Unilateral Condylar Hyperplasia in Surgeons’ Perspective—A Narrative Review

Round 1

Reviewer 1 Report

·       The main topic of this article is an unilateral condylar hyperplasia (UCH), so it is recommended to focus on the UCH instead of mandibular asymmetry (MA).

·       It is recommended to present and explain the full treatment materials and schematic illustrations with the narrative review for the readers to understand easily.   

·       It is recommended to add a section to review the stability after orthodontic camouflage treatment, condylectomy and/or orthognathic surgery.

·       Thank you very much for your hard work.

Author Response

Dear reviewer thank You very much. Response to Reviewer 1 Comments Point 1. – The main topic of this article is an unilateral condylar hyperplasia (UCH), so it is recommended to focus on the UCH instead of mandibular asymmetry (MA). Response 1: Please provide your response for Point 1. (in red) Thank you very much. UCH is related with various degrees of mandibular , facial, skeletal and even dental asymmetries. In order to understand the scope of UCH asymmetyr, some changes will be made in the text to highlight more UCH, and just mention some key MA factors, diffrential diagnostis, its scope and alterations. Thank you for a valuable comment . Point 2. – It is recommended to present and explain the full treatment materials and schematic illustrations with the narrative review for the readers to understand easily. Response 2: Please provide your response for Point 1. (in red) Thank you very much. Updated and more advanced photographs, radiographs, cbct and all data was implemented in the text. Point 3. - It is recommended to add a section to review the stability after orthodontic camouflage treatment, condylectomy and/or orthognathic surgery. Response 3: Please provide your response for Point 1. (in red) Thank you very much. Section was added and explained. Point 4. - Thank you very much for your hard work. Response 4: Please provide your response for Point 1. (in red) Thank you very much. We all deeply appriciate your kind words. They mean very much for us, and wew all Will continue the great work.

Author Response File: Author Response.pdf

Reviewer 2 Report

The Authors have extensively reviewed mandibular asymmetry, but the title of the article relates to Unilateral condylar hyperplasia. As written, they have confused the discussion by including syndromic, tumor and trauma patients. The paper would be considerably improved by limiting the discussion to UCH patients.

The paper needs to be extensively revised for spelling, style, grammar and English language.

The Illustrations are poor and not particularly helpful. Fig 4 shows none of the surgical procedures described. Fig 7 ',..total symmetry correction...' shows significant facial asymmetry probably soft tissue if the boney asymmetry has indeed been corrected. There are no 3D images, no virtual planning images, no cephalometric tracings. 

Growth arresting procedures should be better described.

Caution should be observed in the use of Tc scans and imaging procedures which generate a lot of radiation and in this condition in young persons. may need to be repeated. Prudent 'watch and wait' with serial dental models, simple plain film, radiographs and photographs should be encouraged to reduce radiation exposure.  

'rubber wires' do not exist.

Focusing on UCH would help the Authors to develop an algorithm which would be useful for surgeons. As written, there is little practical or novel value in this presentation. 

I would recommend describing the basic forms of UCH and their clinical manifestations, supported by Photographs, Cephalometric and imaging studies (including 3D). Describe an algorithm for early, intermediate and late treatment with examples of virtual treatment planning now available. 

Author Response

Dear reviewer thank You very much.

Response to Reviewer 1 Comments

Point 1.  – The Authors have extensively reviewed mandibular asymmetry, but the title of the article relates to Unilateral condylar hyperplasia. As written, they have confused the discussion by including syndromic, tumor and trauma patients. The paper would be considerably improved by limiting the discussion to UCH patients.

Response 1: Please provide your response for Point 1. (in red) Thank you very much.  All necessary steps was taken to improve entire article.  On behalf of myself and all co-authors I hope all necessary changes will be sufficient.

Point 2.  – The paper needs to be extensively revised for spelling, style, grammar and English language.

Response 2: Please provide your response for Point 1. (in red) Thank you very much. All necessary steps was taken and applied towards the presented review article.

Point 3. -The Illustrations are poor and not particularly helpful. Fig 4 shows none of the surgical procedures described. Fig 7 ',..total symmetry correction...' shows significant facial asymmetry probably soft tissue if the boney asymmetry has indeed been corrected. There are no 3D images, no virtual planning images, no cephalometric tracings.

Response 3: Please provide your response for Point 1. (in red) Thank you very much. All necessary steps was taken to improve entire article. 

Point 4. -Growth arresting procedures should be better described.

Response 4: Please provide your response for Point 1. (in red) Thank you very much. All necessary steps was taken to improve entire article. 

Point 5. - Caution should be observed in the use of Tc scans and imaging procedures which generate a lot of radiation and in this condition in young persons. may need to be repeated. Prudent 'watch and wait' with serial dental models, simple plain film, radiographs and photographs should be encouraged to reduce radiation exposure. 

Response 5: Please provide your response for Point 1. (in red) Thank you very much.

Point 6.  – 'rubber wires' do not exist.

Response 6: Please provide your response for Point 1. (in red) Thank you very much. This mistake, had been corrected.

Point 7 .   Focusing on UCH would help the Authors to develop an algorithm which would be useful for surgeons. As written, there is little practical or novel value in this presentation.

Response 7: Please provide your response for Point 1. (in red) Thank you very much. A special paragraph concerning a possible algorithm will be added. This is just a simple proposal, because this pathology, namely UCH is greately case related and surgeons-preferences based – however Authors based on thier experience will try to set some new insights into this matter.

Point 8 -   I would recommend describing the basic forms of UCH and their clinical manifestations, supported by Photographs, Cephalometric and imaging studies (including 3D). Describe an algorithm for early, intermediate and late treatment with examples of virtual treatment planning now available.

Response 8 - Please provide your response for Point 1. (in red) Thank you very much. A special paragraph concerning a possible algorithm will be added, along with amore additional photographs and examples of treatment

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

I appreciate the hard work of the authors, making many modifications to their article and responding positively to reviewers’ comments.

 Thank you very much for your hard work.

Author Response

Dear reviewer thank You very much.

Response to Reviewer 1 Comments

Point 1.  – I appreciate the hard work of the authors, making many modifications to their article and responding positively to reviewers’ comments.

 Thank you very much for your hard work.

Response 1: Thank you very much. Dear reviewer Im very happy that your personal valuable comments improved the paper. Thank you very much. With Regards

Author Response File: Author Response.docx

Reviewer 2 Report

The Authors have made a good faith effort to revise the ms. However, the spelling, style and grammar issues remain. 

The 'algorithm' is not clinically useful as stated and needs to be correlated with the surgical treatment options on P 573-. 

Although there are significant changes in the narrative, they do not fully address the comments.

I do not think that the revised ms. adds to our current knowledge, is a significant review of the current literature nor would be clinically helpful to the desired audience.

The Authors should look again at my original review and my further comments in the second review.

Author Response

Dear reviewer thank You very much.

Response to Reviewer 2 Comments

Point 1.  – The Authors have made a good faith effort to revise the ms. However, the spelling, style and grammar issues remain.

Response 1: Thank you very much for the comment. Condylar hyperplasia is challending since the scope of approaches are related with the degree of overgrowth, patients age, scope of coexisted mandibular asymmetry and overgrowth and the degree of malocclusion. Each case is indyvidual, so at this point its not possible to present any clear algorithm. Since 1986 and first case descriptions it still is treated indyvidualy by many Authors, and each one is presenting their own methods. Style and spelling will be improved to meet some criteria, as It succcesfully did satisfy the rest of the reviewers.

Point 2.  – The 'algorithm' is not clinically useful as stated and needs to be correlated with the surgical treatment options on P 573-.

Response 2: Thank you very much for the comment. (red text marks the improvements) – the possible treatemnts from p=573 states clearly that there is a lot of possibilites in UCH treatement which is mostly case and surgeons related. Furthermore, presented herein review is pointing out those situations and possibilities of treatement. All possible Authors philosophy approaches are gathered in Table 1, and there is no possibility to present everything more clearly. Furthermore, If I would wrote a book, then would it be possible to present each case and each scope of asymemtry and overgrowths and my own philosophy of treatement. So far Authors did whatever is possible to improve the paper value based on own clinical cases and experiences from more than 150MA cases.

Point 3.  – Although there are significant changes in the narrative, they do not fully address the comments.

Response 3: Thank you very much for the comment. An Authors based algorythm is implemented in the text. There is not possible to treat each case in the same matter, thats why Authors clearly evaluated and described all possible treatment outcomes and modalities. This review paper presents Authors perspective on condylar hyperplasia. Comments on the stability of each treatemnt exceeds far beyond this paper and will be presented briefly in an original paper. All necessary comments which are related with the topic of the paper and authors surgical knowledge are already in the paper.

Point 4.  – I do not think that the revised ms. adds to our current knowledge, is a significant review of the current literature nor would be clinically helpful to the desired audience.

Response 4: Thank you very much for the comment. As written above, Authors made a review and compared them with own experience. Furthermore all necessary surgical steps and possibilities are presented in the paper -based on the literature - and discussed with Authors results. Its not possible to add a great new insights, but its possible to present ouw experience and philosophy on this pathology, which had been already clearly presented.

Point 5.- The Authors should look again at my original review and my further comments in the second review.

Response 5: Thank you very much for the comment. All issues had been clarified and written in more precise manner, especially after the reviewers hints from the first review:

- 1)   – The Authors have extensively reviewed mandibular asymmetry, but the title of the article relates to Unilateral condylar hyperplasia. As written, they have confused the discussion by including syndromic, tumor and trauma patients. The paper would be considerably improved by limiting the discussion to UCH patients. …….-In order to understand the cause of mandibular asymmetry, its important to known and differentiate other possible causes of mandibular and facial asymmetry. This had been re-arranges and presented more briefly in the text.

- 2)  -The Illustrations are poor and not particularly helpful. Fig 4 shows none of the surgical procedures described. Fig 7 ',..total symmetry correction...' shows significant facial asymmetry probably soft tissue if the boney asymmetry has indeed been corrected. There are no 3D images, no virtual planning images, no cephalometric tracings. ………….- All necessary figures and improved explanation was added and presented in order to show Authors methods of treatement.

- 3) -Growth arresting procedures should be better described…… Dear reviewer either scintigraphy or SPECT are currently nowadays used. Its not other possibility to estimate pathological grown. The studies made in the nuclear medicine department are made according to world standards and are sufficient enoguth. The approach with RTG is not used anymore. While PET examination is not used commonly, generates great costs and not everytime its possible to maed such an examination, expecially SPECT is a dedicated method for  UCH evaluation.

- 4) -Caution should be observed in the use of Tc scans and imaging procedures which generate a lot of radiation and in this condition in young persons. may need to be repeated. Prudent 'watch and wait' with serial dental models, simple plain film, radiographs and photographs should be encouraged to reduce radiation exposure.  ……. – Dear rewiever, wait and see approach is advisavble in small amount of growth cases which tends to self limit in time. In cases of severe overgrowths and massive bone asymmetry which is constantly growing in time is a recquirement for a SPECT and early condylectomy to stop the pathological growth. The earliest cases, which might start at 10-12 years of age are scheduled for LDCT – low dose CT which is safe for children. Secondly at elast one spect should be done app 1/per year or two and ofcourse its also safe. No data in world literature exist on negative influence of LDCT or SPECT in growing pateints. One thing exists for sure, that if neither SPECT nor LDCT is made, the asymmetry might promote some sirious facial and mandibular discrepations.

- 5)  -Focusing on UCH would help the Authors to develop an algorithm which would be useful for surgeons. As written, there is little practical or novel value in this presentation. ……………. -A special paragraph concerning a possible algorithm will be added. This is just a simple proposal, because this pathology, namely UCH is greately case related and surgeons-preferences based – however Authors based on thier experience will try to set some new insights into this matter.

- 6) -   I would recommend describing the basic forms of UCH and their clinical manifestations, supported by Photographs, Cephalometric and imaging studies (including 3D). Describe an algorithm for early, intermediate and late treatment with examples of virtual treatment planning now available………… Dear reviewer everything is added in the manuscript. This paper is supose to be a review and evaluate some surgeons perspective on UCH treatement and diagnostics. All necessary data is written.

Author Response File: Author Response.docx