Trifid mandibular condyle: A case report and literature review

Trifid mandibular condyle: A case report and literature review

G Model JORMAS-618; No. of Pages 4 J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx Available online at ScienceDirect www.sciencedirect.com Case...

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G Model

JORMAS-618; No. of Pages 4 J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx

Available online at

ScienceDirect www.sciencedirect.com

Case Report

Trifid mandibular condyle: A case report and literature review A. Ayat a,*, Z. Boudaoud b, L. Djafer a a b

Department of oral implantology, Central military hospital, Algiers, Algeria Department of oral pathology and medicine, Mustapha Pasha university hospital, Algiers, Algeria

A R T I C L E I N F O

A B S T R A C T

Historique de l’article : Received 26 October 2016 Accepted 9 December 2018

Trifid mandibular condyle is a rare anatomical malformation characterized by a division of the mandibular condylar head. The two articulating surfaces of the bifid condyle are divided by a groove that can be oriented mediolaterally or anteroposteriorly. This anomaly of the mandibular condyle has been described as a condition of unknown ætiology and uncertain pathogenesis. Some authors see it as a result of accidental trauma or forceps delivery, with the two heads occurring one behind the other in the sagittal plane. Reported cases are mostly unilateral and usually asymptomatic. The diagnosis is made after radiographic exploration and precised by advanced imaging techniques such as three-dimensional computerized tomography.

C 2018 Elsevier Masson SAS. All rights reserved.

Keywords: Trifid Bifid mandibular condyle Trauma Facial asymmetry Temporo-mandibular joint disorder 3-D computerized tomography

The trifid mandibular condyle (TMC), is a rare malformation in which the mandibular condyle is triplicated or lobulated. It can be associated with a variety of symptoms. The purpose of this case report is to present a unilateral trifid condyle. The possible causes and the diagnostic are also discussed.

one was in the region of the joint cavity. The posterior condyle had a smooth surface and was slightly inferiorly positioned (Fig. 4,5). Coronal CT images and 3D reconstructions showed that the posterior condyle head was also divided by a groove on the coronal plane. A diagnosis of the trifid right mandibular was retained and no treatment has been performed except a prosthetic dental rehabilitation with decayed teeth care.

2. Case report

3. Discussion

A 40-year-old female patient reported to us with a chief complaint of pain in the right mandibular molar area. History revealed an incident of a road traffic accident about 18 years ago, in which minor injuries on the right side of the face and jaw were described, which did not require any intervention. Extra oral examination revealed a chin deviation to the right side (Fig1). On palpation, the right temporomandibular joint (TMJ) movements were normal. Intra-oral examination revealed a normal opening mouth amplitude with deviation to the right (Fig.2). The orthopantomogram (OPG) showed an anteroposterior oriented bifid right condyle with two distinct condylar heads, separated by a deep V-shaped groove (Fig.3). Computerized tomographic (CT) images showed that the anterior one was under the zygomatic arch distant from the joint cavity within the space delimited by the zygomatic arch and the squamous region, whereas the posterior

Although the mandibular condyle is one of the most common sites of injury to the facial skeleton, it is also the most overlooked and least diagnosed trauma site in the head and neck region [1]. This trauma may lead to many complications and sequelae as the condyle division. The terms ‘‘bifid’’ and ‘‘trifid’’ were derived from the Latin meaning a cleft in two and three parts. The bifid or trifid mandibular condyle is a rare malformation, [2] in which the head of the condyle is duplicated or lobulated. Dennison suggests that the term bifid condyle should be exclusively 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, including other orientations, should be classified as clefts, notches, or gaps, thus considering them to be false bifid condyles [3]. According to the literature, at least 50 cases of bifid mandibular condyles and eight cases of trifid condyles have been described [4– 10]. One exceptional case of tetrafid condyle is also reported [11].

1. Introduction

* Corresponding author. E-mail address: [email protected] (A. Ayat). https://doi.org/10.1016/j.jormas.2018.12.008 C 2018 Elsevier Masson SAS. All rights reserved. 2468-7855/

Please cite this article in press as: Ayat A, et al. Trifid mandibular condyle: A case report and literature review. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.12.008

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Fig. 3. The panoramic radiograph revealed the right anteroposterior double contour of the condyle.

Fig. 1. Photography showing facial asymmetry with deviation of chin to the right.

This number has suddenly increased, probably as a result of improved imaging techniques. In spite of this, the disorder is still considered rare [12]. The ages of the individuals for trifid condyles ranged from 6 to 52 years, with a male to female ratio of 1:2. Three of the cases had bifid condyles on the contralateral side [13,4,8], and one case had a bilateral triplication [9].

Fig. 2. Deviation to the right of the mandible during mouth opening.

The bifid mandibular condyle does not appear to have a predilection for any particular race, age or gender [13]. Most of the patients whose ages are known are over 20 years old [14]. Most of the cases were incidental radiographic findings. The dental panoramic radiograph seems to be the most common view that shows this anomaly [15]. This condyle abnormality has been described as a condition of unknown etiology and uncertain pathogenesis [14]. Many authors, if not all, describe it as a result of trauma like birth trauma, condylar fracture [13]. After a fracture of the mandibular neck, the condyle is displaced anteromedially by the action of the lateral pterygoid muscle [1,3]. A new condylar head develops through metaplasia of local fibroblasts at the normal anatomical site, while the displaced head is undergoing resorption. Consequently, for a certain period of time the patient has, effectively, two condyles or occasionally three, due to multiple fractures of the condylar head, or even a bifid condyle on the right side and a trifid condyle on the left, [13,4] a nonfunctioning anterior condyle, which, being somewhat vestigial, will ultimately be resorbed, and another functioning posterior condyle with a time-dependent growth face. We consider this to be the ‘‘true’’ bifid condyle - where the two condyles are situated anteriorly and posteriorly in the anatomical sagittal plane while the interval between them is oriented in the coronal plane. Endocrinological, pharmacological, and nutritional disorders have also been described as other causes of this developmental abnormality [4]. Also infection, irradiation, and genetic disorders may play a role [16]. Other authors support the theory that the bifid condyle is an embryological malformation. When the foetus 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 the blood supply, it may affect the proper ossification of the condyle and end up producing a bifid condyle [17]. This orientation of the bifid condyle has been classified as anterior-posterior and mediolateral. Szentpetery et al. suggested that when two condylar parts have a sagittal plane, trauma is indicated as the cause, and when the parts have a coronal orientation the persistence of the fibrous septa may be the cause [18]. From the angle of symptoms, 67% of the patients were asymptomatic with no complaint related to the temporomandibular joints; the condition was detected as an incidental finding during dental radiographic examination [15]. Nonetheless, it can be associated with a variety of symptoms, such as pain, restriction of mandibular movement, trismus, swelling, ankylosis, and facial asymmetries. These symptoms may be related to the alteration of the articular surface, hypercondylia, muscle and ligament injuries. The most common

Please cite this article in press as: Ayat A, et al. Trifid mandibular condyle: A case report and literature review. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.12.008

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Fig. 4. Three-dimensional computed tomographic scan of the right mandibular condyle showing a trifid condyle with the presence of an anterior and posterior condyle; a medio-lateral groove is visible on the posterior head.

Fig. 5. Three-dimensional computed tomographic scan of the right mandibular condyle showing a trifid condyle with the presence of an anterior and posterior condyle; a medio-lateral groove is visible on the posterior head.

and predominant symptoms is, by far, temporomandibular joint (TMJ) sounds. It has been suggested that arthritic changes might be seen in most bifid condyle cases and also that ostreoarthrosis might develop in cases resulting from trauma. However, there is not sufficient data to evaluate the long-term effects and complications of bifid condyles, especially in relation to the TMJ function [4,14,19]. Although the panoramic radiograph is a valid diagnostic tool, conventional radiographs are not sufficient [13]. Detailed evaluation of the condylar morphology is also necessary in order to differentiate the trifid mandibular condyle from other degenerative lesions such as tumors, cysts, metastatic or metabolic lesions. Computed tomography (CT) is the best choice for the osseous pathologies of the temporomandibular joint, because it allows bilateral visualization without superimposition [20,21]. In the asymptomatic cases, the treatment is usually conservative and similar to the treatment for the closely associated TMJ pain dysfunction syndrome (analgesics and anti-inflammatory agents, muscle relaxants, physiotherapy, splints) [4,19] and so the patients must be controlled and followed up. Treatment of patients presenting complaints are numerous including arthroscopy, TMJ prosthesis and condyloplasty, but poorly described because most cases are asymptomatic.

4. Conclusion Trifid mandibular condyle is a rare entity, diagnosed accidentally on radiographic examination. Its etiology is controversial. Dental professionals should have knowledge of this anatomic abnormality and of the problems caused in the function and the aesthetics, as well as appropriate treatment modalities. Disclosure of interest The authors declare that they have no competing interest.

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Please cite this article in press as: Ayat A, et al. Trifid mandibular condyle: A case report and literature review. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.12.008