Bifid Condyle: Review of the Literature of the Last 10 Years and ...

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JOURNAL OF
CRANIOMANDIBULAR
PRACTICE,
Copyright © 2010
by CHROMA, Inc.
Manuscript received
September 23, 2009;
revised
manuscript received
December 3, 2009;
accepted
December 4, 2009
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
■ 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.
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.
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. Lopéz-
Lopéz also has received master’s degrees
in implantology from the University of
Sevilla and oral pathology from the
University of Barcelona.
1
The 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 condyles 14 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.

BIFID CONDYLE LOPEZ-LOPEZ ET AL.
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
ankylosis 13 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.
Dennison 2 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.
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.
2 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE APRIL 2010, VOL. 28, NO. 2

LOPEZ-LOPEZ ET AL. BIFID CONDYLE
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
Figure 4
Clinical case No. 2: The panoramic radiograph revealed the left mediolateral
double contour of the condyle.
six months, and progress was observed to be favorable.
Discussion
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
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.
APRIL 2010, VOL. 28, NO. 2 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 3

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/ Gender/ No. of Additional
author med. record Age condyles Orientation Impact Clinical tests
1/Acikgoz Female 54 2 Mediolateral Bilateral Asymptomatic PR, CT
1/Alpaslan Male 40 2 Mediolateral Bilateral Asymptomatic PR, CT, MRI
discovery of
anterior disk
displacement
w/o reduction
1/Antoniades Male 15 2 right Medial, central Bilateral Opening limited PR, CT
T 3 left and lateral 24 mm, no flares
1/Artvinli Female 25 3 Medial, central Left Asymptomatic PR, CT
T and lateral
1/Corchero Female 42 2 Anteroposterior Left Reciprocal click, PR, CT, MRI
lateral displacement
to the left
protrusion 10 mm
1/Daniels Male 32 2 Mediolateral Right Displacement to PR, CT
T the right, limited
opening, protrusion
9 mm
1/De Sales Male 8 2 Mediolateral Right Displacement to PR, CT
T the right
1/Espinosa Male 29 2 Mediolateral Bilateral Asymptomatic PR, CT, MRI
1/Hersek Female 36 2 Anteroposterior Left Facial asymmetry,
T limit lat. right and
protrusion, click left
9/Menezes Female 28 2 Left Asymptomatic PR (all)
Male 30 Left CT (two)
Female 74 Bilateral Transcranial (1)
Female 20 Left
Male 43 Bilateral
Female 53 Right
Female 72 Left
Female 52 Right
Female 29 Right
1/Moraes Female 20 2 Mediolateral Left Asymptomatic PR, MRI,
Rx TMJ
10/Rehman Male T 9 2 Anteroposterior Bilateral Ankylosis CT
Female T 6 Anteroposterior Bilateral Ankylosis
Male T 26 Mediolateral Bilateral Ankylosis
Female T 8 Mediolateral Bilateral Ankylosis
Male T 16 Mediolateral Right Ankylosis
Female T 38 Mediolateral Right Ankylosis
Female T 5 Mediolateral Left Ankylosis
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
Male 47 2 Mediolateral Bilateral Asymptomatic PR, Rx TMJ
Female 39 2 Mediolateral Bilateral Asymptomatic PR, Rx TMJ
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
4 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE APRIL 2010, VOL. 28, NO. 2

LOPEZ-LOPEZ ET AL. 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.
APRIL 2010, VOL. 28, NO. 2 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 5