Prophylactic Coronoidectomy Approach during Stable Bone Osteosynthesis after Major Cranio-Facial Injury in the Temporal Region with Muscle Contusion—Should It Be Used?

Round 1

Reviewer 1 Report (Previous Reviewer 1)

The authors have acted on some of my comments and as a result it does read better now. It will be of interest to a mixed readership which might include some non-maxillofacial surgeons, for whom it provides an interesting read.

Author Response

 

Comments and Suggestions for Authors

Thank you for the review.

Comment 1 - The authors have acted on some of my comments and as a result it does read better now.

Response comment 1 - Dear rewiever thank you very much for kind words. Its all thank to your great comments and golden hints that made this paper better. Thank you

 

Comment 2 -  It will be of interest to a mixed readership which might include some non-maxillofacial surgeons, for whom it provides an interesting read.

Response comment 2 - Dear rewiever thank you very much. Its mostly because your valuable and precious experience to led us to this point.

Author Response File: Author Response.pdf

Reviewer 2 Report (Previous Reviewer 3)

The authors reported a single case of LMO following surgery, and suggested prophylactic coronoidectomy if such presentation occurs in future. However, this is just a single case report and cannot be used as a suggestion for a future protocol. Furthermore, the cause of the LMO in this case are only postulated to be due to temporal muscle scarring without clinical or radiological evidence. How can one say because of a single case, all (100%) of case with injury to temporal area would have similar LMO thus all need coronoidectomy. Further comments as below:

 

1.       In table 1, the algorithm of cases with LMO (most bottom box i.e LMO = related to major temporal bone/muscle injury), the following 2 boxes is stating major trauma but without LMO. This is contradicting the previous flow of the algorithm that already stated there is LMO.

2.       Table 2 suggest a surgeon to performs coronoidectomy without proper evidence to support such procedure is necessary. Only based on clinical hunch? Some decision must be correct while others may not. A clinical or radiological evidence of temporal muscle related causes of LMO must be within the decision-making process or patient would have undergone unnecessary invasive treatment without good indication

3.       Table 1 and 2 should be figure 1 and 2

4.       The authors need to report the mouth opening width before the zygomatic-orbital reduction surgery (line 189 to 196)

5.       The axial and coronal view of the post-operative (after zygomatic-orbital surgery) must be included to allay any queries that the LMO is actually due to the coronoid hitting the zygoma. A statement by the authors that no contact or only furnishing a 3d CT reconstruction (figure 11 to 13 which do not show clearly the area) is not enough.

Author Response

Comments and Suggestions for Authors
Comment 1 - The authors reported a single case of LMO following surgery, and suggested prophylactic coronoidectomy if such presentation occurs in future. However, this is just a single case report and cannot be used as a suggestion for a future protocol. Furthermore, the cause of the LMO in this case are only postulated to be due to temporal muscle scarring without clinical or radiological evidence. How can one say because of a single case, all (100%) of case with injury to temporal area would have similar LMO thus all need coronoidectomy. Further comments as below:
Response comment 1 - Dear rewiever thank you very much for the comment. This is why Authors wrote this paper to present this rare and unusuall case. A case when the main blunt force was administered in the temporal area of the skeleton. No such case have been reported in the world-literautre so far. Just cases after pterional and temporal approach in neurosurgery and muscle scarring which lead to a coronoidectomy are known. 

Comment 2 - In table 1, the algorithm of cases with LMO (most bottom box i.e LMO = related to major temporal bone/muscle injury), the following 2 boxes is stating major trauma but without LMO. This is contradicting the previous flow of the algorithm that already stated there is LMO.
Response comment 2 - Dear rewiever thank you very much for the comment. This was re-arranged. 

Comment 3 - Table 2 suggest a surgeon to performs coronoidectomy without proper evidence to support such procedure is necessary. Only based on clinical hunch? Some decision must be correct while others may not. A clinical or radiological evidence of temporal muscle related causes of LMO must be within the decision-making process or patient would have undergone unnecessary invasive treatment without good indication
Response comment 3 -  Dear rewiever thank you very much for the comment. Coronoidectomy itself has both objectives- diagnostic and curable approach. Since major trauma was present in the temporal area, and LMO started to progress in time, CT of head/facial skeleton enables good diagnsotics and excludes other possible factors. As written in text and presented in the tables/figures. MR on the other hand even if will led to the conclusion that a coronoidectomy is necessary, it all takes time and might lead the patient to provoke even less mouth opening and could result in a very difficult airway and the necessity for a tracheostomy. Thats why Authors entitled the paper prophylactic coronoidectomy, and we all try to hightlight the fact that major temporal bone and muscle injury might lead to LMO and each surgeon and clinician should be aware of that fact. 

Comment 4 - Table 1 and 2 should be figure 1 and 2
Response comment 4 - Dear rewiever thank you very much for the comment. Tables 1-2 were enslited in figures and text was re-arranged. 

 

Comment 5 -  The authors need to report the mouth opening width before the zygomatic-orbital reduction surgery (line 189 to 196)
Response comment 5 - Dear rewiever thank you very much for the comment. Line volume added. 

Comment 6 - The axial and coronal view of the post-operative (after zygomatic-orbital surgery) must be included to allay any queries that the LMO is actually due to the coronoid hitting the zygoma. A statement by the authors that no contact or only furnishing a 3d CT reconstruction (figure 11 to 13 which do not show clearly the area) is not enough.
Response comment 6 -  Dear rewiever thank you very much for the comment. As stated in the article the LMO was not cause by the conflict between coronoid-zygoma. And thats not the issue in the paper, as it was now corrected and re-written. Furthermore presented herein scans show good and propper bone reduction and alignement without any bone conflicts.

Author Response File: Author Response.pdf

Reviewer 3 Report (Previous Reviewer 4)

I read authors' response but I still think the article needs at leats major revision because we do not have any photo showing the post operative mouth opening. And secondly  if mouth opening just after surgery was normal and the problem was the contusion (and so I do not know how mouth opening could be so normal in the immediate post operative period) and the scarring of temporal muscle the patietnts should have undrgone a specifi protocol of physiotherapy and eventually surgery for forced mouth opening under general anaesthesia 

Author Response

Comments and Suggestions for Authors
Comment 1 - I read authors' response but I still think the article needs at leats major revision because we do not have any photo showing the post operative mouth opening.
Response comment 1 - Dear rewiever thank you very much for the comment. There is one photograph directly performed after coronoidectomy, 3rd day after surgery in the day the patient left the hospital. The another appointment in the department was for suture removal in 10 day - at this point we have only a paper report saying that the mouth opening remain the same as after the surgery. So the effect was stable. Such a situation might be realted with the patients family and civic responsibilities during the ongoing war in the Ukraine, since tha patient had Ukrainian relatives. The patient knowns that if there were any problems with limited mouth opening he would visit out ward, bo so far its more than a year and no reports of him are seen. 

Comment 2 - And secondly  if mouth opening just after surgery was normal and the problem was the contusion (and so I do not know how mouth opening could be so normal in the immediate post operative period) and the scarring of temporal muscle the patietnts should have undrgone a specifi protocol of physiotherapy and eventually surgery for forced mouth opening under general anaesthesia 
Response comment2 - Dear rewiever thank you very much for the comment. Answer for those question is presented in the article. Furthermore in LMO physiotherapy is not adequate and it lacks major improvement in mouth opening. Forced mouth opening doesnt influence in the LMO, even if the patient is under general anaesthesia - this is related with the muscle attachements to the coronoid process of the mandible. The only one procedure which can be greately and succesfully performed during general anestheis is the reduction of fully luxated mandible in elderly patients when the time os luxation is more than 5 days.

 

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report (Previous Reviewer 3)

1. The word "Propper" should be "proper" in figure 1

2. Figure 1 is still not understandable as  it is stated that "the presence of limited mouth opening (LMO)" then the next box LMA is stated to be present or not (+/-)

Reviewer 3 Report (Previous Reviewer 4)

no other comments

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

This paper is a simple case report .

It is far too long, the English needs professional revision, there are too many references for a case report, and it is not clear to this reviewer as to why so many authors are needed. The illustrations are good.

I would shorten it , revise the English and attend to my other points - then it may be a useful contribution for this journal.

Author Response

Dear reviewer thank You very much.

Response to Reviewer 1 Comments

 

 

Point 1. This paper is a simple case report .

Response 1: Please provide your response for Point 1. (in red) thank you, ofcourse this paper is a case report, however it points out that in some rare cases a prophylactic coronoidectomy after temporal muscle contusion is quite considerable to perform

Point 2. It is far too long, the English needs professional revision,

Response 2: Please provide your response for Point 2. (in red) thank you, in order to fully described the clinical problem a detailed case description followed by indication and contraindications from literature should be mentioned. Furthermore, since coronoidectomy is a treatment of choice in limited mouth opening, which has a outer-joint related etiology factors, and is not a trismus (which is quite different one), coronoidectomy procedure is considered as not only as a diagnostic procedure, but purely a treatment of choice in case of coronoid mandibular proces-temporalis muscle involvement.

Point 3.  there are too many references for a case report, and it is not clear to this reviewer as to why so many authors are needed.

Response 3: Please provide your response for Point 3. (in red) thank you, there is a limited literaturę concerning a prophylactic coronoidectomy approach, so Authors tried to compare and evaluate the necessity of a prophylactic coronoidetomy approach during stable bone soteosynthesis of major trauma in a simple procedure, insteed of only trust early mechanotherapy, since in major temporal muscle injury this procedure should be done. The numer of Authors are devided in those who operated and diagnosed the patient, Chief anastesiologist who performer an ednoscopic intubation of the patient with about of 1cm of mouth opening, and further authors who specialise in animal models study, which also had some experience in masticatory muscle surgeries in animal models.

Point 4. The illustrations are good.

Response 4: Please provide your response for Point 3. (in red) thank you very much

Point 5. I would shorten it , revise the English and attend to my other points - then it may be a useful contribution for this journal.

Response 5: Please provide your response for Point 3. (in red) thank you very much. On behal;f of myself and all Co-authors I will try to shorten it as much as possible, accoring to your personal very valuable and wise advice, however I have to also consider other reviewer comments as well. At this point paper will be revised and corrected.

Author Response File: Author Response.docx

Reviewer 2 Report

I have reviewed the paper "Prophylactic coronoidectomy approach during stable bone osteosynthesis after major cranio-facial injury in the temporal region with muscle contusion– should it be used?" and found it is well written and can be accepted after major revision and doing the corrections.

The mechanical properties of porous should be described. How is the use of new and artificial scaffolding? What is the effect of porosity on reconstruction?

What is the reason for using this structure for fracture of the joint? How have its mechanical properties been investigated?

What was the type of operation? Can a code of ethics be provided? Can a permit be provided?

Describe the method of prophylactic cricoidectomy. A review of previous content needs improvement.

However, some remained comments like : 

-The Abstract of this article is not vital and should be enhanced.

-The quality of the figures should be improved.

-Finally, the language of the paper needs to be polished.

The following reference are introduced to compare the preparation of tissue. 

Liang, H., Mirinejad, M. S., Asefnejad, A., Baharifar, H., Li, X., Saber-Samandari, S., ... & Khandan, A. (2022). Fabrication of tragacanthin gum-carboxymethyl chitosan bio-nanocomposite wound dressing with silver-titanium nanoparticles using freeze-drying method. Materials Chemistry and Physics, 279, 125770.

-Based on the topic the title is so short and needs to clarify the problem statement clearly. 

-The Figure's quality are too weak please improve the quality and put some arrays on the important part 

-The language of the paper needs major polish.

 

Author Response

Dear reviewer thank You very much.

Response to Reviewer 2 Comments

 

 

Point 1. “ I have reviewed the paper "Prophylactic coronoidectomy approach during stable bone osteosynthesis after major cranio-facial injury in the temporal region with muscle contusion– should it be used?" and found it is well written and can be accepted after major revision and doing the corrections.

Response 1: Please provide your response for Point 1. (in red) thank you very much for kind words and some major wise advices to improve the paper.

Point 2. The mechanical properties of porous should be described. How is the use of new and artificial scaffolding? What is the effect of porosity on reconstruction?

Response 2: Please provide your response for Point 2. (in red) thank you very much. Porosity is ofcourse one of the necessary atributes of propper osteosynthesis while using stable bone osteosynthesis plating and screw system. There ar emany articles discussing on the ehcanical, chemical and physical properties of both bones and titanium nimiplates (https://www.sciencedirect.com/science/art https://www.sciencedirect.com/science/article/abs/pii/S0032386121007436 icle/abs/pii/S0032386121007436;  https://www.mdpi.com/2076-3417/9/5/982 and other ...). Authors added some information about major aspects of this topic suggested by the reviewer.  A corensponsing sentenc about bone stable position, plate stable passive position along with the tension and cotraction lines was added. Perhaps in further studies, Authors will Focus more on the scaffold models, to ensure and improve this important matter.

Point 3. What is the reason for using this structure for fracture of the joint? How have its mechanical properties been investigated?

Response 3: Please provide your response for Point 3. (in red) thank you very much. In presented study the condyle head was not fractures, Head itself has bigger density and volume of cortical layers outside, however inside its still numerous amount of spongious bone. In the other hand, the condylar proces of the mandible has more cortical bone, thats why its biomechanical considerations are so important, especially considering proper plating and screw system to ensure its stability inside the joint, TMJ. Mechnical properties in the TMJ joint, and related condyle head and condylar proces are scheduled to be the factors of future studies in forthcomoming original paper on condylar head stable osteosynthesis in transparotid gland surgical acces. Thank you for the hints and good idea, in future studies! In this presented case, because of no injury in the condyle head and proces area no information was added. Secondly, becase of other reviewres comment on the too-long paper, Authors are trying to make it accoring to rewievers suggestions.

Point 4. What was the type of operation? Can a code of ethics be provided? Can a permit be provided?

Response 4: Please provide your response for Point 4. (in red) thank you very much. Operation was focused firstly on a stable bone osteosynthesis of the fractured zygomatico-malar and orbital bones. Secondly was a coronoidectomy procedure scheduled. Patients approval for the study along with ethics comitee approval was granted. The numer of code was added and provided.

Institutional Review Board Statement: This manuscript is a case report in which the patient cannot be identified, and therefore the requirement for obtaining informed consent from the patient was waived. The study was conducted in accordance with the Declaration of Helsinki. Nevertheless, Authors have an approval for studies No.5/BNR/2022.

 

Point 5. Describe the method of prophylactic cricoidectomy. A review of previous content needs improvement.

Response 5: Please provide your response for Point 5. (in red) thank you very much. More advanced and improved information are added in text.

Due to LMO, orotracheal intubation was performed with an endoscope. Next step was consisted of firstly injection of 10ml of local injection of mixed 0,25% solution consisted of Lignocaine with Norepinephryne 2% (ampule, 2ml, Polfa-Warszawa, Poland) with mixture of Natrium Chlorate 0,9% (Natrium Chloratum 0,9% Fresenius KabiClear, Bad Homburg vor der Höhe, Germany) infiltrated into the submucosa anteriorly in the buccal vestibule and along the left ascending ramus of the mandible. With the usage ob blade 15c (Swann Morton, WR Swann, Owlerton Grn, Hillsborough, Sheffield, England) an incision was placed exceeding from the lateral aspect of the mucosa in the  left ascending ramus of the mandible, with a 5mm margin of tissues towards the mental foramen. After the elevation of mucosal flaps, the external oblique ridge was expose along with adjacent mucosa overlying the anterior border of the ramus. With Obwegeser Periosteal elevators (Obwegeser 38-630-06-07- 38-630-11-07 17,5 cm / 6 7/8", KLS Martin, Tuttlingen, Germany) and Obwegeser Soft Tissue Retractor ( Obwegeser 38-603-40-07, KLS Martin, Tuttlingen, Germany) a visibility on the lower attachment of the lower tendon of the temporalis muscle. The muscle was cut, divided and elevated superiorly to gain more visibility towards the base of the coronoid process. After gaining good visualization, Obwegeser raspators were situated posteriorly from the coronoid base in the mandibular notch, and the process was cut with the Lindemann Bone Burr (165RF.HP.023, Jota AG, Rüth Switzerland). Bone holding forceps  (Jeter-Van Sickels 38-718-01-07, KLS Martin, Tuttlingen, Germany)  ensured that the cut-off coronoid process was not pulled upwards by the muscle tendon, but was completely removed, which enabled good final result. Surgical layers were sutured with 4-0 Vicryl single sutures (Ethicon, Johnson & Johnson Medical N.V., Machelen, Belgium). After the procedure, mouth opening was improved. After further examination and additional mechanotherapy, LMO is not reoccurring (Fig 17).

Point 6. The Abstract of this article is not vital and should be enhanced.

Response 6: Please provide your response for Point 6. (in red) thank you very much. Abstract was improved.

Point 7. The quality of the figures should be improved.

Response 7: Please provide your response for Point 7. (in red) thank you very much. Slight improvements were made, however better quality of radiograms are missing because of some covid-related restrictions in the Authors hospital.

 

Point 8. Finally, the language of the paper needs to be polished.

Response 8: Please provide your response for Point 8. (in red) thank you very much. English modyfication was performer. The majority of changes were deriven after a consultation with a native speaker.

Point 9. The following reference are introduced to compare the preparation of tissue.  - Liang, H., Mirinejad, M. S., Asefnejad, A., Baharifar, H., Li, X., Saber-Samandari, S., ... & Khandan, A. (2022). Fabrication of tragacanthin gum-carboxymethyl chitosan bio-nanocomposite wound dressing with silver-titanium nanoparticles using freeze-drying method. Materials Chemistry and Physics, 279, 125770.

Response 9: Please provide your response for Point 9. (in red) thank you very much. Thank you for the suggestion, was added in text and well adapter.

Point 10. -Based on the topic the title is so short and needs to clarify the problem statement clearly. 

Response 10: Please provide your response for Point 10. (in red) thank you very much. Authors have to leave the title as suggested because of the other comments from rewelers, as well as the structured abstract and introduction secton, so that all co-rewievers have their significant remark on the paper. Some minor changes were made.

Point 11. -The Figure's quality are too weak please improve the quality and put some arrays on the important part 

Response 11: Please provide your response for Point 11. (in red) thank you very much. As stated in issue #7

Point 12. The language of the paper needs major polish.

Response 12: Please provide your response for Point 12. (in red) thank you very much. As stated in issue #8

 

 

Author Response File: Author Response.docx

Reviewer 3 Report

The author presented essentially a single case report of a trismus, which is postulated to be due to temporalis muscle injury and scarring. This however is not proven, and the author did not confirm this  finding by MRI or any clinical findings to suggest this. Furthermore, the procedure itself is not novel. English writing for this paper must also be improved. The introduction section is overly long and draggy. Overall I don't think this case report merits publication in Applied Science based on the lack of novelty and also quality of writing.

Author Response

Dear reviewer thank You very much.

Response to Reviewer 3 Comments

 

 

Point 1. The author presented essentially a single case report of a trismus, which is postulated to be due to temporalis muscle injury and scarring.

Response 1: Please provide your response for Point 1. (in red) thank you, ofcourse this case report present a rare indications of prophylactic coronoidectomy after major temporal muscle injury. So far, in the known literaturę the knowledge and indication for prophylactic coronoidectomy after major cranio-facial trauma, during stable bone osteosynthesis is missing. This is perhaps the first known study which will highlight this issue in a more defined matter. Its very important to understand that trismus od different from LMO-limited mouth opening. Trismus cannot be treated with coronoidectomy, while LMO can be succesfully be treated. Trismus is most commonly greatly influenced by good and early mechanotherapy (cases of- cancer, radiotherapy, abscesses, inflamamations + the timing of treamtnet), while a LMO does recquire surgical procedure, especially when the etiological factor is outside the Joint TMJ. As reported in the article, this prophylactic coronoidectomy had two main aspect, first the diagnostic one, to confirm the major contusion and scarring of temporal muscle (an outside of the TMJ joint related etiology), while its second aim is focused on full tretment of this situation, consisted of coronoid proces cut-off to ensure more stable mouth opening. Literature;

LMO – https://pubmed.ncbi.nlm.nih.gov/31508348/

Trismus - https://pubmed.ncbi.nlm.nih.gov/26098612/

Point 2. This however is not proven, and the author did not confirm this  finding by MRI or any clinical findings to suggest this.

Response 2: Please provide your response for Point 2. (in red) thank you. MRI study is dedicated for any cases of disc luxation, subluxation or its blockage. MRI i salso inadequate to confirm any potential conflict like coronoid proces-zygomatic bone. MR imaging was not necessary because the patient didnt suffer any trauma in the TMJ area, but a massive bluint trauma towards the temporal regio and adjacent lateral orbital wall and zygomatico area. During intitial evaluation no LMO-limited mouth opening was present – it i were present it migh suggest trauma-fracture of the mandibular condyle – clearly visible in the CT. In any case of other possible injury towarde the condyle head, its fragmentation, possible ruoture of capsule and disc injury, then MR could be done. Since the LMO was growing in time, after surgery, despite early and intense mechanotherapy, and during clinical examination TMJ are condyle head mocements were present, and no pain in the TMJ were neither present (which migh conclude a disc entrapment), only CT was necessary. Secondly, there is a limited literature concerning a prophylactic coronoidectomy approach, so Authors tried to compare and evaluate the necessity of a prophylactic coronoidetomy approach during stable bone soteosynthesis of major trauma in a simple procedure, insteed of only trust early mechanotherapy, since in major temporal muscle injury this procedure should be done. The numer of Authors are devided in those who operated and diagnosed the patient, Chief anastesiologist who performer an ednoscopic intubation of the patient with about of 1cm of mouth opening, and further authors who specialise in animal models study, which also had some experience in masticatory muscle surgeries in animal models.

Point 3. Furthermore, the procedure itself is not novel.

Response 3: Please provide your response for Point 3. (in red) thank you. The paper is not about a novel tehcnique, but about a novel approach for a prophylactic coronoidectomy in case of sever temporal muscle trauma and adjacent cranio-faical bones fractures, in order to combine two approaches – stable bone osteosynthesis and prophylactic coronoidectomy, to avoid temporal muscle scarring and contraction in time to avoid as early as possible LMO, and the necessity for a secondary surgery.

Point 4. English writing for this paper must also be improved. The introduction section is overly long and draggy. Overall I don't think this case report merits publication in Applied Science based on the lack of novelty and also quality of writing.

Response 4: Please provide your response for Point 4. (in red) thank you. The English will be improved as the reviewer suggests. Introductin will be changed, along with the scope of other reviewer comment to fit the journal style and be made accoring to all of the reviewer comments. This paper aims in the special issue of Applied Science, focused on biomaterials, especially those used in stable bone osteosynthesis and additionaly described a rare indication for a prophylactic coronoidectomy, which is somehow missing in the literaturę, and yet controversial, but clearly described and explained in the following case report.

Author Response File: Author Response.docx

Reviewer 4 Report

In my view, this article cannot be published because the clinical case presented has a huge bias. In fact, secondary coronoidectomy was necessary because the reduction of the zygomatic fracture was not optimal with the zygome having healed in a lower position than its original location (see postoperative TC with an increased volume of left orbit). This situation therefore caused the persistence of a coronoid-zygomatic interference with the impossibility of post-surgical mechanotherapy to improve mouth opening. In fact, in my experience, if the zygome and coronoid (if the latter is also fractured) are correctly reduced, the opening of the mouth is always perfectly restored through correct and continuous mechanotherapy performed in the first six post-surgical months, mechanotherapy which is able to solve the residual muscle problem by stretching

Round 2

Reviewer 1 Report

This version is an improvement on the first submission but the English is still in need of improvement, either by a native speaker or by Journal staff.

There are still too many authors for a case report  - why are authors EP, MD, MJ, ML and RJ required ? What are software validation, visualisation, resources ?

Author Response

Dear reviewer thank You very much.

Response to Reviewer 1 Comments

 

 

Point 1. This version is an improvement on the first submission but the English is still in need of improvement, either by a native speaker or by Journal staff.

Response 1: Please provide your response for Point 1. (in red) thank you, ofcourse our native speaker will try to see the problem further, however the excellent help from MDPI is always the last, most professional and very helpfull resort. In past year all MDPI paper had been written with the help of same native speaker, and there were some minor problems, which had been not that and issue and together with the MDPI journal board all issues were covered in total with a great overall succes rate.

 

Point .2 There are still too many authors for a case report  - why are authors EP, MD, MJ, ML and RJ required ?

Response 2: Please provide your response for Point 2. (in red) thank you, The A               uthor contribution to the study was re-evaluated and corrected. Some misspellings were found wtih the initials. Now everything is correct. All Authors have their role in each of studies which had been written in the past and are currently ongoing for publications or a under clinical evaluation.

Point 3. What are software validation, visualisation, resources ?

Response 3: Please provide your response for Point 3. (in red) thank you. Those topics are concering those co-Authors who helped in radiological data asessement, evaluation and 3d-reconstruction. Furthermore, some key topics concerning the scoe of surgical intervention and its modalities were widely discussed among the authors before further surgical procedings. As it goes for resources, MDPI recquire funding, therefore thank to our wide network of grants, scintific projects and overall studies we are capable of gathering not only the necessary funding for the studies but we alse improve our surgical facilities in new equipment and surgical tools to be more prepared for similar cases in the future to help the patients even more.

Author Response File: Author Response.docx

Reviewer 2 Report

After careful review of the paper "Prophylactic coronoidectomy approach during stable bone osteosynthesis after major cranio-facial injury in the temporal region with muscle contusion– should it be used?" I found it cannot accept in this form and needs correction therefore, I decide to give major revision the paper.

The Abstract of the article is not structured.

-More physical explanation of results is required.

-The Abstract should be improved.

-The quality of the figures should be improved.

-Finally, the language of the paper needs to be polished.

Comparison of this research with similar studies should be done.

The language of the article needs improvement.

The quality of image number 2 and number 3 should be improved.

References related to this research can be used.

How is the type of molecular analysis determined by the forces involved?

As it is shown the conclusion is just simple lines and not enough considered quality and quantity of the tissue.

quantitative analysis of fluorescence intensity is not discussed properly.

 

 

 

Reviewer 3 Report

Thank you for your attempt to answer this reviewer's query. However I do feel that the comments made earlier was not address satisfactorily. I still believe that "temporal muscle injury, contusion and scarring (line 246)" would definitely be visible in MRI to support the clinical diagnosis . Furthermore, I could not understand why is it called prophylactic when the LMO has occurred before the procedure is performed. It this current form, I still believe it is not up to par yet for publication.

Author Response

Dear reviewer thank You very much.

Response to Reviewer 3 Comments

 

 

Point 1. “ Thank you for your attempt to answer this reviewer's query. However I do feel that the comments made earlier was not address satisfactorily. I still believe that "temporal muscle injury, contusion and scarring (line 246)" would definitely be visible in MRI to support the clinical diagnosis .

Response 1: Please provide your response for Point 1. (in red) thank you very much. During years each case of coronoidectomy I made myself, or with my surgical master were made based on a CT. Coronoidectomy itself is a diagnostic procedure. Even in TMJ arthroplasty or total joint replacement we use CT. In cases of closed-lock syndrome of the TMJ joint, habitual luxation or other TMJ strictly related pathologies we use MRI. Therefore in this study, if patient had increaseing in time limited mouth opening, the case was simple, a diagnsotic coronoidectomy and further mechanotherapy – which was successfull. Furthermore, classic MRI would be not sufficient enough, since a functional MRI when patients is opening/closing mouth is more reliable to asses the function of the disc, lateral pterygoid muscles and the disc-condyle head position in various positions. Even if MRi would be done and temporal muscle contraction would be present, still coronoidectomy is mandatory! Secondly, If we would wait more time, the limited mouth opening would progres in time, and presented herein endoscopic intubation would be unsuccessfull and patient would recquire a tracheostomy for the surgical period. Im awfully sory but MRI is not the panacea for everything, especially when an experienced surgeon had similar cases in the past.

Point 2. Furthermore, I could not understand why is it called prophylactic when the LMO has occurred before the procedure is performed. It this current form, I still believe it is not up to par yet for publication.

Response 2. Please provide your response for Point 2. (in red) thank you very much. Basicaly, Authors of presented herein paper want to point out thats its possible to performe a prophylactic coronoidectomy in major temporal area and muscle injury, when making a simultanous bi-coronal approach to perform an open stable bone ostoesynthsis, rather then wait for the mechanotherapy to work, especially in this paper a standard mechanoterhapy approach after such a great injury was not sufficient enough. World literaturę on prophylactic coronoidectomy is limited, therefore Authors want to point out that majot remporal area trauma should be considered as one of the indications for a prophylactic coronoidectimy.

Author Response File: Author Response.docx