Review Reports - A Retrospective Cohort Study of Traumatic Root Fractures in Primary Dentition: Can Splinting Type Improve Therapeutic Outcomes?

Round 1

Reviewer 1 Report

This study analyzed the long-term results of orthodontic splinting treatment with brackets compared to composite resin splinting alone in teeth with root fractures.

The manuscript is clear, relevant, and presented in a well-structured manner. In addition, it is scientifically sound and presents an appropriate design to test the hypothesis. The results are reproducible depending on the details given in the methods. Figures and tables are appropriate, correctly display the data, and are easy to interpret and understand. Data are interpreted appropriately and consistently throughout the manuscript. A correct statistical analysis is carried out and the conclusions are consistent with the evidence and the arguments presented.

Author Response

Response to Reviewer 1 Comments

Dear reviewer,

Thank you for the report and the suggestions, we found them extremely helpful to improve our manuscript. We provided the suggested corrections for every part of the study, as you can find in the revised manuscript. The English level was overall ameliorated.

Point 1: This study analyzed the long-term results of orthodontic splinting treatment with brackets compared to composite resin splinting alone on teeth with root fractures. The manuscript is clear, relevant and presented in a well-structured manner. In addition, it is scientifically sound and presents an appropriate design to test the hypothesis. The results are reproducible depending on the details given in the methods. Figures and tables are appropriate, correctly display the data, and are easy to interpret and understand. Data are interpreted appropriately and consistently throughout the manuscript. A correct statistical analysis is carried out and the conclusions are consistent with the evidence and the arguments presented.

Response 1:. Dear reviewer, thank you for your constructive comments and for the carried out analysis.

Author Response File: Author Response.docx

Reviewer 2 Report

A retrospective cohort study of traumatic root fractures in primary dentition: can splinting type improve therapeutic out- 3 comes?

A very interesting study, with clinical implications and a good presentation of the subject. However, some minor changes should be made.

Abstract: PCO acronym must be explained

Introduction: The acronyms should be explained (e.g.: TDI) when they are first used. It should be emphasized the lack of clinical data about this subject.

A statistical % of the frequency of intrusion, avulsion, extrusion, and the groups of teeth could be interesting. The fracture types and classifications could be detailed. For a non-specialist, the info about the subject is not easy to find.

The treatment methods (the types of splinting should be detailed rather in introduction than in method).

The main issues about this subject should be acknowledged in the introduction, to familiarize the reader with the subject.

Author Response

Response to Reviewer 2 Comments

Dear reviewer,

Thank you for the report and the suggestions, we found them extremely helpful to improve our manuscript. We provided the corrections suggested for every part of the study, as you can find in the revised manuscript. The English level was overall ameliorated.

Point 1: A very interesting study, with clinical implications and a good presentation of the subject. However, some minor changes should be made. Abstract: PCO acronym must be explained

Response 1: Thank you for the notes, the abstract has been corrected according to your suggestion.

Point 2: Introduction: The acronyms should be explained (e.g.: TDI) when they are first used. It should be emphasized the lack of clinical data about this subject.

Response 2. Thank you for the notes, the correct acronym has been inserted based on your indications. The lack of clinical data of studies for this argument has been correctly specified.

Point 3: A statistical % of the frequency of intrusion, avulsion, extrusion, and the groups of teeth could be interesting. The fracture types and classifications could be detailed. For a non-specialist, the info about the subject is not easy to find.

Response 3: Thanks for the notes. Two bibliographic references on the incidence and frequency of these traumas have been added and the percentage values of the single traumatic types have been reported.

Point 4: The treatment methods (the types of splinting should be detailed rather in introduction than in method). The main issues about this subject should be acknowledged in the introduction, to familiarize the reader with the subject.

Response 4: Thanks for the notes. The topic of the subject has been properly specified and added in the introduction.

Author Response File: Author Response.docx

Reviewer 3 Report

The paper represents the results of retrospective cohort studies of traumatic root fractures in primary dentition. It deals with the use of the splinting types and their influence on the improvements in therapeutic outcomes. The data are important and worth publishing.

The authors could add a few figures from the most interesting case studies of patients.

Author Response

Response to Reviewer 3 Comments

Dear reviewer,

Point 1: The paper represents the results of retrospective cohort studies of traumatic root fractures in primary dentition. It deals with the use of the splinting types and their influence on the improvements in therapeutic outcomes. The data are important and worth publishing. The authors could add a few figures from the most interesting case studies of patients.

Response 1: Thank you for the report and the suggestions, we found them extremely helpful to improve our manuscript. Two images have been added that illustrate the type of treatments adopted in our specific study.

Author Response File: Author Response.docx

Reviewer 4 Report

The maxillary central incisors 48 are the teeth most frequently involved, with an incidence of up to 80% [8]. ... primary or secondary dentition, please specify same for the next sentence (9).

In these cases, the therapy provides splinting and occlusal stabilization [11]. This quote is from a single case report and it is not the typical standard in the treatment of primary teeth. Please quote a minimum of 3-4 sources - which are published recently. Please quote existing dental trauma standards.

The Basic study group (Group 1) initially included 37 patients, of whom 12 did 74 not meet the inclusion criteria, leaving a final number of 25 patients suffering from root 75 fractures of the deciduous incisors, and a total of 27 upper incisors with root fractures. The 76 control group (Group 2) comprised 35 patients with a total of 38 fractures of maxillary 77 primary teeth (Figure 1).

You should have compared an equal number of patients in each oft he groups. With such a small number of cases, method is very questionable

„suitably trained for approximately three months, 96 who worked individually.“ Sounds not experienced to me. How many ears in which subject was the qualification?

Pulp sensitivity was tested both with a cold spray (maximum temperature -26 °C). Please stated how often primary teeth in which age group are tested positive ...

Age at the trauma must be added „ in months“

Tables 2 and 3 are confusing for the reader. Please change the presentation so it is more clear/ shorter

In group 1 the middle third of the root was involved in 68% of cases, the apical third in 24% 193 of cases and the cervical third in 8%. In group 2, the middle third of the root was involved 194 in 91% and the apical third in 9%.

Where there differences visible depending on the location of the root fracture

Same question of cortical bone was involved

Group 1 was splinted for 60-90 days please explain the long splinting times. Please add sources why you do it this way.

Please add picture(s) the way the orthodontic splinting was performed

Minor improvements necessary e.g. Please write the full word before you use the first time a shortening „TDI“ in the introduction.

Author Response

Response to Reviewer 4 Comments

Dear reviewer,

Point 1: The maxillary central incisors are the teeth most frequently involved, with an incidence of up to 80% [8]. ... primary or secondary dentition, please specify same for the next sentence (9).

Response 1: Thank you for the suggestion. It has been specified that it is the deciduous dentition, it has been specified in the text.

Point 2: In these cases, the therapy provides splinting and occlusal stabilization [11]. This quote is from a single case report and it is not the typical standard in the treatment of primary teeth. Please quote a minimum of 3-4 sources - which are published recently. Please quote existing dental trauma standards.

Response 2: Dear reviewer, thank you for the notes. The required bibliographic references regarding the treatments on traumas in the deciduous teeth have been added. Furthermore, it was highlighted how the standards were taken from the IADT guidelines.

Point 3: The Basic study group (Group 1) initially included 37 patients, of whom 12 did 74 not meet the inclusion criteria, leaving a final number of 25 patients suffering from root 75 fractures of the deciduous incisors, and a total of 27 upper incisors with root fractures. The 76 control group (Group 2) comprised 35 patients with a total of 38 fractures of maxillary 77 primary teeth (Figure 1). You should have compared an equal number of patients in each of the groups. With such a small number of cases, method is very questionable.

Response 3: Dear reviewer, thank you for the notes. We have taken into account your condiserations. The number of samples depended on the clinical activity of our department, moreover the sample is homogeneous and there is no significant difference between the number of samples of the two groups. They were also analyzed with the same search parameters. On the other hand, even in the literature there are studies in which there is no exact number between the two groups examined. (e.g. see Cho WC, Nam OH, Kim MS, Lee HS, Choi SC. A retrospective study of traumatic dental injuries in primary dentition: treatment outcomes of splinting. Acta Odontol Scand. 2018 May;76(4):253-256. doi: 10.1080/00016357.2017.1414956. Epub 2017 Dec 11. PMID: 29228861.)

Point 4: suitably trained for approximately three months, who worked individually.“ Sounds not experienced to me. How many ears in which subject was the qualification?

Response 4: Dear reviewer, thank you for the suggestion. The researchers involved in the study were dentists who had already graduated since at least 5 years and had been working in the pediatric dentistry and traumatology department for at least 3 years. They also had a 3-month training program for this study. The note has been added in the text.

Point 5: Pulp sensitivity was tested both with a cold spray (maximum temperature -26 °C). Please stated how often primary teeth in which age group are tested positive ...

Response 5: Dear reviewer, thank you for the suggestion. The ice spray test in deciduous teeth is not always reliable. In patients above 24/30 months the answers were more reliable than in patients below this age group. Therefore, overall, this parameter was partially taken into consideration to define the presence or absence of pulp vitality. In fact, additional tests including radiographic ones were used to define this state. (as confirmed by the guidelines) Day PF, Flores MT, O’Connell AC, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 3. Injuries in the primary dentition. Dent Traumatol 2020;36(4):343-359. https://doi.org/10.1111/edt.12576.) This aspecto has been specified in the text.

Point 6: Age at the trauma must be added „ in months“

Response 6: Thank you for the notes. It has been modified in the text.

Point 7: Tables 2 and 3 are confusing for the reader. Please change the presentation so it is clearer/ shorter.

Response 7: Thank you for the notes. They have been modified according to your suggestion..

Point 8: In group 1 the middle third of the root was involved in 68% of cases, the apical third in 24% of cases and the cervical third in 8%. In group 2, the middle third of the root was involved in 91% and the apical third in 9%. Where there differences visible depending on the location of the root fracture. Same question of cortical bone was involved.

Response 8: Dear reviewer, thank you for the notes. Based on the results obtained, in group 2, in which there was a greater fracture of the middle third of the root, there was also a greater incidence of fracture of the buccal bone cortex. It could be precisely connected to the fact that more cortical fractures occurred.

Point 9: Group 1 was splinted for 60-90 days please explain the long splinting times. Please add sources why you do it this way.

Response 9: Dear reviewer, thank you for your notes. In general, the IADT guidelines were followed but in the case of patients treated with an orthodontic splint it was necessary to intervene with the repositioning of the displaced coronal fragment and in interference with the antagonist arch and this treatment led to a lengthening of the maintenance time for the orthodontic splint.

Point 10: Please add picture(s) the way the orthodontic splinting was performed.

Response 10: Thank you for the notes. The images relating to the chosen treatment have been inserted.

Author Response File: Author Response.docx

Reviewer 5 Report

Dear colleagues, thank you for the study, but I think that it was not well written and presented. Language and scientific improvements need to be considered. The clarification of the methods and materials used with the main clinical significance is not well presented in an understandable format for the readers.

Must be improved!

Author Response

Response to Reviewer 5 Comments

Dear reviewer,

Point 1: Dear colleagues, thank you for the study, but I think that it was not well written and presented. Language and scientific improvements need to be considered. The clarification of the methods and materials used with the main clinical significance is not well presented in an understandable format for the readers.

Response 1: Dear reviewer, thank you for the notes. We proceeded to review the manuscript according to the advice of the other reviewers. We have improved the English language and better clarified the materials and methods and aims of the study. I hope you appreciated the corrections.

Author Response File: Author Response.docx

Round 2

Reviewer 4 Report

Group 1 was splinted for 60-90 days please explain the long splinting times. Please add sources why you do it this way.

Please add literature for studies who have also done it this way

Author Response

Response to Reviewer 4 (Round 2) Comments

Dear reviewer,

Point 1: Group 1 was splinted for 60-90 days please explain the long splinting times. Please add sources why you do it this way. Please add literature for studies who have also done it this way.

Dear reviewer,

Thank you for your suggestion. We have addressed the issue regarding the duration of splinting in Group 1 in the revised manuscript. Specifically, we have included two relevant studies to support our approach. The first study discusses the treatment of two cases of root fractures in maxillary primary central incisors with coronal fragment dislocation. In these cases, repositioning and orthodontic splinting were performed for a duration of 3 months, and the outcomes were closely monitored until the eruption of the permanent teeth, showing excellent results (1). The second study describes a case of root fracture in a maxillary central incisor, which was also treated with a 3-month splinting period, resulting in no damage to the primary tooth or the corresponding permanent tooth (2).

References:

Liu X, Huang J, Bai Y, Wang X, Baker A, Chen F, Wu LA. Conservation of root-fractured primary teeth--report of a case. Dent Traumatol. 2013 Dec;29(6):498-501. doi: 10.1111/edt.12009.
Santos LV, da Hora KC, Alves AC. Successful minimally invasive intervention in a primary central incisor after root fracture: A case report. Dent Traumatol. 2021 Dec;37(6):807-812. doi: 10.1111/edt.12681.

Thank you for your valuable input, and we hope that these additions further strengthen the manuscript.

Author Response File: Author Response.docx

Reviewer 5 Report

Dear Colleagues, Thank you for the modifications, however, English language should be improved to raise the scientific value of your study.

Professional language editing is requested.

Author Response

Response to Reviewer 5 (Round 2) Comments

Dear reviewer,

Point 1: Dear Colleagues, Thank you for the modifications, however, English language should be improved to raise the scientific value of your study.

Response 1: Dear reviewer, thank you for your feedback. We have taken your suggestion into consideration and have further revised the manuscript to improve the scientific value by enhancing the quality of English language. We have enlisted the assistance of a native English speaker for thorough editing and massive and important proofreading of the manuscript as you requested. We appreciate your careful review and valuable input in helping us enhance the clarity and accuracy of our study

Author Response File: Author Response.docx