The Relationship Between Adolescent Orthodontic Treatment and Temporomandibular Disorders: A Systematic Review with Meta-Analysis

1. Summary

Thank you very much for your valuable feedback and constructive suggestions. Your insights have been instrumental in improving the quality of our manuscript. We have carefully considered your comments and made the following revisions.

2. Point-by-point response to Comments and Suggestions for Authors

Comments 1: 1.1 Despite the authors claiming the use of a random-effects model, the forest plot indicates that this study still employed a fixed-effects model finally.

Response 1: As you pointed out, the forest plot incorrectly indicated the use of a fixed-effects model. We have corrected this to ensure a random-effects model was consistently applied. Thank you for pointing this out. It can be found on line 337 of page 10 and Figure 2.

Comments 2: 1.2 The Joanna Briggs Institute (JBI) checklist is designed for cross-sectional studies and is not applicable to longitudinal studies. Furthermore, there is a newer version of the Joanna Briggs Institute (JBI) checklist, and I suggest that the authors update accordingly.

Response 2: Agree. We have, accordingly, updated it to the latest version and differentiated its use for cross-sectional and longitudinal studies. It can be found on lines 195 ~ 196 of page 4, lines 235~238 of page 5, line 247 of page 6 and Table 1.

Comments 3: 1.3 The "Cochrane Bias Assessment Tool for Randomized Controlled Trials" is designed for randomized controlled trials and is not suitable for cross-sectional studies, cohort studies, etc.

Response 3: Accordingly, we have utilized the ROBINS-I checklist to reassess the risk of bias. It can be found on lines 372 ~ 374 of page 11, line 419 of page 12 and Figure 3.

Comments 4: 1.4 1.4 The literature search was not comprehensive enough: I recommend that the authors use a combination of subject terms and free terms in their search strategy.

Response 4: We have enhanced our literature search strategy by including both subject terms and free terms, as suggested. It can be found on lines 169 ~ 175 of page 4.

Comments 5: 2.1 Incorrect data extraction: I suggest the authors reconduct the data extraction, especially regarding sample size!

Response 5: We have re-extracted and corrected the data, particularly concerning the sample sizes. . It can be found on line 310 of page 8 and table 2 of page 9.

Comments 6: 2.2 Duplicate data inclusion: Although overlapping populations was acknowledged in the article, it is evident that the data from Henrikson's three articles likely originate from the same clinical study. In this case, it would be more reasonable to include only one of the three articles.

Response 6: Agree. We have addressed the issue of duplicate data inclusion. Recognizing that Henrikson’s three articles derive from the same clinical study, we have retained only one of them to avoid redundancy. It can be found on line 239 ~ 242 of page 5.

Comments 7: 3.1 The included literature is not up to date, with the latest article from 2021 and the rest being from before 2008. I suggest the authors consider the novelty and necessity of this study.

Response 7: We appreciate your concern about the recency of the included literature. While the field has limited newer studies, we conducted a further review to ensure the inclusion of the most relevant and up-to-date articles. We also emphasized the need for additional studies in this area in our discussion. It can be found on line 735 of page 18 ~ 741 of page 19.

Comments 8: 3.2 The study's subjects are adolescent patients, but the subjects in Egermark (2003) received orthodontic treatment in childhood. The authors may need to reconsider the inclusion of this article.

Response 8: Following your advice, we have clarified the definition of "adolescent" in our manuscript adopting the 10–19 age range as defined by WHO and UN standards for adolescents. Additionally, we have excluded Egermark (2003) from our inclusion criteria and have included Egermark (2005) instead. It can be found on line 147 ~ 149 of page 4, table 2 of page 9.

Comments 9:  I recommend that the authors pay attention to not mixing up these two concepts when writing the article. Please make revisions accordingly.

Response 9: We have revised the manuscript to avoid confusion between the two concepts mentioned and ensured precise and clear descriptions.

1. Summary

Thank you for your thoughtful review and for highlighting the key aspects of our systematic review. We truly appreciate your valuable suggestions and have addressed them as follows:

2. Point-by-point response to Comments and Suggestions for Authors

Comments 1: Provide information on the registration of the systematic review, if applicable;

Response 1: We sincerely thank the reviewer for highlighting the importance of systematic review registration. We fully acknowledge that registering a systematic review, for instance in PROSPERO, is a valuable practice that enhances transparency and helps prevent duplication of research efforts. However, we regret to inform you that this systematic review was not registered prospectively.

Despite this limitation, we have taken every step to ensure that the review strictly adheres to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to maintain methodological rigor and transparency. Specifically:

• PRISMA Checklist: The study was conducted and reported in alignment with the PRISMA 2020 checklist, which guarantees a comprehensive and systematic reporting of key aspects such as research objectives, eligibility criteria, and data synthesis methods.
• PRISMA Flow Diagram: A PRISMA flow diagram was included to provide a clear visual representation of the study selection process, starting from the initial database searches to the final inclusion of studies.
• Protocol Details in the Methods Section: The review’s methods section explicitly details all key methodological decisions, including search strategies, inclusion/exclusion criteria, risk of bias assessment tools (NOS, ROBINS-I), and the use of a random-effects model for meta-analysis.

While we recognize that prospective registration would have further enhanced the transparency of this review, we believe that adherence to PRISMA guidelines has ensured the robustness and reproducibility of our work. We are committed to registering all future systematic reviews to uphold the highest standards of transparency and scientific integrity.

Comments 2: Regarding the results, according to the Authors' investigation, provide a clearer approach on the level of evidence of the relationship between orthodontic treatment and the risk of TMDs. Additionally, I suggest that the Authors discuss more broadly the etiological factors and pathophysiology of TMDs, as well as the biological and biomechanical mechanisms that occur during orthodontic treatment.

Response 2: We sincerely thank the reviewer for the valuable and insightful comments, which have significantly enhanced the quality of our review. Based on your suggestion, we have incorporated the recommended content on line 423 of page 12 ~ line 443 of page 13 and line 571 of page 15 ~ line 593 of page 16 to address this important aspect more comprehensively.

1. Summary

Thank you very much for your thoughtful comments and constructive feedback. We greatly appreciate your insightful suggestions, which have helped us improve the quality and clarity of our work. Below, we outline our responses to your comments:

2. Point-by-point response to Comments and Suggestions for Authors

Comments 1:  The abstract should not contain the titles of its sections.

Response 1: We have removed the section titles from the abstract as per your suggestion. It can be found on lines 16~33 of page 1.

Comments 2: Correctly insert the corresponding author, according to the journal's standards.

Response 2: The corresponding author details have been updated to align with the journal's standards. It can be found on line 13 of page 1.

Comments 3: At the beginning of the introduction, describe the anatomy of the TMJ, with its components such as articular disc, bony surfaces and bilaminar zone.

Response 3: At the beginning of the introduction, we have incorporated a detailed description of the anatomy of the temporomandibular joint (TMJ), including components such as the articular disc, bony surfaces, and the bilaminar zone, as you recommended. It can be found on line 39 of page 1 ~ line 58 of page 2.

Comments 4: Insert the use of the PICO strategy into the methodology.

Response 4: Thank you for emphasizing the importance of explicitly incorporating the PICO strategy in the methodology. We have now structured and clarified the use of the PICO framework in the Methods section, ensuring greater transparency and alignment with systematic review standards. It can be found on lines 147 ~ 152 of page 4.

Comments 5: Overall, contextualizing, the manuscript represents an important focal point in Dentistry, is well written and conducted. I suggest increasing the number of references in the discussion.

Response 5: We are grateful for your positive feedback on the manuscript's overall quality and its significance in dentistry. Following your suggestion, we have increased the number of references in the discussion section to provide broader context and support for our findings. It can be found on line 767 of page 19 ~ line 921 of page 22.