3D Printing Approach in Maxillofacial Surgery in Iran: An Evaluation Using the Non-Adoption, Abandonment, Scale-Up, Spread, and Sustainability (NASSS) Framework

Round 1

Reviewer 1 Report

Minor revisions to English grammar are needed to improve the readability of the manuscript. 

The authors mentioned the several domains involved in the NASSS frame work. However no discussion relating to the domains stipulated in the methods section were included in the body of the text. The authors should relate the information gathered based on the aforementioned domains.

The manuscript is not well structured and quite confusing to read even though most of the statement is based on references and sounds generic.

Why is there a sudden appearance of section number (3, 3-1, 3.2.1.) when no prior upper sections were indicated. this adds further confusion on what is actually being discussed.

Figures 1, 2, and 4 need to be substantially improved. Figures should be able to convey information with minimal text.

Figure 6 is a Table, not a figure. 

 Figures 8 and 9 are not necessary. Authors should construct/make their own visual representation comparison between policy processes.

Minor revisions to English grammar are needed to improve the readability of the manuscript. 

Author Response

Reviewer1

Comments and Suggestions for Authors

Minor revisions to English grammar are needed to improve the readability of the manuscript.

Thank you so much for your constructive comments. We carefully read the paper and fixed the typos. For instance, we changed:

• Domain 2 delves onto the complexities of 3D printring technology, focusing on its operational effectiveness, reliability, and speed. Technology requires developing new , specific skills for its successful application to: Domain 2 explores the complexities of 3D printing technology, focusing on its operational effectiveness, reliability, and speed. This technology necessitates the development of new, specific skills for its successful application.

2) The complexity in this domain emerges from resistance among healthcare professionals and patients to adopting new technologies.

3)Having a robust health information system that can generate and store such data is crucial for the successful implementation of 3D printing technology in Maxillofacial surgery to:  The successful implementation of 3D printing technology in Maxillofacial surgery relies

4)3D printing technology can streamline the process of creating surgical guides and other surgical tools, reducing the time and cost of maxillofacial surgery to Streamlining surgical tool creation, 3D printing cuts time and costs in Maxillofacial surgery.

5) The most frequent clinical indications of 3D printing technology in maxillofacial settings are for dental implant surgery to: The most common clinical indications of 3D printing technology in maxillofacial settings include dental implant surgery.

The authors mentioned the several domains involved in the NASSS framework. However, no discussion relating to the domains stipulated in the methods section were included in the body of the text. The authors should relate the information gathered based on the aforementioned domains.

Thank you for your insightful feedback on our manuscript. We value your recommendations and the opportunity to enhance the clarity and quality of our work. Regarding your comments on the discussion related to the NASSS framework domains, we respectfully highlight that our original submission included a detailed examination of how our findings connect to each NASSS framework domain, particularly within the results section. We believe this section addresses the concerns raised and provides a comprehensive overview of the impact of each domain on the adoption of 3D printing technology in Iranian maxillofacial surgery.

We suggest examining these parts of our manuscript closer to gain a clearer understanding of our analysis. We appreciate your feedback and the opportunity to refine our work further.

The manuscript is not well structured and quite confusing to read even though most of the statement is based on references and sounds generic.

Thank you so much for your constructive comments. We have meticulously reviewed our manuscript to address the concerns raised, ensuring to clarify and enhance the readability of our work. Specifically, we have made the following changes to address the feedback:

1. Revised the explanation in Domain 2 to clarify the complexities of 3D printing technology, focusing on its operational effectiveness, reliability, and speed and highlighting the need for developing new specific skills for successful application.
2. Addressed the adaption resistance issue more directly, clarifying the challenges healthcare professionals and patients face when adopting new technologies.
3. Emphasized the critical role of a robust health information system in the successful implementation of 3D printing technology in maxillofacial surgery, making the necessity for accurate data generation and storage more explicit.
4. Streamlined how 3D printing technology optimizes the creation of surgical guides and tools, thereby reducing surgery time and costs, to more succinctly communicate these benefits.
5. I updated the section on clinical indications for 3D printing technology in maxillofacial settings to ensure the language is precise and effectively reflects the most common applications.

These revisions significantly improve the manuscript by enhancing clarity and directly addressing the concerns raised. We intend to make our arguments and findings as accessible as possible to the reader, and we hope that these changes demonstrate our commitment to this goal.

Why is there a sudden appearance of section number (3, 3-1, 3.2.1.) when no prior upper sections were indicated. this adds further confusion on what is actually being discussed.

Thank you for your observation regarding the structure and numbering of sections in our manuscript. We understand your concern about the appearance of detailed section numbers starting from section 3 without explicit numerical labelling of earlier sections, such as the introduction and methods.

To clarify and rectify this confusion:

Explicit Section Numbering: We have now explicitly numbered all major sections from the beginning of the manuscript to maintain continuity and logical progression. This includes:

1) Introduction

2) Materials and Methods

3) Results

4)Discussion

5)Conclusion

This change ensures a seamless flow and logical buildup from the general introduction of the topic to the more detailed discussions within the results section.

Detailed Subsections: For the subsections within the Results, such as "3-1) The WHO Health Systems Framework" and subsequent detailed analyses "3-1-1...," we have maintained the detailed numbering to provide clear navigation through the nuanced discussions of the WHO Health Systems Framework and the NASSS framework. The same detailed approach has been applied to "3-2) NASSS Framework" with its corresponding detailed subsections "3-2-1...," ensuring each subsection is easily identifiable and traceable.

Introduction of Subsection Structure Early: To further aid the reader, we've introduced a brief overview of the subsection structure early in the manuscript. This outline aims to prepare the reader for the detailed analysis in the Results section, thereby minimizing confusion and enhancing readability.

Figures 1, 2, and 4 need to be substantially improved. Figures should be able to convey information with minimal text.

Thank you for your insightful feedback regarding our manuscript's Figures 1, 2, and 4. We have carefully considered your suggestion to ensure that our figures effectively convey information with minimal text reliance.

Upon thorough review, we have updated Figure 2 to enhance its clarity and visual communication, as you recommended. We made significant improvements to ensure it more intuitively represents the application of the NASSS Framework to 3D printing in maxillofacial surgery, with visual enhancements to succinctly convey the framework's domains and relevance.

Regarding Figures 1 (The WHO Health Systems Framework) and 4 (3D Printing Process in Maxillofacial Surgery), after a detailed reevaluation, we believe these figures already meet the criteria of conveying essential information efficiently with minimal textual explanations. Figure 1 is a straightforward adaptation of the WHO framework widely recognized and understood in the health research community. Figure 4 succinctly illustrates the process of 3D printing application in maxillofacial surgery, focusing on visual simplicity and clarity. We aimed to balance the detail with accessibility, ensuring these figures support the manuscript's narrative without overwhelming the reader with excessive text.

However, understanding the importance of your feedback, we are open to specific suggestions on how to refine Figures 1 and 4 further to enhance their clarity or informativeness. We are committed to ensuring that all aspects of our manuscript meet the highest standards of quality and clarity.

We appreciate your guidance in this matter and look forward to your further suggestions.

Figure 6 is a Table, not a figure. 

Thank you for your attention to detail. We acknowledge the oversight regarding Table 6 as Figure 6 in our manuscript. We have corrected this to accurately reflect its nature as a table. We appreciate your understanding and patience.

Figures 8 and 9 are not necessary. Authors should construct/make their own visual representation comparison between policy processes.

Thank you for your guidance regarding Figures 8 and 9. We have removed these figures from the manuscript based on your valuable suggestion.

Comments on the Quality of English Language

Minor revisions to English grammar are needed to improve the readability of the manuscript. 

Thank you for your feedback regarding the quality of our manuscript's English. We have carefully reviewed the text and made the necessary grammatical revisions to enhance its readability and ensure it meets the publication standards.

Submission Date

18 February 2024

Date of this review

08 Mar 2024 08:25:38

Reviewer 2 Report

The article is interesting for dental surgeons and material engineers in Iran. The authors have done a great job investigating all these references to build up this study. However some references are missing - I left comments in the pdf manuscript file, and I have noticed only one self-citation of the authors in this review, maybe they should put more their own references to show their compentence in this area.

Comments for author File: Comments.pdf

Author Response

Reviewer 2

Comments and Suggestions for Authors

The article is interesting for dental surgeons and material engineers in Iran. The authors have done a great job investigating all these references to build up this study. However, some references are missing—I left comments in the pdf manuscript file, and I have noticed only one self-citation of the authors in this review. Maybe they should put more of their own references to show their competence in this area.

Thank you very much for your encouraging words and valuable feedback on our manuscript. We are grateful for your thorough review and the specific comments in the PDF file, which have greatly aided us in refining our study.

In response to your suggestions, we have carefully reviewed our reference list and added the missing citations as indicated in your comments. Additionally, recognizing the importance of demonstrating our expertise and contributions to the field, we have incorporated additional self-citations where relevant further to showcase our competence and previous work in this area.

We hope these updates adequately address your concerns and strengthen the manuscript. Your guidance has been instrumental in enhancing the quality of our work, and we are eager to hear any further feedback you may have.

Reviewer 3 Report

This is an interesting manuscript. However, it only represents a philosophical or theoretical conceptualization about the adoption of 3D printing approach in Maxillofacial surgery in Iran. At this point, it is necessary that the authors obtain fresh information of each point through surveys and interviews with the local actors potentially involved with the adoption and potential use of this technology in Iran.

English  is ok

Author Response

Reviewer 3

Comments and Suggestions for Authors

This is an interesting manuscript. However, it only represents a philosophical or theoretical conceptualization about the adoption of 3D printing approach in Maxillofacial surgery in Iran. At this point, it is necessary that the authors obtain fresh information of each point through surveys and interviews with the local actors potentially involved with the adoption and potential use of this technology in Iran.

Thank you so much for your constructive comment. We deeply appreciate your insights and suggestions for enhancing our manuscript with empirical data. While the current manuscript aims to provide a theoretical and conceptual framework for adopting 3D printing in maxillofacial surgery in Iran, we recognise the importance of grounding these ideas in practical experiences and perspectives. To this end, we are developing a follow-up study involving comprehensive surveys and interviews with maxillofacial surgery specialists, healthcare policymakers, and other key stakeholders in Iran. This forthcoming research is designed to capture a wide range of insights on the adoption, challenges, and potential impact of 3D printing technology in maxillofacial surgery. We believe integrating empirical data with our theoretical conceptualisations will significantly enrich our understanding and provide a more holistic view of the opportunities and hurdles facing 3D printing adoption in Iran's healthcare sector. We look forward to sharing these findings in future publications.

Round 2

Reviewer 1 Report

The authors have addressed most of the comments.

However, figure 1 still contains too much text. If the information within cannot be conveyed by constructing your figure,  tabularize the information.

No further comments.

Author Response

Thank you so much for your insight. We summarized all of the items again as best as we could. Dear reviewer, based on The NASSS Framework, we decided to assess all aspects considered in this framework in one figure to enhance understanding of each section. For this reason, we included it as a figure in our manuscript.

Reviewer 3 Report

During my first round of review I rejected this manuscript, because it did not reflex the title and the aims suggested by the authors. In view that not empirical information was not added to the new version of the manuscript I continue with the same decision taken previously.

Author Response

The response is in the Word file which has been attached

Author Response File: Author Response.pdf

Round 3

Reviewer 3 Report

All my concerns were addressed.