Beruflich Dokumente
Kultur Dokumente
REVIEW
doi: 10.1111/j.1834-7819.2011.01312.x
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
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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
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.
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 thickenings 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
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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 suggested 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 mandibular 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 important 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.7,13,15,20,3032 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 suggested 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 suggested that the IAN was anterior to the blood vessels in
70% of cases while in 20% of cases, the IAN was
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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 administration of IANBs even safer and more effective. Considering 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 pterygomandibular 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 pterygotemporal 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 2025 mm. Following this, the needle should be withdrawn 12 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
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