Diode Laser Surgery of Peripheral Developing Odontoma in a Pediatric Patient: A Case Report with Narrative Review of the Literature

Round 1

Reviewer 1 Report

• Dear Authors,
• My review identified a significant concern regarding the diagnosis. Based on the microscopic findings presented in Figure 3, the features are strongly suggestive of a developing odontoma in soft tissue, or a peripheral developing odontoma rather than a peripheral ossifying fibroma. This is supported by the presence of the following structures: tubular dentin, dental follicle, dental papilla, cementum-like calcifications, and ameloblast-like cells. Additionally, the typical location of peripheral ossifying fibroma is the gingiva, whereas the reported case is present in the palate

Suggestions:

• Revise the diagnosis throughout the manuscript to reflect that the presented lesion is a developing odontoma. This includes the case report, discussion, and conclusion sections.
• Highlight the unique nature of this finding: This case report could be a valuable contribution to the literature due to the rarity of developing odontoma in soft tissue.
• Consider consulting with an oral pathologist to confirm the revised diagnosis

Comments for author File: Comments.pdf

Author Response

Diagnosis has been revised accordingly

Reviewer 2 Report

This is an interesting case mainly due to the age of the patient and the unusual location of this lesion. The review performed is complete, interesting and relevant to the subject of the case.

There are only two points that should be clarified:

It should be justified why a CT scan was performed on the patient who  required general anesthesia because of his age. In the clinical image there is no suspicion of malignancy or deep extension, why did they not perform an intraoral radiological examination?, is there any problem with the patient's behavior? As the article points out, the use of sedation during treatment is always preferable to general anesthesia, so it should be well justified why the CT scan was performed under general anesthesia and how they tried other diagnostic options to avoid subjecting the patient to the radiation of a CT scan and the risk of general anesthesia.

Although the text states that there are no artifacts from the diode laser in the specimen (which is possible but unusual), in image 3a it can be seen in the lower right margin that there is a hyperchromatic area, which could correspond to an artifactual area. This area should be explained in the histopathologic image.

Author Response

This is an interesting case mainly due to the age of the patient and the unusual location of this lesion. The review performed is complete, interesting and relevant to the subject of the case.

There are only two points that should be clarified:

It should be justified why a CT scan was performed on the patient who  required general anesthesia because of his age. In the clinical image there is no suspicion of malignancy or deep extension, why did they not perform an intraoral radiological examination?, is there any problem with the patient's behavior? As the article points out, the use of sedation during treatment is always preferable to general anesthesia, so it should be well justified why the CT scan was performed under general anesthesia and how they tried other diagnostic options to avoid subjecting the patient to the radiation of a CT scan and the risk of general anesthesia.

Although the text states that there are no artifacts from the diode laser in the specimen (which is possible but unusual), in image 3a it can be seen in the lower right margin that there is a hyperchromatic area, which could correspond to an artifactual area. This area should be explained in the histopathologic image.

Thank you  for your kind suggestions. Patient was uncooperative thus requiring such approach. the surgery in fact was performed in conscious sedation as fast by diode laser use. as for the histological image about laser interaction with tissue, It is correct your observation but we explain in the text that the laser tissue interaction does not provide artefact to the mail lesion which can be responsible of incorrect or undefined diagnosis, while  it remains limited to the peripheral area (margins) where minimal thermal effects may be evident of the section. thank you for your suggestions.  

Reviewer 3 Report

This is an interesting case report of a POF affecting a 4 yo child which was successfully treated by diode laser, and a comprehensive review of the epidemiology, clinical presentation, pathophysiology, histopathological features, differential diagnosis, prognosis and treatment. POF is uncommon in children and the description of new cases is important. I would like to list some comments in order to improve the quality of the study.

1. The location in the hard palate is uncommon and should be well discussed. While the lesions described in the differential diagnosis are well accepted by lesions in the gingiva, many of them do not fit in lesions without gingival involvement. I would like some comments about the possibility of irratational/traumatic fibroma, exostosis, osteoma due to the calcification detected in the CT scan, and other benign tumors of the connective tissue with presence of dystrophic calcification.

2. The small number of histological images and in low magnification raise some questions. First, the hypercellularized and reactive stroma composed by fusiform cells (fibroblasts) is missing. The large calcified structure, in low power, resembles features of dentin and cementum and aspects of immature pulp tissue (dental papilla). There are also areas in which this immature tissue is surrounded by odontogenic epithelial-like cells, such as those found in the dental follicle (inner and outer enamel epithelium cells). On the low right corner, there are areas of dystrophic calcifications? Usually the bone is woven and trabecular, but more mature lesions may display lamellar type. Please add new images to eliminate any doubt about the diagnosis, which seems correct, and improve the histological description.

3. The text is well-written, but I think that the term radiograph/radiographies should be used instead of radiogram/radiograms.

Author Response

Thank you for your detailed comments. The final diagnosis has been revised in Developing Odontoma and so clinical and radiological features have been corrected. All suggestions you kind provide to improve the paper have been done. Thank you again for your revision.

Reviewer 4 Report

This is an interesting paper describing the treatment of peripheral ossifying fibroma in children. Though the review of literature was mostly extensive, the treatment of POF with teeth involvement should be discussed considering the most affected locations in gingiva or palatal mucosa. Should these teeth (permanent or deciduous ) be retained or extracted? The authors' idea need to be mentioned in this review.

Author Response

thank you for suggestion. In the text with underline several time the necessity of conservative treatment (also by diode laser surgery) to perform a resolutive surgery but at the same time preserving when possible the adjacent teeth.

thank you again for your kind revision

Round 2

Reviewer 1 Report

Overall, the manuscript is informative and well-structured, making it suitable for publication. However, a few minor revisions could further strengthen it:

1.     Abstract: There appears to be a discrepancy between the reported location of the lesion in the abstract (buccal aspect of the anterior maxilla) and the actual location (palatal area). Please clarify this inconsistency.

2.     Reference check: Consider adding references for some sentences, particularly in the first paragraph of the "clinical-radiological features and differential diagnosis" section.

3.     Depending on the journal's word count limit, consider summarizing the manuscript. Focus on condensing less critical details while maintaining the core findings and discussion points.

Comments for author File: Comments.docx

 I recommend considering a revision focused on grammar and writing style.

Author Response

1. Abstract: There appears to be a discrepancy between the reported location of the lesion in the abstract (buccal aspect of the anterior maxilla) and the actual location (palatal area). Please clarify this inconsistency.

DONE

1. Reference check: Consider adding references for some sentences, particularly in the first paragraph of the "clinical-radiological features and differential diagnosis" section.

DONE

3. Depending on the journal's word count limit, consider summarizing the manuscript. Focus on condensing less critical details while maintaining the core findings and discussion points.

DONE