"Mandibular subluxation using a putty splint: a strategy to optimize access to the distal internal carotid artery in a minimally invasive manner".

Abstract

Purpose: This study aims to describe and evaluate a minimally invasive technique to improve surgical access to the distal cervical segment of the extracranial internal carotid artery (DCSICA) by performing a controlled mandibular subluxation assisted by a prefabricated occlusal splint.

Methods: Seven patients requiring surgical exposure of DCSICA were selected. Diagnoses included five Shamblin III carotid body tumors, one internal carotid artery (ICA) aneurysm, and one case of ICA stenosis. Preoperatively, patients were instructed to protrude the mandible to the maximum extent within their physiological range. An occlusal registration was taken using putty pad material in this position to fabricate a splint guiding the mandible into a controlled subluxation position. Intraoperatively, the splint was placed and stabilized using maxillomandibular fixation (MMF) with titanium miniscrews and wire.

Results: This technique was successfully performed in all seven patients. Intraoperatively, an estimated increase of 15-20 mm in surgical exposure of the DCSICA was achieved, allowing improved access to the artery. No intraoperative or postoperative complications were observed. None of the patients exhibited signs or symptoms of temporomandibular joint dysfunction, malocclusion, or issues related to the splint or fixation technique during the postoperative follow-up.

Conclusion: Controlled mandibular subluxation using a prefabricated occlusal splint stabilized with maxillomandibular fixation is a safe, effective and minimally invasive technique to increase surgical exposure of the DCSICA. It offers a less invasive alternative to traditional bone-resection methods, reducing operative morbidity while preserving temporomandibular joint integrity. Its implementation can facilitate complex cervical vascular procedures while minimizing patient morbidity.