Bill Klaproth (Host): This is an AAOMS On the Go podcast. I'm Bill Klaproth, and joining us today is Dr. Nicholas Callahan and Dr. Michael Miloro. They are here to discuss a study recently published in the Journal of Oral and Maxillofacial Surgery titled Immediate Inferior Alveolar Nerve Reconstruction with Ablative Mandibular Resection Results in Functional Sensory Recovery.

Dr. Callahan and Dr. Miloro, welcome.

Nicholas F. Callahan, MPH, DMD, MD, FACS: Bill, thank you for having us this morning.

Michael Miloro, DMD, MD, FACS: Hi Bill, it's great to be here with you.

Host: You bet. Thank you again. Dr. Callahan and Dr. Miloro, interested to talk about this. Dr. Miloro, let me start with you. Can you tell us what led you and your team to pursue this research topic? And what was the development process?

Michael Miloro, DMD, MD, FACS: Well, you know, Bill, the idea for this study started about 10 years ago or more. And it's, the genesis has evolved since that time with four of my head and neck surgeons that I've been working with over the past 13 years. Starting about 2015 or so, there were some case series that were put out talking about whether or not, nerve reconstruction with ablative mandibular resection could result in functional neurosensory recovery.

And one of those papers actually had, came from our institution. And they were just small case series of less than 10 patients for most of them. And it got me thinking that we should put together a landmark study with a much larger database to really confirm or disprove whether or not what we're doing for patients is actually efficacious.

So, starting about 2013, we began to keep track of every single nerve graft that we did. And over that past 10 years or so, we came up with 164 subjects and we put together the data. As you can imagine, it's really difficult to keep data on that many patients. And we put together this study that really documents the fact that if we perform neurosensory reconstruction at the time of mandibular resection that we can result in functional sensory recovery.

Host: Yeah, this is uh, really fascinating. Dr. Miloro, and all this information, your study is available in JOMS right now, is that correct?

Michael Miloro, DMD, MD, FACS: It is, it was published just this year, in fact, 2024, and it's available online at joms.org. 

Host: Thirteen years! That's a long uh, time.

Michael Miloro, DMD, MD, FACS: A long time through four head and neck surgeons keeping track of all of the data, including, the age, the sex, the length of the graft, the specific pathology that we were treating, the type of bone graft that we used, the soft tissue flaps that we used, really a lot, a lot of data to keep track of. But it really showed that in these cases where we're resecting a large part of the lower jaw, we have a large segment of a nerve deficit that we can reconstruct it with a long span allograft. And we're talking about greater than four centimeters, in most cases, seven centimeter nerve grafts.

Host: Well, this is really important information, and it's really going to help a lot of people. Wow. Thirteen years, 164 subjects. And Dr. Callahan, did your study's conclusion match your original hypothesis?

Nicholas F. Callahan, MPH, DMD, MD, FACS: It really did. We've known that uh, you can get pretty good success rates in these patients, but they've all been in much smaller groups, and as you know, like small groups are really prone to errors and bias and things of that sort. So, you know, looking at this much bigger group, it really gives us a much more robust data point.

And it really did prove that these nerve grafts can be very successful, particularly in benign disease. I think we have a little bit more work to look at our malignant population, our radiation population, hopefully with some studies to come in the future there, but we really show that you can get very good success rates in these patients and improve their quality of life quite a bit in a much shorter amount of time than we used to be able to.

Host: Again, this is really important information. So then, Dr. Miloro, can you speak to that? Can you explain the relevancy of this research to the specialty?

Michael Miloro, DMD, MD, FACS: Just to piggyback on what Dr. Callahan said. What we found in this study was overall, we were able to achieve an 80 percent success rate in both benign and malignant disease, but in benign disease alone, we were able to achieve a 94 percent success rate. So that's really a critical aspect of this study, and also so the two most important factors in this study were age of the patient and the pathology, whether or not it was benign or malignant.

So we found that benign lesions were five times more likely to undergo neurosensory recovery than malignant. And we found that every pediatric patient, every patient under 18 years of age achieved neurosensory recovery. So, so those are really critical key points of this study and for relevance to the specialty, I think that all oral and maxillofacial surgeons should know about this, whether or not they treat benign or malignant disease just so that they can inform their patients adequately and seek out centers of excellence like ours that does offer nerve allograft procedures when the mandible needs to be resected.

Host: So you said two main things that you found. Age was a big consideration and whether or not it was benign. Is that correct?

Michael Miloro, DMD, MD, FACS: Correct. Yes.

Host: So, again, this is great information and very relevant to the specialty, as you say. So then, Dr. Callahan, I guess the next question would be, or one of the many questions is, how can the average OMS apply your research, these findings, to his or her everyday practice?

Nicholas F. Callahan, MPH, DMD, MD, FACS: Well, we're hoping that you know, everyone who is doing resections in the OMS community is at least going to be offering every patient a nerve graft, because we know that they can definitely improve quality of life. But for the average OMS in the community who maybe is not treating these patients themselves, we just want them to be aware that these are options and uh, that we want to make sure that these patients are getting to places where they can get the most comprehensive and complete treatment that they can, to rebuild them in as few surgeries with the least amount of morbidity and the most amount of success possible.

Host: And let me ask you each a question. Dr. Miloro, let me start with you. Did anything surprise you in this research, your journey? Was there any, oh, wow, moment like, wow, here, we've figured this out or we've, here's something we really didn't know. Was there an, oh, wow, moment for you within your research journey?

Michael Miloro, DMD, MD, FACS: It's a good question, Bill. I think we kept track of the specific length of the allograft and the thought was that the longer the graft you have, the lower success rate you're gonna have because we're asking the nerves to grow through that graft to the other side. And if that length is increased, there's gonna be a lower chance that the nerve will make it all the way through.

And what we found actually is that there was no difference in success rate, even with the longest allograft that we have, and that's seven centimeters long. So that was pretty remarkable that even with that long of a graft, patients did recover sensation sometimes within several months of the repair. And, I think that was a little bit surprising to us.

Host: Yeah. So the nerve will grow through a longer section where before you thought, eh, not as possible.

Michael Miloro, DMD, MD, FACS: Right. Exactly.

Host: Interesting. And Dr. Callahan, how about you? Any, wow, moments for you?

Nicholas F. Callahan, MPH, DMD, MD, FACS: I think the biggest thing that I take away from this is that there's still more work to do. You know, when we're thinking about our next studies and we're thinking about how we look at this, we know we got very good success with benign disease, and there's a bit of a confusing data points in the malignant patients.

And some of that's because they're more complicated patients. A lot more of them are lost to follow up. So, you know, it makes me think our next study uh, which we're actively working on, is going to be to look at these patients and control for some of those biases and see if we can get the same outcomes in the malignant population that we're getting in the benign population.

Host: Is this going to be another 13 year study? The next one, do you think?

Nicholas F. Callahan, MPH, DMD, MD, FACS: Uh, Hopefully not.

Host: Oh my goodness. So I know it's recently been published in JOMS, Dr. Miloro, what's the initial feedback that you've heard or received?

Michael Miloro, DMD, MD, FACS: Tremendous. As Dr. Callahan said, the people that are doing this in their centers are slowly but surely adopting adding a nerve allograft into their treatment protocol algorithms. And it's really funny because I think patients are much more involved in their own care these days.

So they're online and they're looking at publications themselves. And we see many patients who come to us because they know we do this. They know that we offer nerve grafting and they want that to be an option for them. So, we've heard from our collaborators and other oral surgeons at different centers throughout the country and throughout the world that this is really a landmark paper and it makes them really want to consider adding this to their treatment protocols.

Host: Throughout the world, as you said, so, you both have to feel really good about the work that you've put into this. And Dr. Callahan, you said there's still a little bit more to go on this or this isn't the final subject. Will you add as you learn more in the future about this? 

Nicholas F. Callahan, MPH, DMD, MD, FACS: I hope we add to this study and get more and more patients involved and treated and hopefully continue to provide the best care we can for this patient population.

Host: Yeah, absolutely. Well, this has been fascinating. I want to thank you both about talking about your landmark research. And before we go, I'd love to get additional thoughts from each of you before we wrap up. Dr. Miloro, anything else you want to add about your research project?

Michael Miloro, DMD, MD, FACS: Just the take home point, I think most oral surgeons can understand that in this study, 94 percent of patients who received the graft achieved neurosensory recovery. Only 7 percent of patients who did not receive a graft achieved neurosensory recovery. So 94 percent versus 7%. So that's really compelling evidence to consider nerve grafting during ablative mandibular resection.

Host: Yeah, that's really good info. And then Dr. Callahan, how about you? Anything else you want to add?

Nicholas F. Callahan, MPH, DMD, MD, FACS: When we think about nerve grafting from a provider standpoint, we don't often give the same power to it that patients do. I see a lot of patients that have big mandibular tumors, and when we talk about removing big segments of their jaw and reconstructing them, the two things they always ask about are the nerve and teeth, you know, not the big segment of the jaw that we're taking out or any of the soft tissues or anything like that. The things that are relevant to the patients are their teeth and then are they going to be able to feel.

And sometimes I think as providers, we sometimes think about the nerve as an afterthought but it is really front and center in a lot of these patients view of what's happening to them and, really important for their quality of life. 

Host: Yeah, very well said. Well, Dr. Callahan and Dr. Miloro, thank you so much again. The study is now published in the Journal of Oral and Maxillofacial Surgery, or JOMS. It's titled Immediate Inferior Alveolar Nerve Reconstruction with Ablative Mandibular Resection Results in Functional Sensory Recovery.

Gentlemen, thank you again for your time. We appreciate it.

Michael Miloro, DMD, MD, FACS: Thank you, Bill.

Nicholas F. Callahan, MPH, DMD, MD, FACS: Thank you, Bill.

Host: And once again, that's Dr. Nicholas Callahan and Dr. Michael Miloro. For more information, please visit AAOMS.org/joms. That's J O M S, JOMS. And if you found this podcast helpful, please share it on your social media. And don't forget to subscribe. Thanks for listening.