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CASE REPORT
Year : 2013  |  Volume : 1  |  Issue : 2  |  Page : 80-82

Bilateral bifid mandibular condyle: Report of a case with condylar fractures


1 Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Abant İzzet Baysal University, Isparta, Turkey
2 Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Abant İzzet Baysal University, Isparta, Turkey, Faculty of Dentistry, İzmir Katip Çelebi University, İzmir, Turkey

Date of Web Publication21-Oct-2013

Correspondence Address:
Elif Tarim Ertas
Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, İzmir Katip Çelebi University, İzmir
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-3841.120127

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  Abstract 

Bifid mandibular condyle is an uncommon anatomic variation with a varied etiology implicated with its development. It can be symptomatic or the majority of the cases are diagnosed incidentally during radiographic examination. Bifid mandibular condyle may have a developmental origin or may occur secondary to trauma. The purpose of this paper is to report a case with bilateral bifid mandibular condyles associated with a history of condylar fractures presented with computed tomography and panoramic radiography findings.

Keywords: Bifid mandibular condyle, condyle fracture, computed tomography, trauma


How to cite this article:
Ertas ET, Sahman H, Atici MY. Bilateral bifid mandibular condyle: Report of a case with condylar fractures. J Oral Maxillofac Radiol 2013;1:80-2

How to cite this URL:
Ertas ET, Sahman H, Atici MY. Bilateral bifid mandibular condyle: Report of a case with condylar fractures. J Oral Maxillofac Radiol [serial online] 2013 [cited 2019 Jun 20];1:80-2. Available from: http://www.joomr.org/text.asp?2013/1/2/80/120127


  Introduction Top


Bifid mandibular condyle (BMC) is an uncommon anomaly that has a vertical depression or deep cleft in the center of the condylar head in the anteroposterior or mediolateral plane. [1] It may be developmental or acquired and usually the patients with BMC have no significant complaints or clinical features such as pain or dysfunction. [2],[3] In the literature, Hrdlicka (1941) is the first author who describes BMC in a case series of 21 skull specimens [4] and then Schier firstly in 1948 reported this condition in a living persons. [5] The condyle cleft into two parts and duplication of the condyle results into an appearance of a "double" or "bifid" condylar head with distinct or indistinct groove. BMC is more often unilateral, but sometimes it may be bilateral. [1],[6]

BMC has an unclear etiology and although it is generally associated with trauma, several factors like an obstructed blood supply or other embryopathy, developmental anomalies, condylar fracture, perinatal trauma and surgical condylectomy are cited as other possible factors. [1],[7] The misdirected muscle fibers [8] and the fibrous septa of vascular bodies can separate the condyle head while the developmental period. [9] and also infection, irradiation, teratogenic drug use and genetic variance may play a role on the etiology of BMC. [3]

Bifid condyle is usually found incidentally during routine radiographic examinations. But some patients may have signs and symptoms of temporomandibular dysfunction, including joint noises and pain. [1] The presence of BMC is not determined by age or gender and the findings are among ages of 3 to 67 years. [10]

In this report, a 5-year-old girl with bilateral BMCs due to the history of trauma was presented with computed tomography (CT) and panoramic radiography (PR) findings.


  Case Report Top


A 5-year-old girl was referred to our clinic with the complaint of dental problems. From her medical anamnesis, due to a serious accident history (falling from third floor to hoist way) at the age of 2 and consecutive condyle operations, a panoramic examination was performed in order to evaluate the teeth and jaw bones. In the panoramic radiograph, bilateral BMC as a consequence of head trauma was detected [Figure 1]. Pre- and post-operative CT examinations were obtained from her medical records and the resulted symphysis and bilateral condylar fractures were treated with surgical operation using mini plaques and condylar relocation [Figure 2]. Post-operative CT images showed two distinct anterior and posterior heads of both condyles in the appearance of bilateral BMC [Figure 3].
Figure 1: Panoramic radiograph of the 5-year-old child showing bilateral bifid mandibular condyles

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Figure 2: a. 3D Reformatted image of the girl showing bilateral condylar fractures and symphysis fracture. b. 3D Reformatted image of the CT sections showing right condylar fracture. c. 3D Reformatted image of the CT sections showing left condylar fracture. d. Coronal view of the CT section showing bilateral condylar fractures

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Figure 3: a. Coronal view of the CT sections taken 1.5 year after postoperatively. b. 3D Reformatted images of the patient showing right bifid mandibular condyle occurred postoperatively. c. 3D reformatted images of the patient showing left bifid mandibular condyle occurred postoperatively

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In the extra-oral examination, there was no asymmetry on the face and in the clinical examination no objective symptom including limitation in the mouth opening, TMJ dysfunction, pain, sound, or asymmetry were observed. Similar to most BMC cases the patient was asymptomatic.


  Discussion Top


Duplication of mandibular condyle is a rare anomaly and generally has unclear etiology. Szentpetery et al. observed 1882 cadaveric skulls and found the incidence of BMC to be 0.48%. [2],[11] We know that up till now only two epidemiological studies have been carried out on living subjects. In 2008, Menezes et al. and, in 2010, Miloðlu et al. examined panoramic radiographs and found the incidence of BMC to be 0.018% and 0.3% respectively in different populations. [12],[13] This high frequency shows that BMC is a more frequent condition since it is frequently discovered with the use of advanced techniques of radiography such as CT, CBCT, and MRI. [13],[14]

The exact etiology of BMC is generally unknown. [2],[13],[15] Two major etiologies play a role on BMC. [2] However, the most suitable theory depends on traumatic origin. [15] Thomason and Yusuf have suggested prior trauma as an etiology and they reported two cases of unilateral BMC after condylar fracture. [16] Antoniades et al. also presented unilateral BMC after a sagittal condylar fracture. [10] Sales et al. reported a case of BMC 4 years after condylar fracture. [7] Poswillo [17] and Walker [18] presented an animal study that BMC can result from trauma. And also minor trauma can affect the growth center of the condyle and may result in a variation such as BMC. [10],[15] The second theory is based on obstruction of blood supply and fibrous septa in embryologic period. [2] Blackwood stated that condylar cartilage can be divided by fibrous septa during early developmental period. [19] Also, Moffet et al. described developmental effects in BMC. [9] However, Gundlach found no evidence of fibrous septa in BMC cases. [8] In our case, there was a history of trauma and the bilateral BMCs occurred due to the condylar fractures.

The morphology of BMC may range from shallow groove to distinct condylar heads and the orientation may be in anteroposterior or mediolateral direction. [2],[14],[19] This orientation has been used a differentiating factor for etiology. The mediolateral position is related to a developmental cause while anteroposterior position has been associated with a traumatic event. [11] Szentpetery et al. suggested that condylar heads in the sagittal plane indicates the trauma and the heads in the coronal plane indicates the fibrous septa as the etiology. [20] Loh [21] and Wu [22] reported that this may be true for many cases. In this case report, the condylar heads were in the sagittal plane as shown in the figure and compatible with the finding of Szentpetery.

The majority of cases are detected during the routine imaging procedure. In most cases, symptoms like TMJ dysfunction and pain are not evident. [2] However, in some reports, BMC is associated with TMJ disorders like pain, sounds, and restricted mandibular movement. [15] Ankylosis and facial asymmetries have also been reported. [23],[24],[25] In our case, the patient had no clinical symptoms like most of the cases reported in the literature.

In general, panoramic and other conventional techniques are sufficient for diagnosis. But in symptomatic patients advanced imaging techniques may be necessary for treatment planning. [26] CT scan is the best choice for detection of BMC without superpositioning. [2],[26] However, because of excessive radiation in CT, clinicians should prefer CBCT techniques in TMJ examinations. In addition, MRI allows imaging the soft tissues and surrounding articular structures and this makes MRI the gold-standard technique for TMJ radiographies. [26]

67% of patients with BMC are asymptomatic. In symptomatic cases, the treatment depends on presenting complaints of patient. In the presence of articular derangement, occlusal splints and arthroscopic surgery should be a treatment choice. But articular ankylosis may need surgical condylectomy or arthroplasty. [2]

As a conclusion, BMC is a rare morphologic variation of condyle with generally an unknown etiology. In the present report, a 5-year-old girl was presented with bilateral BMCs occurred due to condylar fractures. The parents were informed about the changes in the condyles and long-term follow-up was recommended in case-potential subsequent clinical symptoms.


  Acknowledgements Top


This case was presented in a poster presentation given at 13 th Congress of EADMFR, 13-16 June 2012, Leipzig, Germany

 
  References Top

1.Stuart C. White, M. J. Pharoah. Oral radiology: principles and interpretation. 6th Ed. Elsevier Publications, 2009, 485.  Back to cited text no. 1
    
2.Faisal M, Ali I, Pal US, Bannerjee K. Bifid mandibular condyle: Report of two cases of varied etiology. Natl J Maxillofac Surg 2010;1:78-80.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.Sales MA, Oliveira JX, Cavalcanti MG. Computed tomography imaging findings of simultaneous bifid mandibular condyle and temporomandibular joint ankylosis: Case report. Braz Dent J 2007;18:74-7.  Back to cited text no. 3
    
4.Stadnicki G. Congenital double condyle of the mandible causing temporomandibular joint ankylosis: Report of case. J Oral Surg 1971;29:208-11.  Back to cited text no. 4
    
5.Ramos FM, Filho JO, Manzi FR, Boscolo FN, Almeida SM. Bifid mandibular condyle: A case report. J Oral Sci 2006;48:35-7.  Back to cited text no. 5
    
6.Sahman H, Sisman Y, Sekerci AE, Tarim-Ertas E, Tokmak T, Tuna IS. Detection of bifid mandibular condyle using computed tomography. Med Oral Patol Oral Cir Bucal 2012;17:e930-4.  Back to cited text no. 6
    
7.de Sales MA, do Amaral JI, de Amorim RF, de Almeida Freitas R. Bifid mandibular condyle: Case report and etiological considerations. J Can Dent Assoc 2004;70:158-62.  Back to cited text no. 7
    
8.Gundlach KK, Fuhrmann A, Beckmann-Van der Ven G. The double-headed mandibular condyle. Oral Surg Oral Med Oral Pathol 1987;64:249-53.  Back to cited text no. 8
    
9.Moffett B. The morphogenesis of the temporomandibular joint. Am J Orthod 1966;52:401-15.  Back to cited text no. 9
    
10.Antoniades K, Karakasis D, Elephtheriades J. Bifid mandibular condyle resulting from a sagittal fracture of the condylar head. Br J Oral Maxillofac Surg 1993;31:124-6.  Back to cited text no. 10
    
11.Shriki J, Lev R, Wong BF, Sundine MJ, Hasso AN. Bifid mandibular condyle: CT and MR imaging appearance in two patients: Case report and review of the literature. AJNR Am J Neuroradiol 2005;26:1865-8.  Back to cited text no. 11
    
12.Menezes AV, de Moraes Ramos FM, de Vasconcelos-Filho JO, Kurita LM, de Almeida SM, Haiter-Neto F. The prevalence of bifid mandibular condyle detected in a Brazilian population. Dentomaxillofac Radiol 2008;37:220-3.  Back to cited text no. 12
    
13.Miloglu O, Yalcin E, Buyukkurt M, Yilmaz A, Harorli A. The frequency of bifid mandibular condyle in a Turkish patient population. Dentomaxillofac Radiol 2010;39:42-6.  Back to cited text no. 13
    
14.Rehman TA, Gibikote S, Ilango N, Thaj J, Sarawagi R, Gupta A. Bifid mandibular condyle with associated temporomandibular joint ankylosis: A computed tomography study of the patterns and morphological variations. Dentomaxillofac Radiol 2009;38:239-44.  Back to cited text no. 14
    
15.Sahman H, Etoz OA, Sekerci AE, Etoz M, Sisman Y. Tetrafid mandibular condyle: A unique case report and review of the literature. Dentomaxillofac Radiol 2011;40:524-30.  Back to cited text no. 15
    
16.Thomason JM, Yusuf H. Traumatically induced bifid mandibular condyle: A report of two cases. Br Dent J 1986;161:291-3.  Back to cited text no. 16
    
17.Poswillo DE. The late effects of mandibular condylectomy. Oral Surg Oral Med Oral Pathol 1972;33:500-12.  Back to cited text no. 17
    
18.Walker RV. Traumatic mandibular condylar fracture dislocations. Effect on growth in the Macaca rhesus monkey. Am J Surg 1960;100:850-63.  Back to cited text no. 18
    
19.Blackwood HJ. The double-headed mandibular condyle. Am J Phys Anthropol 1957;15:1-8.  Back to cited text no. 19
    
20.Szentpetery A, Kocsis G, Marcsik A. The problem of the bifid mandibular condyle. J Oral Maxillofac Surg 1990;48:1254-7.  Back to cited text no. 20
    
21.Loh FC, Yeo JF. Bifid mandibular condyle. Oral Surg Oral Med Oral Pathol 1990;69:24-7.  Back to cited text no. 21
    
22.Wu XG, Hong M, Sun KH. Severe osteoarthrosis after fracture of the mandibular condyle: A clinical and histologic study of seven patients. J Oral Maxillofac Surg 1994;52:138-42.  Back to cited text no. 22
    
23.Farmand M. Mandibular condylar head duplication. A case report. J Maxillofac Surg 1981;9:59-60.  Back to cited text no. 23
    
24.Forman GH, Smith NJ. Bifid mandibular condyle. Oral Surg Oral Med Oral Pathol 1984;57:371-3.  Back to cited text no. 24
    
25.Quayle AA, Adams JE. Supplemental mandibular condyle. Br J Oral Maxillofac Surg 1986;24:349-56.  Back to cited text no. 25
    
26.Sahman H, Sekerci AE, Ertas ET, Etoz M, Sisman Y. Prevalence of bifid mandibular condyle in a Turkish population. J Oral Sci 2011;53:433-7.  Back to cited text no. 26
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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