Trifid mandibular condyle: A case report ¨ zden Kansu, DDS, PhD,b Ankara, Turkey Leyla Berna Artvinli, DDS, PhD,a and O HACETTEPE UNIVERSITY
A few cases of bifid, but no case of trifid mandibular condyle, have been reported in the literature. This article presents the first reported case of trifid mandibular condyle in a living subject with a history of previous trauma to the temporomandibular joint (TMJ). Additionally, the patient’s other condyle was bifid. The patient had no complaint related to the functions of TMJ except for minimal weakness following chewing. The etiology and the prognosis of bifid and trifid condyle are discussed briefly. We considered computed tomography essential to rule out early stages of TMJ pathology in similar cases that resemble trifid mandibular condyle on conventional radiographs. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:251-4)
The bifid mandibular condyle is a rare anomaly with an uncertain cause. Early cases of bifid mandibular condyle were reported on dried specimens by Hrdlicka in 1941.1 Reported cases in living people and dried specimens are mostly unilateral. The morphology of the bifidity ranges from grooving to discrete condylar heads. On the other hand, no reported case of trifid mandibular condyle exists in the literature. We discuss an occurrence of trifid mandibular condyle and concurrent bifid mandibular condyle and the etiology and prognosis of these anomalies. CASE REPORT A 25-year-old woman appeared in our clinic with the complaint of caries. Her medical history was noncontributory except for a childhood accident involving the head and neck region. Intraoral examination revealed an anterior open bite and caries on all molar teeth. During the extraoral examination, an indistinct scar under the chin was seen. Although the mandibule was slightly deviated to the left side, the functions of the temporomandibular joint (TMJ) were normal. The panoramic radiograph that was taken to assess the deviation showed that the shapes of both condyles were abnormal (Fig 1). Her TMJs were then imaged with the specific TMJ mode of the panoramic machine to evaluate the form of the condyles better. This radiograph clearly demostrated that the right condyle had a grooving in the anteroposterior direction (Fig 2). Upon questioning, the mother of the patient reported that the patient had fallen from tree when she was 3 and that the only medical care she had received following the accident was suturing the laceration under her chin. The mother also stated that the patient had no difficulty on chewing after the
Research Assistant, Department of Oral Diagnosis and Radiology, Faculty of Dentistry, Hacettepe University, Ankara, Turkey. b Associate Professor, Department of Oral Diagnosis and Radiology, Faculty of Dentistry, Hacettepe University, Ankara, Turkey. Received for publication Mar 10, 2002; returned for revision Jun 18, 2002; accepted for publication Jul 20, 2002. © 2003, Mosby, Inc. 1079-2104/2003/$30.00 ⫹ 0 doi:10.1067/moe.2003.93
accident. Nevertheless, the patient now complained of minor weakness of the jaws after chewing. The patient’s birth was uneventful, and there was no reported history of medication during pregnancy. Although the shape of the left condyle resembled a trifid condyle on the panoramic radiograph, a computed tomography (CT) scan was taken to rule out early stages of TMJ pathology. CT images revealed no sclerotic or lytic lesion on the left condyle (Fig 3). The 3-dimensional reconstructed view of the left condyle showed that the first and the second heads were situated medially and laterally respectively and that the third head was in the posterior of the first and the second heads and was closer to the second head (Fig 4). Treatment planning included restoration of caries and follow-up of the TMJs’ function and morphology.
DISCUSSION The etiology of bifid mandibular condyle is not fully understood. Three reported cases of bifid mandibular condyle in 1 adult and 2 children have developed during the healing period of condylar fracture.2,3 Furthermore, Stadnicki4 has reported a bifid mandibular condyle in a child who received forceps trauma during delivery. In 2 other reported cases, authors were also able to relate the anomaly to obvious history of previous trauma to TMJ.5,6 These examples support the claim that trauma involving TMJ may result in bifid mandibular condyle. However, bifid condyles may exist in patients with no history of related trauma.7-14 Alternatively, some authors have suggested developmental origin as the cause of bifid mandibular condyle. Moffett15 has postulated that the retention of connective tissue septa, normally present at an early prenatal age, is responsible for the problem. Gundlach10 has produced bifid condyles in animal studies by injecting a teratogenic substance into the animal during pregnancy. Quayle and Adams9 have proposed that endocrine disorders, nutritional deficiency, infection, trauma, irradiation, and genetic factors can be the cause. In our case the scar under the patient’s chin gave some clue about the direction of the trauma, which supports that the TMJs were influenced by the accident. 251
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Fig 1. The panoramic radiograph displaying the abnormally shaped mandibular condyles.
Fig 2. The TMJ projection exhibiting the right mandibular condyle with a grooving in anteroposterior direction.
Also, the previous medical history of the patient made us think that the trauma did not cause fracture. The delivery of the patient was uneventful following a normal pregnancy during which her mother took no medication. So, in this patient, childhood TMJ trauma seems responsible for both bifid and trifid condyle. In our opinion, concurrence of the trifid and the bifid condyle suggests that these 2 anomalies are the variations of the same clinical entity.
Functional disturbances of TMJ have not been reported in the majority of cases of bifid mandibular condyle. These cases have been diagnosed on radiographs that have been taken for other reasons.8,10-14 Surgery has been performed in symptomatic cases.4-6,9 In our case, no surgery has been planned for bifid and trifid condyle because of the absence of symptoms. If one considers that TMJ complaints are reported to develop progressively in patients with bifid mandibular
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Fig 3. Successive CT sections (from a to d) demonstrating the contours of the left mandibular condyle.
Fig 4. Three-dimensional reconstructed view showing the locations of 3 poles.
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condyles, in our patient the absence of significant complications for 22 years is an indicator of good prognosis. In this present case, panoramic radiography was a valid diagnostic tool in the diagnosis of bifid mandibular condyle. On the other hand, the images of the left condyle on the conventional radiographs were not sufficient to reach final diagnosis. It was essential to conduct CT examinations to rule out early stages of TMJ pathology (eg, ostechondroma) before naming the case as trifid mandibular condyle. REFERENCES 1. Hrdlicka A. Lower jaw: Double condyles. Amer J Phys Auth 1941;28:75-89. 2. Thomason JM, Yusuf H. Traumatically induced bifid mandibular condyle: a report of two cases. Br Dent J 1986;161:291-3. 3. Antoniades K, Karakasis D, Elephtheriades J. Bifid mandibular condyle resulting from a sagital fracture of the condylar head. Br J Oral Maxillofac Surg 1993;31:124-6. 4. Stadnicki G. Congenital double condyle of the mandible causing temporomandibular joint ankylosis: report of case. J Oral Surg 1971;29:208-11. 5. To EWH. Mandibular ankylosis associated with a bifid condyle. J Craniomaxillofac Surg 1989;17:326-8. ¨, O ¨ nerci M, Kansu H, Uysal S, Eryilmaz M. Bifid 6. Kansu O
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Reprint requests: Dr. Leyla Berna Artvinli ¨ niversitesi Dis¸hekimligˇ i Faku¨ ltesi Hacettepe U Oral Diagnoz-Radyoloji Anabilim Dali Sihhiye, 06100 Ankara TURKEY [email protected]