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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 29  |  Issue : 1  |  Page : 60-62

Bifid condyle: Radiographic dilemma


Department of Oral Medicine and Radiology, Indira Gandhi Institute of Dental Sciences, Sri Balaji Vidyapeeth University, Pillaiyarkuppam, Puducherry, India

Date of Submission22-Jul-2016
Date of Acceptance21-Jun-2017
Date of Web Publication04-Aug-2017

Correspondence Address:
Sivasankari Thirunavukarasu
Department of Oral Medicine and Radiology, Indira Gandhi Institute of Dental Sciences, Pillaiyarkuppam - 607 403, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.JIAOMR_84_16

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   Abstract 

One of the most important and unique joints in the body is the temporomandibular joint (TMJ). When diagnosing patient with temporomandibular disorder (TMD) symptoms, the possibility of unusual causes must also be considered. Therefore, radiologic examinations prove to be an invaluable tool in the diagnosis of TMJ disorders. Computer tomography is the ideal imaging method to evaluate the condyle morphology and to rule out any degenerative process to achieve the differential diagnosis. The purpose of this article is to report two cases of fracture mimicking bifid condyle.

Keywords: Condyle, fracture, regeneration, trauma


How to cite this article:
Thirunavukarasu S, Sekizhar V, Ranghdol V, Vendan L. Bifid condyle: Radiographic dilemma. J Indian Acad Oral Med Radiol 2017;29:60-2

How to cite this URL:
Thirunavukarasu S, Sekizhar V, Ranghdol V, Vendan L. Bifid condyle: Radiographic dilemma. J Indian Acad Oral Med Radiol [serial online] 2017 [cited 2020 May 31];29:60-2. Available from: http://www.jiaomr.in/text.asp?2017/29/1/60/212095


   Introduction Top


Diagnosis of fractures of mandibular condyle can be counted among the most controversial issues in maxillofacial traumatology. The fractures of the condyle represent 29–40% of the fractures of the facial skeleton and approximately 20–35% of all mandibular fractures.[1] Clinical and animal research has repeatedly demonstrated the remarkable regenerative capacity of the condylar process, especially following trauma. Falls, blows to the contralateral face or ipsilateral preauricular area, or chin injuries should alert the examiner to the possibility of a condylar/subcondylar injury. The mandible has unique and important morphological and functional features. The mandible is the only bone in the face that moves in relation to the skull. In addition, the mandible bears powerful muscular stresses. Plain radiography (most commonly) and computed tomography (CT) help to ascertain the location of the fracture, the degree and direction of displacement, and the presence or absence of associated injuries. All of this information is vital in developing an appropriate treatment plan. The radiographic appearances of fractured condyle mimicking neocondyle are illustrated in the following two case reports. It is common for an oral diagnostician to misdiagnose the radiographic mass as a benign or malignant tumor.


   Case Reports Top


Case 1

A 22-year-old male patient reported for replacement of missing tooth in the upper front tooth region and also gave a history of difficulty in hearing and ear pain in the left year since 1 week. History revealed that he had trauma 10 months earlier, for which intermaxillary fixation was done for a period of 1 month. On examination, patient had restricted mouth opening associated with deviation of mandible towards left side for past 2 months, hypomobility in the left temporomandibular joint (TMJ), and left side occlusal derangement was noticed. Based on the history and clinical features, we arrived at a provisional diagnosis of left condylar fracture. Bony ankylosis of condylar head and osteoma were considered in the differential diagnosis.

The orthopantomograph (OPG) [Figure 1] revealed a radiopaque mass approximately 2 × 1 cm medial to the left condylar region. Patient was referred to department of ENT for the complaint of ear pain; they evaluated and reported it as associated left ear canal fracture. CT axial section [Figure 2] at the level of TMJ revealed a well-defined hyperdense mass in the left TMJ with Hounsfield unit of +1000 units, which was suggestive of medially displaced fractured segment. Three-dimensional images clearly indicated a bony mass.
Figure 1: OPG shows radiopaque mass seen inferomedially in the left side condylar region

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Figure 2: CT axial section shows well-defined hyperdense mass in the left TMJ suggestive of medially displaced fractured segment

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Case 2

A 25-year-old male patient presented with the chief complaint of deviation of the jaw towards the right side while opening mouth for past 6 months. He gave a history of trauma 6 months before, followed by pain in the right TMJ during mastication. On extraoral examination, mouth opening was restricted to approximately 25 mm. A clicking sound was elicited in the right TMJ and there was occlusal derangement with open click. The muscles of mastication were not tender on palpation. With the help of the abovementioned clinical features and examination, we came to the provisional diagnosis of right condylar fracture.

OPG revealed [Figure 3] a radiopaque mass present inferiomedially in the right condylar region, following which open-closed lateral oblique radiograph of the TMJ was obtained which revealed radiopaque mass in the right side of the condylar head resembles benign neoplasm. CT in the bony window in both coronal and axial sections [Figure 4] showed linear condylar fracture on right side with displacement of condylar segment anteroinferiorly mimicking bifid condyle.
Figure 3: OPG showed radiopaque mass present medially in the right condylar region

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Figure 4: CT axial section showed the right side condylar fracture with displacement of condylar segment anteroinferiorly

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   Discussion Top


Condylar fractures in young individuals are important because of the risk of the mandibular growth center being affected in the condylar head, which can lead to growth retardation and facial asymmetry.[2] Bone tissue has the capacity to regenerate following immobilization. The exact mechanism that induces spontaneous bone regeneration is not fully understood, however, several factors including the patient’s age, preservation of the periosteum, infection, postoperative immobilization, and genetic behavior have been suggested to influence this process. Age is an important influential factor in the process of spontaneous bone regeneration.[3] It is suggested that in younger patients bone regeneration is increased due to higher cellular activity. In the above mentioned case reports, patients were young, and in the first case report, there was intermaxillary fixation for a period of 1 month.

Studies have demonstrated that, after fracture of the mandibular condyle in children, there is an excellent chance that the condylar process would regenerate to approximately its original size and a small chance that it would overgrow after the injury.[4] Condylar fractures may give rise to serious problems, such as growth disturbances of the face, disorders of the TMJ, malocclusion, and chronic dislocation and pain on the injured side. Cellular and molecular events are responsible for the formation of bone during embryogenesis. Nonsurgical therapy is the method of choice for younger individuals. In fact, there is an excellent chance of regeneration and continued normal development after fracture in growing patients.[5]

The mechanism behind neocondyle is not clearly understood. Undifferentiated mesenchymal cells which migrate along with the new blood vessels differentiate into osteoprogenitor cells, which have the potential to differentiate to osteoblasts and give rise to bone formation. Vascular endothelial growth factor (VEGF), a potent regulator of neovascularization, was expressed in the condyles and glenoid fossa of growing rats.[1],[6] Neovascularization and new bone formation are closely related.

Experimental and clinical studies have shown the great potential for compensation and remodeling of the condyle. Li et al., used Wistar rats to investigate the mechanism in favorable healing of pediatric condylar fractures.[7] The authors concluded that the growth potential and remodeling capability of a condyle during its growing period might be the intrinsic factor for the favorable prognosis of condyle fracture.[8]

Periosteum is responsible for the development of new bone. Chlamer et al. suggested that inducing agent, osteogenic precursor cell, and environment are responsible for growth. Recently, McNamara et al. reported histological changes associated with mandibular advancement in adult Rhesus monkeys. In these monkeys, adaptive changes of the condylar cartilage were evident after 3 weeks of advancement.[9],[10]

Delvin and Solan proposed that monoclonal antibodies (RUNX2) Runt-related transcription factor 2 (SB-10 and SB-20) can identify cells undergoing osteogenic differentiation. Disturbance of RUNX2 activity in embryological mice cause lack of bone formation in skull and mandible.[9] This implies clinical and animal research has repeatedly demonstrated the remarkable regenerative capacity of the condylar process.


   Conclusion Top


In both the cases, patients were in same age group, their chief complaint was also in the same region, and both the cases revealed similar trauma history, and the radiographic interpretation were also same; however, there is a different history of management for the trauma in the first patient who was treated by IMF, and the second patient who did not report back for the treatment. Both the case reports are a unique example of the misleading two-dimensional radiographic diagnosis, which was precisely diagnosed by obtaining a three-dimensional image for the same pathology. It is essential to conduct CT assessment to rule out the early stages of TMJ pathology. The choice for CT scan depicts the advantages of this modality of imaging over other methods.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
De villa GH, Chen CT, Chen YR. Spontaneous bone regeneration of the mandible in an elderly patient: A case report and review of the literature. Chang Gung Med J 2003;26:363-9.  Back to cited text no. 1
[PUBMED]    
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
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3.
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. Am J Neuroradiol 2005;26:1865-8.  Back to cited text no. 3
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4.
Stefanou EP, Fanourakis IG, Vlastos K, Katerelou J. Bilateral bifid mandibular condyles- Report of four cases. Dentmaxillofac Radiol 1998;27:186-8.  Back to cited text no. 4
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5.
Melo SL, Barbosa JM, Peixoto AC, Santos TS, Gerbi M. Bilateral bifid mandibular condyle: A case report. Int J Morphol 2011;29:922-6.  Back to cited text no. 5
    
6.
Mainali S, Tandon S. Bifid mandibular condyle with ankylosis in a 3-year-old child: A rare presentation and review. Contemp Clin Dent 2010;1:40-4.  Back to cited text no. 6
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7.
Tanner JM, Friedlander AH, Chang TI. Bilateral bifid mandibular condyles diagnosed with three-dimensional reconstruction. Dentmaxillofac Radiol 2012;41:691-5.  Back to cited text no. 7
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8.
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. 8
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9.
Cuccia AM, Caradonna C. Case report condylar growth after non-surgical advancement in adult subject: A case report. Head Face Med 2009;5:15.  Back to cited text no. 9
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10.
Hedge S, Praveen BN, Shetty SR. Morphological and radiological variations of mandibular condyles in health and diseases: A systematic review. Dentistry 2013;3:154.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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