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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 2  |  Page : 34-39

Modified tangential Peeyush's technique: A simplified radiographic technique to visualize zygomatic arch fracture


1 Department of Dentistry, AIIMS, Patna, Bihar, India
2 Department of Oral Medicine and Radiology, Faculty of Dental Sciences, IMS, BHU, Varanasi, Uttar Pradesh, India
3 Department of Oral Medicine and Radiology, Government College of Dentistry, Indore, Madhya Pradesh, India
4 Department of Oral and Maxillofacial Surgery, Dental College Azamgarh, Azamgarh, Uttar Pradesh, India
5 Department of Oral Medicine and Radiology, Narsinhbhai Patel Dental College and Hospital, Visnagar, Gujarat, India

Date of Submission06-May-2022
Date of Decision12-Jun-2022
Date of Acceptance15-Jun-2022
Date of Web Publication22-Jul-2022

Correspondence Address:
Peeyush Shivhare
Department of Dentistry, AIIMS, Patna, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jomr.jomr_11_22

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  Abstract 


Introduction: Zygomatic arch (ZA) fractures are common in facial trauma. The imaging techniques for the ZA include submentovertex (SMV) and jug handle (a variation of the SMV view) views. These radiographic techniques require neck hyperextension to make the canthomeatal line parallel to the film receptor. Most of the time, these patients will be having cervical injuries also which makes these imaging techniques challenging. Aims and Objectives: This observational study aimed to estimate the efficacy of modified tangential Peeyush's technique (MTP technique) as an alternative to SMV view in patients with ZA fracture along with neck pain. Materials and Methods: A digital panoramic radiography machine and other standard equipment for radiography were used. Twenty patients with clinically diagnosed ZA fracture were selected and imaged using two different techniques, i.e., technique A (canthomeatal line to be about 30°–45° in relation to image receptor) and technique B (MTP technique). Images obtained with both techniques were evaluated for the presence of ZA fracture. The results were tabulated and compared. Results: Technique A showed partial visualization of ZA in 55% of the cases, whereas ZAs were not visualized in 45% of cases. ZA was evident in 100% of the sample selected in technique B (MTP technique). Conclusion: Modified Peeyush's tangential technique can be applied in patients having ZA fracture with neck pain.

Keywords: Jug handle view, tangential techniques, zygomatic arch


How to cite this article:
Shivhare P, Kumar A, Parihar A, Haidry N, Sah N, Singh A. Modified tangential Peeyush's technique: A simplified radiographic technique to visualize zygomatic arch fracture. J Oral Maxillofac Radiol 2022;10:34-9

How to cite this URL:
Shivhare P, Kumar A, Parihar A, Haidry N, Sah N, Singh A. Modified tangential Peeyush's technique: A simplified radiographic technique to visualize zygomatic arch fracture. J Oral Maxillofac Radiol [serial online] 2022 [cited 2022 Dec 5];10:34-9. Available from: https://www.joomr.org/text.asp?2022/10/2/34/351749




  Introduction Top


The zygomatic arch (ZA) comprises a zygomatic process of the temporal bone and the temporal process of the zygomatic bone joined by the zygomaticotemporal suture. Isolated ZA fractures are frequently observed in maxillofacial injuries.[1] Fractures of the ZA cause significant functional and cosmetic morbidity. The ZA is one of the most common facial bones to get fractured in a midfacial injury due to a facial blow or road traffic accident. Clinically, a ZA fracture commonly presents as depression over the involved side of the face. Depressed fracture of the zygoma can be missed clinically due to soft-tissue swelling obscuring the bony defect.[2]

The common method used for imaging the ZA is the submentovertex (SMV) view[3] and the jug handle view (a variation of the SMV view) radiographs.[4] Other methods used infrequently include tangential projection[4] and the Watson technique.[5] Recently, other techniques have been tried for imaging ZA, for example, using intraoral X-ray machine with occlusal radiograph[6] and bisector method.[7]

Out of these techniques, usually, SMV is considered the gold standard but the patient has to extend the neck far backward making this technique painful for some patients, thus contraindicated in patients with suspecting neck injuries.[4] This arises the need for an alternative technique to evaluate ZA without causing any discomfort for those patients. Therefore, this study was performed to find the efficacy of the modified tangential Peeyush's technique (MTP technique) in a patient with suspected ZA fracture along with neck pain using a panoramic machine.


  Materials and Methods Top


This observational cross-sectional study was carried out in the Department of Oral Medicine and Radiology in Nobel Medical College Teaching Hospital, Nepal, for a duration of 3 months from January 2021 to March 2021. Ethical clearance was obtained from the institutional ethical committee (NMCTH/572/2021) under the guidelines provided by the “World Medical Association Declaration of Helsinki on ethical principles for medical research involving humans for studies.” The nature of the study was explained explicitly to the subjects and prior consent was obtained for the study.

Sample size analysis

The sample size determination was done as described below:

  • The average number of patients reporting to the department with ZA fracture per month is 6–8
  • The study duration was of 3 months.
  • Hence, the target population was 20–24.
  • Considering the above factors, 20 cases were enrolled for the study. (Keeping margin of error at 5%, confidence level at 95%, and response distribution at 50%).


Hence, the study enrolled 20 patients visiting the Department of Oral Medicine and Radiology in Nobel Medical College Teaching Hospital, Nepal, with clinically diagnosed ZA fracture for a time duration of 3 months.

A detailed case history recording along with a clinical examination was performed to find the nature of the injury. Only the cases suspected with isolated ZA were included. Out of the 20 subjects, 15 were males and 05 were females.

Inclusion criteria for the study included patients with clinically diagnosed isolated ZA fracture, completely conscious, and cooperative patients without any neurological symptoms [Figure 1], [Figure 2].
Figure 1: An example of the radiographic image without modification

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Figure 2: Visualization of the depressed zygomatic arch fracture using the modified tangential technique

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Exclusion criteria of the study included the patients with multiple facial bone fractures, the patients with known cervical injuries, uncooperative patients, and patients with previous computed tomography (CT) reports (to prevent over radiation exposure). The armamentarium used was the digital panoramic radiography (Carestream CS 8100) machine and lead apron. The panoramic radiography machine was operated at 70 kV (voltage) and 10 mA (current), with 10 s exposure time.

Technique A

After the detailed case history and examination, the patients were subjected to radiographic investigation following radiation safety measures. Each patient was made to stand/sit on a stool and advised to extend his/her neck to the maximum possible limit without any discomfort. Most of the patients were able to extend their neck to make the canthomeatal line at 40°–45° in relation to the image receptor. The midsagittal plane was kept perpendicular to the image receptor.

Thus, the first radiograph of the patient was exposed by making the canthomeatal line at 30°–45° angle to the image receptor. The central ray was directed perpendicular to the image receptor. Radiographic images were evaluated for the presence of the ZAs [Figure 3], [Figure 4], [Figure 5].
Figure 3: The patient was advised for maximum possible neck extension without any discomfort. MSP plane was kept perpendicular to the image receptor. MSP: Midsagittal plane

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Figure 4: Canthomeatal line (CML) is 30°–45° to the image receptor (F)/45°–60° to the central beam of X-ray (X) for technique A

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Figure 5: First radiographic exposure/technique A (the zygomatic arch was partially appreciated)

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Technique B

For the technique B/MTP technique, the patients were advised to rotate the midsagittal plane 15° toward the affected side keeping the same 30°–45° angulations of canthomeatal line with the image receptor [Figure 6]. This maneuver allowed the ZA of interest to be projected onto the film without superimposition of the skull vault or facial bones. Radiographic images were evaluated for the presence of the ZA [Figure 7].
Figure 6: Second radiographic exposure (patient rotating the median sagittal plane 15° toward the side of interest (15° MSP) maintaining 30°–45° angulations of canthomeatal line to the image receptor (technique B). MSP: Midsagittal plane

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Figure 7: Zygomatic arch completely appreciated in technique B (MTP technique). MTP Technique: Modified tangential Peeyush's technique

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The results of both techniques were tabulated. A digital radiograph was advised for all patients to avoid unnecessary exposure (ALARA principle). Even if both techniques were performed in the same patient thus two exposures were made, still, the combined radiation dose (4–12 μSV) was significantly lower than the cone-beam computed tomography (CBCT) (68–1073 μSV)/CT scan (860–1500 μSV) for just evaluating an isolated ZA fracture.[8]


  Results Top


A total of 20 patients with suspected ZA were included in the study, out of which 15 were males and 5 were females [Table 1] and [Table 2]. Radiographic images of both techniques were evaluated for the presence of the ZAs. Technique A showed partial visualization of ZA in 55% of the cases, whereas ZAs were not visualized mainly due to overlapping with the outer cortical border of parietal and temporal bones in 45% of cases. ZA was evident in 100% of the sample selected in technique B (MTP technique) [Table 1] and [Table 3].
Table 1: Master table of the cases selected for the study

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Table 2: Details of age and gender

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Table 3: Details of the zygomatic arch visualization based on the technique used

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  Discussion Top


ZA fracture is a common finding in middle facial fractures.[2] The imaging of the ZA is very important in the diagnosis and management of ZA fractures. The commonly used radiographic techniques for imaging ZA fracture include SMV and jug handle view.[3] The tangential technique is especially advised to evaluate unilateral depressed ZA fracture. Mostly the patients have severe pain in the facial and cervical region, with or without cervical injuries.[4] In the commonly used radiographic techniques such as jug handle view or SMV view, the patient has to extend the neck backward making the technique painful for some patients.[4]

CT/CBCT is the imaging technique of choice in midfacial fracture cases. The cost, availability of the machine, and the high radiation dose are some of the biggest limitations of these modalities.

The MTP technique was similar to the tangential technique described in the literature,[4] but the following changes have been made. First, this technique was performed in a dental setting using a panoramic machine in a standing or sitting position, making the performed technique unique. Second, the patients were not forced to align the canthomeatal line 90° to the central beam of the X-ray, to avoid neck pain. Most of the patients were able to extend their neck backward making an angle of about 30°–45° to the film receptor. Third, the patients were not forced to rotate their head 15° away from the side of interest avoiding unnecessary neck movement and discomfort.

The following advantages of this technique were observed:

  1. This technique decreases the amount of neck extension of the patient thus decreasing the uneasiness as compared to other techniques
  2. The technique is fit to evaluate depressed ZA fracture
  3. The technique can be indicated for postoperative evaluation of ZA fracture with low-dose exposure instead of high exposure to CT/CBCT.


The following were the limitations observed with this technique:

  1. Image only one ZA at a time, thus, a second exposure may be required to compare with the ZA of the normal side
  2. Magnification of the ZA as the central beam is not projected perpendicular to the ZA.


The study utilized the digital panoramic machine but the technique can be performed in other extraoral radiographic machines in keeping the patient standing or sitting with the same radiographic technique. However, the exposure parameter differs to 70 kV and 40 mAs.

The comparison between the gold standard SMV technique and with MTP technique is summarized in [Table 4].
Table 4: Comparison of submentovertex with modified tangential Peeyush's technique

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Limitation of the study

Although SMV is considered a gold standard technique for ZA evaluation, our study did not include SMV to compare our technique due to the patient's discomfort and pain. Thus, accuracy and specificity could not be assessed.


  Conclusion Top


The MTP technique can be applied in patients having depressed ZA fracture with neck pain. This technique can surely be an alternative to conventional SMV, especially in the presence of a panoramic radiographic setup.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chaurasia BD, Garg K. Osteology of head and neck. In: Chaurasia BD, Garg K, editors. BD Chaurasia's Human Anatomy: Regional and Applied Dissection and Clinical, Head, Neck and Brain. 4th ed., Vol. 3. New Delhi: CBS Publishers and Distributors; 2004. p. 3-44.  Back to cited text no. 1
    
2.
Fonseca RJ, Marciani RD, Turvey TA. Management of zygomatic fractures. In: Fonseca RJ, Marciani RD, Turvey TA, editors. Oral and Maxillofacial Surgery. 2nd ed., Vol. 2. St. Louis, MO: Elsevier; 2009. p. 182-3.  Back to cited text no. 2
    
3.
Tetradis S, Kantor ML. Extraoral radiographic examinations. In: White SC, Pharoah MJ, editors. Oral Radiology: Principles and Interpretation. 6th ed. St. Louis, Missouri: Mosby Elsevier; 2009. p. 191-206.  Back to cited text no. 3
    
4.
Whitley AS, Sloane C, Hoadley G, Moore AD, Alsop CW. The facial bones and sinuses. In: Whitley AS, Sloane C, Hoadley G, Moore AD, Alsop CW, editors. Clark's Positioning in Radiography. 12th ed. London: Hodder Arnold; 2005. p. 268.  Back to cited text no. 4
    
5.
Watson AR. New view for zygomatic arch. Radiology 1974;110:724.  Back to cited text no. 5
    
6.
Siddana SG, Muniraju M. Simplified zygomatic arch radiographic technique to overcome the drawback of jug handle view. J Indian Acad Oral Med Radiol 2014;26:390-2.  Back to cited text no. 6
  [Full text]  
7.
Yada N, Uchida K, Nagami A, Itakura K, Matsumura A, Komatsu A. Examination of axial zygomatic arch radiographs using the bisector method. Nihon Hoshasen Gijutsu Gakkai Zasshi 2008;64:948-54.  Back to cited text no. 7
    
8.
White SC, Pharoah MJ, editors. Safety and protection. In: Oral Radiology: Principles and Interpretation. First South Asia Edition. New Delhi, India: RELX India Private Limited; 2015. p. 32.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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