Attempting to Determine the Relationship of Mandibular Third Molars to the Mandibular Canal on Digital Panoramic Radiography; Using CBCT as Gold Standard

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This manuscript radiologically evaluates the relationship between mandibular third molars and the mandibular canal, comparing the results of digital panoramic radiography and quantitative image analysis with cone beam computed tomography as the gold standard. The study includes a well-defined sample and introduces fractal analysis and histograms as innovative approaches. However, the authors need to supplement the paper and address the criticisms found and set out below.

1. Could the authors integrate the comparison between DPR and CBCT within a broader context of diagnostic monitoring? Recent studies have developed solutions for monitoring SAR and temperature variations in interaction with human tissues using smart electronic devices. The authors could integrate these studies into the Introduction because they demonstrate how monitoring with electronic devices improves safety in interactions with human tissues.

2. Could fractal analysis and histogram methods be extended with soft computing approaches to improve classification accuracy? Authors should integrate the Methods Discussion with the study doi: 10.2478/jee-2025-0007, because it highlights how nonlinear analysis can classify structural anomalies relevant for trabecular bone assessments.

3. Have the authors evaluated the potential of artificial intelligence models (e.g., LSTM or U-Net) to improve DPR image prediction?

4. Could FEM modelling and AI-enhanced monitoring support conclusions about the mandibular canal relationships? I'm not asking the authors to implement a model from scratch, but only to integrate the Discussion with the study doi: 10.3390/electronics14112268, because it shows how hybrid FEM and AI approaches can be applied in diagnostic imaging.

5. What are the considerations for the electronic interface for clinical imaging systems such as CBCT and DR?

6. The study uses FA/HA retrospectively: How could the authors improve the prospective characterisation of defects and artefacts due to image reconstruction?

7. Could impedance-based approaches integrate radiographic predictors into the risk of nerve injury? The authors should integrate the Limitations/Future Perspectives section by referring to study 10.3390/eng5030084, as it proposes alternative diagnostic methods.

8. How would mechanical stress analysis approaches help refine your trabecular bone assessment?

9. Is it possible to transfer your FA/HA methodology to biomedical sensor monitoring contexts?

10. Could the DPR-CBCT comparative methodology inspire optimised diagnostic protocols?

Author Response

Dear Reviewer,

Thank you very much for your valuable suggestions and contributions. We have made the revisions you requested and highlighted them in red within the manuscript.

Sincerely,

Umut Pamukcu

Comments 1. Could the authors integrate the comparison between DPR and CBCT within a broader context of diagnostic monitoring? Recent studies have developed solutions for monitoring SAR and temperature variations in interaction with human tissues using smart electronic devices. The authors could integrate these studies into the Introduction because they demonstrate how monitoring with electronic devices improves safety in interactions with human tissues.

Response 1. Based on your recommendation, we've integrated the relevant information into the "Introduction" section. The relevant phrase is highlighted in red between lines 53-63.

Comments 2. Could fractal analysis and histogram methods be extended with soft computing approaches to improve classification accuracy? Authors should integrate the Methods Discussion with the study doi: 10.2478/jee-2025-0007, because it highlights how nonlinear analysis can classify structural anomalies relevant for trabecular bone assessments.

Response 2.Based on your recommendation, we've integrated the relevant information into the "Discussion" section. The relevant statement is highlighted in red between lines 340-344.

Comments 3. Have the authors evaluated the potential of artificial intelligence models (e.g., LSTM or U-Net) to improve DPR image prediction?

Response 3. Based on your recommendation, we've integrated the relevant information into the "Discussion" section. The relevant statement is highlighted in red between lines 398-402. I would also like to point out that we are currently conducting a similar study on this subject, and we hope to see it published in the literature in the coming days.

Comments 4. Could FEM modelling and AI-enhanced monitoring support conclusions about the mandibular canal relationships? I'm not asking the authors to implement a model from scratch, but only to integrate the Discussion with the study doi: 10.3390/electronics14112268, because it shows how hybrid FEM and AI approaches can be applied in diagnostic imaging.

Response 4. Based on your recommendation, we've integrated the relevant information into the "Discussion" section. The relevant statement is highlighted in red between lines 398-402.

Comments 5. What are the considerations for the electronic interface for clinical imaging systems such as CBCT and DR?

Response 5. I can't say we have sufficient knowledge on this topic. Furthermore, considering the context of the article, it seems a bit out of scope. Since I didn't see any opportunity to include or discuss this topic anywhere in the article.

Comments 6. The study uses FA/HA retrospectively: How could the authors improve the prospective characterisation of defects and artefacts due to image reconstruction?

Response 6. These analyses commonly apply to retrospective images in healthcare settings, including dentistry. Despite the artefact reduction algorithms and user instructions (patient positioning, exposure parameters, etc.) available in imaging devices, these analyses cannot be applied if defects and artefacts are present in relevant areas of the images.

Comments 7. Could impedance-based approaches integrate radiographic predictors into the risk of nerve injury? The authors should integrate the Limitations/Future Perspectives section by referring to study 10.3390/eng5030084, as it proposes alternative diagnostic methods.

Response 7.Based on your recommendation, we've integrated the relevant information into the "Discussion" section. The relevant statement is highlighted in red between lines 403-406.

Comments 8. How would mechanical stress analysis approaches help refine your trabecular bone assessment?

Response 8. Mechanical stress analysis is a method commonly used in dentistry to examine the trabecular bone surrounding loaded structures such as implants. However, in our current study, the mandibular third molars we examined were selected from among impacted teeth, as they are intraoral structures not subject to any occlusal or other forces. Therefore, we believe it would be inappropriate to use or discuss a method such as mechanical stress analysis here.

Comments 9. Is it possible to transfer your FA/HA methodology to biomedical sensor monitoring contexts?

Response 9.Based on your recommendation, we've integrated the relevant information into the "Discussion" section. The relevant statement is highlighted in red between lines 406-411.

Comments 10. Could the DPR-CBCT comparative methodology inspire optimised diagnostic protocols?

Response 10. This was the most critical outcome we anticipated from this study. Our primary objective was to review the relatively limited use of CBCT and the utility of DPR, which uses less radiation, as a diagnostic tool in evaluating the relationship of mandibular third molars to the mandibular canal.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

The paper titled ``Attempting to Determine the Relationship of Mandibular Third Molars to the Mandibular Canal on Digital Panoramic Radiography; Using CBCT as Gold Standard``,  addresses the importance of knowing the relationship between mandibular third molars (M3s) and the mandibular canal to prevent postoperative complications like excessive bleeding and numbness during tooth extraction.

The paper needs some revision before its final acceptance:  

1. The study's retrospective nature introduces biases, as variables like imaging protocols and equipment settings couldn't be controlled. For better standardization, please consider a prospective.
2. The small sample of 60 patients limits the generalizability and statistical power of the findings. A larger sample would provide more robust results and help detect subtle differences.
3. The study didn't account for clinical variables like inflammation, which could influence bone density and radiographic appearance. It would be interesting to incorporate these factors for a more comprehensive analysis.
4. The paper lacks specific information on the DPR and CBCT machines and their exposure parameters, which is crucial to reproduce the study and evaluate potential sources of variability.
5. Although the study found significant associations with high-risk radiological signs, their interpretation on DPR is subjective and depends on the clinician. Please discuss in detail this limitation.
6. The paper provides insufficient detail on how the Regions of Interest (ROIs) were selected. Please explain the choice of the 20x20 pixel size and a standardized placement method, since these factors impact the results.
7. While Lacunarity is identified as a promising tool, the study doesn't provide specific thresholds or cutoff values for its use in clinical practice. Please discuss this point and the corresponding aspects in terms of diagnostic accuracy, including sensitivity and specificity.

Author Response

Dear Reviewer,

Thank you very much for your valuable suggestions and contributions. We have made the revisions you requested and highlighted them in red within the manuscript.

Sincerely,

Umut Pamukcu

Comments 1. The study's retrospective nature introduces biases, as variables like imaging protocols and equipment settings couldn't be controlled. For better standardization, please consider a prospective.

Response 1. The possibility that the study's retrospective nature would affect radiographic evaluation or analysis was attempted to be overcome by obtaining all images using the same device and imaging protocols. This situation is highlighted in red between lines 131-136.

Comments 2. The small sample of 60 patients limits the generalizability and statistical power of the findings. A larger sample would provide more robust results and help detect subtle differences.

Response 2. Choosing a large sample size is certainly important for obtaining more precise results. However, based on the results of our pre-study power analysis (highlighted in red between lines 103-105) and comparison with similar sample sizes in the literature (Al Ali, S., Jaber, M. Correlation of panoramic high-risk markers with the cone beam CT findings in the preoperative assessment of the mandibular third molars. J Dent Sci. 2020, 15, 75-83.,de Melo Albert, D.G.; Gomes, A.C.; do Egito Vasconcelos, B.C.; de Oliveira e Silva, E.D., Holanda, G.Z. Comparison of orthopantomographs and conventional tomography images for assessing the relationship between impacted lower third molars and the mandibular canal. J Oral Maxillofac Surg. 2006, 64, 1030-1037.), we concluded that the sample size would be sufficient. However, based on your recommendation, we added a statement regarding the sample size limitation to the limitations and highlighted in red between lines 396-398.

Comments 3. The study didn't account for clinical variables like inflammation, which could influence bone density and radiographic appearance. It would be interesting to incorporate these factors for a more comprehensive analysis.

Response 3. As is the case in studies examining a parameter thought to cause changes in bone microarchitecture, we believed that the relationship between M3 and the canal could only be clearly demonstrated if all other parameters were fixed. Therefore, we selected cases where we believed the bone structure was unaffected (or minimally affected) except for the tooth's relationship with the mandibular canal. However, it is true that this suggestion could be implemented in other studies.

Comments 4. The paper lacks specific information on the DPR and CBCT machines and their exposure parameters, which is crucial to reproduce the study and evaluate potential sources of variability.

Response 4. The brands and exposure parameters of both machines are given in the "Materials and Methods" section, and highlighted in red between lines 131-135, 176-180.

Comments 5. Although the study found significant associations with high-risk radiological signs, their interpretation on DPR is subjective and depends on the clinician. Please discuss in detail this limitation.

Response 5. Based on your recommendation, we've integrated the relevant information into the "Discussion" section. The relevant statement is highlighted in red between lines 334-337.

Comments 6. The paper provides insufficient detail on how the Regions of Interest (ROIs) were selected. Please explain the choice of the 20x20 pixel size and a standardized placement method, since these factors impact the results.

Response 6. Based on your recommendation, we've corrected the relevant information into the "Materials and Methods" section. The relevant statement is highlighted in red between lines 159-167.

Comments 7. While Lacunarity is identified as a promising tool, the study doesn't provide specific thresholds or cutoff values for its use in clinical practice. Please discuss this point and the corresponding aspects in terms of diagnostic accuracy, including sensitivity and specificity.

Response 7. Based on your recommendation, we've added the ROC analysis results to the "Results" section. The relevant statement is highlighted in red between lines 232-235.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors have answered all my questions. The paper can be accepted for publication in its present form.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

All the suggested corrections have been taken into account. Now, the paper is accepted.