title: Mandibular subluxation for distal internal carotid exposure: technical considerations.
abstract: OBJECTIVE
  Carotid endarterectomy (CEA) has become one of the most commonly performed vascular procedures, because of the beneficial outcome it has when compared with medical therapy alone and because of the anatomic accessibility of the artery. In cases of distal carotid occlusive disease, high cervical carotid bifurcation, and some reoperative cases, access to the distal internal carotid artery may limit surgical exposure and increase the incidence of cranial nerve palsies. Mandibular subluxation (MS) is recommended to provide additional space in a critically small operative field. We report our experience to determine and illustrate a preferred method of MS.
  
  
  METHODS
  Techniques for MS were selected based on the presence or absence of adequate dental stability and periodontal disease. All patients received general anesthesia with nasotracheal intubation before subluxation. Illustrations are provided to emphasize technical considerations in performing MS in 10 patients (nine men and one woman) who required MS as an adjunct to CEA (less than 1% of primary CEAs). Patients were symptomatic (n = 7) or asymptomatic (n = 3) and had high-grade stenoses demonstrated by means of preoperative arteriography.
  
  
  RESULTS
  Subluxation was performed and stabilization was maintained by means of: Ivy loop/circumdental wiring of mandibular and maxillary bicuspids/cuspids (n = 7); Steinmann pins with wiring (n = 1); mandibular/maxillary arch bar wiring (n = 1); and superior circumdental to circummandibular wires (n = 1). MS was not associated with mandibular dislocation in any patient. No postoperative cranial nerve palsies were observed. Three patients experienced transient temporomandibular joint discomfort, which improved spontaneously within 2 weeks.
  
  
  CONCLUSIONS
  Surgical exposure of the distal internal carotid artery is enhanced with MS and nasotracheal intubation. We recommend Ivy loop/circumdental wiring as the preferred method for MS. Alternative methods are used when poor dental health is observed.
authors.affiliation: Division of Vascular Surgery, Department of Surgery, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark 07103-2714, USA.
authors.forename: G T
authors.initials: GT
authors.lastname: Simonian
authors.forename: P J
authors.initials: PJ
authors.lastname: Pappas
authors.forename: F T
authors.initials: FT
authors.lastname: Padberg
authors.forename: A
authors.initials: A
authors.lastname: Samit
authors.forename: M B
authors.initials: MB
authors.lastname: Silva
authors.forename: Z
authors.initials: Z
authors.lastname: Jamil
authors.forename: R W
authors.initials: RW
authors.lastname: Hobson
mesh_terms: D000328:Adult; D000368:Aged; D001858:Bone Nails; D001864:Bone Wires; D002343:Carotid Artery, Internal / Q000601:surgery*; D016893:Carotid Stenosis / Q000601:surgery*; D016894:Endarterectomy, Carotid / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008334:Mandible / Q000601:surgery*; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology