Criterion Validity of the Newly Developed Occlusal Cant Index

Round 1

Reviewer 1 Report

In the Methods section of the article, Figure 3 should be written on pages 4 (As shown in Figure 2) and 5 (of the OC angle) instead of Figure 2.
The conclusion should be rewritten as it is too general. In orthodontics, there are other well-known diagnostic radiographic projections (e.g., laterolateral radiographs) on which skeletal bone discrepancies can be assessed. Therefore, the posterior-anterior (PA) cephalometric radiograph should be mentioned as a standard diagnostic tool for measuring the Occlusal Cant Index in this study. It should be noted that the high (criterion) validity of the diagnosis of occlusal cant is statistically confirmed by a group of experienced orthodontists.

Author Response

In the Methods section of the article, Figure 3 should be written on pages 4 (As shown in Figure 2) and 5 (of the OC angle) instead of Figure 2.

The conclusion should be rewritten as it is too general. In orthodontics, there are other well-known diagnostic radiographic projections (e.g., laterolateral radiographs) on which skeletal bone discrepancies can be assessed. Therefore, the posterior-anterior (PA) cephalometric radiograph should be mentioned as a standard diagnostic tool for measuring the Occlusal Cant Index in this study. It should be noted that the high (criterion) validity of the diagnosis of occlusal cant is statistically confirmed by a group of experienced orthodontists.

The conclusion was amended. In the method section, the PA radiograph was mentioned as a standardized method. In orthodontics, PA radiographs are the standard to assess occlusal cant, and recently 3D CBCT is the most accurate for skeletal assessment. Kindly note that the participants used radiographic measurements in this study to apply the proposed index. 

Reviewer 2 Report

What has been labeled as "Figure 1" is actually a Table and should be labeled as such.

I recommend that additional references be added concerning the analysis of Alhuwaish and Almoammar to describe the sources/causes of occlusal plane canting (ie. maxillary, mandibular, temporomandibular joint etc.)

The English text requires improvement

Author Response

What has been labelled as "Figure 1" is actually a Table and should be labeled as such.

The conversion to a table was made and all relevant amendments were made.

I recommend that additional references be added concerning the analysis of Alhuwaish and Almoammar to describe the sources/causes of occlusal plane canting (ie. maxillary, mandibular, temporomandibular joint etc.)

There was no analysis produced by Alhuwaish and Almoammar, instead, a proposed index was published an initial validation was conducted. The details of the index were introduced to the reader in the introduction section. The causes of occlusal cant are, in our opinion, out of this paper's scope.

The English text requires improvement

English editing was done for the document.

Reviewer 3 Report

In spite of the well aprreciated efforts by the authors, there are some modification in the concept that remained unanswered and that need to be clarified before publication is considered;

 

General comments – less than 3 degree occlusal plane degree have little impact on orthodontic tx plaining, therefore, what is the rationale of the current study and clinical significance?

 

Major 

The study involved 36 PA views from four patients. Please explain whether there was any powder analysis done for the study? 

 

Figure 2 – Figures are too small to make clarification, and must be revised.

 

What is the original occlusal cant before manipulation? 

 

For manual tracing – please validate or add the reference for mid-reference plane? Manual tracing is subjective and the current sample size is too low so that may have increase chance of bias as your current study design was for validation of previous published work? 

 

Please clearly specify the maximum occlusal plane degree if it was more than 3 degree? 

 

Why left side have error in Table 2, please specify?

“a set of 36 prepared and randomly ar- ranged PA cephalometric images were presented, and each participant was directed to first measure the traced OC angle manually and then classify the OC at each PA cephalo- metric image using the newly developed OCI.”                                                    

Just measure?  OR tracing? If it was measured - it should not differ in both side in Grade 1.

 

References

It should be thoroughly revised and must follow the journal guidelines (Pls do not shorten the number of pages)

 

If you feel that your paper could benefit from English language polishing, you may wish to consider having your paper professionally edited for English language?

Author Response

General comments – less than 3 degree occlusal plane degree have little impact on orthodontic tx plaining, therefore, what is the rationale of the current study and clinical significance?

The rationale of the current study is to validate by criterion process the newly developed index for occlusal cant. Currently, there are no available indexes in the literature considering the tilt in the occlusal plane.  From a clinical perspective, according to Kokich et al., 2004, a cant of 2 mm or more is of clinical significance.

 

Major

The study involved 36 PA views from four patients. Please explain whether there was any powder analysis done for the study?

The sample size was calculated, and an estimation based on a power of 0.9 at a P-value of 0.05 confirmed that the required number of participants to be enrolled was 36. This was stated in page 10.

 

Figure 2 – Figures are too small to make clarification and must be revised.

Figure 2 illustrates the different PA radiographs that were used in the study. It is certainly small, however, it is impossible to enlarge the images without consuming lots of pages upon publication.

 

What is the original occlusal cant before manipulation?

As stated in the manuscript, the selected radiographs were with zero occlusal cant.

 

For manual tracing – please validate or add the reference for mid-reference plane? Manual tracing is subjective and the current sample size is too low so that may have increase chance of bias as your current study design was for validation of previous published work?

Kindly be advised that the participants did not trace the radiographs. Instead, the participants measured the angle of occlusal cant, and then applied the index, which would allow for assessing the criterion validation of the index. The lines were chosen according to reference number 16, which was written on page 8. The sample size was calculated, and an estimation based on a power of 0.9 at a P-value of 0.05 confirmed that the required number of participants to be enrolled was 36. This was stated in page 10.

 

Please clearly specify the maximum occlusal plane degree if it was more than 3 degree?

As stated in the manuscript, the manipulated radiographs included 0-4 in clockwise and counterclockwise rotations.

 

 

Why left side have error in Table 2, please specify?

“a set of 36 prepared and randomly ar- ranged PA cephalometric images were presented, and each participant was directed to first measure the traced OC angle manually and then classify the OC at each PA cephalo- metric image using the newly developed OCI.”                                                   

Just measure?  OR tracing? If it was measured - it should not differ in both side in Grade 1.

The insignificant errors were related to selecting the appropriate category or direction of the occlusal cant using the OCI. It did not affect the overall validation of the index. As mentioned in the Discussion section, page 14, paragraph 1, this may be attributed to fatigue and level of concentration. As mentioned earlier, the participants measured the angle and did not trace the radiographs. 

Round 2

Reviewer 3 Report

Dear Authors, thank you for resubmitting your revised paper. After having checked this version, still a considerable number of aspects would seem preventing your manuscript from being ready to proceed. Indeed, this would seem astonishing, please see below.

 

1. Please add the reference that the author response about occlusal cant of 2 mm or more have clinical significance and discuss.

 

2. Pls use each PA radiographs that was used in figure 2 as supplementary file for review.

 

3. I’m still confused about the methodology in which the authors measured in the PA radiographs of zero original occlusal cant and rotate clockwise and anti-clock wise. The authors should use the participants who had 2 mm or more occlusal cant in PA radiographs?

 

References

It should be thoroughly revised and the authors are still failing to adhere to the  journal's guideline.

(Pls do not shorten the number of pages)

  

Please note that authors submitting a paper do so on the understanding that it has been read and approved by all authors". thus would mean that all authors would correct/revise/improve a draft according to reviewer’s recommendations and in particular this should be mandatory with a revised draft. In total, this resubmitted manuscript is not considered ready to proceed.

Author Response

1. Please add the reference that the author response about occlusal cant of 2 mm or more have clinical significance and discuss.

Please note that this manuscript aimed to validate by criterion validate a recently proposed index. The boundaries as discussed in the original published article were based on occlusal detection. Hence, the clinical significance and other related details of occlusal cant are out of the scope of this manuscript. In addition, occlusal cant is ideally measured in degrees in clockwise and anticlockwise rotation. The article by Kokich et al (Reference no. 17) used millimetric measurement of occlusal cant.

 

2. Pls use each PA radiographs that was used in figure 2 as supplementary file for review.

 A supplementary file is included in this submission containing all 36 radiographs.

 

3. I’m still confused about the methodology in which the authors measured in the PA radiographs of zero original occlusal cant and rotate clockwise and anti-clock wise. The authors should use the participants who had 2 mm or more occlusal cant in PA radiographs?

As mentioned in response to comment number 1. This manuscript did not focus on the clinical significance, it is indeed a continuation of a study that proposed a new index to categorize occlusal cant (Alhuwaish HA, Almoammar KA. Development and validation of an occlusal cant index. BMC Oral Health. 2022 Apr 15;22(1):127. doi: 10.1186/s12903-022-02156-8. PMID: 35428238; PMCID: PMC9013076.). The focus of this manuscript was to test criterion validation of the newly proposed index. As explained in the methods section (Pages 8-10), the PA cephalometric radiographs with zero degrees of occlusal cant were manipulated to 1 – 4 in clockwise and anti-clockwise directions. The participants were asked to measure the cant and apply the index. I hope this resolves the confusion.

 

References

It should be thoroughly revised and the authors are still failing to adhere to the  journal's guideline. (Pls do not shorten the number of pages)

The references were amended according to the journal’s guidelines. Thank you very much for the time and the valuable comments raised.