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Anatomical Study of the Pterygospinous and Pterygoalar Bony Bridges and

Foramens in Dried Crania and its Clinical Relevance

Article  in  International Journal of Morphology · June 2010

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Int. J. Morphol.,
28(2):405-408, 2010.

Anatomical Study of the Pterygospinous and Pterygoalar

Bony Bridges and Foramens in Dried Crania and its
Clinical Relevance

Estudio Anatómico de los Puentes Óseos y Forámenes Pterigoespinoso

y Pterigoalar en Cráneos Secos y su Relevancia Clínica

*
Iván Suazo Galdames; **Daniela Zavando Matamala & ***Ricardo Luiz Smith

SUAZO, G. I.; ZAVANDO, M. D.; SMITH, R. L. Anatomical study of the pterygospinous and pterygoalar bony bridges and foramens
in dried crania and its clinical relevance. Int. J. Morphol., 28(2):405-408, 2010.

SUMMARY: The ossification of the intrinsic ligaments of the sphenoid bone has been reported in the literature. The presence of
bony bridges by ossification of the pterygospinous and pterygoalar ligaments has clinical significance in the infratemporal fossa contents.
The purpose of this study is to analyze the prevalence of ossification of these ligaments and assess morphometrically the pterygospinous
(Civinini’s) and pterygoalar (crotaphitico-buccinatorius) foramens. A total of 312 human skulls from the collection of Universidade
Federal de São Paulo (UNIFESP) were used to assess the presence of total or partial ossification in pterygospinous (Types I and II) and
pterygoalar (Types III and IV) ligaments. Of the sample, 37.18% had some degree of ossification; in Type I, ossification was found in
1.6%, while Types II, III and IV had 13.14, 3.84, and 22.43%, respectively. The pterygospinous foramen presented an average diameter
between 10.626–7.366 mm, whereas for the pterygoalar foramen it was between 5.202–3.793 mm. The presence of these formations
must be considered in the therapeutic procedures that are performed in the infratemporal region, in assessing pain affecting the territory
innervated by the mandibular nerve.

KEYWORDS: Pterygospinous ligament; Pterygoalar ligament; Infratemporal fossa; Foramen ovale; Porus crotaphitico-
buccinatorius.

INTRODUCTION

The presence of ossification in the pterygospinous and by Tebo, 1968) is directed from the spine of the sphenoid
pterygoalar ligaments have clinical significance as these bone to the pterygospinous process when ossified,
ligaments establish relationships with the oval foramen and establishing the pterygospinous foramen.
because of the effects that emerge from it, such as increasing
difficulty in accessing the oval foramen in a therapeutic Rouviére & Delmas (1999) stated that the
approach. pterygospinous ligament divides the sphenomandibular
ligament into two independent, of which the interpterygoid
In terms of its prevalence, Nayak et al. (2007) fascia is thin. Lateral to the interpterygoid fascia is another
analyzed 416 Indian dried skulls; 9.61% of the samples fibrous plate inserted in the greater wing of the sphenoid and
presented the pterygospinous bony bridges, of which 5.76% in the superior segment of the posterior edge of lateral plate
was complete and 3.84% was incomplete. On the other hand, in the pterygoid process. Its superior edge becomes flat and
Kapur et al. (2000) in an earlier study obtained a lower forms an innominated ligament, described by Hyrtl in 1862
prevalence of 1.31% of complete pterygospinous ligament (Cited by Tebo), and posteriorly called pterygoalar ligament
ossification, from a sample of 305 Croats’ skulls. The (Antonopoulou et al., 2008) which when it is ossified, mold
pterygospinous ligament described by Civinini in 1835 (cited the pterygoalar foramen (porus crotaphitico-buccinatorius).

*
Universidad de Talca, Chile.
**
Universidad Autónoma de Chile, Chile.
***
Department of Morphology and Genetic. Universidade Federal de São Paulo, Brazil.

405
 SUAZO, G. I.; ZAVANDO, M. D.; SMITH, R. L. Anatomical study of the pterygospinous and pterygoalar bony bridges and foramens in dried crania and its clinical relevance.
Int. J. Morphol., 28(2):405-408, 2010.

These formations are related laterally with the oval foramen, posterior edge of the lateral lamina of the pterygoid
from which the mandibular nerve emerges, and then enters in the process and a process that emerges from the
infratemporal fossa. In this position, the mandibular nerve can be anterolateral area of the base of sphenoid spine. In this
compressed as a result of the pterygoid muscle contraction causing case, it is the pterygoalar foramen (crotaphitico-
pain (Krmpotic´-Nemanic et al., 1999). Peuker et al. (2001) described buccinatorius) (Fig. 3).
a case in which the lingual nerve was trapped between the
pterygospinous bony bridge and the medial pterygoid muscle; this
variation is associated with pain and alterations in speech.

It is known that the pterygospinous and pterygoalar bony

bridges are of great importance to the anesthetic treatment of the
mandibular nerve and for therapeutics for the trigeminal ganglion (Das
& Paul, 2007; Singh et al., 1993), because their presence hinders access
to the needle in the vicinity of the oval foramen.

The purpose of this study was to determine the prevalence of

pterygospinous and pterygoalar bony bridges and to analyze Fig. 1. Type I presented complete ossification of
morphometricaly the homonyms foramen in a collection of pterygospinous ligament. In this case, it is the
contemporary skulls and discuss their clinical implications. pterygospinous or Civinini’s foramen. CF: Civinini fora-
men, SphS: Sphenoid spine.

MATERIAL AND METHOD

By nonprobability convenience sampling, 312 dry human

skulls belonging to the collection of the UNIFESP with records of
sex, age, and origin were selected. The ages of individuals up to the
dates of death was between 18 and 100 years old, the average age of
the sample was 42.32 (SD 14.842). Of the total sample, 212 (67.9%)
were male skulls, whereas female skulls were 100 (32.1%). Of the
312 skulls, 284 represent Brazilians individuals, which constitute 91%
of the group. The remaining 9% (n = 28) is distributed among 11
other nationalities. Skulls that showed visible evidence of
abnormalities such as trauma or obvious morphological asymmetries
Fig. 2. Type II, incomplete ossification of pterygospinous
were excluded from this study.
ligament, there is a lengthening of the pterygospinous
process. PtsP: Pterygospinous process, SphS: Sphenoid
The skulls were examined by one observer, in groups of 40 spine.
skulls and those that had complete or partial ossification of the
pterygospinous and pterygoalar ligaments were identified. The Type IV: presented incomplete ossification of
following descriptions are given for ossification of the two ligaments: pterygoalar ligament: there is an elongation of a process
in spina shape that originates from the anterolateral area
Type I: presented complete ossification of pterygospinous of the sphenoid spine base, but that does not reach
ligament: there is a bony bridge that leads from the pterygospinous sufficiently elongation to contact with the lateral lami-
process to the apex of the sphenoid spine. In this case, it is the na of the pterygoid process. This was an inclusion
pterygospinous foramen (Fig. 1). criteria for considering the elongated process that
emerges from the sphenoid spine. It is a fact that in the
Type II: presented incomplete ossification of pterygospinous lateral norma, at least half the foramen ovale is hidden
ligament: there is a lengthening of the pterygospinous process, but (Fig. 4).
fails to contact the sphenoid spine. In this case, the pterygospinous
foramen is partially formed (Fig. 2). In cases where there was complete ossification
of the ligaments (Type I and III), the maximum and
Type III: presented complete ossification of pterygoalar minimum diameter of the pterygospinous foramen and
ligament: there is a bony bridge between the superior segment of the pterygoalar foramen were determined.

406
 SUAZO, G. I.; ZAVANDO, M. D.; SMITH, R. L. Anatomical study of the pterygospinous and pterygoalar bony bridges and foramens in dried crania and its clinical relevance.
Int. J. Morphol., 28(2):405-408, 2010.

With the data obtained, prevalence rates for the of 312 human dry skulls from the UNIFESP collection, the cases
four proposed types were estimated, differentiating the distribution of partial and complete pterygospinous and pterygoalar
bilateral, right, and left presentations. ligaments ossification are presented in Table I.

Of the total sample, only five (1.6%) present complete

ossification of the pterygospinous ligament, constituting the foramen
of the same name (Civinini’s foramen) (Fig. 1). The maximum
diameter of this foramen was 10.626 mm (SD 2.85) and the average
minimum diameter was 7.366 mm (SD 1.29). The complete
ossification of pterygoalar ligament was found in 12 cases (3.84%),
which presents the formation of the pterygoalar foramen (crotaphitico-
buccinatorius foramen) (Fig.3), whose maximum diameter was 5.202
mm (SD 1.005) and the minimum diameter was 3.793 mm (SD 1.54).

DISCUSSION
Fig. 3. Type III, complete ossification of pterygoalar
ligament. In this case, it is the pterygoalar or crotaphitico-
buccinatorius foramen. Cr-Bu: Crotaphitico-buccinatorius
The sphenoid bone presents a series of intrinsic ligaments:
(white arrow).
interclinoid, caroticoclinoid, pterygospinosus, and pterygoalar
ligaments. Ossification process with different clinical implications
has been reported for all.

The present study analyzed the presence of total or partial

pterygospinosus and pterygoalar ligaments ossification. These
formations occupy a deep and high portion in the infratemporal fossa
establishing important relationships with the mandibular nerve and
its branches, the otic ganglion, the median meningeal artery and vein,
the tympanic nerve, the medial and lateral pterygoideus muscles. These
are compressed against the bone formations and are capable of
generating clinically important alterations (Krmpotic´-Nemanic et al.;
Peuker et al.; von Lüdinghausen et al., 2006).

Fig. 4. Type IV, incomplete ossification of pterygoalar

The prevalence of pterygospinosus bony bridges has been
ligament: there is an elongation of a process in spina shape reported by different authors with different results. For a sample, Wood-
that originates from the anterolateral area of the sphenoid Jones (1931) reported an 8% pterygospinosus ligament ossification in
spine base. PtaP: Pterygoalar process (white arrow). Hawaiian skulls. Nayak et al. indicated that such bridges was completely
ossified in 5.76% of the cases analyzed by them. Peker et al. (2002)
reported the presence of this bridge in 8.8% in skulls of an Anatolian
RESULTS population. In this study, the prevalence of complete pterygospinosus
ligament ossification was only 1.6%, much lower than those reported
A total of 116 skulls (37.18%) had some kind in the earlier studies. This could be attributed to the age of this sample
of the variation; the most frequent was incomplete (average 42.32 years), as the emergence of ossification process is
ossification of pterygoalar ligament. From the samples associated with increasing age of subjects (Cammisa et al., 1998).

Type I Type II Type III Type IV

n % n % n % n %
Bilateral 0 0.00 16 5.12 4 1.28 24 7.69
Right 2 0.64 35 11.21 8 2.56 38 12.17
Left 3 0.96 22 7.05 8 2.56 56 17.94
Total 5 1.60 41 13.14 12 3.84 70 22.43

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 SUAZO, G. I.; ZAVANDO, M. D.; SMITH, R. L. Anatomical study of the pterygospinous and pterygoalar bony bridges and foramens in dried crania and its clinical relevance.
Int. J. Morphol., 28(2):405-408, 2010.

Most cited investigations related to the pterygospinosus approach through the supra and the infrazygomatic via,
ligament ossification and the formation of the homonym fora- decreasing the effectiveness of extraoral anesthetic treatment
men did not mention the implications of these variations; technique of the mandibular nerve; (ii) the complete ossification
however, from a clinical point of view the presence of of the pterygoalar ligament determines the formation of the
ossification in the pterygoalar ligament is even more important pterygoalar foramen (crotaphitico-buccinatorius), which is
for two reasons: (i) when pterygoalar ligament is partially much smaller in diameter compared with the pterygospinosus
ossified the bony prominence not mentioned in anatomical foramen (Civinini’s). The pterygoalar ligament completely
nomenclature, is projected anterolaterally to be a spine that prevents access to the mandibular nerve or trigeminal ganglion
partially covers the access to the oval foramen from a lateral from foramen ovale by the supra or infrazygomatic via.
SUAZO, G. I.; ZAVANDO, M. D.; SMITH, R. L. Estudio anatómico de los puentes óseos y forámenes pterigoespinoso y Pterigoalar en
cráneos secos y su relevancia clínica. Int. J. Morphol., 28(2):405-408, 2010.

RESUMEN: La osificación de los ligamentos intrínsecos del hueso esfenoides ha sido reportada en la literatura. La presencia de puentes
óseos por osificación de los ligamentos pterigoespinoso y pterigoalar tiene importancia clínica debido a las relaciones que éstas formaciones estable-
cen con el contenido de la fosa infratemporal. El propósito de este estudio fue analizar la prevalencia de la osificación de estos ligamentos y evaluar
morfométricamente los forámenes pterigoespinoso (Cinivini's) y pterigoalar (crotaphitico-buccinatorius). Se utilizaron 312 cráneos humanos de la
colección de la UNIFESP, se evaluó la presencia de osificación total o parcial de los ligamentos pterigoespinoso (Tipos I y II) y pterigoalar (Tipos III
y IV). Un 37,18 % de la muestra presentó algún grado de osificación, el tipo I se encontró en un 1,6%%, el tipo II en un 13,14%, el tipo III en un
3,84% % y el tipo IV en un 22,43%. El foramen pterigoespinoso presentó un diámetro medio de entre 10,626 – 7,366 mm, mientras que para el
foramen pterigoalar estuvieron entre 5,202 – 3,793 mm. La presencia de estas formaciones debe ser considerada en los procedimientos terapéuticos
que se realicen en la región infratemporal y en la evaluación de cuadros dolorosos que afectan al territorio inervado por el nervio mandibular.

PALABRAS CLAVE: Ligamento Pterigoespinoso; Ligamento Pterigoalar; Fosa infratemporal; Foramen oval; Foramen crotaphitico-
buccinatorius.

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Email: [email protected]
Accepted: 22-01-2010

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