Surgery First and Aligners: A Case Report Combining In-House Surgical Guides and Pre-Adapted Titanium Plates
, Inleel Lundgård Shino 2, Stratos Vassis 1, Karen Eich Hammer 3, Kasper Dahl Kristensen 1, Thomas Klit Pedersen 4, Sven Erik Nørholt 4 and Jytte Buhl 2
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsDear Authors
Thank you very much for the Case Description Introducing Surgery First and Aligners: Connection with internal surgical guides and pre -adapted titanium tiles. I would like to draw your attention to several issues from the reviewer's obligation.
1. In the presented manuscript, it is enough to repeat technical information once, e.g. version 11.9 Dolphin Imaging and Management Solutions, CHATSWORTH, CALIF) Others can be removed from the text
2. Please add the abbreviations included in the text at the end
3. I suggest including citing https://doi.org/10.3390/jcm13195726
Author Response
Please see the attachment.
Author Response File: 
Author Response.pdf
Reviewer 2 Report
Comments and Suggestions for AuthorsI thank the editor for inviting me to review the manuscript entitled “Surgery first and aligners: a combination with in-house surgical guides and preadapted titanium plates”.
Title: the title should reflect that this is a case report.
Abstract: I suggest that the authors include the total range of the three questionnaires, with brief indication of the anchors. In this way, the sentence of “a decreased score was reported” makes more clinical sense (i.e., is a decreased score reflecting better functioning?)
Introduction: this requires many more references to support their statements
Methods:
- Line 72: indications vs contraindications of this treatment option should be discussed, to inform the readers and enhance clinical applicability. Maybe these should be discussed in the introduction
- Figure 1 should have the eyes of the patient covered for privacy and confidentiality
- Lines 79-93: it would be easier to follow if the description of the case was divided into subsections: Extraoral examination; Skeletal examination; Intraoral examination; Dental examination; Diagnosis; Treatment options (as an example).
- When was the previous orthodontic treatment completed? (line 82)
- Lines 105-107: these questionnaires need to be explained in total range, what domains they assess, what higher values mean, what anchors mean.
- All the timeline of the method could also be provided graphically in a figure (maybe replacing table 1).
- Picture of the initial and final clincheck may also be useful to visualize in a figure, as well as the initial VTO
- Line 183: What does it mean “unweighted” and “weighted”? again, it is difficult to give sense to these numbers because the scoring was not described earlier in the manuscript
- Is there any long-term follow-up of this case?
Discussion: this is very brief, but anyway exhaustive of the choice made during and before the surgery, it well explains the rational of the auxiliaries and approached utilized during the surgery.
It could be expanded on the use of corticotomies. The authors have indicated that there is no other reports of the use of corticotomies within the context of orthognathic surgery. This is also a question that I would rise. Why were the corticotomies deemed necessary? The use of the corticotomies is justified to accelerate treatment and tooth movement in that they are constituting a trauma and for the acceleration of the healing process. Why the orthognathic surgery itself was not considered enough as a trauma but corticotomies were deemed necessary in addition to the orthognathic surgery?
Author Response
Please see the attachment.
Author Response File: Author Response.pdf
Reviewer 3 Report
Comments and Suggestions for AuthorsSefidroodi et al. present a case report on an individually planned workflow combining CAT with surgery first orthognathic approach (SFOA) in collaborating with engineers for in house production of surgical guides and customized titanium plates. The authors are suggested to thoroughly revise the manuscript before considering for publication. Specific comments and suggestions for revision are below:
Abstract:
The abstract could mention the novelty of this study.
Introduction:
There is barely any work cited before Line 47. The authors are suggested to thoroughly review the literature to guide the Introduction section.
The rationale and novelty of this study could be highlighted in the introduction.
The authors could consider stating the gaps in existing research that this case report addresses, and why in-house production of guides and plates represents a significant advancement.
Methods:
It would be helpful to include more information about the quality control of the in-house manufacturing process. How is the precision of the surgical guides ensured? Are there any known limitations of using in-house guides and plates compared to commercially available products? Adding such details will improve the reproducibility and credibility of the technique.
There appears to be a jump from Methods to Discussion. The Objective Assessment and Quality of Life Evaluation section is unclear.
Discussion:
The writing of the discussion could be significantly improved. Critical analysis of the limitations of the combined SFOA-CAT approach could be included. Long-term stability could be discussed. Adding a more critical discussion of limitations and comparisons to alternative approaches would also strengthen the manuscript.
Comments on the Quality of English LanguageCould be improved.
Author Response
Please see the attachment.
Author Response File: Author Response.pdf
Round 2
Reviewer 2 Report
Comments and Suggestions for AuthorsThe authors have uploaded the wrong point-by-point response to my previous comments. As such, I still do not know why they deemed appropriate to add corticotomies to a maxillofacial surgery interventions, given that this latter is already aggressive enough to cause acceleration in the treatment plan.
Line 73-74: If the authors are saying that there are already two other references, why is their study needed? And in what is their study different from the other two referenced protocols?
Author Response
Dear reviewer 2,
My sincerest apologies, somehow your responses was mixed up with the other reviewers. Please see the attached template for the previous comments.
Comment 1: The authors have uploaded the wrong point-by-point response to my previous comments. As such, I still do not know why they deemed appropriate to add corticotomies to a maxillofacial surgery interventions, given that this latter is already aggressive enough to cause acceleration in the treatment plan.
Response 1: Please see the attachment for response (response 13).
Comment 2: Line 73-74: If the authors are saying that there are already two other references, why is their study needed? And in what is their study different from the other two referenced protocols?
Response 2: Great point. As mentioned in line 73-74, there are no guidelines on what cases that our suitable for surgery first orthognathic approach (SFOA) combined with clear aligner therapy (CAT). Thereby we can't provide any references on if our case fits the criteria regarding malocclusion and skeletal deformities for this type of approach. The guidelines presented in the literature (reference 27) are merely discussing some scenarios were SFOA-CAT can be used by using the ClinCheck to visualise if the case is suitable:
"ClinCheck to make compensatory modifications termed as
‘Surgical Jump’. A ‘surgical jump’ aids in not only visualisation, but also, ascertains evaluation
of ‘Occlusal Interferences’ in all three dimensions. Therefore, the primary objectives of visualising or pre-viewing a surgical jump, in the beginning itself, is a pre-requisite of incorporating CAT in SFOA, as it (1) identifies the feasibility of performing surgery-first or (2) whether the
case requires any presurgical decompensation, and subsequently (3) assist in the fabrication surgical guides or bite wafers using ClinCheck (a detailed description of ‘Surgical Jump’ is provided in the case presentation)."
Our approach is done without using the ClinCheck software. In our opinion describing the post surgical occlusion is extremely time consuming in our opinion. This approach is also only occlusion driven and not facial driven. Our facial driven protocol opens up to use any aligner software as well as in-house manufacturing of the aligners.
The other reference 28 describes our own protocol in details, specifically how to solve the challenges related to the post surgical occlusion. This case report is an example of the workflow presented in reference 28.
To summarize there are no official guidelines on case selection using SFOA-CAT. Our protocol allows for using all types of aligner softwares in an efficient way and our case report is an example of this method.
Author Response File: Author Response.pdf
Reviewer 3 Report
Comments and Suggestions for AuthorsThe manuscript has been improved prior to the initial submission. I reviewed the point-by-point response and can see that the authors have thoroughly addressed the comments and provided clarifications for several points. I would recommend publishing the article at the discretion of the academic editor.
Author Response
On behalf of our team I would like to thank you for your feedback and recommendation.
Round 3
Reviewer 2 Report
Comments and Suggestions for AuthorsThe authors have now addressed my new and previous comments. I agree with the current version of the manuscript for publication.
