The standard approach for carotid endarterectomy cannot provide adequate exposure of the distal internal carotid artery in the presence of high cervical carotid bifurcation or high plaque. Limited accessibility of the distal internal carotid artery has resulted in the development of various operative techniques. Mandibular subluxation is the most simple and least invasive technique, but it does require invasive maneuvers, such as wiring, to stabilize the mandible. We use a mouthpiece made by the dentist to stabilize the mandible in the physiologic subluxated position. This technique provides an adequate exposure of the distal internal carotid artery as with the other methods, and the risk of morbidity is very low.

Regarding "Mandibular subluxation stabilized by mouthpiece for distal internal carotid artery exposure in carotid endarterectomy"We read with interest the report by Yoshino et al 1 of their technique for achieving mandibular subluxation for distal internal carotid artery (ICA) exposure. The indications for extended carotid exposure are well established, and mandibular subluxation is a minimally invasive procedure to gain 15 to 20 mm additional exposure of the ICA. The authors advocate the use of a custom-made resin mouthpiece. The possible advantages of this method would be reduced oral injury and infection, avoidance of dislocation of the temporomandibular joint (TMJ) and short preparation time. We recently reported in the Journal of Vascular Surgery on the use of ipsilateral monocortical miniscrews and wiring for this indication 2 with the same advantages as stated in their article. We do not recognize the described injury and infection to the oral cavity in our routine. These complications are extremely rare due to the excellent blood support to the alveolar ridge and the minimally invasive nature of miniscrews. Only in cases of an extremely resorbed mandibula could wound healing disturbances theoretically occur.Second, there is the issue of the practical applicability and stability of the described resin mouthpiece. It was possible to produce a mouthpiece in 57% of the described patients. In our population, this amount would be even lower due to periodontal disease and absence of dentition. Next to the issue of the presence of an adequate dentition, it would be interesting if the authors describe whether the resin mouthpiece has enough stability and retention on the existing dentition to withstand the muscular retraction forces during operation, which can reduce the amount of subluxation and subsequently the exposure of the ICA.A third possible disadvantage of this technique is the thickness of the mouthpiece. Interposition of resin material between the dental arches causes opening of the bite and movement of the mandibular angle in a backward direction over the desired exposed area of the ICA. Therefore, we feel it should be desired to produce a position of maximum flexion in the TMJ. The suggestion that the production of a mouthpiece of mandibular subluxation in an awake situation will produce fewer disturbances to the TMJ than performing this in general anesthesia is unsubstantiated. In our experience, mandibular subluxation without dislocation of the TMJ can easily be achieved in the experienced hands of a dentist or maxillofacial surgeon. We have not had the experience that patients suffered from postoperative TMJ complaints. We do see that the extension of the subluxation under general anesthesia is greater that in an awake patient, which gives a better exposure of the ICA.In summary, the suggested benefits of a resin mouthpiece over the use of monocortical screws may be questioned. It is more expensive, time-consuming in preparation, and, in our opinion, not as reliable as using monocortical miniscrews...