British Journal of Oral and Maxillofacial Surgery (2003) 41, 236–239

© 2003 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/S0266-4356(03)00113-X, available online at www.sciencedirect.com

Variations in the anatomy of the inferior alveolar nerve

A. Anıl, ∗ T. Peker, ∗ H. B. Turgut, ∗ I. N. Gülekon, ∗ F. Liman †

∗ Department of Anatomy, Faculty of Medicine, Gazi University, Beş evler-Ankara, Turkey;
†Tıp Fakültesi Caddesi 17/9 Cebeci-Ankara, Turkey

SUMMARY. Variations in the anatomy of the inferior alveolar nerve were seen in 2 of the 20 dissections of
the infratemporal fossa in 10 cadavers. A connecting nerve branch that originated from the auriculotemporal
nerve joined the inferior alveolar nerve on both sides. The second part of the maxillary artery passed between
the mandibular nerve, the root of the inferior alveolar nerve, and the connecting nerve branch which formed a
loop. The maxillary artery seemed to be entrapped. Neurovascular entrapment can cause pain and numbness.
Anatomical variations in this region should be kept in mind, particularly in cases of failed treatment of trigeminal
neuralgia.
© 2003 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Infratemporal fossa; Inferior alveolar nerve; Auriculotemporal nerve; Variation; Neurovascular
entrapment

INTRODUCTION MATERIAL AND METHODS

The infratemporal fossa is difficult to approach technically
for both anatomists and surgeons.1 It contains two mus-
cles of mastication, the maxillary vessels and the ramifica-
tion of the mandibular nerve.2 Variations in the branching
pattern or topographical relationships of the mandibular
nerve often account for failure to obtain adequate local
anaesthesia for routine oral and dental procedures, and
for the unexpected injury to branches of the nerve during
operations.3 In addition, variations in the course of the
mandibular nerve may be important for the microsurgical
anastomosis of damaged inferior alveolar nerves that oc-
cur as a result of the increase in the number of mandibu-
lar osteotomies and other reconstructive operations.3,4
Knowledge of the anatomy of the infratemporal fossa
is essential for the treatment of all lesions in this re-
gion.
Anatomical variations of the mandibular nerve and its
branches have been described by several authors.1,5–8 As
the anatomical variation in the inferior alveolar nerve was
bilateral in one of our cases, it was rare and worth com-
paring with previously reported studies. In addition, we
think that gathering information about the variation of
the mandibular nerve and the distribution of its nerve fi-
bres will enable us to design a treatment for intractable
pain.
236
During routine dissections of the infratemporal fossa in 10
cadavers, we found a variation in the anatomy of the infe-
rior alveolar nerve on both sides in a 75-year-old man. The
masseter and temporal muscles and ramus of the mandible
were removed to expose the infratemporal fossa. After re-
moving the lateral pterygoid muscle and pterygoid plexus,
the branches of the mandibular nerve were clearly visible
(Fig. 1). During the dissection an operating microscope
(Zeiss, Opmi-Pico, Oberkochen) was used. Longitudinal
sections from the branches of the mandibular nerve were
taken from the points noted in the illustration. The sections
were stained by Woelcke’s method9 and haematoxylin and
eosin for the myelin sheath (Fig. 2).
RESULTS
Variations in the anatomy of the inferior alveolar nerve
were found in 2 of the 20 dissections. The auriculotempo-
ral nerve emerged from the posterior root of the mandibu-
lar nerve and passed backwards. A connecting nerve
originated from the auriculotemporal nerve and joined
the inferior alveolar nerve on both sides. These two nerve
branches and the mandibular nerve formed a loop remi-
niscent of the brachial plexus, and the second part of the
 Variations in the anatomy of the inferior alveolar nerve 237

Fig. 1 Variation in the anatomy of the inferior alveolar nerve on the right side (a) and on the left (b); M: mandibular nerve; fo: foramen ovale; an:
auriculotemporal nerve; ma: maxillary artery; bn: buccal nerve; ln: lingual nerve; ian: inferior alveolar nerve; mn: mylohyoid nerve; ∗: root of the
inferior alveolar nerve; ∗∗: connecting branch originating from the auriculotemporal nerve and joining the inferior alveolar nerve.

Fig. 2 Diagram of the variation of the inferior alveolar nerve and photomicrographs of the branches of the mandibular nerve (Woelcke’s method and
haematoxylin and eosin stains for myelin sheath; original magnification × 40); M: mandibular nerve; fo: foramen ovale; an: auriculotemporal nerve;
ma: maxillary artery; ln: lingual nerve; ian: inferior alveolar nerve; mn: mylohyoid nerve; ∗: root of the inferior alveolar nerve; ∗∗: connecting nerve
branch originating from the auriculotemporal nerve joining the inferior alveolar nerve; →: thin myelin sheaths; : thick myelin sheaths.
238 British Journal of Oral and Maxillofacial Surgery
maxillary artery passed through the loop. At that site,
there was probably vascular entrapment of the maxillary
artery. The lingual and mylohyoid nerves followed a nor-
mal course (Fig. 1). Longitudinal microscopic sections
were taken from the branches of the mandibular nerve on
both sides to investigate the types and distribution of the
nerve fibres. Light microscopy showed the myelin sheaths
as thick dark bands which covered the axons, which
were unstained or stained only lightly; at intervals the
sheath was discontinuous and formed the nodes of Ran-
vier (Fig. 2). As for the thickness of the myelin sheaths
in the longitudinal sections, those of the nerve fibres in
the mylohyoid nerve were the thickest whereas those in
the lingual and inferior alveolar nerves were the thinnest.
The myelin sheaths of the fibres in the main trunk of
the inferior alveolar nerve and in the nerve branches,
the anatomy of which was variant, were both thick and
thin (Fig. 2).
DISCUSSION
Although there are many reports in the journals about
the anatomical variations of the mandibular nerve and its
branches,1,5–8 bilateral variation in the inferior alveolar
nerve is rare. Knowledge of the anatomical variations in
this region is important not only for adequate local anaes-
thesia but also important for dental, oncological and re-
constructive operations.
The third branch of the trigeminal nerve gives off the
nerve to the lateral pterygoid muscle, and the buccal, the
masseteric, deep temporal, auriculotemporal, lingual and
inferior alveolar nerves in the region of the infratemporal
fossa.10,11 The lingual and the inferior alveolar nerves
generally pass between the lateral and the medial ptery-
goid muscles to their terminal sites.2,10 However, the
mandibular nerve is fixed between the foramen ovale and
the mandibular foramen. The nerve can be compressed
as a result of both its course and its relation to the sur-
rounding structures, particularly when passing between
the medial and the lateral pterygoid muscles. When the
pterygoid muscles contract, both the inferior alveolar
nerve and the lingual nerve may be compressed. As the
lingual nerve runs between muscular elements, tension
and compression are probably avoided. The result is pain,
particularly during chewing; and it may eventually cause
trigeminal neuralgia.7,12
Racz and Maros1 reported four types of variations of
the lingual nerve; the first at the origin of the nerve, the sec-
ond at the point of ramification, the third at the branches
of the nerve and the fourth at the anastomosing branches
of the mylohyoid nerve. They reported that the most im-
portant variations of the lingual nerve were in the region
where the nerve originated from the mandibular nerve.
Although we did not find such a variation, we agree with
Racs and Maros that the most important variations are to
be seen at the origin of the mandibular nerve in the in-
fratemporal fossa. On the other hand, Zoud and Doran4
noted that the main trunk of the inferior alveolar nerve had
a branching structure reminiscent of the brachial plexus of
the upper limb. We found a similar appearance; a branch
originated from the auriculotemporal nerve and joined the
inferior alveolar nerve on both side, forming a structure
like the brachial plexus.
Ortuğ and Moriggl13 noted that the maxillary artery
passed between the inferior alveolar nerve and the lingual
nerve. There was also a connection between these two
nerves just behind the maxillary artery. The artery passed
medial to the inferior alveolar nerve and lateral to the lin-
gual nerve. We found that the maxillary artery passed lat-
eral to the inferior alveolar and lingual nerves on both sides
and an anastomotic branch between the auriculotemporal
and the inferior alveolar nerves bounded the artery below.
The maxillary artery was compressed by this loop.
Nerve fibres are divided into A, B and C types. A and B
fibres are myelinated whereas C fibres are unmyelinated.
A nerve fibres are the thickest and are concerned primarily
with somatic motor function and proprioceptive sensation
while B and C nerve fibres have smaller axons.14 On the
periphery of nerve fibres, the myelin sheath is seen as a
thick dark band in longitudinal sections.15 Pennisi et al.16
investigated the myelin fibres of the ophthalmic, maxillary
and mandibular nerves in three cadavers. They reported
that the diameter of the fibres in ophthalmic, maxillary and
mandibular nerves were similar while some fibres in the
mandibular nerve (probably motor branches) were thicker.
In the present study, we found that the myelin sheaths in
the mylohyoid nerve were the thickest, and myelin sheaths
in the lingual and inferior alveolar nerves (probably sen-
sory branches) were the thinnest. The myelin sheaths of
the fibres in the main trunk of the inferior alveolar nerve
and in the branches that showed variation in anatomy were
both thick and thin.
Neurovascular anatomical variations in the infratem-
poral fossa are rare. These variations may cause numb-
ness, regional pain or headache, so the surgeon and den-
tist should always be suspicious of signs of neurovascular
compression in the infratemporal fossa.
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The Authors
A. Anıl PhD
T. Peker MD
H. B. Turgut PhD
I. N. Gülekon MD, PhD
Department of Anatomy, Faculty of Medicine
Gazi University, Beşevler-Ankara, Turkey
F. Liman PhD
Tıp Fakültesi Caddesi 17/9 Cebeci-Ankara, Turkey
Correspondence and requests for offprints to: Dr Afitap Anıl, Gazi
Üniversitesi Tıp Fakültesi, Anatomi Anabilim Dalı, Dekanlık Binası,
06500 Beşevler-Ankara, Turkey. Tel: +90 312 2141000/6991;
Fax: +90 312 2124647; E-mail: afitap@gazi.edu.tr
Accepted 24 May 2003