A Novel Reverse Zygomatic Implant Approach: Step-by-Step Protocol and Cadaveric Validation for Trismus and Maxillectomy Sequelae—Part 1

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Step-by-Step Protocol and Cadaveric Validation for Trismus and Maxillectomy Sequelae. Part 1.”

Overall, I find the study to be well conceived, clearly structured, and scientifically sound. The manuscript addresses a highly challenging clinical scenario—severe trismus and post-oncologic maxillary defects—where conventional zygomatic implant placement is often not feasible. The proposed reverse insertion approach represents a novel and clinically relevant concept. To my knowledge, only isolated case-based descriptions of similar strategies have been previously reported, making this contribution original and timely.

The study design is appropriate for a preliminary validation of a new surgical protocol. The use of a fresh-frozen cadaver model, combined with virtual planning, CAD/CAM-guided placement, and postoperative CT superimposition for quantitative deviation analysis, demonstrates methodological rigor. The comparison between superior and inferior orbital approaches further strengthens the scientific value of the work. The inclusion of a 3D-printed verification bar to assess prosthetic alignment adds practical relevance and reinforces the translational aspect of the study.

The manuscript is logically organized, with a clear background rationale, detailed step-by-step protocol, and coherent presentation of results. The conclusions are consistent with the data presented and appropriately framed within the limitations of a cadaveric feasibility study. The mention of a forthcoming clinical series is also valuable, as it outlines a logical continuation of this research line.

In summary, this is a well-structured and innovative contribution that expands the surgical armamentarium for complex maxillary rehabilitation. I believe it provides meaningful preliminary evidence supporting the feasibility and anatomical safety of the reverse zygomatic implant approach.

 

Author Response

Comment 1: 

Overall, I find the study to be well conceived, clearly structured, and scientifically sound. The manuscript addresses a highly challenging clinical scenario—severe trismus and post-oncologic maxillary defects—where conventional zygomatic implant placement is often not feasible. The proposed reverse insertion approach represents a novel and clinically relevant concept. To my knowledge, only isolated case-based descriptions of similar strategies have been previously reported, making this contribution original and timely.

The study design is appropriate for a preliminary validation of a new surgical protocol. The use of a fresh-frozen cadaver model, combined with virtual planning, CAD/CAM-guided placement, and postoperative CT superimposition for quantitative deviation analysis, demonstrates methodological rigor. The comparison between superior and inferior orbital approaches further strengthens the scientific value of the work. The inclusion of a 3D-printed verification bar to assess prosthetic alignment adds practical relevance and reinforces the translational aspect of the study.

The manuscript is logically organized, with a clear background rationale, detailed step-by-step protocol, and coherent presentation of results. The conclusions are consistent with the data presented and appropriately framed within the limitations of a cadaveric feasibility study. The mention of a forthcoming clinical series is also valuable, as it outlines a logical continuation of this research line.

In summary, this is a well-structured and innovative contribution that expands the surgical armamentarium for complex maxillary rehabilitation. I believe it provides meaningful preliminary evidence supporting the feasibility and anatomical safety of the reverse zygomatic implant approach.

Response to Comment: Thank you very much for your kind comments.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for this interesting manuscript. Please, address my comments below:

1. Line 23 – please, add some actual numerical results regarding the deviation and distal deflection.
2. Line 28 – why are Conclusions in a separate line here?
3. Line 29 – make sure to clearly state which anatomical structures can be damaged or are avoided when taking this approach.
4. Line 172 – what irrigation? Specify here that it was saline (0.9 %?).
5. Line 197 – check your reference to Fig 1b.
6. Line 202 – check your reference to Fig 1c.
7. Line 212 – paths perhaps? I see two canals.
8. Line 214 – emergence perhaps?
9. Line 242 – what is meant by an anatomical compromise here? Please, specify.
10. Line 244 – how was this objectified?
11. Line 246 – how was this assessment performed?
12. Figure 5b – in what direction is this measured? You mentioned that both mesio-distal and bucco-palatal directions were considered.
13. Figure 5 – review the numbering in lines 252 to 261.
14. Table 1 is not a table, but a box.
15. Table 1 – you write zygomatic bone, then zygoma bone… Rephrase if needed.
16. Line 284 – please, discuss whether this would be similar in a living patient.
17. Line 287 – would you have any suggestions as to how to assess the primary stability in an objective manner?
18. Table 2 – what is “oral visual distance”? Why not just “distance”?
19. “Preoperatory CT-scan distance to premaxilla osteot omy comparing (mm)” – what do you mean by “comparing”? The same the next line of the “table”
20. Figure 5d – how did you acquire this image?
21. Line 350-1 – how can you assess all of these based on your methodology?
22. Line 352 – how was this examined?
23. Would you suggest changing the drilling/implantation guide? If yes, how?
24. Line 384-5 – is this really about the surgical access technique?
25. Line 400 – why do you suggest that the anterior implants would bear the highest mechanical stress?
26. Line 402 – why is the diameter concept mentioned here for the first time? Why?
27. Line 418 – why do you plan to publish that separately if you already have the data?
28. Line 430 – why do you have a Patents section here that is empty?

Please, respond to ALL of my comments one by one.

Kind regards.

Author Response

Response to Reviewer 2 Revision 1 Prosthesis Journal

We really appreciate your thorough review. Changes have been marked in yellow.

 

1. Comment 1: Line 23 – please, add some actual numerical results regarding the deviation and distal deflection.

Response 1: Thank you for your comment. We have added numerical results in lines 26-28:  “deviation at zygomatic bone being at the zygomatic bone 1.25 mm in the superior approach vs 2.32 in the inferior approach, intraorally 4.7 mm vs 7.3 mm, and in angular deviation 1.85º vs 5.63º”.

1. Comment 2: Line 28 – why are Conclusions in a separate line here?

Response 2: Thank you for pointing this out. Sorry, it must have been a typing error during the adjustment to the template that remained unadverted, we have corrected it.

1. Comment 3: Line 29 – make sure to clearly state which anatomical structures can be damaged or are avoided when taking this approach.

Response 3: Thank you for remarking this. This has already been adressed in the text:

• Lines 154-156: “Each implant was positioned to maximize zygomatic bone contact while avoiding critical structures such as the orbit, infraorbital foramen, zygomaticofacial canal, and temporal fossa. “
• Lines 243-244 : “...or involvement of anatomical structures such as the orbit, temporal fossa, infraorbitary nerve or the skin.”

but we have added a comment in the summary (lines 32-33): “Penetrating the orbit, injuring the skin or the infraorbitary nerve could be possible but guided surgery seems to prevent it. “

1. Comment 4: Line 172 – what irrigation? Specify here that it was saline (0.9 %?).

Response 4: Indeed, we must explain irrigation was saline 0’9%, otherwise it is not clear. It has been added to the text.

1. Comment 5: Line 197 – check your reference to Fig 1b.

Response 5: Thank you for pointing this out, it is figure 2b. Figure 1 was added in a final phase of revision of the manuscript and the reference was not adjusted. We have corrected it.

1. Comment 6: Line 202 – check your reference to Fig 1c.

Response 6: Thank you for pointing this out, it is figure 2c. Figure 1 was added in a final phase of revision of the manuscript and the reference was not adjusted. We have corrected it.

1. Coment 7: Line 212 – paths perhaps? I see two canals.

Response 7: Indeed, there are 2 paths, it is a plural noun, not a singular one. It has been corrected.

1. Comment 8: Line 214 – emergence perhaps?

Response 8: Thank you for bringing this up. It was a false friend, we hace corrected the word “emergency” to “emergence”.

1. Comment 9: Line 242 – what is meant by an anatomical compromise here? Please, specify.

Response 9: Thank you for highlighting this. By anatomical compromise we meant involvement of important anatomical structures such as the orbit, temporal fossa, infrorbitary nerve or the skin. We think we didn’t express it correclty, so we have been changed the text, adding examples of structures that should not be harmed during the procedure.

10. Comment 10: Line 244 – how was this objectified?

Response 10: Thank you for your insight. This was initially a by both surgeons performing the surgery, A.F.F and C.M.P,  during surgery, and it was later revised with the postoperative CT-scan.

 

11. Comment 11: Line 246 – how was this assessment performed?

Response 11: Thank you for your comment. Preoperative planning was superimposed to the final CT-scan and the planned postion of the implants was compared to the final one. Measurements were made with the help of Avinent bioingenieers to assess the diferent values.

1. Comment 12: Figure 5b – in what direction is this measured? You mentioned that both mesio-distal and bucco-palatal directions were considered.

Response 12: Thank you for your remark. We originally wanted to measure this way, but in real practice, as it was an intraoral visual measure, we measured with a ruler from the center of one implant to the other. Not being able to measure in two planes. This has been corrected in the text: “Lineal inter-implant distances within each hemiarch”  .

1. Comment 13: Figure 5 – review the numbering in lines 252 to 261.

Response 13: Thank you for detecting this error. Numbering has been appropiately reviewed.

1. Comment 14: Table 1 is not a table, but a box.

Response 14: Thank you for raising this point. We agree that it is a box indeed, but we wanted to display in a clear way all the procedures involved in the technique, step by step. We think this can make it more accessible for readers. We can made some changes to make the table more concise.

1. Comment 15: Table 1 – you write zygomatic bone, then zygoma bone… Rephrase if needed.

Response 15: Thank you for pointing that. At point 4 zygoma bone was changed for zygomatic bone, which is the official term.

1. Comment 16: Line 284 – please, discuss whether this would be similar in a living patient.

Comment 16: Thank you for raising this point. This could also be applied to living patients, in the same form polyamide guides are used in maxillofacial surgery as cutting guides for osteotomies or drilling guides for screw positions in patient-specific implants. Precision could be enhanced in this case usiong navigation both in the placement of the guides and during drilling and implant insertion (lines 399-402).

1. Comment 17: Line 287 – would you have any suggestions as to how to assess the primary stability in an objective manner?

Comment 17: This is a very interesting point. Primary stability in conventional implants could have been assessed in and objective manner using Osstell. However, we have not found literatura adressing this use. We do not dispose of such han equipment at our Hospital nor in the Anatomy Department, either. However, stability in zygomatic implants, which always sway at the end, depends on the splinting of all the implants by the  denture.

1. Comment 18: Table 2 – what is “oral visual distance”? Why not just “distance”?

Response 18: Glad to hear your thoughts. We wanted to measure and reflect the actual intraoperatory measures, as they were the immediate reference available to assess if the placement was similar to expected. Asa we modified the table to make it easier to read, it has been changed to “lineal measurements”.

1. Comment 19: “Preoperatory CT-scan distance to premaxilla osteotomy comparing (mm)” – what do you mean by “comparing”? The same the next line of the “table”

Response 19: Thank you for spotting this mistake. We think it was unadvertedly pasted while processing the table. It is just the distance from the medial implant to the remaining premaxilla bone. We have corrected it.

1. Comment 20: Figure 5d – how did you acquire this image?

Response 20: Figure 5d is a figure created with power point by the autor A.F.F to represent the actual occlusal vision the autors obtained intraorally. We thought it is the figure thar better represented the actual concordance.

1. Comment 21: Line 350-1 – how can you assess all of these based on your methodology?

Response 21:Many thanks for your comment. We believe, according to our personal experience both in conventional implantology and implantology over free flaps when reconstructing oncologic surgery, that when the Ackerman bar has good concordance with the implants’ emergence, a prosthesis can be placed. Obviously, rigurous and científic implant surgery requires precise implant placement guided by prosthesis.

In oncologic surgery, the defect is guided by the extent of the ressection required. Being able to place a prosthesis is of great importance and enhances quality of life, but has to be adapted to the remanining anatomy. In this cases, implants sometimes have to be placed in suboptimal positons, but with adequate splinting between the other implants and the prosthesis, it generally has satisfactory results.

A deviation of 6.46 and 8.14 mm is a big distance, but considering deviation at the entry point on the left side was already 3.77  and 5.64 mm, we must consider if the positioning of the  drilling guide was correct or inexact. What is more, our study evaluates zygomatic implants, that due to their length sway more, adding further inaccuracies at the intraoral end.

1. Comment 22: Line 352 – how was this examined?

Response 22: Sorry, line 352 corresponds to a blank line. We think your comment is referred to lines 350-351 “ The prosthetic space and angulation of all four abutments were sufficient to allow fabrication of a fixed dental prosthesis without mechanical interference or excessive divergence.” This was evaluated with the Ackerman bar, assessing the concordance of the introral emergence with the bar. Even in non-oncological patients, precision of 100% is never achieved. We observed quite good concordance, though not totally precise. In our surgical experience, oncological patients with immediate reconstruction with bony flaps and implant placement are not always totally precise but, we have obtained good dental rehabilitations with good long term prosthetic results. Although measuring mouth opening in cadaveric specimens is very difficult due to stiffness, it seemed that there was at least 20mm to be able to place a prosthesis. Thank you for your feedback.

23. Comment 23: Would you suggest changing the drilling/implantation guide? If yes, how?

Response 23: We believe that the guide design was correct. I could be improved if adding more flanges could improve fixation on the osseous borders and avoid small adjustment errors. What could make a big difference would be having a specific set of drills, which wasn’t available for the surgery. We depended on comercialy available drills, which wasn’t totally adapted to our implant design. Obviously, having titanium guides would have been the most precise, as they do not have the slight flexion thas polyamide guides present, but that would be way too expensive.

1. Comment 24: Line 384-5 – is this really about the surgical access technique?

Response 24: . The 5.0-mm thread diameter was dimensioned to enhance cortical anchorage, consistent with mechanical principles described for conventional zygomatic implants

1. Comment 25: Line 400 – why do you suggest that the anterior implants would bear the highest mechanical stress?

Response 25: Excuse us, it is an error. Posterior implants bear the highest mechanical stress, as reported by varios autors, such as Tezerişener  et al. Comparison of stress distribution around all-on-four implants of different angulations and zygoma implants: a 7-model finite element analysis. BMC Oral Health. 2024 Feb3;24(1):176. doi: 10.1186/s12903-023-03761-x. It has been changed and the reference added.

1. Comment 26: Line 402 (now line 415) – why is the diameter concept mentioned here for the first time? Why?

Comment 26: We appreciate your comment. The diameter of the implant is previously described in the design of the implant (lines 116-117):  “The implant diameter ranges from 4.1 mm (passive stem) to 5.0 mm (active threaded portion)” and it also appears in Figure 2a.

27. Comment 27: Line 418 – why do you plan to publish that separately if you already have the data?

Response 27: In our opinion, gathering both the description of the technique, the new desing of the implant and the results of the study with the cases is much too extense for only one article. That is why we thoought it would be better to describe de technique and the new implant design with one case and then in another article all the results.

1. Comment 28: Line 430 – why do you have a Patents section here that is empty?

Response 28: Sorry, we didn’t realise there was not a statement in this section. As there is not a patent for the moment and the section is not mandatory, the section has been erased.

 

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

110 changed portion by segment

159  - maxillectomy cutting guide for reproducible bone defect creation

160  -a zygomatic drilling guide to control osteotomy angulation and depth

Table 1 needs to be modified; it is not very schematic or clear.   Line 251 the description of the figure 5 is too long   Line 373 It would be advisable to briefly describe the results reported by Dawood et al. and to comment on whether they are similar to, or differ from, those observed in the present study.   At the end of the discussion it wolud be interesting limitations, clinical implications and future research

Author Response

Response to Reviewer 3 Revision 1 Prosthesis Journal

We are grateful for your detailed feedback. Changes have been marked in blue.

 

1. Comment 1: 110 changed portion by segment

Response 1: Thank you for bringing this up. We have changed it to segment.

 

2. Comment 2: 159  - maxillectomy cutting guide for reproducible bone defect creation

Response 2: We appreciate your input. However, we are not sure if we understood the comment, maybe the reviewer thought the sentence wasn’t clear. It has been changed to “to create a reproducible bone defect”.

 

3. Comment 3: 160  -a zygomatic drilling guide to control osteotomy angulation and depth

Response 3: Thank you for your remark. Obviously the drilling guide is not for osteotomy, but “to control implant insertion and its angulation”. Perhaps the previous comment was also related to this one.

 

4. Comment 4: Table 1 needs to be modified; it is not very schematic or clear.  

Response 4: We are grateful for your feedback. We have reformulated the table to try to make it esier to read.

 

5. Comment 5: Line 251 the description of the figure 5 is too long  

Response 5: We are thankful for your comment. With this figure we have tried to show in a visual manner the diferent measures obtained in this study. We have removed a sentence in b) that had inadvertedly been pasted there, as it just repeated d).

6. Comment 6: Line 373 It would be advisable to briefly describe the results reported by Dawood et al. and to comment on whether they are similar to, or differ from, those observed in the present study.   At the end of the discussion it wolud be interesting limitations, clinical implications and future research

Response 6:

Dawood et al in their study  only placed one reverse zygomatic implant on one side affected by an hemimaxillectomy, combining it with 2 conventional zygomatic implants on the other side. They did not address the problem of the limited mouth opening nor provided data regarding differences in accuracy between planification and final result. We already included limitations of our study (lines 428-431). As we also commented (lines 433-436), there is ongoing futher research on more cadaveric specimens to  asess if results are really reproducible, safe and precise enough. This could have promising clinical implications, offering patients the opportunity to rehabilitate their dentition, which would otherwise be difficult. It would also allow to investigate difficulties in prosthesis placement (lines 438-441).

Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

This manuscript introduces a novel reverse-insertion zygomatic implant technique designed to address clinical limitations in patients with severe trismus or post-maxillectomy anatomical changes. The topic is clinically relevant and innovative, and the authors present a well-structured proof-of-concept cadaveric study with detailed surgical planning, CAD/CAM guidance, and postoperative accuracy assessment.

The concept of inserting the implant from the zygomatic bone toward the oral cavity represents a potentially valuable solution for cases in which conventional zygomatic implant placement is not feasible. Overall, the study is scientifically sound and the methodology is well described.

However, several aspects of the manuscript could be improved to enhance clarity, scientific rigor, and readability.                                                                                                                         

Major Comments

1. Limited Sample Size
   The study is based on a single cadaveric specimen with four implants. Although the authors acknowledge this limitation, the discussion should more clearly emphasize that conclusions about clinical applicability remain preliminary.

2. Clinical Translation
   The manuscript states that clinical validation with eight additional cases is forthcoming. It would strengthen the paper if the authors briefly outline the expected clinical protocol or outcome parameters for those cases.

3. Deviation Analysis
   The reported intraoral deviations (up to 8.14 mm) are relatively large compared to conventional implant accuracy. Although the authors state that the deviation remains clinically acceptable, additional explanation is needed regarding prosthetic tolerance and biomechanical implications.

4. Biomechanical Considerations
   Because reverse insertion changes load distribution, the discussion could benefit from further analysis of potential biomechanical consequences such as:

• implant bending stress

• prosthetic load transfer to the zygoma

• long-term stability.

Minor Comments

1. Language and Grammar
   Several sections contain grammatical inconsistencies and could benefit from professional English editing.

2. Figure Clarity
   Some figures (particularly surgical images) could be improved with clearer labeling and higher resolution.

3. Figure Captions
   Figure captions should be slightly expanded to make them self-explanatory without requiring the reader to refer to the main text.

4. Table Formatting
   Table 2 contains many numerical parameters; the readability could be improved by simplifying the structure or dividing it into two smaller tables.

5. Terminology Consistency
   Ensure consistent terminology when referring to:

• "reverse-insertion implant"

• "reverse zygomatic implant"

• "retrograde insertion".

Strengths of the Study

• Innovative surgical concept.

• Detailed step-by-step protocol.

• Integration of CAD/CAM planning and surgical guides.

• Quantitative accuracy assessment using CT superimposition.

• High clinical relevance for maxillofacial reconstruction.

Comments on the Quality of English Language

The manuscript is generally understandable; however, the English language requires minor improvement for clarity and readability. Some sentences are grammatically complex or contain minor grammatical inconsistencies. Careful language editing and proofreading by a native English speaker or professional editing service would improve the overall flow and precision of the manuscript.

Author Response

Response to Reviewer 4 Revision 1 Prosthesis Journal

Changes have been marked in green.

This manuscript introduces a novel reverse-insertion zygomatic implant technique designed to address clinical limitations in patients with severe trismus or post-maxillectomy anatomical changes. The topic is clinically relevant and innovative, and the authors present a well-structured proof-of-concept cadaveric study with detailed surgical planning, CAD/CAM guidance, and postoperative accuracy assessment.

The concept of inserting the implant from the zygomatic bone toward the oral cavity represents a potentially valuable solution for cases in which conventional zygomatic implant placement is not feasible. Overall, the study is scientifically sound and the methodology is well described.

However, several aspects of the manuscript could be improved to enhance clarity, scientific rigor, and readability.                                                                                                                         

Major Comments

1. Comment 1: Limited Sample Size
   The study is based on a single cadaveric specimen with four implants. Although the authors acknowledge this limitation, the discussion should more clearly emphasize that conclusions about clinical applicability remain preliminary.

Response 1: We appreciate your feedback. A comment on the conclusions of clinical applicability remaining preliminary has been added to the discussion (line 432-435): “As the sample is small, conclusions about clinical applicability remain preliminary. Further validation in clinical series is required to determine the feasibility of the different approaches and possible technical difficulties during surgery, as well as long-term biomechanical behavior, prosthetic performance, and complication rates.”

1. Comment 2: Clinical Translation
   The manuscript states that clinical validation with eight additional cases is forthcoming. It would strengthen the paper if the authors briefly outline the expected clinical protocol or outcome parameters for those cases.

Response 2: Thank you for your remark. We have modified the final part of the discussion (lines 440-441) to improve this: “It is expected that accuracy will tend tower deviations around 1-3 mm and less than 5º.”

If this further research confirmed satisfactory results, it could be introduced to clinical practice and help patients without alternatives for oral rehabilitation.“

1. Comment 3: Deviation Analysis
   The reported intraoral deviations (up to 8.14 mm) are relatively large compared to conventional implant accuracy. Although the authors state that the deviation remains clinically acceptable, additional explanation is needed regarding prosthetic tolerance and biomechanical implications.

Response 3: Thank you for your remark. As we stated (lines 339-341), right side obtained better results than the left one, as deviations were smaller, due better access or to possible mispositioning of the drilling guide. However, in mouth we checked with the Ackerman-bar and the personal opinion of the surgeons is that  the emergence would be good to provide a prosthesis. Having said this, emergences of implants out of the ideal position may lead to worse hygiene and thus bacterial periimplant filtration,  bulky prostheses, possible difficulty in correct phonetics and overload of prosthetic components, with risk of prosthetic failure.

1. Comment 4: Biomechanical Considerations
   Because reverse insertion changes load distribution, the discussion could benefit from further analysis of potential biomechanical consequences such as:

• implant bending stress
• prosthetic load transfer to the zygoma
• long-term stability.

Response 4: We appreciate your feed back. However, we think these items may be assesed with more information once we have studied the further 8 cases.

Minor Comments

1. Comment 5: Language and Grammar
   Several sections contain grammatical inconsistencies and could benefit from professional English editing.

Response 5: Thank you for your input. English in the manuscript has been revised to try to solve the problems refered.

1. Comment 6: Figure Clarity
   Some figures (particularly surgical images) could be improved with clearer labeling and higher resolution

Response 6: Your perspective is very helpful. Figures have been adjusted, with better resolution. We have improved labeling (3b, 4e, 4g, 5b).

1. Comment 7: Figure Captions
   Figure captions should be slightly expanded to make them self-explanatory without requiring the reader to refer to the main text.

Response 7: We welcome your feedback. We have reviewed the captions and tried to make them more self-explanatory. However, another reviewer asked to shorten some of the captions.

1. Comment 8: Table Formatting
   Table 2 contains many numerical parameters; the readability could be improved by simplifying the structure or dividing it into two smaller tables.

Response 8: Thank you for the helpful input. Table 2 has been divided in two smaller ones (Tables 2 and 3) and the items have been simplified to try to make them more understandable.

1. Comment 9: Terminology Consistency
   Ensure consistent terminology when referring to:

• "reverse-insertion implant"
• "reverse zygomatic implant"
• "retrograde insertion".

Response 9: Thank you for your comments. We used the 3 differents terms to avoid repetition, but as you suggestes, we tried to unify the terms to be more consistent. 

 

Strengths of the Study

• Innovative surgical concept.
• Detailed step-by-step protocol.
• Integration of CAD/CAM planning and surgical guides.
• Quantitative accuracy assessment using CT superimposition.
• High clinical relevance for maxillofacial reconstruction.

 

Comments on the Quality of English Language

The manuscript is generally understandable; however, the English language requires minor improvement for clarity and readability. Some sentences are grammatically complex or contain minor grammatical inconsistencies. Careful language editing and proofreading by a native English speaker or professional editing service would improve the overall flow and precision of the manuscript.

 

Response to Quality of English Language: English has been thoruoughly revised.

 

 

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

thank you for addressing all of my comments - to my satisfaction. I feel that the manuscript has been much improved, and I am happy to have participated in the process.

Considering the material selection (polyamide), I recommend you to briefly go through and refer to this manuscript: DOI 10.1007/s44411-024-00011-6 , and discuss the materials that could be perhaps explored in your workflow within your Discussion.

Thank you and have a nice day.

Author Response

Coment 1: Thank you for addressing all of my comments - to my satisfaction. I feel that the manuscript has been much improved, and I am happy to have participated in the process.

Considering the material selection (polyamide), I recommend you to briefly go through and refer to this manuscript: DOI 10.1007/s44411-024-00011-6 , and discuss the materials that could be perhaps explored in your workflow within your Discussion.

Thank you and have a nice day.

Answer 1: Thank you once more for expanding on your contributions. We have the manuscript and included a short reference to other materials that could be used to produce the surgical guides: “The polyamide guides could also be applied to living patients, as used in other maxillofacial surgeries. Beyond the widespread use of polyamide, other polymers suitable for surgical guides are PMMA, valued for its translucency and low cost, and PEEK, characterized by its enhanced mechanical properties. [19]”.

Author Response File: Author Response.pdf