Eur Arch Otorhinolaryngol (1999) 256 : 205–208
G E N E R A L O TO L A RY N G O L O G Y
J. Krmpotić-Nemanić · I. Vinter · J. Hat · D. Jalšovec
Mandibular neuralgia due to anatomical variations
Received: 7 July 1998 / Accepted: 16 July 1998
Abstract In our large collection of macerated human
adult skulls and disarticulated skulls of young individuals
we found cases with an extremely large lateral lamina of
the pterygoid process. The medial wall of the infratemporal
fossa was defined as its formation by the lateral lamina of
the pterygoid process and the medial pterygoid muscle.
The muscular part formed two-thirds and the lateral lamina
one-third of this wall. In cases of a very large lateral lam-
ina in our specimens nearly the whole medial wall was os-
seous. The third portion of the trigeminal nerve gives off
the lingual nerve and alveolar mandibular nerve in the re-
gion of the infratemporal fossa. These two nerves generally
passed between the lateral and medial pterygoid muscles to
their terminal sites. In cases of extremely large lateral lam-
inae the nerves had to make a curve in their course, follow-
ing the shape of the enlarged lamina. During contraction of
the pterygoid muscles both nerves can be compressed.
Since the lingual nerve runs between muscular elements,
tension and compression is probably avoided. In contrast,
the mandibular nerve fixed between the oval and mandibu-
lar foramina cannot avoid tension and compression. The
result is possible pain, especially during chewing, and may
finally create a trigeminal neuralgia. Similar symptoms
could be provoked by a foramen pterygospinale or ovalis
canal replacing the foramen ovale.
Key words Facial pain · Trigeminal neuralgia ·
Anatomic variations of the skull · Lateral lamina of the
pterygoid process · Foramen pterygospinale · Spina of
the sphenoidal bone
Introduction
Trigeminal neuralgia is a symptom evoked by various fac-
tors inclusive of inflammation of the paranasal sinuses,
J. Krmpotić-Nemanić (쾷) · I. Vinter · J. Hat · D. Jalšovec
Anatomy Department “Drago Perović”, Medical Faculty Zagreb,
Šalata 11, Box 916, HR-10000 Zagreb, Croatia
© Springer-Verlag 1999
viral infections, dental disease, vascular compression and
certain tumors [1–5]. There exist, however, genuine cases
in which the cause cannot be defined. Involvement in gen-
eral affects the second and third divisions of the trigemi-
nal nerve.
Our present investigations were devised to examine
possible genuine anatomic cause of mandibular neuralgia.
In our large collection of macerated skulls we found cases
with extremely large lateral laminae of the pterygoid
process, as well as rare cases with foramen pterygospinale
and other specimens with an ovalis canal. In all these
cases the mandibular nerve could be compressed during
life, resulting in mandibular neuralgia.
Material and methods
In l00 skulls of adults (ranging from 18–95 years of premortem
age) we measured the width of the lateral lamina of the pterygoid
process at the level of the pterygospinous process, as well as the
distance of the pterygospinous process to the spina of the sphenoid
bone (Fig. 1). In 20 isolated macerated sphenoid bones varying
from 5 to 17 year of age before death we examined the increase in
width of the lateral lamina. We also paid attention to the possible
existence of a foramen pterygospinale and/or ovalis canal. CT
imaging (with a Schimadzu SCT 408005 in an oblique projection)
was used to demonstrate the possibilities for diagnosing features of
the lateral lamina.
Results
The lateral lamina of the pterygoid process together with
the medial pterygoid muscle was seen to form the medial
wall of the infratemporal fossa. The relation of the os-
seous to the muscular part was in general 1 : 3. In case of
a very large lateral lamina or in case of the existence of a
foramen pterygospinale the medial wall of the infratem-
poral fossa was nearly completely osseous (Figs. 2A, B, 3).
In specimens from young individuals (5–17 years of
age) the width of the lateral lamina varied in the region of
pterygospinosus process from 5 to 17 mm (Table 1). In
one case only the width of the lateral lamina was 20 mm.
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A B
1 2

Fig. 1 Schematic drawing displaying the distances measured in

the specimens examined. A Width of the lateral lamina of the
pterygoid process at the level of the processus pterygospinosus. B
Distance of the pterygospinous process to the spine of the sphenoid
bone
Fig. 2 Schematic drawing of the posterior view of the infratempo-
ral fossa A in cases of average width of the lateral lamina and B in
the case of a very large lateral lamina (1). Also shown are the lin-
gual nerve (2), the alveolar mandibular nerve (3), the medial ptery-
goid muscle (4) and lateral pterygoid muscle (5)
Fig. 3 Schematic drawing of the right infratemporal fossa to show
a very large lateral lamina (1), lingual nerve (2) and alveolar 3
mandibular nerve (3)

Table 1 Width of the lateral

lamina of the pterygoid process Age Young individuals Adults
at the level of pterygospinous (5–17 years of age) (18–95 years of age)
process and the distance be-
tween the pterygospinous Left Right Left + right Left Right Left + right
process and spina of the sphe-
noid bone Width of lateral
lamina (in mm) 6–16 5–17 5–17 10–23 10–24 10–24
–
x 11.05 11.70 11.38 17.01 16.67 16.83
SD 3.09 3.56 3.30 2.84 3.28 3.08
Distance between
pterygosp. process
and spina (in mm) 11–20 8–20 8–20 9–23 11–20 9–23

4A
5 6A
6B
Fig. 4 A Extremely large right lateral lamina (l) in a 76-year-old
woman. The width of the lamina was 32 mm. B CT imaging of the
same specimen in an oblique projection
Fig. 5 Long sphenoidal spine in a 72-year-old man
Fig. 6 A Right infratemporal fossa of a 70-year-old man displaying a
large lateral lamina (l) and the foramen pterygospinale (fp) as result of
ossification of the ligamentum pterygospinale of Civinini. Also shown
is an ovalis canal (co). B Left infratemporal fossa in the same speci-
men, displaying also a large lateral lamina (l) and the pterygospinale
foramen (fp). C CT imaging of the same specimen as the right side.
The ovalis canal (co) and pterygospinale foramen (fp) are shown
207
4B
6C
The width of the lateral lamina varied in adults from 10 to
24 mm. In 5 of the l00 skulls investigated we found an ex-
tremely large lamina ( 24–32 mm). The appearance of the
large lateral lamina was in general unilateral. In a single
case a large lateral lamina was found on both sides of the
skull. The distance between the pterygospinous process
and spine of the sphenoid bone varied from 8 to 20 mm in
the bones from the young individuals, while the same dis-
tance was similar in the older individuals (ranging from
9 to 23 mm). As shown in Fig. 4, the distance between the
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Fig. 7 Left pterygospinal foramen and a large lateral lamina in a
73-year-old man
pterygospinous process and the sphenoid spine was re-
duced in the presence of a very long spine. The ptery-
gospinous process was very small or missing in 29 cases
in adults and in two cases in young individuals.
The pterygospinous process was connected with the
angular spine of the sphenoid bone by pterygospinale lig-
ament. The final phase in the ossification of the ligament
was the appearance of the pterygospinale foramen. The
pterygoid nerve and artery ran through this foramen. The
medial wall of the infratemporal fossa in cases with the
pterygospinale foramen was completely osseous except
for the foramen itself (Fig. 5). A pterygospinale foramen
was found in five adult specimens. In two of these cases
the foramen was bilateral (Fig. 6 A–C). In specimens from
the younger individuals the pterygospinale foramen could
not be found.
In two of the adult skulls examined an ovalis canal was
found instead of a foramen ovale. The length of this canal
was 6 mm, while its anteroposterior width was 2 mm.
Discussion
The third division of the trigeminal nerve gives off its two
main branches at the level of the foramen ovale: the lin-
gual nerve and inferior alveolar (mandibular) nerve. Both
branches run in their course between the two pterygoid
muscles to their destination. The lingual nerve embedded
in soft muscular tissue is not exposed to tension or com-
pression. The mandibular nerve, which is fixed in its
course between the foramen ovale and mandibular fora-
men, has to cross the enlarged lateral lamina of the ptery-
goid process or the ossified pterygospinal ligaments at the
foramen pterygospinale [6]. With contraction of the ptery-
goid muscles, the nerve can be entrapped between the
bone and the muscles. This tension and compression may
result in pain in the region supplied by the nerve. So-
called true mandibular neuralgia might be the result of
this tension and compression. Additionally, the nerve can
be compressed within a long and narrow ovalis canal In
such cases adequate CT imaging defines the shape of the
medial wall of the infratemporal fossa, as well as shows
the existence of an ovalis canal.
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