Bifid Condyle

n CASE REPORTS
Bifid Condyle: Review of the Literature of the Last 10
Years and Report of Two Cases
José López-López, M.D., Ph.D.; Raúl Ayuso-Montero, D.D.S., Ph.D.;
Enric Jané Salas, M.D., Ph.D.; Xavier Roselló-Llabrés, M.D., Ph.D.
0886-9634/2802000$05.00/0, THE
JOURNAL OF
CRANIOMANDIBULAR
PRACTICE,
Copyright © 2010
by CHROMA, Inc.
Manuscript received
September 23, 2009;
revised
manuscript received
December 3, 2009;
accepted
December 4, 2009
Bifid mandibular condyle is a rare anomaly; there are several theories about its etiology, and it has been
studied in both prehistoric and historic skulls, as well as in living human beings. It is a frequent, although
unexpected, finding in asymptomatic individuals during radiological treatment. Presented here is a
review of the literature over the past 10 years and two new cases of unilateral bifid condyle.
Computerized tomography is usually considered the test of choice for establishing the differential diagnosis, although in certain cases, its use seems questionable. The distinction between bifid condyle and
condylar notch or cleft has been described in the literature, it is proposed a criteria for defining bifid
condyle depending on the level of the two heads. It is suggested that further testing such as MRI or CT
be carried out only in cases where the therapeutic approach involves an active treatment. It is proposed
that bifid condyle is described as that which presents two condylar heads emerging from the neck of the
condyle or further down.
Address for correspondence:
Dr. Raúl Ayuso-Montero
Faculty of Dentistry
Dept. of Prosthodontics
University of Barcelona
Campus de Bellvitge
C/Feixa Llarga s/n
L’Hospitalet de Llobregat
Barcelona E-08907
Spain
E-mail: raulayuso@ub.edu
T
he term bifid condyle has been described as a condition of unknown etiology and uncertain pathogenesis.1,2 Duplication of the mandibular condyle
is rare and has been studied both in prehistoric and historic skulls,2,3 as well as in living human beings.4-10 It is a
rare and unexpected radiologic finding in asymptomatic
individuals.4,5,8-10 Other cases occur with functional ankylosis of one or both temporomandibular joints (TMJ).11,12
Different authors describe bifid condyle as a result of
trauma (application of forceps during birth,11 condylar
fracture by accident,1,6,13-15 surgical condylectomy). This
theory is based on the fact that after a condylar neck fracture, an antero-medial displacement of the condyle takes
place due to the action of the external pterygoid muscle,
such that it produces a metaplasia of the local fibroblasts
in the condylar neck, which in turn develops a new
condylar head in the normal anatomic location, while the
displaced condyle begins a resorption process. Thus, for a
time, two or more condyles14 or a double condyle on one
side and a triple condyle on the other side may be present.15 In these cases, one of the condyles (anterior) does
not function and one of them (posterior) does.
Dr. José Lopéz-Lopéz has a M.D. degree
from Autonoma of Barcelona University,
Spain and a Ph.D. from the University of
Barcelona. He is a full professor of oral
medicine in the Department of Dentistry
at the University of Barcelona. Dr. LopézLopéz also has received master’s degrees
in implantology from the University of
Sevilla and oral pathology from the
University of Barcelona.
1
BIFID CONDYLE
Other authors support the theory that bifid condyle is
an embryological malformation. When the fetus is about
20 weeks old, a septum of vascular fibers appears in the
cartilage of the condyle, extending all the way to the interior of the bone. This septum disappears at about the nineteenth week of life, such that if one suffers an injury or
there continues to be a shortage of blood supply, it may
affect the proper ossification of the condyle and end up
producing a bifid condyle.7,9
Surgery is usually indicated only in cases of condylar
ankylosis13 or when there is significant pain when chewing,16 which is usually secondary to trauma. Displaced
articular disks, causing pain and/or dysfunction may also
be an indication for surgery. As for cases, which are
asymptomatic or there is mild temporomandibular dysfunction, the treatment is usually conservative. Computerized tomography is most often considered the test of
choice for establishing the differential diagnosis.17
Some authors have documented cases with additional
tests such as Panoramic Radiograph (PR),4,18 Computerized Tomography (CT),6,8,10-11,13-15 Magnetic Resonance
Imaging (MRI),1,5,9 and as aforementioned, they are often
cases in which the patient is asymptomatic and the
condyle is functioning normally when the diagnosis is
made unexpectedly. In addition, the therapeutic approach
does not vary depending on the results of the additional
tests. In this sense, it seems reasonable to question the
need for further tests that are invasive and do not alter the
treatment.
Dennison2 suggests that the term bifid condyle should
only be reserved for cases in which they appear both in
the anterior and posterior part of the sagittal plane, suggesting that the rest of the cases should be classified as a
cleft, notch, or gap, thus considering them to be false
bifid condyles. This study presents two new cases of unilateral bifid condyle.
Clinical Case No. 1
Case number one is a female patient aged 70 years,
who requested oral rehabilitation, and had not been clinically diagnosed with temporomandibular dysfunction
(TMD). She had normal opening (Figure 1) without
signs or symptoms in the joints or muscles. During the
radiological testing (PR) for treatment planning, the
image showed a double contour of the condyle (Figure
2), which can be seen in the left temporomandibular joint
(TMJ). In the medical history, the patient reported childhood trauma on that side of the face, which resulted in
not being able to open the mouth for several days. The
therapeutic approach was the prosthodontic rehabilitation
of the patient without active therapeutic treatment of
the TMJ.
2
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE
LOPEZ-LOPEZ ET AL.
Figure 1
Clinical case No. 1: Normal mouth opening.
Clinical Case No. 2
Case number two is a female patient aged 53 years who
was referred by a general dentist for TMJ evaluation. The
patient presented discomfort in the jaw when waking up
in the morning. The clinical evaluation revealed a displacement of seven mm in the opening on the right side of
Figure 2
Clinical case No. 1: Detail of the double contour of the left TMJ
condyle. The emergence of the second head can be observed beneath
the neck of the larger condyle.
APRIL 2010, VOL. 28, NO. 2
LOPEZ-LOPEZ ET AL.
BIFID CONDYLE
six months, and progress was observed to be favorable.
Discussion
Figure 3
Clinical case No. 2: Displacement seven mm to the right at maximum
opening.
the mouth (Figure 3), normal lateralities, stiff end-feel,
and positive muscle palpation on the right and left external pterygoid, insertion of the right and left temporal, and
left masseter muscles. The PR revealed the left mediolateral double contour of the condyle (Figure 4). The therapeutic approach was conservative, making a splint that
would provide decompression of the joints and relaxation
of the muscles. The patient was seen for a checkup after
In the last ten years, we have found 30 cases of bifid
condyle referenced in the literature (Table 1). It is an
unexpected finding in routine checkups such as the PR,
which is the most common way it is diagnosed. That is,
most patients who are diagnosed are asymptomatic and
have normal joint function.4,5,8-10 In these types of patients,
the case is often documented with supporting tests such
as a CT, MRI, or both,1,5-6, 8-10,12-15 although the usefulness
of conducting such tests is questionable, since they
involve a financial and time commitment on the part of
the patient whose prognosis is not going to change.
(Moreover, in the case of the CT, the patient receives
radiation.) However, the diagnostic orientation and
therapeutic treatment in patients who show symptoms
or who have abnormal function may justify performing
such tests.
However, the designation of bifid condyle has also
been discussed, and it has been proposed to reserve the
name exclusively for antero-posterior cases while considering the rest to be false bifid condyles.2 In this sense, it
would be advisable to analyze each case in order to determine if it corresponds to a gap or if it is an actual bifid
condyle, given that it does not seem reasonable to set the
criteria according to which direction the condylar heads
are facing. It could be the case that the central split of the
condyle was so deep that it exceeded the entire condyle,
actually presenting two condylar heads in the lateromedial direction,6-7,13 with subsequent adjustment of the
remaining joint structures (menisci, muscular insertions,
ligaments and glenoid cavity).
For this reason, and in an effort to simplify the terminology, it is proposed that the criteria for defining bifid
condyle be determined according to whether or not the
condylar heads emerge from the neck of the condyle or
further down, regardless of the spatial orientation, given
that functionally speaking they should be considered in
the same manner.
Conclusions
Figure 4
Clinical case No. 2: The panoramic radiograph revealed the left mediolateral double contour of the condyle.
APRIL 2010, VOL. 28, NO. 2
It is suggested that further tests, such as MRI or CT, be
carried out only in cases where the therapeutic approach
involves an active treatment.
In order to simplify the terminology used, it is proposed that bifid condyle is described as that which presents two condylar heads emerging from the neck of the
condyle or further down, regardless of the direction in
which they are facing.
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE
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BIFID CONDYLE
LOPEZ-LOPEZ ET AL.
Table 1
Thirty (30) Bifid Condyles Documented in the Literature Over the Past 10 Years in Living Humans
No. of patients/
author
1/Acikgoz
1/Alpaslan
Gender/
med. record
Female
Male
1/Antoniades
Male
T
Female
T
Female
1/Artvinli
1/Corchero
1/Daniels
Male
T
1/De Sales
Male
T
Male
Female
T
1/Espinosa
1/Hersek
9/Menezes
1/Moraes
Female
Male
Female
Female
Male
Female
Female
Female
Female
Female
Age
54
40
15
No. of
condyles
2
2
Orientation
Mediolateral
Mediolateral
Impact
Bilateral
Bilateral
Bilateral
Left
25
2 right
3 left
3
42
2
Medial, central
and lateral
Medial, central
and lateral
Anteroposterior
32
2
Mediolateral
Right
8
2
Mediolateral
Right
29
36
2
2
Mediolateral
Anteroposterior
Bilateral
Left
28
30
74
20
43
53
72
52
29
20
2
Mediolateral
Left
Left
Bilateral
Left
Bilateral
Right
Left
Right
Right
Left
2
10/Rehman
Left
Clinical
Asymptomatic
Asymptomatic
discovery of
anterior disk
displacement
w/o reduction
Opening limited
24 mm, no flares
Asymptomatic
Reciprocal click,
lateral displacement to the left
protrusion 10 mm
Displacement to
the right, limited
opening, protrusion 9 mm
Displacement to
the right
Asymptomatic
Facial asymmetry,
limit lat. right and
protrusion, click left
Asymptomatic
Asymptomatic
Additional
tests
PR, CT
PR, CT, MRI
PR, CT
PR, CT
PR, CT, MRI
PR, CT
PR, CT
PR, CT, MRI
PR (all)
CT (two)
Transcranial (1)
PR, MRI,
Rx TMJ
CT
Male T
9
2
Anteroposterior
Bilateral
Ankylosis
Female T
6
Anteroposterior
Bilateral
Ankylosis
Bilateral
Ankylosis
Mediolateral
26
Male T
Female T
8
Mediolateral
Bilateral
Ankylosis
Male T
16
Mediolateral
Right
Ankylosis
Ankylosis
Right
Mediolateral
Female T
38
Ankylosis
Left
Mediolateral
Female T
5
Male T
44
Mediolateral
Right
Ankylosis
Female T
7
Mediolateral
Right
Ankylosis
Male I
20
Mediolateral
Left
Ankylosis
1/Sales
Female
8
2
Mediolateral
Left
Ankylosis
CT
2/Shiriki
Female
45
2
Mediolateal
Right
Headache, clicks
CT, MRI
Female M
17
2
Mediolateral
Left
Asymptomatic
4/Stefanou
Female
55
2
Mediolateral
Bilateral
Asymptomatic
PR, Rx TMJ
PR, Rx TMJ
Asymptomatic
Bilateral
Mediolateral
Male
47
2
Mediolateral
Bilateral
Asymptomatic
PR, Rx TMJ
Female
39
2
Female
69
2
Mediolateral
Bilateral
Asymptomatic
Rx TMJ
1/Tunçbilek
Male T
8
2
Mediolateral
Left
Asymptomatic
PR, CT
T: trauma; I: infection; M: microtia, PR: panoramic radiograph; CT: computerized tomography; MRI: magnetic resonance
imaging; Rx TMJ: lateral radiograph of TMJ
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LOPEZ-LOPEZ ET AL.
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BIFID CONDYLE
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Dr. Raúl Ayuso Montero received a D.D.S. and Ph.D. degrees from the
University of Barcelona, Spain. He also has master’s degrees in prosthodontics from the same university and implantology from the University of
Sevilla. Dr. Montero is a professor of prosthodontic medicine in the
Department of Dentistry at the University of Barcelona.
Dr. Enric Jané Salas received an M.D. degree from Autonoma of
Barcelona, University of Barcelona, Spain and a Ph.D. from the
University of Barcelona. He also has a master’s degree in endodontics
from the same university. Dr. Salas is a professor of oral medicine in the
Department of Dentistry at the University of Barcelona.
Dr. Xavier Roselló-Llabrés received an M.D. degree from Autonoma of
Barcelona, University of Barcelona, Spain and a Ph.D. from the
University of Barcelona. He is a professor of oral medicine in the
Department of Dentistry at the University of Barcelona.
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