Gummy Smile Improvement during Growth Period Using a Simple Bite Jumping Appliance and High-Pull J-Hook HeadGear: A Case Series Study

Round 1

Reviewer 1 Report

The present study aimed to present the treatment of gummy smile by means of a simple bite jumping appliance and high-pull J-hook headgear. The originality of this study consisted in the use of this technique in three patients aged 8 to 10 years, while it was used only in adult patients. 

The study is well written, and the data are clear and ordered in a logically sequence. However, the scientific relevance appears to be low (being just a report of 3 cases) 

I have made some comments that might help the authors to improve the quality of the manuscript, as described.

- If a guideline for case reports has been used, please quote it.

- In the first paragraph, the causes of the gummy smile should be mentioned: altered passive eruption, short upper lip, etc. Also, other possible relationships with the aforementioned conditions and oral and periodontal health, other than aesthetic, should be quoted to justify early intervention.

- It is not very clear why the authors refer to the overeruption of the maxillary anterior teeth. It seems more appropriate to refer to superior dentoalveolar extrusion or excessive growth of the upper jaw. Moreover, I think it is important to specify how the differential diagnosis was made between the causes of the gummy smile, before treating the patients.

Author Response

Dear Editors and Reviewers

We would like to thank the reviewers and editors for their time and effort to review this manuscript. Thank you very much for reviewing our manuscript and offering valuable advice.

We have addressed your comments with point-by-point responses, and revised the manuscript accordingly. Please consider the attached manuscript that has been revised according to the reviews. Response to each reviewer's comments follows this letter.

＜Comments from Reviewer 1.＞

Point1: If a guideline for case reports has been used, please quote it.

[Response to point 1]

The text in the Introduction section has been revised as follows. “Consent was obtained from patients and their guardians for their inclusion in this report according to Ethical Guidelines for Medical and Health Research Involving Human Subjects in Japan.”

Point2: In the first paragraph, the causes of the gummy smile should be mentioned: altered passive eruption, short upper lip, etc. Also, other possible relationships with the aforementioned conditions and oral and periodontal health, other than aesthetic, should be quoted to justify early intervention.

[Response to point 2]

We have added " altered passive eruption, short upper lip" to the first paragraph of Introduction section.

The following sentence was added to the Introduction section. “Also, gummy smiles are considered an instigation factor for gingivitis in anterior maxillary region [8,9], and improvement of the gummy smile from a young age is considered beneficial.”

Point3: It is not very clear why the authors refer to the overeruption of the maxillary anterior teeth. It seems more appropriate to refer to superior dentoalveolar extrusion or excessive growth of the upper jaw. Moreover, I think it is important to specify how the differential diagnosis was made between the causes of the gummy smile, before treating the patients.

[Response to point 3]

We have revised to "excessive growth of the upper jaw" as recommended.

Regarding the judgment of "the vertical excessive growth of the upper jaw", we made a diagnosis referring to "the maxillary anterior tooth height (Is-Is')".

Author Response File: Author Response.docx

Reviewer 2 Report

The manuscript entitled „gummy smile improvement during growth period using a simple bite jumping appliance and high pull j-hook headgear“ aims at assessing the eligibility to use the combination of the two appliances in growing patients.

I have the following comments:

Title

- add that it is a case series

Abstract

• Add the type of study (case series)
• in the abstract, please mention for which patients the appliance is indicated (vertical growth pattern / horizontal growth pattern, all), if you refer to patients with class ii and retroclined incisors (class II,2), or class I patients with surarposition of incisors
• Not clear what is meant by maxillary prognathism? In the case series, all patients had the prognathism, but is it only applicable to these pat?

Introduction

• Among conventional methods, add intrusion of incisors, extrusion of posterior teeth using activator, bite ramps
• Brackets are not limited to 14/15 years, this is incorrect
• Please be precise with the target group, incisors erupt quite early (7 to 8 years), so apices are closed during regular treatment; additionally, for the timing, it has to be differentiated whether indirect or direct correction of gummy smile is indicated (if there is a combination with a deep bite, there might also be some extrusion of posterior teeth)

Methods

• do you have any PROMs, how did patients perceive the headgear treatment?
• Please add the WITS appraisal to the ceps-measurements

Discussion

• please comment on the treatment duration which was quite long in the respective cases
• I would not be so critical with the anchor screws, we have great results with this technique, and they can also be placed in the palate to indirectly anchor the molars, and connected to a 2-4 appliance. I would just mention that this is an alternative, especially in case that patients do not want screws, or in case that they are lost for example; treatment duration, however, appears to be much longer so for a scientifically sound evaluation, this should be not discussed with personal believes but with facts;
• I would only add a conclusion in which it is stated that this was a case series and therefore future studies are needed to assess the ideal treatment for specific subgroups of patients, the ideal timing and so on.
•  

Author Response

Dear Editors and Reviewers

We would like to thank the reviewers and editors for their time and effort to review this manuscript. Thank you very much for reviewing our manuscript and offering valuable advice.

We have addressed your comments with point-by-point responses, and revised the manuscript accordingly. Please consider the attached manuscript that has been revised according to the reviews. Response to each reviewer's comments follows this letter.

＜Comments from Reviewer 2.＞

Point1: Title

• add that it is a case series

[Response to point 1]

We have added "a case series" to the Title.

Point2: Abstract

• Add the type of study (case series)
• in the abstract, please mention for which patients the appliance is indicated (vertical growth pattern / horizontal growth pattern, all), if you refer to patients with class ii and retroclined incisors (class II,2), or class I patients with surarposition of incisors
• Not clear what is meant by maxillary prognathism? In the case series, all patients had the prognathism, but is it only applicable to these pat?

[Response to point 2]

We have added "case series" to the Abstract.

The text in the Abstract has been revised as follows. "Methods: We improved the gummy smiles of three class II patients with the vertical excessive growth of the upper jaw, during their growth period, using a simple bite jumping appliance (SBJA) and a high pull J-hook headgear.", "Conclusion: It is suggested that a combined use of high-pull J-hook headgear and SBJA is an effective way of improving gummy smiles in class II patients with the vertical excessive growth of the upper jaw, during their growth period."

We consider it applicable only to class II patients with the vertical excessive growth of the upper jaw.

Point3: Introduction

• Among conventional methods, add intrusion of incisors, extrusion of posterior teeth using activator, bite ramps
• Brackets are not limited to 14/15 years, this is incorrect
• Please be precise with the target group, incisors erupt quite early (7 to 8 years), so apices are closed during regular treatment; additionally, for the timing, it has to be differentiated whether indirect or direct correction of gummy smile is indicated (if there is a combination with a deep bite, there might also be some extrusion of posterior teeth)

[Response to point 3]

We have added "intrusion of incisors, extrusion of posterior teeth using activator, bite ramps " to conventional methods of the Introduction section.

The following sentence in the Introduction section was removed. "A multi-bracket device in combination with treatment is used for patients of 14 to 15 years of age."

The text in the Introduction section has been revised as follows. " Here, we used SBJA [14] in combination with the high-pull J-hook headgear to suppress the vertical excessive growth of the upper jaw in three class II patients with the vertical excessive growth of the upper jaw during the growth period."

Point4: Methods

• do you have any PROMs, how did patients perceive the headgear treatment?
• Please add the WITS appraisal to the ceps-measurements

[Response to point 4]

The OHIP-14 total score (up to 56) for the three patients was 4 (case 1), 7 (case 2), and 8 (case 3), respectively.

Three patients and their parents are satisfied with the treatment results. Also, regarding the headgear, we received opinions that it was possible to use it without any discomfort.

We have added WITS to ceps-measurements.

Point5: Discussion

• please comment on the treatment duration which was quite long in the respective cases
• I would not be so critical with the anchor screws, we have great results with this technique, and they can also be placed in the palate to indirectly anchor the molars, and connected to a 2-4 appliance. I would just mention that this is an alternative, especially in case that patients do not want screws, or in case that they are lost for example; treatment duration, however, appears to be much longer so for a scientifically sound evaluation, this should be not discussed with personal believes but with facts;
• I would only add a conclusion in which it is stated that this was a case series and therefore future studies are needed to assess the ideal treatment for specific subgroups of patients, the ideal timing and so on.

[Response to point 5]

The following sentence was added to the Discussion section. “Also, all patients were unavailable for 12 hours on some days, resulting in a long treatment period. This is considered a disadvantage of removable devices.”

The following sentence was added to the Discussion section. “However, the lengthening of the treatment period must be considered.”

The following sentence was added to the conclusion section. “However, this study was a case series and therefore future studies are needed to assess the ideal treatment for specific subgroups of patients, the ideal timing and so on.”

Author Response File: Author Response.docx

Round 2

Reviewer 2 Report

"Also, all patients were unavailable for 12 hours on some days, resulting in a long treatment period. This is considered a disadvantage of removable device" - this sentence is still defficult to understand. 

Author Response

We would like to thank the reviewers and editors for their time and effort to review this manuscript. Thank you very much for reviewing our manuscript and offering valuable advice.

We have addressed your comment with response and revised the manuscript accordingly. Please consider the attached manuscript that has been revised. Response to each reviewer's comments follows this letter.

＜Comments from Reviewer 2.＞

"Also, all patients were unavailable for 12 hours on some days, resulting in a long treatment period. This is considered a disadvantage of removable device" - this sentence is still defficult to understand.

[Response]

The text in the Discussion has been revised as follows. "Also, the treatment duration was long in all three cases. It took time for the effect of the appliance to appear. It is considered that long treatment duration is a demerit of the method of improving gummy smiles using SBJA and high-pull J-hook headgear."

Author Response File: Author Response.docx