral landmarks of Inferior Alveolar Nerve (IAN) block

Demonstrate understanding of the nerve and blood supply to the teeth and soft tissues
CHAPTER 5

PROFESSOR ALVEOLAR – HE KNOWS HIS

ANATOMY!

A retired university Professor of Anatomy, Professor Alveolar, has been referred to your practice for
extraction of a lower right second premolar that has a vertical root fracture. You explain to the
professor that you will need to give an inferior alveolar nerve (IAN) block and also anaesthetise his
lingual nerve. He is intrigued by the anatomical issues involved with the technique and asks you to
point out the relevant intra-oral landmarks in his mouth. He also wants you to explain the anatomical
rationale behind the IAN block technique, to show him where you will insert the needle and to
describe the path of the needle within the tissues. You give him an IAN block and also deposit 0.5ml
of LA on withdrawal. After 2-3 minutes he reports feeling numb but when you press the forceps down
on his 45 he screams out in pain and yells, “What’s going on!” Rather embarrassed, you tell him that
there are several possibilities and that you’ll need to gather some more information before you can be
sure. “I’ll be very interested to hear your explanation,” mutters the professor.

An intra-oral photograph accompanies this scenario you should try to label all the relevant intra-oral
landmarks for an IAN block injection on the image.
 IAN block:
Nerves – IAN + lingual
- Sufficient for most restorations
- Need to numb up (long) buccal nerve (CN V(3))
- Do not get confused with Bu branch of CN VII

Anatomical region of interest (in 3D space):

Pterygomandibular (PM) space

Entry point for IAN block:

Pterygotemporal depression (b/w PM raphe & coronoid notch
Height – b/w Mx and Mn planes when mouth is wide open
Angle: Opposite second premolars

Common problems (poor technique or anatomical variation):

Height too low – opening not wide enough/ jaw closing during LA admin / loss of orientation re lip covering Mn teeth
Lack of stretching cheek – cannot locate the pterygotemporal depression
Inadequate amount of LA – e.g. 0.5 carpule is not enough for IAN; need to administer at least 0.5 carpule for Bu nerve
Anatomical variations , e.g. presence of sphenomandibular ligament; not waiting long enough for LA to diffuse
“Infected areas are difficult to anaesthetise”.
 WARNINGS

Temporary blindness, and occasionally permanent blindness, are

rare but serious complications of IAN block administration!!!

Remember Maxillary artery!!

MUST ASPIRATE!

Facial nerve paralysis – usually temporary - can also be a

challenging, embarrassing and sometimes a serious complication!
Pterygomandibular raphe –
blue cord

Pterygoid Hamulus 
mylohyoid line behind the
mandibular 3rd molars
 DR TUBEROSE – COMPLICATIONS AFTER AN LA

Your first patient of the day is Dr Tuberose who is one of the local general medical practitioners. He
presents with toothache in the upper right molar region. After examining him, you decide to give a
posterior superior alveolar nerve block (tuberosity block) prior to treating the tooth. The doctor is very
interested in the LA procedure and asks you to describe the technique to him and indicate which
structures in his mouth will be anaesthetised. A few minutes after giving the LA, you notice a swelling on
the side of Dr Tuberose’s face that progresses downward and forward towards the lower anterior region of
his cheek. Dr Tuberose also notices that his vision has become blurred. He is very concerned by these
events and so are you. He wants to know what has happened and why.
 Infratemporal fossa: boundaries

Roof - the greater wing of the sphenoid bone and the temporal bone

Medial wall - the lateral pterygoid plate

Anterior wall - the posterior wall of the maxilla

Lateral wall - the medial aspect of the ramus of the mandible

There is no distinct inferior boundary.

Arterial and venous supply of the face
-from last class meeting

Baker (2015), p186, 187

Infratemporal fossa

Venous drainage in the Infratemporal

fossa & its communications

1. Pterygoid venous plexus

2. Maxillary vein
3. Superficial temporal vein
4. Retromandibular vein
5. Facial vein
6. Middle meningeal vein
7. Accessory meningeal vein
8. Opthalmic vein
9. Posterior superior alveolar vein
10. Inferior alveolar vein

Bleeding from pterygoid venous

plexus - haematoma
Infratemporal fossa
Arterial supply in the Infratemporal fossa

MAXILLARY ARTERY - branches

PART 1
1. Deep auricular
2. Anterior tympanic
3. Middle meningeal
4. Accessory meningeal
5. Inferior alveolar

PART 2
6. Deep temporal artery
7. Pterygoid
8. Masseteric
9. Buccal

PART 3
Around 8 branches in the
pterygopalatine fossa and orbits
- will be covered in future class meetings
Infratemporal fossa
Nerve supply in the Infratemporal fossa

MANDIBULAR NERVE – branches

Motor to masticatory muscles (1st branchial
arch; sensory to other structures)

MAIN TRUNK
1. Medial Pterygoid
2. Nervous spinosus
3. Otic ganglion (Parasympathetic)
4. Tensor palate + tensor tympani

ANTERIOR PART
5. Deep temporal
6. Nerve to masseter
7. Lateral pterygoid
8. Buccal

POSTERIOR PART
9. Auriculotemporal
10. Lingual
11. Inferior alveolar  nerve to mylohypoid
 Infratemporal fossa
Chorda tympani (VII)

Maxillary artery Upper head

of lateral pterygoid
Lower head
Inferior alveolar artery

Deep head
of medial pterygoid
Superficial head
Long buccal n.

Inferior alveolar n.
Lingual n.
 Ackland video

4.8.8 Cranial nerve V3

4.4.4 Muscles of mastication: pterygoid muscles
Anatomical variations: bifid mandibular nerves

Lew and Townsend (2006).

 Trifid mandibular canal

Recent honours findings by K Shah

Accessory innervation (distal to 47)

Recent honours findings by K Shah

 Anterior loop of the mental nerve

Iyengar et al. Detection of anterior loop and other patterns of entry of mental nerve into the mental
foramen: a radiographic study in panoramic images. Journal of Dental Implants 2013; 3: 21-25.
Pterygopalatine fossa (in preparation for the week after)

Maxillary n.

Infraorbital n.

Posterior Middle Anterior superior alveolar nerves

Pterygopalatine fossa (in preparation for the week after)

Nasopalatine n.

Greater palatine n.

Lesser palatine n.s

Self-directed learning: will be reviewed in class meetings for Pain Control
Self-directed learning: will be reviewed in class meetings for Pain Control