A Semi-Automatic Approach for Holistic 3D Assessment of Temporomandibular Joint Changes
Round 1
Reviewer 1 Report
Reviewer’s Comments:
The manuscript “Semi-Automatic Morphovolumetrical Assessment of the Temporomandibular Joint: Validation of a Holistic Approach” is a very interesting work. In this work, the literature lacks a validated holistic approach for three-dimensional (3D) assessment of the temporomandibular joint (TMJ) including all three adaptive processes, which are believed to contribute to the position of the mandible: 1) adaptive condylar changes, 2) glenoid fossa changes, and 3) condylar positional changes within the fossa. Hence, the purpose of the present study was to propose and validate a semi-automatic approach for 3D assessment of the TMJ from cone-beam computed tomography (CBCT) following Orthognathic Surgery. The TMJs were 3D reconstructed from a pair of superimposed pre- and postoperative (two years) CBCT scans, and spatially divided into sub-regions. The changes of the TMJ were calculated and quantified by morphovolumetrical measurements. To evaluate the reliability, intra-class correlation coefficients (ICC) were calculated at a 95% confidence interval on measurements of two observers. The approach was deemed reliable if the ICC was good (> 0.60). Pre- and postoperative CBCT scans of ten subjects (nine female; one male; mean age 25.6 years) with class II malocclusion and maxillomandibular retrognatia, who underwent bimaxillary surgery, were assessed. The results are consistent with the data and figures presented in the manuscript. While I believe this topic is of great interest to our readers, I think it needs major revision before it is ready for publication. So, I recommend this manuscript for publication with major revisions.
1. In this manuscript, the authors did not explain the importance of the Holistic Approach in the introduction part. The authors should explain the importance of Holistic Approach.
2) Title: The title of the manuscript is not impressive. It should be modified or rewritten it.
3) Correct the following statement “The validation showed that the proposed approach has good to excellent reliability for semi-automatic 3D assessment of the TMJ from CBCT including all three adaptive processes”.
4) Keywords: The Holistic Approach is missing in the keywords. So, modify the keywords.
5) Introduction part is not impressive. The references cited are very old. So, Improve it with some latest literature like 10.3390/molecules27217368, 10.3390/molecules27207129
6) The authors should explain the following statement with recent references, “The inter-observer reliability of the measurements were summarized using mean absolute differences (MAD) and standard deviations (SD)”.
7) Add space between magnitude and unit. For example, in synthesis “21.96g” should be 21.96 g. Make the corrections throughout the manuscript regarding values and units.
8) The author should provide reason about this statement “Figure 2 shows Bland-Altman plots of the inter-observer agreement for the volumetric and mean surface distance condylar measurements, glenoid fossa RMS distance measurements and change in minimum joint space distance”.
9. Comparison of the present results with other similar findings in the literature should be discussed in more detail. This is necessary in order to place this work together with other work in the field and to give more credibility to the present results.
10) Conclusion part is very long. Make it brief and improve by adding the results of your studies.
11) There are many grammatic mistakes. Improve the English grammar of the manuscript.
Author Response
We thank the reviewer for the kind words and for taking the time to review our submission.
1. In this manuscript, the authors did not explain the importance of the Holistic Approach in the introduction part. The authors should explain the importance of Holistic Approach.
We have now more clearly explained the importance of a holistic approach in the introduction:
“In order to study and understand the postoperative stability and functionality following orthognathic surgery, the focus should not solely be on the condylar changes, but importantly, on the change of the entire TMJ, involving all three adaptive processes.”
2. Title: The title of the manuscript is not impressive. It should be modified or rewritten it.
The title has been revised:
“A Semi-Automatic Approach for Holistic 3D Assessment of Temporomandibular Joint Changes”
3. Correct the following statement “The validation showed that the proposed approach has good to excellent reliability for semi-automatic 3D assessment of the TMJ from CBCT including all three adaptive processes”.
The statement has been changes to:
“The proposed semi-automatic approach demonstrated good-excellent reliability for holistic 3D assessment of the TMJ including all three adaptive processes.”
4. Keywords: The Holistic Approach is missing in the keywords. So, modify the keywords.
“Holistic assessment” has been added to the keywords.
5. Introduction part is not impressive. The references cited are very old. So, Improve it with some latest literature like 10.3390/molecules27217368, 10.3390/molecules27207129
We have included one additional recent reference:
- Andriola, F.O.; Haas Junior, O.L.; Guijarro-Martinez, R.; Hernandez-Alfaro, F.; Oliveira, R.B.; Pagnoncelli, R.M.; Swennen, G.R. Computed tomography imaging superimposition protocols to assess outcomes in orthognathic surgery: a systematic review with comprehensive recommendations. Dentomaxillofac Radiol 2022, 51, 20210340, doi:10.1259/dmfr.20210340.
The two proposed papers on molecular biology are irrelevant to the present study. We believe we have now included all relevant literature on the subjects. The older literature are key studies with important definitions and findings relevant to the present study.
6. The authors should explain the following statement with recent references, “The inter-observer reliability of the measurements were summarized using mean absolute differences (MAD) and standard deviations (SD)”.
References to recent work that also use these values to summarize the data has been added:
“…similar to related reliability studies [9-11,13,19,22].”
7. Add space between magnitude and unit. For example, in synthesis “21.96g” should be 21.96 g. Make the corrections throughout the manuscript regarding values and units.
Space has been inserted between values and units as required.
8. The author should provide reason about this statement “Figure 2 shows Bland-Altman plots of the inter-observer agreement for the volumetric and mean surface distance condylar measurements, glenoid fossa RMS distance measurements and change in minimum joint space distance”.
The statement has been simplified to:
“Figure 3 shows Bland-Altman plots of the inter-observer agreement on the measurements.”
9. Comparison of the present results with other similar findings in the literature should be discussed in more detail. This is necessary in order to place this work together with other work in the field and to give more credibility to the present results.
Additional comparison of the present results with the related literature has been included in the discussion section:
“The reliability of the present 3D assessment of condylar changes is in line with the related studies by Verhelst et al. [22] and Xi et al. [27], who reported similar ICC and MAD values.”
10. Conclusion part is very long. Make it brief and improve by adding the results of your studies.
The length of the conclusion has been reduced. The first line of the conclusion provides the overall result of the study.
11. There are many grammatic mistakes. Improve the English grammar of the manuscript.
The manuscript has been proof read for grammatical errors.
We sincerely hope the revision meets the expectations of the reviewer.
Reviewer 2 Report
The paper aimed to validate an approach to assess the TMJ following surgery.
I find the paper rather confusing. The method proposed to have a method that can compare the TMJ changes following surgery. Firstly, this semi-automatic method was not described in the paper but the author expected the reader to search and read up on such method. It would be good if it was supplemented with images of how the methods were done. How much the method mimics that of the cited paper was not clear. The author attempted to assess the validity by comparing the measurements made by two different investigators. However, the author should have described what is the current acceptable or gold method. If not this should be compared with a model first. To determine if a new method is acceptable, one needs to be clear on the concept of validity and reliability. Then one can compare the accepted/gold method with the new method. One should also then compare the inter and intra - rater reliability of such new method.
Overall, I was not convinced if this method was valid and reliable.
Author Response
We thank the reviewer for the suggestions to improve the manuscript and for taking the time to review our submission.
1. Firstly, this semi-automatic method was not described in the paper but the author expected the reader to search and read up on such method. It would be good if it was supplemented with images of how the methods were done.
We have elaborated on the semi-automatic method in the method section and included a new Figure 2 illustrating the process.
2. How much the method mimics that of the cited paper was not clear.
This is the first time a holistic approach is proposed that constitutes all three adaptive processes in the TMJ that are believed to contribute to the position of the mandible. The cited paper [4] solely presented a clinical evaluation of mandibular glenoid fossa changes following orthognathic surgery. Hence, a clinical study and not a method study, including only one of the adaptive processes.
The other cited paper [19] presented a comparative study on two different registration techniques. The findings of this paper were used in the present study for selection of the best technique for registration on the mandibular ramus in the semi-automatic method. This has been elaborated in the method section:
“Surface-based registration was used for the alignment, which was shown to be more accurate and reliable than voxel-based registration for assessment of mandibular condyle remodeling [19].”
3. The author attempted to assess the validity by comparing the measurements made by two different investigators. However, the author should have described what is the current acceptable or gold method. If not this should be compared with a model first. To determine if a new method is acceptable, one needs to be clear on the concept of validity and reliability. Then one can compare the accepted/gold method with the new method. One should also then compare the inter and intra - rater reliability of such new method.
We acknowledge the reviewers comment on validity. We have discussed how the accuracy of the image segmentation and 3D reconstruction of the mandibular condyles has previously been validated in recent literature [22]. To this end, the accuracy of the superimposition techniques which were used in the semi-automatic implementation of the method has been previously validated in [18,19]. Hence, the present study focused on the reliability of the new holistic approach. This has been clarified in the introduction:
“No studies have been identified, which propose a validated holistic approach for 3D assessment of the TMJ including all three adaptive processes. However, the accuracy of the 3D assessment of condylar changes from CBCT has been studied previously and the assessment was shown to be highly accurate for both volumetric and surface discrepancy measurements [22]. Similarly, superimposition on the cranial base and the mandibular ramus has shown high accuracy [18,19]. Hence, the purpose of the present study was to propose and validate the reliability of a semi-automatic approach for 3D assessment of the TMJ from cone-beam computed tomography (CBCT) following Orthognathic Surgery, including condylar and glenoid fossa changes, as well as the interrelated positional changes.”
Again, we thank the reviewer for the constructive feedback to improve our manuscript, and sincerely hope the revision meets the expectations of the reviewer.
Round 2
Reviewer 2 Report
Thank you for the improvement of the paper. However, the authors should still be careful when using the terms validity and reliability. Since the study did not compare the new method with another method (ideally a gold standard), then one should avoid claiming for validity. The study only compared the reliability/reproducibility of its method. Hence, my suggestion would be to change the abstract :
1) The literature lacks a validated holistic approach for three-dimensional (3D) assessment of the temporomandibular joint (TMJ)... to The literature lacks a reliable holistic approach for three-dimensional (3D) assessment of the temporomandibular joint (TMJ)..
2) Hence, the purpose of the present study was to propose and validate a semi-automatic approach for 3D assessment of the TMJ from cone-beam computed tomography (CBCT) following oOrthognathic sSurgery... to Hence, the purpose of the present study was to propose and assess the reliability of a semi-automatic approach for 3D assessment of the TMJ from cone-beam computed tomography (CBCT) following oOrthognathic sSurgery. Similarly in the introduction, the aims should be modified accordingly.
Author Response
We thank the reviewer for the additional suggestions to improve the manuscript and for taking the time for a second round of reviewing our submission.
Thank you for the improvement of the paper. However, the authors should still be careful when using the terms validity and reliability. Since the study did not compare the new method with another method (ideally a gold standard), then one should avoid claiming for validity. The study only compared the reliability/reproducibility of its method. Hence, my suggestion would be to change the abstract :
1) The literature lacks a validated holistic approach for three-dimensional (3D) assessment of the temporomandibular joint (TMJ)... to The literature lacks a reliable holistic approach for three-dimensional (3D) assessment of the temporomandibular joint (TMJ)..
2) Hence, the purpose of the present study was to propose and validate a semi-automatic approach for 3D assessment of the TMJ from cone-beam computed tomography (CBCT) following oOrthognathic sSurgery... to Hence, the purpose of the present study was to propose and assess the reliability of a semi-automatic approach for 3D assessment of the TMJ from cone-beam computed tomography (CBCT) following oOrthognathic sSurgery. Similarly in the introduction, the aims should be modified accordingly.
We agree that solely the reliability/reproducibility of the proposed method was assessed in the study. The abstract, the aims in the introduction, and the discussion have been changed according to the reviewer’s suggestions.
We sincerely hope the minor revision meets the expectations of the reviewer.
