A third level of significance is achieved when the skull cup is seen in the context of other images. One of the more common settings for the cup is in the hands of Mahakala. Since Mahakala in the overcomer of all obstacles on the way to enlightenment, the presence of the skull cup compliments his significance by emphasizing the impermanence of the body. Similarly, the skull cup is often found in the context of the Heruka deities, such as Cakra Samvara and Hevajra. The skull cup is frequently depicted in the left hand of Padma Sambhava, signifying the guru's realization of impermanence and absolute voidness.
Skull cups have a significant role in Tibetan Buddhist rituals.
Very complex rituals exist describing how cups should be made, from whom, and for what ritual. Those relating to dpal ldan lha mo, for example, are made from the skull of a child born from an incestuous union. It is important to note that skull cups are only made from the skulls of those who died by other causes. Skull cups are also used for holding holy water. During Tibetan liturgy, a Lama would dip his fingers into the bowl at intervals during the service and flip the water into the air for spirits.