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CASE REPORT
Year : 2018  |  Volume : 21  |  Issue : 2  |  Page : 251-255

Surgical Management of a Bilateral Bifid Condyle: Diagnosis, Three-dimensional Reconstruction, and Treatment – A Report of a Case and Review of the Literature


Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Gazi University, Ankara, Turkey

Date of Acceptance24-May-2017
Date of Web Publication21-Feb-2018

Correspondence Address:
Prof. H Uluturk
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Gazi University, Biskek Caddesi 1., Sokak 06510 Emek, Ankara
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_389_16

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   Abstract 


Bifid condyle is a rare entity with a difficult diagnosis and usually identified as an incidental finding on routine radiographic examination. The etiology is not well known, possible causes may be developmental, traumatic, vascular, abnormal muscle pulling, nutritional, endocrinal, teratogenic, and infections. The orientation of the condylar heads can behelpful for the etiological diagnosis.This case report describes a 56-year-old woman who suffered from a unilateral, progressively increasing, radiating pain which intensified with the movement of the mandible and includes information about the diagnosis, management, radiographic and three-dimensional model features and review of the literature.

Keywords: Bifid condyle, condylectomy, symptomatic, three-dimensional reconstruction


How to cite this article:
Uluturk H, Yücel E, Okur B, Akinci O, Atac M S. Surgical Management of a Bilateral Bifid Condyle: Diagnosis, Three-dimensional Reconstruction, and Treatment – A Report of a Case and Review of the Literature. Niger J Clin Pract 2018;21:251-5

How to cite this URL:
Uluturk H, Yücel E, Okur B, Akinci O, Atac M S. Surgical Management of a Bilateral Bifid Condyle: Diagnosis, Three-dimensional Reconstruction, and Treatment – A Report of a Case and Review of the Literature. Niger J Clin Pract [serial online] 2018 [cited 2022 Nov 30];21:251-5. Available from: https://www.njcponline.com/text.asp?2018/21/2/251/225945




   Introduction Top


The term “bifid” originated from the Latin word meaning “separated into two parts.” In oral and maxillofacial surgery, “bifid condyle” is a rare anomaly where there is a depression or deep cleft in the center of the condylar head in the anteroposterior or mediolateral plane.[1],[2] In 1941, the existence of bifid mandibular condyle (BMC) was first diagnosed in specimen,[2] and 7 years later in 1948, Schier reported the first living case of bifidism.[3]

The exact etiology of BMC is controversial. Possible causes may be developmental, traumatic, vascular, abnormal muscle pulling, nutritional, endocrinal, teratogenic, and infections.[4],[5] To differentiate between etiologic factors is often challenging. In addition to this, it can be helpful to establish the orientation of the supernumerary condyle head – if the heads are oriented mediolaterally or anteroposteriorly – for the etiological diagnosis. Moreover, Dennison et al. considered that only the anteroposterior-oriented condyles are “true” BMC and that those in mediolateral position must be excluded from the grouping and instead be termed “condylar notching.”[6] The mediolateral orientation is generally believed to be developmental, whereas anteroposterior orientation is mostly associated with a traumatic event.[3] Another point to mention is that BMC can be unilateral or bilateral, but medical literature reveals that BMC occurs more often unilaterally than bilaterally. In addition, it is usually found accidentally during routine radiographic examinations.

A case of bilateral bifid condyles, responsible for dysfunction of the temporomandibular joint (TMJ), is hereby presented.


   Case Report Top


A 56-year-old woman was referred to the Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Gazi University, Turkey, with a chief complaint of left-sided, progressively increasing, radiating pain which intensified with the movement of the mandible. Her medical history was noncontributory except that she had undergone bilateral TMJ surgeries for chronic pain. The first operation, a bilateral condylectomy, was performed 15 years previously, and according to her medical history, the patient's symptoms subsided a little after the operation. 12 months later, the patient had a trauma to the left side of the mandible (fell from downstairs) and had to undergo a second operation [Figure 1]. Subsequently, the patient reported bilateral TMJ pain with aggravated symptoms 2 years following surgery. The pain radiated to the temporal and auricular region of the left and right sides.
Figure 1: A computed tomography view (coronal crossing) of the left bifid condyle in 2013

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TMJ examination consisted of palpation of the muscles of mastication and palpation of TMJ region. During the examination, tenderness in the lateral pterygoid muscle on the left side and masseter muscles on both sides was noted.

Computed tomography (CT) images showed two distinct lateral and medial heads in both condyles, the cleft on the left side being more evident [Figure 2] and [Figure 3]. These smaller, nonarticulating secondary heads were detected medially, and although apparently contiguous with the larger normally positioned condylar heads, a constriction between the two was noted [Figure 4]. Finally, bilateral BMC probably due to trauma was diagnosed. Using the open-mouth CT images, a three-dimensional reconstruction was rendered, providing a much clearer depiction of the condylar heads [Figure 5].
Figure 2: A computed tomography (coronal crossing) of the left bifid condyle in 2016

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Figure 3: A computed tomography of the bilateral bifid condyles in 2016

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Figure 4: A three-dimensional view of the left bifid condyle

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Figure 5: (a-c) The three-dimensional reconstruction model of the bilateral condyles

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The patient was then prepared for surgery. Under general anesthesia, the right TMJ was exposed through intraoral approach. Over the buccal shelf, an intraoral incision was made and the soft tissue of the ascending ramus was removed. After removal of excess tissue, an osteotomy was carried out at the coronoid process with a small fissure bur, and a condylectomy was performed at the level of the condylar neck on the right side. On the left side, the same procedure was performed [Figure 6] and [Figure 7]. The incision was closed with vacuum drainage. Postoperative recovery was without any complications, and the patient reported no pain at the 1st month follow-up visit [Figure 8] and [Figure 9].
Figure 6: The removed right bifid condyle and the coronoid process with the three-dimensional reconstruction model

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Figure 7: The removed left bifid condyle with the three-dimensional reconstruction model

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Figure 8: Temporomandibular joint X-ray on the 1st month follow-up

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Figure 9: A panoramic X-ray on the 3rd month follow-up

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   Discussion Top


BMC is a rare anomaly and its etiology is generally unknown; however, the most likely etiologies are accidental condylar fractures and surgical condylectomy.[3],[4],[5],[7] López-López et al. suggest that a metaplasia of the local fibroblasts in the condylar neck develops a new condylar head in the normal anatomic location while a resorption process begins at the displaced condyle.[5] In relation with this theory, an anteromedial displacement of the condyle appears after the condylar neck fracture because of the action of the external pterygoid muscle.[3]

The orientation of the mandibular head is very important for the diagnosis of the etiology of BMC. In 1998, Stefanou et al. described BMC as a single separate neck irrespective of whether the heads are oriented mediolaterally or anteroposteriorly.[8] Dennison et al. in 2008 suggested that “true” BMC must be oriented anteroposteriorly and that those presenting in mediolateral position should be excluded from the grouping and termed “condylar notching.”[6]

In the past 20 years, 89 BMC cases have been reported in medical literature [Table 1]. About 34 of these had a history of trauma. The orientation of the condyle has been described in only 51 cases, with the most common orientation being mediolateral position. Of these 51 patients, 29 had a previous history of trauma. Only ten cases were mentioned with anteroposterior orientation of the condyle and five of them were determined to be congenital.
Table 1: English literature in which the origin, orientation, and the impact of the bifid mandibular condyle is mentioned (last 20 years)

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In 2010, López-López et al. declared that, irrespective of the orientation of the condylar head, both condylar heads have to emerge from the condylar neck in order to be considered a “true” BMC.[5] López-López et al. suggested describing bifid condyle as which presents two condylar heads emerging from the neck of the condyle or further down, regardless of the direction in which they are facing.[5] However, we think that this is a rare entity and a depression between the condylar heads is enough to diagnose a bifid condyle.

Suzana Lubambo de Melo et al. observed that most cases of bifid condyle were asymptomatic.[9] However, other workers have reported that 65 of 89 patients with bifid condyle have presented with complaints associated with TMJ as listed in [Table 1]. It is therefore important that, during the examination of patients with TMJ complaints, bifid condyles should be considered.


   Conclusion Top


For an accurate diagnosis, it is important to simplify the terminology. It is, therefore, suggested that bifid condyle is described as an entity which presents two condylar heads with a cleft between them, regardless of the orientation of the condyles. Nevertheless, in each insoluble maxillofacial pain case, bifid condyle must be considered a rare entity. Due to this, we think that knowledge concerning BMC should be made available to more maxillofacial surgeons and dentists today, especially since bifid condyle diagnosis has become more common in the recent years as radiographic techniques have improved.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Ertas ET, Sahman H, Atici MY. Bilateral bifid mandibular condyle: Report of a case with condylar fractures. J Oral Maxillofac Radiol 2013;1:80.  Back to cited text no. 1
  [Full text]  
2.
Hrdlička A. Lower jaw: Double condyles. Am J Phys Anthropol 1941;28:75-89.  Back to cited text no. 2
    
3.
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. 3
[PUBMED]  [Full text]  
4.
Rehman T, 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. Dentomaxillofacial Radiol 2009;38:239-44.  Back to cited text no. 4
    
5.
López-López J, Ayuso-Montero R, Salas EJ, Roselló-Llabrés X. Bifid Condyle: Review of the Literature of the Last 10 Years and Report of Two Cases. Cranıo 2010;28:136-40.  Back to cited text no. 5
    
6.
Dennison J, Mahoney P, Herbison P, Dias G. The false and the true bifid condyles. Homo 2008;59:149-59.  Back to cited text no. 6
    
7.
Daniels JS, Ali I. Post-traumatic bifid condyle associated with temporomandibular joint ankylosis: Report of a case and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:682-8.  Back to cited text no. 7
    
8.
Stefanou EP, Fanourakis IG, Vlastos K, Katerelou J. Bilateral bifid mandibular condyles. Report of four cases. Dentomaxillofac Radiol 1998;27:186-8.  Back to cited text no. 8
    
9.
Melo SL, Barbosa JMN, Peıxoto AC, Santos TS, Gerbı M. Bilateral bifid mandibular condyle: A case report. Int J Morphol 2011;29:922-26.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1]



 

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