A Replicable and Reproducible Digital Method for Quantifying Maxillary Sinus Airway Changes after Sinus Lifts Using the Lateral Window Approach Technique—A Retrospective Study
Round 1
Reviewer 1 Report
I appreciate the work done by the authors but there are major concerns:
- Reading through the authors did not convince the reader why scanning the patient twice is justifiable. The pre-operative I support for possible surgical planning, but the post-operative scan is not clinically warranted.
- What is the clinical relevance of "quantifying" the size of maxilla or nasal cavity after sinus lift?
- The method is not novel. It is automatic segmentation using a known/common software that uses grey-threshold range to segment air.
Author Response
Dear Reviewer 1:
I’m pleased to resubmit the manuscript of the work entitled, “A Replicable and Reproducible Digital Method for Quantifying Maxillary Sinus Airway Changes after Sinus Lifts Using the Lateral Window Approach Technique. A Retrospective Study”.
Reviewer 1: Moderate English changes required
Response: In order to adapt to the reviewer's 1 comments, we have send the manuscript to the English Editing Service of MDPI. We attached the Certificate.
Reviewer 1: Reading through the authors did not convince the reader why scanning the patient twice is justifiable. The pre-operative I support for possible surgical planning, but the post-operative scan is not clinically warranted.
Response: In order to adapt to the reviewer's 1 comments, we clarify that the first CBCT scan was performed before the sinus lift and the second CBCT scan was performed in order to plan the dental implants after the sinus lift procedure. We have provided this information in the Material and Methods section.
Reviewer 1: What is the clinical relevance of "quantifying" the size of maxilla or nasal cavity after sinus lift?
Response: In order to adapt to the reviewer's 1 comments, we clarify that the decrease in the volume of the maxillary sinus has been reported a potential predictive factor of obstructive sleep apnea, which is defined as a type of sleep apnea caused by partial or complete obstruction of the upper pharyngeal airway; however, Kim et al showed a significant association between the obstructive sleep apnea and a decreased ratio of maxillary sinus volume to the whole nasal airway (Kim YJ, Shin HK, Lee DY, Ryu JJ, Kim TH. Decreased maxillary sinus volume is a potential predictor of obstructive sleep apnea. Angle Orthod. 2020 Jul 1;90(4):556-563). We have provided this information in the Summary, Introduction and Discussion sections.
Reviewer 1: The method is not novel. It is automatic segmentation using a known/common software that uses grey-threshold range to segment air.
Response: In order to adapt to the reviewer's 1 comments, we clarify that previous studies used also a digital technique to measure the volume of the maxillary sinus; however the digital measurement technique were not validated. In addition, the digital technique requires the adjustment of the bone density range by selecting the Hounsfield units and the reference points placement inside the maxillary sinus to define the air density. These values provide the digital imaging software the sensibility to measure completely the volume of the maxillary sinus by differencing the other tissues density. We have provided this information in the Material and Methods section.
We take this opportunity to thank the recommendations and suggestions made by the reviewers to improve the document.
Yours sincerely,
Reviewer 2 Report
This article is interested in volumetric variations of the maxillary sinus after sinus elevation during pre-implant bone grafting. The authors present a new digital quantification method showing reliable and reproducible results. The innovative method and the statistical work are the strong points of this study.
Nevertheless, I think this paper could be improved:
1/ The clinical interest of this measurement technique for an implantologist (or oral and maxillofacial surgeon) is not highlighted enough in the summary and the introduction. The article should be reworked with the arguments in the discussion.
2/ Arguments contained in the discussion highlight the ease of the measurement technique to be used before sinus lift. Why not conclude this article with these preoperative advantages? Finally, what is the real interest of using this measurement technique after sinus elevation if not to show that a bone graft decreases sinus volume?
3/ In the experimental section, the Valsalva maneuver is mentioned to assess the condition of the sinus membrane. Were patients who had a perforation of this membrane included in the study? Isn't the 8-month period between preoperative and postoperative CBCT, without implant placement (?), a little high?
4/ I think the methodology for the placement of the yellow dots defining the air density should be better developed.
5/ The position and patency of the ostium in the superior medial aspect of the sinus is an important consideration before sinus lift surgery. Could this digital imaging analysis method provide information on sinus permeability before and after surgery? Major argument to develop, to illustrate if possible and to discuss please.
Finally, this article shows a good statistical study to prove the reliability of this digital method but clearly lacks clinical relevance.
Author Response
Dear Reviewer 2:
I’m pleased to resubmit the manuscript of the work entitled, “A Replicable and Reproducible Digital Method for Quantifying Maxillary Sinus Airway Changes after Sinus Lifts Using the Lateral Window Approach Technique. A Retrospective Study”.
Reviewer 2: English language and style are fine/minor spell check required
Response: In order to adapt to the reviewer's 2 comments, we have send the manuscript to the English Editing Service of MDPI. We attached the Certificate.
Reviewer 2: The clinical interest of this measurement technique for an implantologist (or oral and maxillofacial surgeon) is not highlighted enough in the summary and the introduction. The article should be reworked with the arguments in the discussion.
Response: In order to adapt to the reviewer's 2 comments, we have highlighted the clinical interest of the suggested digital measurement technique in the Summary, Introduction and Discussion sections.
Reviewer 2: Arguments contained in the discussion highlight the ease of the measurement technique to be used before sinus lift. Why not conclude this article with these preoperative advantages? Finally, what is the real interest of using this measurement technique after sinus elevation if not to show that a bone graft decreases sinus volume?
Response: In order to adapt to the reviewer's 2 comments, we have added a sentence by highlighting the ease of the measurement technique to be used in the Conclusion section. Moreover, the authors have clarified that the real interest of the novel digital measurement technique lies in providing a method to accurate measure the notable decrease of the volume of the maxillary sinus after the sinus lift using the lateral window approach technique; which could lead the development of the obstructive sleep apnea, preventing the normal breathing during sleep; especially in bilateral sinus lift. Therefore it is recommended further research to analyze the risk of sinus lift technique to cause the appearance of obstructive sleep apnea. We have provided this information in the Summary, Introduction and Discussion sections.
Reviewer 2: In the experimental section, the Valsalva maneuver is mentioned to assess the condition of the sinus membrane. Were patients who had a perforation of this membrane included in the study? Isn't the 8-month period between preoperative and postoperative CBCT, without implant placement (?), a little high?
Response: In order to adapt to the reviewer's 2 comments, we clarify in the selection criteria that the patients with a perforation of the Schneider membrane were excluded from the study. We clarify that it was the mean time and it depended on the grafting material used.
Reviewer 2: I think the methodology for the placement of the yellow dots defining the air density should be better developed.
Response: In order to adapt to the reviewer's 2 comments, we have clarified the yellow dots in the Material and Methods section.
Reviewer 2: The position and patency of the ostium in the superior medial aspect of the sinus is an important consideration before sinus lift surgery. Could this digital imaging analysis method provide information on sinus permeability before and after surgery? Major argument to develop, to illustrate if possible and to discuss please.
Response: In order to adapt to the reviewer's 2 comments, we have analyzed the position and permeability of the maxillary sinus ostium before and after the maxillary sinus lifts using the lateral window approach technique by this novel digital method proposed, and showed that no maxillary sinus stenosis were diagnosed preoperatively and that the maxillary sinus ostium remained permeable after the maxillary sinus lifts. We have provided this information in the Material and Method, Results and Discussion sections.
We take this opportunity to thank the recommendations and suggestions made by the reviewers to improve the document.
Yours sincerely,
Round 2
Reviewer 1 Report
Please check the literature (some samples of relevant articles given below) and consider a wider and more common reasons of why maxillary size matters. Placing risk of obstructive sleep apnea as a sole reason appears odd and more like an after-thought.
- Alsufyani N, El-Hakim H, Major P. Prevalence of maxillary sinus hypoplasia and association with variations in the sinonasal complex: a cone beam CT study. Clin Oral Investig. 2021 Sep;25(9):5463-5471. doi: 10.1007/s00784-021-03854-3. Epub 2021 Mar 4. PMID: 33661447.
-Chen YW, Lee FY, Chang PH, Huang CC, Fu CH, Huang CC, Lee TJ. A paradigm for evaluation and management of the maxillary sinus before dental implantation. Laryngoscope. 2018 Jun;128(6):1261-1267. doi: 10.1002/lary.26856. Epub 2017 Sep 16. PMID: 28921521.
-Karslioglu H, Sumer AP. Evaluation of maxillary sinus findings after dental implant and sinus floor augmentation procedures with cone-beam computed tomography. Niger J Clin Pract. 2020 Oct;23(10):1477-1482. doi: 10.4103/njcp.njcp_695_19. PMID: 33047709.
Author Response
Dear Reviewer 2:
I’m pleased to resubmit the manuscript of the work entitled, “A Replicable and Reproducible Digital Method for Quantifying Maxillary Sinus Airway Changes after Sinus Lifts Using the Lateral Window Approach Technique. A Retrospective Study”.
Reviewer 2: Please check the literature (some samples of relevant articles given below) and consider a wider and more common reasons of why maxillary size matters. Alsufyani N, El-Hakim H, Major P. Prevalence of maxillary sinus hypoplasia and association with variations in the sinonasal complex: a cone beam CT study. Clin Oral Investig. 2021 Sep;25(9):5463-5471. doi: 10.1007/s00784-021-03854-3. Epub 2021 Mar 4. PMID: 33661447. Chen YW, Lee FY, Chang PH, Huang CC, Fu CH, Huang CC, Lee TJ. A paradigm for evaluation and management of the maxillary sinus before dental implantation. Laryngoscope. 2018 Jun;128(6):1261-1267. doi: 10.1002/lary.26856. Epub 2017 Sep 16. PMID: 28921521. Karslioglu H, Sumer AP. Evaluation of maxillary sinus findings after dental implant and sinus floor augmentation procedures with cone-beam computed tomography. Niger J Clin Pract. 2020 Oct;23(10):1477-1482. doi: 10.4103/njcp.njcp_695_19. PMID: 33047709.
Response: In order to adapt to the reviewer's 2 comments, we have included the references suggested by the reviewer 2 and others related references in the Introduction and Discussion sections, that describe the etiological factors of maxillary sinus hypoplasia. In addition, the importance of an accurate, repeatable and reproducible maxillary sinus volume measurement technique that allows preoperative diagnosis of anatomical alterations of the sinonasal complex is emphasized.
We take this opportunity to thank the recommendations and suggestions made by the reviewers to improve the document.
Yours sincerely,
Reviewer 2 Report
I thank the authors for making notable corrections to their manuscript.
After re-reading the entire article, I think that the clinical interest in sleep apnea should not be the main interest but only in the discussion. Indeed, the scientific evidence for the relationship between sleep apnea and sinus elevation is unfounded. In the introduction (and abstract), the clinical interest might be to look at the changes in sinus volume and airway complex with a reliable technique.
I think the additional figure (number 4) also brings correlated information to the clinic and I thank the authors for this work.
Author Response
Dear Reviewer 2:
I’m pleased to resubmit the manuscript of the work entitled, “A Replicable and Reproducible Digital Method for Quantifying Maxillary Sinus Airway Changes after Sinus Lifts Using the Lateral Window Approach Technique. A Retrospective Study”.
Reviewer 2: The clinical interest of this measurement technique for an implantologist (or oral and maxillofacial surgeon) is not highlighted enough in the summary and the introduction. The article should be reworked with the arguments in the discussion.
Response: In order to adapt to the reviewer's 2 comments, we have empathized in the Abstract and Introduction sections the clinical interest of this measurement technique for an implantologist, based on the arguments presented in the Discussion section.
Reviewer 2: After re-reading the entire article, I think that the clinical interest in sleep apnea should not be the main interest but only in the discussion. Indeed, the scientific evidence for the relationship between sleep apnea and sinus elevation is unfounded. In the introduction (and abstract), the clinical interest might be to look at the changes in sinus volume and airway complex with a reliable technique.
Response: In order to adapt to the reviewer's 2 comments, we have highlighted in the Abstract and Introduction sections that the clinical interest of this study is to provide a reliable measurement technique that provides the implantologist with an accurate pre-operative measurement tool that makes sinus lift more predictable.
We take this opportunity to thank the recommendations and suggestions made by the reviewers to improve the document.
Yours sincerely,
