Distal internal carotid exposure: a simplified technique for temporary mandibular subluxation

Distal internal carotid artery exposure can be technically demanding even for experienced vascular surgeons. Although a variety of techniques have been described to facilitate such exposure, temporary mandibular subluxation has emerged as the simplest and least debilitating approach. Current techniques for maintaining temporary mandibular subluxation during distal internal carotid artery procedures, including maxillomandibular arch bar fixation and circummandibular/transnasal wiring, have been time consuming and associated with complications. Over the last 4 years a new simplified technique of temporary mandibular subluxation fixation has been used in 14 patients requiring distal internal carotid exposure. Indications for operation included extended carotid endarterectomy (8), carotid body tumor excision (2), repair of distal internal carotid artery trauma (2), and repair of postendarterectomy pseudoaneurysm (2). Among patients with healthy teeth, unilateral temporary mandibular subluxation was maintained by interdental wiring from the ipsilateral mandibular bicuspids to the contralateral maxillary bicuspids. In edentulous patients or those with chronic periodontal disease, temporary mandibular subluxation was maintained with diagonal wiring between maxillary and mandibular Steinmann pins. No instances of malocclusion, dental injury, or local infection were observed. Transient postoperative cranial nerve dysfunction was observed in three patients. Transient ipsilateral temporomandibular joint pain occurred in three patients. Two patients developed permanent cranial nerve injuries unrelated to temporary mandibular subluxation. These data suggest that temporary mandibular subluxation by diagonal interdental/Steinmann pin wiring is safe, expeditious, and effective in facilitating exposure of the distal internal carotid artery.