Relationship Between the Changes in the Inclination of the Incisors and Soft Gingival Tissue Remodeling During the First Phase of Orthodontic Treatment Without Premolar Extraction

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

- The study explores an important and underreported topic — the relationship between incisor inclination changes and gingival soft tissue remodeling during early orthodontic treatment. It is well-designed, using both CBCT and 3D scans, but would benefit from stronger clarity, analysis, and clinical interpretation.

- The study would benefit from more detailed justification of the sample size. Was a power analysis performed to confirm that 71 subjects were sufficient to detect clinically relevant changes?

-The choice of non-parametric tests is appropriate given the data distribution, but the manuscript lacks effect size or confidence intervals, which are necessary to interpret the magnitude and clinical relevance of findings.

- The correlation coefficients (mostly weak to moderate) should be interpreted with caution and discussed in terms of biological plausibility, not just statistical significance.

- Consider adding a multivariate model (e.g., regression) to adjust for confounders such as age, sex, or initial gingival thickness, rather than relying solely on pairwise non-parametric correlations.

-Table 1 is dense and difficult to read. Simplify by separating upper and lower incisors into two tables or grouping variables (CCH, GTH_CEJ, GTH_1mm) under subheadings.

-Figures 1–6 are informative but could be enhanced by labeling significant correlations directly on the plots with trend lines for clarity.

-The manuscript would benefit from explicitly stating mean changes and clinical thresholds (e.g., a 0.1–0.2 mm CCH increase may not be clinically perceptible).

-The discussion successfully integrates previous findings but can be improved by emphasizing clinical implications: What threshold of inclination change begins to pose a risk for gingival thinning or height reduction? How should clinicians modify torque or archwire selection in patients with thin biotypes? The clinical significance of small (<0.2 mm) changes in gingival height or thickness should be clearly distinguished from statistically significant but biologically minor effects.

-Ensure consistent use of “retro-inclination,” “re-inclination,” and “proclination” across all sections to avoid confusion.

-Mention absence of long-term follow-up or second treatment phase evaluation.

-Acknowledge omission of keratinized gingiva width, probing depth, and vertical tooth movement data.

-Discuss generalizability limits since the sample excluded extraction and surgical cases.

Author Response

Please find our response in the attachment.

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review the paper entitled "Relationship between the changes in the inclination of the incisors and soft tissue remodeling during the first phase of orthodontic treatment without premolar extraction"

I have read the manuscript.

1. Title:

The title is clear and accurate.

 

2. Abstract:

Without premolar extraction – is there any other tooth extracted (eg. lower incisor?)

CBCT befor and after OT – is it ethical

 

3. Material and Methods

Line: 105: what defines »the need for OT«

Line 158: Teeth were assigned into three groups: retro-inclination (lingual crown inclination <0°), proclination-low (buccal crown inclination between 0° and 5°) or proclination-high (buccal crown inclination >5°). Which inclination is standard for upper and lower incisors?

Line: 169: intraoral scan befor and after alignment phase, and CCH and GTH measurements

During orthodontic alignment with brackents gingival tissue is often more or less inflamed and consequently swollen. How is this taken into account in the measurements? And in comparison to healthy nonswollen gingiva.

Line 190: The graphs were created with ??  (the sentence is not ended)

 

4. Results

Bucally and palataly- the CCH after first phase is different. Thicknes on buccal side was significantly increased?

Is that also due to different inflamation of gingiva?  

     5. Conclusions

The reduction in gingival height and thickness during the alignment phase was greater in the upper incisors.

In my experience, inflammation and thus swelling of the gingiva is greater in the lower incisors region. How is this taken into account in the results? Or is it at all?

 

    6. References

Corrects the reference 33, 35

Author Response

Please find our response in the attachment.

Author Response File: Author Response.docx

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

I have read your manuscript with great interest. However, I believe the manuscript would benefit from several improvements to enhance clarity, scientific rigor, and reader engagement.

I wish you success!

 

With the title worded like this, without having read the article yet, I was under the impression that the position of the lips would be discussed. Consider changing the title to specify that you are investigating the relationship between tooth position and gingival changes.

Introduction

47-48 There are repetitions of expressions in one sentence

Please describe more specifically and logically the tooth movements that are associated with the onset of gingival recessions. Not all dental movements of the front teeth (incisors and canines) can cause gingival recessions. Most often, vestibular inclination of the incisors and vestibulo-oral displacement of the canines are movements that can cause these negative processes.

I think the introduction should have a more logical sequence of the discussed parameters that relate to the study. In this form, various topics are commented on piecemeal and without connection.

Materials and Methods

Study population.

To the inclusion criteria, I think you should add: complete documentation, including.........; signed informed consent for treatment plan and participation in the study; uninterrupted treatment process (appearance for all examinations).

In the inclusion criteria I did not find a requirement for the position of the canines relative to the incisors. Quite often, the canines guide the movement of the incisors and are the cause of their more vestibular inclination, which is also associated with the appearance of recessions. Crowding alone cannot be a criterion. The incisors do not stand in isolation in the dental arch.

The material section describes the number of patients included in the study, but does not describe how many and which teeth of the patients the measurements were taken on.

There are redundant sentences in the text - lines 189-190.

 

Results

In the results, the incisors are evaluated in groups according to their inclination. These groups should have been defined in the material and methods section. This will make it clear how many teeth are included in the different groups and the results will track the changes and differences between the individual groups.

Discussion

The references include 41 authors, of which only 19 are from the last 10 years. The discussion makes comparisons with data from authors derived from cephalometric analyses, while this study was done with CBCT images. The soft tissue images in the two studies have their differences, which I did not find a discussion about. For example, authors: 1, 8, and others

The own data are discussed in the discussion, but there are not enough comparisons with other studies. If this were done, the topic would be of a confirmatory nature or questions that are not yet sufficiently clarified would arise.

Author Response

Please find our response in the attachment.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript is clear, well-organized, and scientifically sound. The methods are appropriate, the results are presented coherently, and the discussion is well aligned with current evidence. The study adds meaningful value to the existing literature, and no major revisions are required.

I recommend acceptance of the paper in its current form.

Reviewer 3 Report

Comments and Suggestions for Authors

I accept all the changes made. The manuscript now has a more complete and scholarly expression.