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Congratulations to the authors on their excellent work! The manuscript is well-written, adheres to the journal’s guidelines, and represents a valuable contribution to the literature. The revisions have successfully addressed the prior concerns, ensuring clarity and scientific rigor.
I am pleased to recommend this manuscript for publication. Well done!
The authors have accurately addressed most of the required revisions in the revised version of the article. The text is written in clear English. It includes appropriate references to relevant literature and provides enough background and context from the field. The article follows a professional structure, with the inclusion of figures and tables. I recommend accepting it for publication.
Original, primary research that aligns with the journal's Aims and Scope. The research question is clearly defined, significant, and relevant, with an explanation of how it addresses an identified gap in knowledge. Methods are detailed enough to allow for replication.
The study presents a significant contribution to the literature on dental autotransplantation. Conclusions are clearly articulated, directly tied to the original research question, and confined to supporting evidence.
The revisions have effectively addressed the previous concerns
The revisions have effectively addressed the previous concerns
The revisions have effectively addressed the previous concerns
The revisions have effectively addressed the previous concerns, enhancing clarity and scientific rigor. Congratulations to the authors. I am happy to recommend this manuscript for publication.
Dear authors
Thank you for submitting your manuscript. The reviewers have recognized the importance and potential impact of your study on root canal therapy for autotransplanted third molars, but they have also identified several areas that require substantial revisions. Key issues include inconsistencies in the use of tense, the need for additional methodological details, corrections to references and citations, and clarification of the study’s null hypothesis. Additionally, the abstract and various sections of the manuscript need to be revised for clarity and precision, especially regarding follow-up periods and the specific conditions under which the study was conducted. Please address these concerns comprehensively to improve the manuscript’s quality and readability before resubmission.
Please address these concerns comprehensively to improve the manuscript’s quality and readability before resubmission. Additionally, ensure that all reviewer questions and comments are fully addressed to avoid multiple rounds of revisions.
This is an interesting manuscript, titled "To emphasize the importance of root canal therapy for autotransplanted third molars: a 6-year follow-up cohort of 167 teeth in Southern China." The study aims to investigate the prognostic factors influencing the success of autotransplanted third molars, with a particular focus on the impact of root canal therapy (RCT). The manuscript presents a comprehensive analysis based on a 6-year follow-up of 167 autotransplanted teeth and evaluates various factors affecting their success and survival. The manuscript provides valuable insights into the impact of RCT on the success of autotransplanted teeth. It is generally well-organized and supported by data but requires revisions to enhance clarity, precision, and practical relevance. Addressing the identified weaknesses will strengthen the manuscript's contributions to the field of dental autotransplantation. To enhance the quality of this report, I have provided some comments and suggestions, listed below according to manuscript sections:
Title:
- The title is adequately descriptive and includes important details about the study.
- Revise the title for brevity while maintaining clarity: “Efficacy of Root Canal Therapy for Autotransplanted Third Molars: A 6-Year Cohort Study of 167 Teeth in Southern China.
Abstract:
- “Patients underwent autogenous tooth transplantation to replace non-retainable molars with third molars”; Please indicate whether both upper and lower third molars were included in the autotransplantation procedure in this study.
- Revise the following sentence: "third molars with Moorrees tooth development stage > 4" to clarify whether stage 4 is included or not. If only stages 5 and 6 are included, please use the "Greater than or Equal to" symbol (≥5).
- The abstract presents conflicting information about the follow-up periods. Initially, it suggests a 6-year follow-up, but later it mentions a median follow-up of 28.5 months and a minimum of 6 months. The follow-up period should be reported consistently throughout the abstract to avoid confusion. If the study indeed spans up to 6 years, this should be clearly communicated, specifying the range of follow-up durations and the median duration (under the background, methods, and results subheadings).
- "Our findings underscore the importance of RCT in transplanted teeth."; This conclusion should be tailored to align with the study sample, which did not include teeth with open apices. Authors can modify the sentence to read: '… the importance of RCT in transplanted teeth with closed or semi-closed apices.'
- Please draw conclusions within the limitations of the present study and ensure this is clearly indicated in the abstract.
Keywords:
- The main manuscript lacks keywords. Authors should include a keywords section to improve the manuscript's indexing in relevant databases.
- Relevant keywords can include: “Oral Surgery”, “Dental Autotransplantation”, “Impacted Teeth”, and “Root canal treatment”.
Introduction:
- The introduction is well-written and informative but could be improved with more concise content. It would be stronger with a clearer transition to the specific aims and hypotheses of the study.
- Although the authors mentioned certain indications for autogenous tooth transplantation in the introduction, stating that 'Most commonly, autogenous tooth transplantation is applied to replace non-retainable first or second molars with third molars of a similar size and shape,' they should also include additional indications for autogenous dental transplantation to provide a more comprehensive overview (kindly refer to: doi: 10.7759/cureus.29030). These indications include replacement of permanent teeth associated with poor prognosis, replacement of developmentally missing teeth, management of alveolar clefts, repositioning impacted or ectopic teeth, management of oroantral communications, autotransplantation of deciduous teeth as space maintainers, and cases of maxillomandibular reconstructions.
- The introduction should address the lack of consensus regarding the necessity of performing root canal therapy (RCT) after autogenous tooth transplantation. Among practitioners, there is debate about whether RCT should be conducted before, during, or after transplantation, with some advocating for it only if clinical or radiographic signs of pulp necrosis appear (cite: doi: 10.1016/j.amsu.2022.104501 , and doi: 10.1016/j.amsu.2022.103470). The manuscript should clarify these differing perspectives in clinical practice.
Materials and Methods:
- There are minor issues with clarity and completeness, such as the lack of details on specific clinical parameters and the timing of RCT.
- “.. patients have at least a healthy third molar”; It should be specified whether both upper and lower third molars are eligible for inclusion in the current study.
- A detailed description of the inclusion criterion 'Moorrees tooth development stage > 4' should be added.
- The eligibility criteria should include information on: patients gender, the status of the third molar (erupted, partially erupted, or fully impacted), the function of the third molar (functional or non-functional), periodontal condition (presence or absence of periodontitis), general oral health, difficulty of extraction, extraction technique (need for bone debridement), and whether cases of bruxism, traumatic extractions, extended extraction times, prolonged transplant extraoral time, or multiple fitting attempts in the recipient site were excluded.
- Did the current study sample include transplantation only to recent extraction sockets, or did it also encompass surgically created sockets?
- Did this study include diabetic participants or smokers?
- The following exclusion criterion is not consistent with what is mentioned in the abstract: 'Patients with less than 12 months of follow-up or who were lost to follow-up were excluded from the analysis.'
- “All surgical procedures were performed under an infra-alveolar nerve block”; If the 'inferior alveolar nerve block' was intended, please clarify. In this case, the entire sample consists of lower molars (both in the recipient site and donor teeth), correct?
- “Extraction of the affected tooth: Using standardized surgical instruments and standardized minimally invasive techniques.”; Please provide additional details on the minimally invasive techniques used.
- Please provide additional details on the technique used for extracting the donor tooth. Specifically, clarify whether bone removal was necessary and if piezosurgery was utilized.
- “If extraction and transplantation are performed simultaneously, the affected tooth should be extracted first, followed by the donor tooth.”; This is absolutely correct. Additionally, it is important to surgically prepare the recipient site to ensure it is ready to receive the donor tooth before the extraction of the donor tooth to minimize the extra-alveolar time.
- Was a tooth replica utilized during the preparation of the recipient site?
- “If the root of the donor tooth fractures and the remaining root length is more than 2/3 of the total root length with sufficient support, perform immediate extraoral (microscopic) apical surgery and retrograde root canal preparation and filling during the surgery for transplantation”; Why was autotransplantation not performed in these cases without retrograde filling? There are publications indicating the potential benefits of apicoectomy for teeth with fully formed roots in promoting revascularization after autotransplantation, i.e. “fragile fracture apicoectomy” (doi: 10.1111/iej.13230). These considerations can be discussed further in the discussion section of the manuscript.
- “Preparation of the recipient area alveolar socket”; Please provide detailed information on the methods used to prepare the recipient site.
- “Trimming and suturing the mucoperiosteal flap”; Typically, there is no need to ‘trim’ the mucoperiosteal flap. The authors may consider adding clarifications on this point.
- Details on “Occlusal adjustment and fixation” should also be added. Was the position of the transplanted tooth crown adjusted to be infra-occlusal? Exactly at what level? How was the fixation performed? Was it achieved solely with sutures, or were splints used as well? Please provide full details.
- There is a discrepancy in the reported timing of RCT. The abstract states that ‘159 cases (95%) received RCT within 3 months,’ whereas the methods section mentions that ‘patients are advised to complete RCT within 2 to 4 weeks after tooth autotransplantation.’ Please clarify and ensure consistency in the reporting of this timing.
- Since authors are presenting findings from a completed study, their reporting should be in the past tense, not the present or future tense. For example, instead of stating 'We will perform the radiographic examinations at the follow-up of 1 year,' it should be phrased as 'We performed the radiographic examinations at the 1-year follow-up. Other examples from the manuscript include ‘we will advise the patients to complete the RCT’, ‘the surgical assistance will record’, ‘Any complications or undesired outcome will be notified’, etc.
- Please specify the methods used for radiographic examination during the follow-up periods. Complete details are requested.
- Authors stated that the surgical assistant will record whether a collagen sponge is used to fill the socket. Please explain the use and purpose of filling the recipient socket with a collagen sponge before or during autotransplantation.
- Author stated that “X-ray shadow of the alveolar bone margin (i.e., hard bone plate)” is one of the success criteria. Do they mean reformation of lamina dura? If yes, please clarify. However, absence of the lamina dura alone is not considered a definitive sign of failure for the autogenous dental transplant. It is preferable to clarify and discuss this point further in the discussion section of the text.
- The following sentence needs to be rephrased for clarity: “As unsuccessful teeth could be rescued by further treatment and avoid the fate of failure, leading to a extreme low failure rate, we mostly analyzed the success and unsuccess in this article.”
Results:
- The results section provides a clear account of the study's findings, including success and survival rates, and statistical analyses of prognostic factors.
- The use of tables and figures is appropriate.
- Please add four additional columns to Table 2 to include the following information for each failed case: the extraoral time, the number of fitting attempts during transplantation, smoking status, and a notes column indicating any special conditions the participant had (e.g., periodontitis, bruxism, traumatic occlusion, extra trauma during extraction, diabetes mellitus, poor oral hygiene, etc.).
Discussion:
- Some points that need further discussion were provided in previous comments.
- Please discuss the following points regarding the limitations of the study in the discussion section of the manuscript: The longevity of autogenous dental transplants, like other restorative dental treatments such as crowns, bridges, or traditional dental implants, as well as the patient’s own teeth, is significantly affected by various factors, including general health, oral health status, the level of care provided to these teeth, and the use of different oral hygiene practices and health behaviors.
Conclusions:
- In the conclusions section, after stating, "In conclusion, our study suggests that performing RCT in transplanted teeth significantly correlates with the success of autotransplantation in adult patients," the authors should also address the potential presence of other factors that might contribute to the failure of teeth autotransplantation.
- The conclusions could be more detailed in terms of practical recommendations and implications for future research.
Figures:
- The clinical images are of high quality and clarity, providing a detailed visual representation of the procedure and effectively illustrating the workflow.
The manuscript presents a research article that aligns well with the aims and scope of the journal. Research question is well defined, relevant, and meaningful. Comments on the methods section have been provided.
Comments regarding the validity of the findings, as well as suggestions for improving the reporting, have been provided. The authors should address the potential presence of other factors that could contribute to the failure of teeth autotransplantation in their conclusions. Additionally, incorporating more detailed practical recommendations and implications for future research would strengthen the conclusions.
1] Please check the grammar and spelling and correct them; many places are written in the future tense when they should be in the past tense. For example, lines 129-131.
2] Please correct the few references written in capital letters. For example, lines 325-327 and 346-347.
3} Few of the tables and figures were not cited in the text. Please cite them in the proper locations.
4) Mention company and country name of the materials and software mentioned in the literature.
1) What was the null hypothesis in this study, and what was its outcome? Please mention it.
2) During the procedure, the donor tooth was preserved in normal saline after being extracted from its socket. What was the reason for using it? According to the literature, Hank's balanced salt solution and coconut water are the best storage media for such teeth
(Ustad F, Ali FM, Kota Z, Mustafa A, Khan MI. Autotransplantation of teeth: A review. Am J Med Dent Sci. 2013;1:25–30.)
3) Was there any disinfectant solution applied, or was there any other therapeutic protocol followed on the donor tooth roots after their extraction? If yes mention it.
NO COMMENT
It is a well-written manuscript on an important topic, but it needs some suggested modifications
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