HEAD & NECK CME

ABBREVIATION KEY
PMR ⫽ pterygomandibular raphe
RMT ⫽ retromolar trigone

Received September 2, 2015;

accepted January 1, 2016.

Review of the Pterygomandibular From the Department of Radiology,

University of Florida College of
Medicine, Jacksonville, Florida.

Raphe Educational Exhibit at American

Society of Neuroradiology, ASNR
53rd Annual Meeting and The
D. Rao, S.J.S. Sandhu, C. Ormsby, P. Natter, D. Haymes, I. Cohen, and M. Jenson Foundation of the ASNR
Symposium 2015, April 25–30,
2015, Chicago, Illinois.
Please address correspondence to
Dinesh Rao, MD, University of Florida
College of Medicine Jacksonville, 655
CME Credit W 8th Street, Clinical Center, 2nd
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ABSTRACT
The pterygomandibular raphe is an important conduit in the spread of head and neck
malignancy. Recognition of this structure and its associated anatomy is necessary for image
interpretation and subsequent treatment of oral cavity cancers. From the pterygomandib-
ular raphe, tumor can spread into other subsites of the oral cavity and pharynx. The extent
of tumor may not be evident on clinical examination but can be detected on imaging. We
reviewed the anatomy of the pterygomandibular raphe and provided examples of its in-
volvement in head and neck cancers.

Learning Objective: Recognize the importance of the pterygomandibular raphe in the

spread of oral cavity squamous cell carcinoma.

INTRODUCTION spread of tumor to other areas of the oral

It was estimated that 30,260 patients cavity. Recognition of involvement of the
would develop oral cavity cancer in the PMR and routes of spread of tumor from
United States in 2015, with squamous cell the PMR is necessary for accurate assess-
carcinoma being the most common histol- ment of disease and to avoid incomplete
ogy.1 The oral cavity begins at the lips and treatment.
extends posteriorly to the junction of the
circumvallate papillae and anterior tonsil- ANATOMY
lar pillar. The hard palate, floor of the The PMR was first described in 1784 as a
mouth, oral tongue, and gingiva are ame- tendon between the upper and lower jaw.3
nable to direct visualization. Mucosal tu- It has previously been referred to as the
mors are routinely detected by physical ex- ligamentum pterygomandibular,4 ligamen-
amination; however, the direct spread of tum intermaxillare or pterygomaxi,5 apa-
tumors that involve the submucosa and neurose buccinatopharygee,6 and raphe
deeper anatomic structures can be demon- buccinpharyngica.7 The word “raphe” has
strated on CT and MR imaging.2 The a Greek derivation, meaning “a seam like
pterygomandibular raphe (PMR) is an of- union.” Classically, the PMR has been de-
ten overlooked structure in the spread of scribed as a tendinous band of buccopha-
oral cavity cancer. Recognition of tumor ryngeal fascia subjacent to the mucosal
that involves the PMR is important be- surface of the retromolar trigone (RMT). It
cause it can act as a conduit for direct serves as the point of attachment of the

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Fig 1. Illustrations, depicting the relationships of the PMR in the oral cavity. A, The PMR (asterisk) serves as a point of attachment of the buccinator
(short arrow) and the superior constrictor (long arrow) muscles. B, View from above shows the PMR (asterisk) lies deep to the RMT (triangle outline);
the buccinator (short arrow) and superior pharyngeal constrictor (long arrow) muscles are again depicted. C, Parasagittal image shows the PMR
(asterisk) attaches superiorly to the hamulus of the medial pterygoid plate (arrowhead); the buccinator (short arrow) and superior pharyngeal
constrictor (long arrow) muscles are shown. (Illustrations by C. Ormsby.)

buccinator and the superior pharyngeal constrictor muscle

(Fig 1).8-10
The raphe attaches superiorly to the hamulus of the me-
dial pterygoid plate and inferiorly to the posterior aspect of
the mylohyoid ridge of the mandibular cortex. The anterior
border of the PMR attaches to the buccinator muscle, and
the posterior border attaches to the superior pharyngeal
constrictor. The buccinator and superior pharyngeal con-
strictor muscles have a common insertion on the PMR. It is
because of this commonality that the PMR serves as a junc-
tion among the oral cavity, oropharynx, and nasophar-
ynx.10 The general location of the raphe can be inferred
from the pterygomandibular fold, which is covered by mu-
cosa positioned posterior to the last molar (Fig 2). The fold
and raphe are located lateral to the RMT and are important
landmarks in the administration of local anesthesia to the
inferior alveolar nerve.11

ANATOMIC VARIATION OF THE PMR

The classic description of the PMR as a thin fascial band is
not supported by cadaveric studies. Shimada and Gasser12 Fig 2. Photograph of the posterior oral cavity (outlined); the pterygo-
studied 60 adult American adults and fetuses, and found mandibular fold (triangular outline) is the mucosal covering of the PMR;
variability in the anatomy of the PMR. These investigators the RMT is posterior to the last mandibular molar (long arrow); oral
tongue (short arrow).
categorized the PMR into 3 distinct subtypes. Type A raphe
has a broad triangular shape superiorly, with the absence of
a fascial attachment inferiorly (Fig 3A). Type B raphe is the junction of the superior pharyngeal constrictor muscle and
closest to the classic description, with a broad fascial tendon the buccinator (Fig 4A–C). Contrast-enhanced CT can be
that serves as an attachment for the superior pharyngeal use; however, image quality is often degraded by dental
constrictor and buccinator muscles (Fig 3B). Type C is a amalgam artifacts.15 Although dental amalgam can also
complete absence of the raphe. This variant is found in 36% affect image quality on MR imaging, axial T2 FSE images
of specimens and results in continuity of the 2 muscles (Fig are useful for locating relevant anatomy and evaluating for
3C). In addition, all of the fetuses studied exhibited the type tumor spread. Axial T1-weighted images can also be used to
B anatomy, which indicates that changes to the PMR likely evaluate for involvement of adjacent fat and soft-tissue
occur in the postnatal period. Also, the prevalence of types planes.
A to C varies among the races.13
THE RMT AND THE PMR
IMAGING OF THE PMR The RMT is the most important subsite of the oral cavity
The PMR is beyond the resolution of conventional CT and with respect to the PMR.16 Approximately 7% of tumors
MR imaging.14 Its position can be inferred by locating the that affect the oral cavity arise from the RMT.17 The RMT

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Fig 3. A, Type A raphe (asterisk), with a broad triangular shape superiorly and absence of the raphe inferiorly. B, Type B raphe (asterisk), with a broad
fascial region that widely separates the buccinator and superior pharyngeal constrictor muscles. C, Type C raphe with complete absence of the raphe,
and continuity of the buccinator and superior pharyngeal constrictor muscles.

Fig 5. Axial T2-weighted image. Arrows indicate potential routes of tumor

spread from the RMT; the alveolar ridge (a) and buccal mucosa (b) are po-
tential sites of tumor spread anteriorly; the masticator space (m), mandible
(mb), and superior constrictor muscle (p) are susceptible posteriorly.

dibular ramus (Fig 4C). Squamous cell carcinoma can arise

from the RMT or spread to it from the tonsils or the base of
the tongue. Tumor can spread from the RMT to several
different directions because of the unique location at the
junction of the oral cavity and the oropharynx. The alveolar
Fig 4. Axial T2-weighted images from cranial to caudal. A, The PMR at- ridge of the mandible is susceptible anteriorly (Fig 5). The
taches superiorly to the medial pterygoid hamulus plate (arrowhead). B, mandibular ramus, the masticator space, and pharyngeal
The approximate position of the PMR (asterisk), serving as the attach-
constrictor muscles are vulnerable posteriorly (Figs 5 and
ment of the buccinator (short arrow) and superior pharyngeal constrictor
(long arrow) muscles. C, The PMR lies deep to the RMT (red outline). 6). Tumor can also spread superior medially into the buccal
mucosa and fat lateral to its insertion on the medial ptery-
is a triangular region of mucosa within the oral cavity, goid plate as well inferiorly to the floor of the mouth (Figs 7
posterior to the last mandibular molar, which overlays the and 8). The position of the RMT superficial to the PMR
posterior mandibular body and inferior aspect of the man- allows direct spread of tumor. The PMR serves as scaffold-

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Fig 6. A and B, Axial contrast-enhanced CT images show tumor (X), with involvement of the buccal soft tissues (b) and masticator space (asterisk), and
with spread along the superior pharyngeal constrictor muscle (arrow). C, Axial fused PET/CT confirms hypermetabolic tumor (X).

Fig 7. Sagittal (A), axial (B), and coronal (C) contrast-enhanced CTs show an RMT tumor (t) that involves the PMR (asterisk), with extension superiorly
to the pterygoid plates (p) and anterior inferiorly along the floor of the mouth (F).

Fig 8. Axial (A), sagittal (B), coronal (C) contrast-enhanced CTs, demonstrating enhancing tumor (t) that involves the right PMR (asterisk indicates
approximate position); note the inferior extension to the floor of the mouth (F) and cephalad extension to the hamulus of the medial pterygoid plate
(p).

ing for tumor growth superiorly from the oral cavity.18 Because tumor spread from the RMT may be submuco-
Tumor can spread from the PMR to the masticator space sal, it may not be evident on clinical examination. Imaging,
superior laterally and the buccal space anteriorly, and also therefore, plays a crucial role in the detection of tumor
into the buccal fat posterior to the maxillary sinus. Virtually spread via the PMR. A mucosal lesion noted on physical
all cancers that spread along the PMR originate from or examination may be underestimated, therefore, not com-
involve the RMT.19 Perineural spread may also occur along pletely treated. Tumor recurrence and/or progression can
the inferior alveolar nerve and mandibular branch of the occur if the extent of the primary tumor is not recognized
trigeminal nerve. (Fig 9). Tumor involvement of other oral cavity subsites can

124 兩 Neurographics 2017 March/April; 7(2):121–125; www.neurographics.org

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