The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons

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With advancements in digital workflows and CAD/CAM technologies, clear aligner therapy (CAT) has emerged as a potential adjunct in surgical cases. However, its clinical application remains under-researched. This study aimed to exploratorily assess the knowledge, clinical experience, and attitudes of orthodontists and oral and maxillofacial surgeons in Saudi Arabia regarding CAT in orthognathic surgery patients. Methods A cross-sectional survey was conducted from April 1 to May 31, 2023, using a closed-ended online questionnaire distributed to specialists across Saudi Arabia. The survey gathered demographic and clinical data. Statistical analysis included descriptive methods, chi-square testing, and univariate regression. Given the limited sample size, inferential analyses were performed for exploratory purposes and interpreted cautiously. Results Out of 278 invited participants, 46 complete responses (16.5%) were received, which was substantially lower than the calculated minimum sample size. Most participants were aged 31–40 years and had 6–10 years of experience. Orthodontists accounted for 65.2% of the respondents, with oral and maxillofacial surgeons at 34.8%. While most treated 1–4 orthognathic patients monthly, 80% had no experience using CAT in these cases Although CAT was commonly used in routine orthodontic practice, its application in orthognathic surgery cases was limited. Exploratory regression analysis suggested a possible association between clinician age and CAT usage (R2 = 0.38), whereas gender and years of experience did not show clear associations. Conclusion This exploratory survey suggests that clinical experience with CAT in orthognathic surgery remains limited among surveyed clinicians in Saudi Arabia. The findings highlight perceived challenges related to surgical workflows, including pre-surgical alignment, intraoperative fixation, and postoperative occlusal control. Given that the achieved sample size (n = 46) was substantially lower than the calculated minimum requirement (n = 302), the results should be interpreted as preliminary observations and exploratory findings rather than definitive conclusions. Findings should be interpreted cautiously due to the small sample size and exploratory design. 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F1000Research 2026, 14 :1001 ( https://doi.org/10.12688/f1000research.170095.4 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Revised The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons [version 4; peer review: 1 approved, 1 approved with reservations] Previously titled: The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontics and Oral and Maxillofacial Surgeons Ahmad Salem Assari https://orcid.org/0000-0002-1940-7359 1,2 , Muslat A Bin Rubaia’an https://orcid.org/0000-0002-6497-0984 1,3 , Diaa Taisir Al-Marhoun 4 , [...] Hayat Arafah 5 , AlAnood N Bin Saedan 6 , Hajar Dar Salamah 4 , Raneem Mohammed Aljomiey 4 Ahmad Salem Assari https://orcid.org/0000-0002-1940-7359 1,2 , Muslat A Bin Rubaia’an https://orcid.org/0000-0002-6497-0984 1,3 , [...] Diaa Taisir Al-Marhoun 4 , Hayat Arafah 5 , AlAnood N Bin Saedan 6 , Hajar Dar Salamah 4 , Raneem Mohammed Aljomiey 4 PUBLISHED 07 May 2026 Author details Author details 1 Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, College of Medicine and Dentistry, Riyadh Elm University, Riyadh, Riyadh Province, Saudi Arabia 2 Department of Dentistry, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia 3 Department of Maxillofacial Surgery, Prince Sultan Military Medical City, Riyadh, Riyadh Province, Saudi Arabia 4 Dental Clinic, Riyadh, Saudi Arabia 5 Alwattan medical complex 3, Riyadh, Saudi Arabia 6 Saudi Board in Periodontics, College of Medicine and Dentistry, Riyadh Elm University, Riyadh, Riyadh Province, Saudi Arabia Ahmad Salem Assari Roles: Conceptualization, Methodology, Project Administration, Supervision, Writing – Review & Editing Muslat A Bin Rubaia’an Roles: Methodology, Resources, Supervision, Writing – Review & Editing Diaa Taisir Al-Marhoun Roles: Data Curation, Formal Analysis, Investigation, Writing – Original Draft Preparation Hayat Arafah Roles: Data Curation, Formal Analysis, Investigation, Writing – Original Draft Preparation AlAnood N Bin Saedan Roles: Data Curation, Formal Analysis, Investigation, Writing – Original Draft Preparation Hajar Dar Salamah Roles: Data Curation, Formal Analysis, Investigation, Writing – Original Draft Preparation Raneem Mohammed Aljomiey Roles: Data Curation, Formal Analysis, Investigation, Writing – Original Draft Preparation OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Health Services gateway. Abstract Background Orthognathic surgery corrects severe skeletal discrepancies that cannot be addressed by orthodontics alone. With advancements in digital workflows and CAD/CAM technologies, clear aligner therapy (CAT) has emerged as a potential adjunct in surgical cases. However, its clinical application remains under-researched. This study aimed to exploratorily assess the knowledge, clinical experience, and attitudes of orthodontists and oral and maxillofacial surgeons in Saudi Arabia regarding CAT in orthognathic surgery patients. Methods A cross-sectional survey was conducted from April 1 to May 31, 2023, using a closed-ended online questionnaire distributed to specialists across Saudi Arabia. The survey gathered demographic and clinical data. Statistical analysis included descriptive methods, chi-square testing, and univariate regression. Given the limited sample size, inferential analyses were performed for exploratory purposes and interpreted cautiously. Results Out of 278 invited participants, 46 complete responses (16.5%) were received, which was substantially lower than the calculated minimum sample size. Most participants were aged 31–40 years and had 6–10 years of experience. Orthodontists accounted for 65.2% of the respondents, with oral and maxillofacial surgeons at 34.8%. While most treated 1–4 orthognathic patients monthly, 80% had no experience using CAT in these cases Although CAT was commonly used in routine orthodontic practice, its application in orthognathic surgery cases was limited. Exploratory regression analysis suggested a possible association between clinician age and CAT usage (R 2 = 0.38), whereas gender and years of experience did not show clear associations. Conclusion This exploratory survey suggests that clinical experience with CAT in orthognathic surgery remains limited among surveyed clinicians in Saudi Arabia. The findings highlight perceived challenges related to surgical workflows, including pre-surgical alignment, intraoperative fixation, and postoperative occlusal control. Given that the achieved sample size (n = 46) was substantially lower than the calculated minimum requirement (n = 302), the results should be interpreted as preliminary observations and exploratory findings rather than definitive conclusions. Findings should be interpreted cautiously due to the small sample size and exploratory design. READ ALL READ LESS Keywords Orthognathic surgery, Clear aligner therapy (CAT), Orthodontics, Oral and maxillofacial surgery, Saudi Arabia, Surgical orthodontics Corresponding Author(s) Ahmad Salem Assari ( [email protected] ) Close Corresponding author: Ahmad Salem Assari Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2026 Salem Assari A et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Salem Assari A, A Bin Rubaia’an M, Taisir Al-Marhoun D et al. The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons [version 4; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 14 :1001 ( https://doi.org/10.12688/f1000research.170095.4 ) First published: 29 Sep 2025, 14 :1001 ( https://doi.org/10.12688/f1000research.170095.1 ) Latest published: 07 May 2026, 14 :1001 ( https://doi.org/10.12688/f1000research.170095.4 ) Revised Amendments from Version 3 This revised version improves clarity, consistency, and overall structure compared with the previous publication. The methods are now more transparent, with clearer reporting of the sampling process, response rate, and study limitations, and the study is more appropriately presented as exploratory. The Results and Discussion sections have been reorganized for better flow and interpretation, with stronger links to the tables and current literature. The Conclusion has also been shortened to clearly highlight the main findings and their clinical relevance. This revised version improves clarity, consistency, and overall structure compared with the previous publication. The methods are now more transparent, with clearer reporting of the sampling process, response rate, and study limitations, and the study is more appropriately presented as exploratory. The Results and Discussion sections have been reorganized for better flow and interpretation, with stronger links to the tables and current literature. The Conclusion has also been shortened to clearly highlight the main findings and their clinical relevance. See the authors' detailed response to the review by Tiago Fialho See the authors' detailed response to the review by Abdelrahman MA Mohamed READ REVIEWER RESPONSES Introduction Orthognathic surgery remains the treatment of choice for adults with severe dentofacial deformities or skeletal discrepancies that cannot be corrected by orthodontic camouflage alone. 1 , 2 Successful outcomes require a coordinated interdisciplinary approach involving both orthodontists and oral and maxillofacial surgeons. 1 , 2 Orthodontic management for surgical cases traditionally involves pre-surgical decompensation using fixed appliances followed by post-surgical refinement. This study primarily refers to the conventional orthodontics-first approach, where pre-surgical orthodontic preparation is essential prior to orthognathic surgery. Although surgery-first protocols have been introduced in recent years, they eliminate or reduce the need for extensive pre-surgical orthodontics and therefore involve different clinical considerations. As such, the present investigation focuses on clinician perspectives within the orthodontics-first framework, where the role of clear aligner therapy in pre- and post-surgical phases remains clinically relevant. Fixed appliances, typically metal or ceramic brackets connected by archwires, remain the gold standard in this context due to their ability to deliver controlled tooth movements in all three planes of space. 3 , 4 However, growing aesthetic demands, changing patient preferences, and concerns about oral hygiene and periodontal health have contributed to decreased patient acceptance of fixed appliances. 5 – 7 The introduction of clear aligner therapy (CAT) in the late 20th century has provided an alternative, especially for patients prioritizing aesthetics and comfort. 8 Initially indicated for mild to moderate malocclusions, CAT has evolved considerably with advances in digital imaging, 3D printing, and biomechanical modeling, allowing treatment of increasingly complex dental movements. 1 , 6 , 9 – 11 CAT now features transparent, removable trays generated through digital treatment planning, offering improved aesthetics, patient comfort, oral hygiene, and reduced chair time. 7 , 8 Its use in combination with surgery is emerging; however, its role differs between orthodontics-first and surgery-first protocols. In orthodontics-first approaches, CAT may be used in pre- and post-surgical phases, whereas in surgery-first protocols its role is more limited and evolving. 7 Meanwhile, in Saudi Arabia, the demand for clear aligners has risen in tandem with global trends as patients increasingly seek orthodontic solutions that are less conspicuous and more comfortable than traditional braces. 12 However, there is little evidence exploring clinicians’ readiness, experience, or confidence in integrating CAT into surgical orthodontics. This gap in empirical data limits understanding of how practitioners perceive its feasibility in complex surgical workflows. 13 , 14 This knowledge gap presents a barrier for both orthodontists and oral and maxillofacial surgeons in utilizing CAT effectively for complex skeletal discrepancies. Region-specific studies indicate that orthognathic surgery is among the most frequently performed oral and maxillofacial procedures in Saudi teaching hospitals, 15 and patient motivation is often driven by aesthetic concerns, with satisfaction rates exceeding 90%. 16 , 17 Moreover, research highlights anatomical variations between regions within the country such as greater microgenia and longer facial profiles in southern populations which further emphasizes the need for personalized surgical planning and broader adoption of advanced, adaptable technologies like CAT. 13 , 18 Given the rising popularity of CAT and the evolving landscape of orthodontic practice, there is a need to evaluate clinician perspectives in surgical contexts. The current study aimed to assess the knowledge, clinical experience, attitudes, and practices of Saudi orthodontists and oral and maxillofacial surgeons regarding the use of clear aligner therapy in orthognathic surgery patients. Methodology Study design, setting and ethical consideration This cross-sectional study was ethically approved by the Institutional Review Board (IRB) of Riyadh Elm University (Approval No. [FUGRP/2023/303/929]) and conducted in full accordance with the Declaration of Helsinki. All participants received detailed information about the study objectives, procedures, and data confidentiality, and provided electronic informed consent prior to participation. Participation was voluntary, and anonymity and data confidentiality were maintained throughout. A closed-ended, self-administered questionnaire was designed online using Google Forms and distributed among orthodontists and maxillofacial surgeons practicing in Saudi Arabia. The survey was conducted between April 1 and May 31, 2023. Participants were recruited through professional email lists, social media platforms, and direct distribution via professional organizations, including the Saudi Orthodontic Society and regional oral and maxillofacial surgery networks. To minimize sampling bias, invitations were sent broadly to licensed practitioners across academic, private, and governmental sectors. Sample size and population According to recent data from the Saudi Commission for Health Specialties and regional workforce reports, there are an estimated 900–1,100 orthodontists and 400–500 oral and maxillofacial surgeons actively practicing in Saudi Arabia. 19 Our sampling frame of 278 clinicians was drawn from professional networks and academic institutions, covering a cross-section of these specialties. The required sample size was calculated using the standard formula for a finite population: n = Z 2 × p × q × N e 2 ( N − 1 ) + Z 2 × p × q Where: • n = required sample size • N = total population of orthodontists and oral and maxillofacial surgeons in Saudi Arabia (≈ 1,400) • Z = 1.96 (for 95% confidence level) • p = 0.5 (assumed proportion) • q = 1 − p • e = 0.05 (margin of error) Based on these parameters, the minimum required sample size was n = 302. Although the theoretical minimum sample size was calculated as 302 participants, the final number of complete responses obtained was lower due to the voluntary nature of survey participation and the specialized target population. Consequently, the present study should be interpreted as an exploratory survey investigation rather than a fully powered inferential study. The statistical analyses were therefore conducted primarily to identify preliminary patterns and associations rather than to support definitive population-level conclusions. To maximize recruitment and account for expected non-response, the questionnaire was distributed to 278 clinicians who were accessible through professional networks, academic contacts, and professional organizations such as the Saudi Orthodontic Society and regional oral and maxillofacial surgery networks. A non-probability convenience sampling method was used, which is appropriate for exploratory research involving geographically dispersed professional populations. Given the niche focus on surgical orthodontics and CAT, targeted sampling via professional channels was necessary to reach experienced clinicians. While convenience sampling may introduce selection bias, it remains an accepted approach in preliminary, perception-based clinical surveys. This approach may introduce self-selection bias , as clinicians with prior interest in or experience with clear aligner therapy may have been more likely to respond. Certain inclusion criteria were set for the selection of the study population: orthodontists and oral and maxillofacial surgeons practicing in Saudi Arabia, regardless of gender, with or without previous experience in the use of clear aligners for orthognathic surgeries. Likewise, exclusion criteria were also set: practitioners unwilling to participate in the study, incomplete responses, and general dentists. A visual flowchart of the recruitment and inclusion/exclusion process is provided in Figure 1 , illustrating the total number of professionals contacted, eligibility screening, and final response count. Given the achieved sample size, the results of inferential statistical analyses presented in this study should be interpreted as exploratory and hypothesis-generating rather than confirmatory. Figure 1. Flowchart of participant recruitment and selection process. This figure illustrates the sampling method, survey distribution, inclusion and exclusion criteria, and the final sample of orthodontists and oral and maxillofacial surgeons who participated in the study. Given the 16.5% response rate, potential non-response and self-selection biases were acknowledged. Low participation rates are common in clinician-based surveys due to professional workload and voluntary participation. To reduce bias, invitations were distributed through multiple channels (academic institutions, the Saudi Orthodontic Society, and social media), and anonymity was maintained to encourage honest responses. Non-parametric tests were applied to accommodate small-sample variability, and results were interpreted descriptively within an exploratory framework. Although only 46 valid responses were obtained compared to the calculated minimum of 302, this reflects the limited pool of eligible specialists in Saudi Arabia. The small sample size reduces statistical power and increases the risk of Type II error; however, the study was designed as exploratory rather than inferential. Despite these limitations, the findings provide valuable pilot data on clinician awareness and readiness to integrate Clear Aligner Therapy (CAT) in orthognathic practice and establish a foundation for future multicenter research with adequate power and broader participation. Data collection instrument The questionnaire comprised four sections. The first section includes demographic data. The second section was related to the current experience in orthognathic surgery and CAT. The third section addressed the knowledge of CAT used in orthognathic surgery patients. The fourth section was related to CAT practice in orthognathic surgery patients. To account for differences in expertise, the questionnaire included items assessing each respondent’s level of clinical involvement in orthognathic surgery cases such as the number of surgical cases managed per year, their role in interdisciplinary treatment planning, and prior use of CAT in such cases. Participants were also asked about their familiarity with digital and surgery-first workflows. These measures helped ensure that responses reflected informed perspectives and allowed subgroup comparisons based on clinical experience. Validity and reliability The content validity of the questionnaire was assessed by two subject-matter experts an orthodontist and an oral and maxillofacial surgeon who evaluated each item for clarity, relevance, and alignment with the study objectives. Based on their feedback, minor linguistic modifications were made, and two items were reworded to eliminate ambiguity, particularly regarding post-surgical treatment steps. No items were removed, as all were deemed essential to the study scope. To assess reliability, the questionnaire was pilot-tested with 20 participants, who completed the survey twice, one week apart. Responses were compared using Cohen’s Kappa statistic, which demonstrated substantial agreement (κ > 0.70), confirming good test–retest reliability of the instrument. Statistical analysis All the statistical analysis was performed using the Statistical Package for the Social Sciences Software (version 27, SPSS, Chicago, IL, USA). A total of 50 responses were received, of which 4 were incomplete and excluded from the final analysis, leaving 46 valid responses for statistical evaluation. Descriptive statistics were used to summarize participant demographics, experience with orthognathic surgery and CAT, knowledge of CAT application, and related clinical practices. Given the limited sample size, the statistical analyses were primarily descriptive, and inferential tests were conducted for exploratory purposes only. Frequencies, percentages, means, and standard deviations (SD) were calculated for quantitative variables, while associations between categorical variables were tested using the chi-square test. Due to the small sample size, some expected cell counts may have been limited; therefore, these analyses were interpreted cautiously as exploratory indicators rather than confirmatory statistical evidence. Only fully completed questionnaires were retained to ensure data quality, and no imputation methods were applied due to the small dataset. Prior to inferential testing, data normality was assessed using the Shapiro–Wilk test and inspection of histograms and Q–Q plots. The results indicated that the data were not normally distributed (p < 0.05), justifying the use of non-parametric tests. Accordingly, the Mann–Whitney U test was applied to compare knowledge levels between orthodontists and oral and maxillofacial surgeons using median knowledge scores derived from relevant questionnaire items. This approach was chosen over the independent samples t-test due to the non-normal distribution and small sample size. The analysis yielded a p-value of 0.59 indicated no statistically significant difference between the two groups. A univariate linear regression analysis was performed to assess the relationship between demographic variables (age, gender, and professional experience) and the reported use of Clear Aligner Therapy (CAT) among orthodontists and oral and maxillofacial surgeons. The CAT usage variable was treated as a continuous composite score derived from questionnaire responses reflecting the frequency of CAT use in clinical practice. Model assumptions including linearity, independence, homoscedasticity, and normality of residuals were verified. The model produced an R 2 value of 0.38, suggesting that age accounted for approximately 38% of the observed variation in CAT usage within this dataset. Given the limited sample size and exploratory nature of the study, the regression results should be interpreted as hypothesis-generating observations rather than definitive predictors of CAT adoption. This moderate explanatory power supports the model’s exploratory rather than predictive nature. Given the small sample size (n = 46), the analyses were interpreted cautiously. The limited number of responses may have reduced statistical power and increased the likelihood of Type II error—meaning that true associations could remain undetected. While no formal correction for multiple comparisons (e.g., Bonferroni adjustment) was applied, the results were interpreted cautiously because multiple statistical tests were conducted in a relatively small dataset. Accordingly, the study should be interpreted as an exploratory survey intended to provide preliminary insights into clinician perceptions of CAT in orthognathic surgery. Results A total of 46 complete responses were obtained from 278 invitations, yielding a response rate of 16.5%. Given the limited sample size, the following results are presented primarily as descriptive observations. While this response rate is modest, it is within the range reported for similar surveys targeting specialized medical professionals. The study included 46 participants, predominantly male (67.4%) and aged mostly between 31-40 years (54.3%). Most participants had 6-15 years of professional experience (58.7%) and were mainly orthodontists (65.2%) or oral and maxillofacial surgeons (34.8%) (Supplementary Table S1). Among orthodontists (N = 30), 66.7% saw 1-4 orthognathic surgery patients monthly, and 56.7% practiced clear aligner therapy (CAT) with 1-10 patients weekly. However, 80% of respondents reported no prior experience using CAT in orthognathic surgery patients, indicating limited exposure to this treatment modality. (Supplementary Table S2). These findings should be interpreted within the context of the limited sample size, which may affect the reliability and external validity of the results. Detailed demographic and baseline characteristics are provided in Supplementary Tables S1 and S2 . Among oral surgeons (N = 16), half examined 5-10 orthognathic surgery patients weekly. About 44% treated 1-4 patients with CAT, while another 44% reported no CAT use, suggesting variable levels of clinical exposure to CAT among surgeons ( Table 1 ). Table 1. The current experience of the oral and maxillofacial surgeons in orthognathic surgery and use of Clear Aligner Therapy (CAT) (N = 16). Categories Frequency range (No. of patients) Frequency (n) Percentage (%) p-value How often do you see orthognathic surgery patients in your practice weekly? 1-4 5 31.2 0.30 CI: (25.5, 74.5) 5-10 8 50 >15 3 18.8 How many orthognathic surgery patients have you treated using clear aligners (pre or post-surgery) 1-4 7 43.8 0.02 CI: (19.5, 68.1) 5-10 1 6.2 >15 1 6.2 None 7 43.8 Orthodontists expressed challenges primarily in pre-surgical alignment, leveling, and space closure, with 26.7%-36.7% agreeing on difficulties. Most agreed that malocclusion type influences the choice between CAT and fixed appliances (83.3%) ( Table 2 ). Table 2. Knowledge of the orthodontists regarding CAT (N = 30). Questions Response (frequency (%)) Agree Strongly agree Disagree Strongly disagree Neutral I don’t know Not applicable It is challenging to achieve the needed pre-surgical alignment required for accurate surgical setup 5 (16.7) 5 (16.7) 8 (26.7) 2 (6.7) 6 (20) 3 (10) 1 (3.3) It is challenging to achieve the needed pre-surgical levelling to facilitate orthognathic surgical movements 7 (23.3) 1 (3.3) 7 (23.3) 2 (6.7) 8 (26.7) 4 (13.3) 1 (3.3) It is challenging to achieve the needed pre surgical space closure necessary for orthognathic preparation 6 (20) 5 (16.7) 10 (33.3) 1 (3.3) 4 (13.3) 3 (10) 1 (3.3) The type of malocclusion plays a role in the treatment choice (CAT vs fixed appliance) for surgical planning 8 (26.7) 17 (56.7) 0 (0) 1 (3.3) 2 (6.7) 1 (3.3) 1 (3.3) CAT takes longer pre-surgical time compared with fixed appliances 4 (13.3) 3 (10) 8 (26.7) 1 (3.3) 11 (36.7) 1 (3.3) 2 (6.7) CAT pre-surgical outcomes are similar to fixed appliance treatment 5 (16.7) 4 (13.3) 5 (16.7) 3 (10) 7 (23.3) 2 (6.7) 4 (13.3) It is challenging to achieve the needed post-surgical refinement using CAT 5 (16.7) 3 (10) 7 (23.3) 2 (6.7) 7 (23.3) 4 (13.3) 2 (6.7) It is challenging to obtain post-surgical occlusion and stability with CAT 10 (33.3) 3 (10) 8 (26.7) 1 (3.3) 3 (10) 3 (10) 2 (6.7) Oral surgeons highlighted challenges in surgical planning and intraoperative fixation, but many disagreed that final stable occlusion post-surgery was difficult to achieve ( Table 3 ). Table 3. Knowledge of the oral and maxillofacial surgeons regarding CAT (N = 16). Questions Response (frequency (%)) Agree Strongly agree Disagree Strongly disagree Neutral I don’t know It is challenging to perform the surgical planning in CAT 4 (25) 1 (6.2) 2 (12.5) 3 (18.8) 5 (31.2) 1 (6.2) It is challenging to achieve intraoperative intermaxillary fixation (IMF) in CAT 5 (31.2) 3 (18.8) 3 (18.8) 2 (12.5) 2 (12.5) 1 (6.2) It is challenging to use the interim splint during the surgical procedure in CAT 3 (18.8) 2 (12.5) 2 (12.5) 3 (18.8) 5 (31.2) 1 (6.2) It is challenging to obtain a final stable occlusion after the surgery 3 (18.8) 2 (12.5) 6 (37.5) 1 (6.2) 4 (25) 0 (0) CAT can be used with segmental osteotomies procedures 5 (31.2) 3 (18.8) 3 (18.8) 3 (18.8) 1 (6.2) 1 (6.2) CAT can be used with excessive maxillary or mandibular movements (advancement and setback) 6 (37.5) 4 (25) 1 (6.2) 3 (18.8) 1 (6.2) 1 (6.2) CAT can be used with excessive rotational movements 7 (43.8) 1 (6.2) 2 (12.5) 2 (12.5) 3 (18.8) 1 (6.2) CAT can be used in surgery first concept 7 (43.8) 3 (18.8) 1 (6.2) 1 (6.2) 3 (18.8) 1 (6.2) CAT can be used in mandible first concept 6 (37.5) 2 (12.5) 3 (18.8) 1 (6.2) 3 (18.8) 1 (6.2) No significant difference in overall knowledge of CAT between orthodontists and oral surgeons was found (p = 0.59), suggesting comparable expertise levels ( Table 4 ). Table 4. Comparison of average knowledge scores between orthodontists and oral surgeons (Mann-Whitney U test). Question item Orthodontists (Mean score) CI: (3.42, 4.26) Oral surgeons (Mean score) CI: (3.95, 4.48) p-value Q1 3.72 3.56 0.59 (3.42, 4.26) Q2 3.48 4.25 Q3 3.97 4.44 Q4 4.86 3.94 Q5 3.41 4.31 Q6 3.65 4.5 Q7 3.39 4.25 Q8 4.25 4.44 Q9 4.25 Post-surgical management commonly required fixed appliances and temporary anchorage devices (TADs), but only 6.7% felt fully confident in using CAT in orthognathic cases ( Table 5 ). Table 5. Responses of study orthodontists CAT practice in orthognathic surgery patients (N = 30). Question Responses (frequency (%)) Always Often Sometimes Never Rarely I don’t know Not Applicable The case complexity drive your decision in selecting CAT as a treatment choice 18 (60) 4 (13.3) 4 (13.3) 1 (3.3) 1 (3.3) 1 (3.3) 1 (3.3) The availability of the needed digital tools affect your decision in selecting CAT as a treatment of choice 8 (26.7) 6 (20) 9 (30) 3 (10) 2 (6.7) 1 (3.3) 1 (3.3) The cost of the treatment plays a major role in selecting CAT as a treatment choice 10 (33.3) 7 (23.3) 9 (30) 2 (6.7) 0 (0) 1 (3.3) 1 (3.3) The patient demands drive your decision in selecting CAT as a treatment choice 8 (26.7) 10 (33.3) 8 (26.7) 0 (0) 1 (3.3) 2 (6.7) 1 (3.3) The skills of the maxillofacial surgeon drive your decision in selecting CAT as a treatment choice 5 (16.7) 8 (26.7) 8 (26.7) 4 (13.3) 2 (6.7) 1 (3.3) 1 (3.3) The cooperation of the maxillofacial surgeon drive your decision in selecting CAT as a treatment choice 9 (30) 7 (23.3) 8 (26.7) 2 (6.7) 1 (3.3) 1 (3.3) 2 (6.7) The patient cooperation affect your decision in selecting CAT as a treatment (before or after surgery) 16 (53.3) 10 (33.3) 1 (3.3) 1 (3.3) 0 (0) 1 (3.3) 1 (3.3) The reduced time of the treatment plays a major role in selecting CAT as a treatment choice 9 (30) 5 (16.7) 9 (30) 3 (10) 2 (6.7) 1 (3.3) 1 (3.3) The reduced number of visits of the treatment plays a major role in selecting CAT as a treatment choice 8 (26.7) 5 (16.7) 10 (33.3) 3 (10) 2 (6.7) 1 (3.3) 1 (3.3) The reduced pain during treatment plays a major role in selecting CAT as a treatment choice 4 (13.3) 3 (10) 9 (30) 6 (20) 5 (16.7) 1 (3.3) 2 (6.7) CAT combined with fixed appliances is required before the surgery 5 (16.7) 4 (13.3) 14 (46.7) 2 (6.7) 2 (6.7) 2 (6.7) 1 (3.3) Fixed appliance bonding is needed for post-surgical management 4 (13.3) 7 (23.3) 16 (53.3) 0 (0) 1 (3.3) 1 (3.3) 1 (3.3) Temporary anchorage device (TADS) are needed for post-surgical management 0 (0) 5 (16.7) 18 (60) 0 (0) 5 (16.7) 1 (3.3) 1 (3.3) You are confident of using CAT in orthognathic patients 2 (6.7) 4 (13.3) 13 (43.3) 3 (10) 3 (10) 4 (13.3) 1 (3.3) Fixed appliances were often requested pre-surgery (43.8%), and intraoperative fixation relied mostly on IMF screws (37.5%) ( Table 6 ). Table 6. Responses of study oral and maxillofacial surgeons CAT practice in orthognathic surgery patients (N = 16). Question Responses (frequency (%)) Always Often Sometimes Never Rarely I don’t know Not applicable The surgery time is increased in CAT cases 1 (6.2) 2 (12.5) 3 (18.8) 3 (18.8) 5 (31.2) 2 (12.5) 0 (0) It is difficult to control the post-operative occlusion on CAT patients 2 (12.5) 2 (12.5) 8 (50) 1 (6.2) 1 (6.2) 2 (12.5) 0 (0) How frequent you ask the orthodontist to bond fixed appliances before the surgery (if the pre-surgical orthodpntics was using clear aligner) 7 (43.8) 5 (31.2) 1 (6.2) 1 (6.2) 0 (0) 1 (6.2) 1 (6.2) How frequent do you rely on IMF screws for intraoperative IMF 6 (37.5) 3 (18.8) 3 (18.8) 1 (6.2) 3 (18.8) 0 (0) 0 (0) How frequent do you rely on TADS intraoperative IM 2 (12.5) 2 (12.5) 1 (6.2) 5 (31.2) 5 (31.2) 1 (6.2) 0 (0) How frequent do you rely on archbars intraoperative IMF 1 (6.2) 3 (18.8) 2 (12.5) 5 (31.2) 4 (25) 1 (6.2) 0 (0) The post-operative occlusion for CAT cases is guided using elastics 2 (12.5) 3 (18.8) 4 (25) 1 (6.2) 4 (25) 1 (6.2) 1 (6.2) The post-operative occlusion for CAT is guided using wires 1 (6.2) 1 (6.2) 3 (18.8) 4 (25) 3 (18.8) 3 (18.8) 1 (6.2) How frequent do you rely on TADS to manage post-operative occlusion relapse 1 (6.2) 3 (18.8) 4 (25) 5 (31.2) 0 (0) 2 (12.5) 1 (6.2) How frequent do you rely on arch bars to manage post-operative relapse 2 (12.5) 1 (6.2) 2 (12.5) 7 (43.8) 2 (12.5) 1 (6.2) 1 (6.2) How frequent do you rely on orthodontic fixed appliance to manage post-operative relapse 6 (37.5) 1 (6.2) 5 (31.2) 2 (12.5) 2 (12.5) 0 (0) 0 (0) Age showed a statistically significant association with CAT usage among both orthodontists (p = 0.01, adjusted R 2 = 0.284) and oral surgeons (p = 0.02, adjusted R 2 = 0.25); however, given the limited sample size and exploratory design, this finding should be interpreted as hypothesis-generating rather than confirmatory. Gender and years of experience showed no significant correlation ( Table 7 ). Table 7. Univariate linear regression model for correlation between CAT usage and demographical parameters. Variable R 2 Adjusted R 2 P-value Orthodontists Gender 0.021 -0.014 0.44 Age 0.383 0.284 0.01 Experience 0.154 0.019 0.361 Oral and maxillofacial surgeons Gender 0.05 -0.01 0.38 Age 0.30 0.25 0.02 Experience 0.13 0.07 0.15 Discussion Overview of findings While traditional fixed appliances have long been the standard in pre and post-surgical orthodontic treatment, there is growing interest in the application of clear aligners, especially given their aesthetic appeal and enhanced patient comfort. However, the survey revealed a range of opinions on the suitability of CAT for managing complex skeletal discrepancies often requiring surgical intervention. This study offers exploratory insights into how Saudi orthodontists and oral and maxillofacial surgeons perceive the integration of CAT in orthognathic cases. Out of the professionals surveyed, 46 responded, yielding a response rate of 16.5%. Respondents represented diverse regions and included proportionate representation of both orthodontists and oral surgeons. The results revealed general awareness of CAT and its emerging role in orthognathic cases within the surveyed Saudi sample, while also highlighting uncertainty regarding its practical application. The Mann-Whitney U test did not detect a statistically significant difference in overall CAT knowledge between orthodontists and surgeons (p = 0.59). However, given the limited sample size, this observation should be interpreted cautiously and considered hypothesis-generating rather than conclusive. While the response rate was modest, it aligns with comparable clinician-based surveys internationally, where participation rates commonly range between 15–25%. Nevertheless, the low response rate may introduce non-response bias, as clinicians with prior interest or familiarity with clear aligner therapy may have been more inclined to participate. 20–22 Despite this, the responses provide valuable preliminary insights into clinician perspectives within Saudi Arabia, a region where such data remain limited. These findings should be interpreted with caution, as the convenience sampling strategy and low response rate may limit the representativeness of the sample and introduce self-selection bias. Knowledge and attitudes toward CAT The findings of the present study highlight several clinically relevant themes regarding CAT use in orthognathic cases. A significant proportion of respondents reported challenges with pre-operative positioning, leveling, and space-closing with CAT. Most agreed that the type of malocclusion affects the choice between CAT and a fixed appliance, with opinions divided on whether CAT outcomes are comparable to fixed appliances, particularly in post-surgical occlusion. These findings may suggest that Saudi clinicians recognize the potential of CAT but remain cautious regarding its predictability in complex cases. Similar caution has been reported globally, with clinicians citing limitations in root control, torque, and vertical adjustments. 20 , 21 Systematic reviews suggest that while CAT is increasingly effective for mild-to-moderate malocclusions, evidence for its use in surgical orthodontics remains limited. 23–25 Regional variation in responses may reflect differences in population density, clinical training, and access to CAT systems. In South Korea, where computer-assisted orthognathic surgery (CAOS) is more established, clinicians report more advanced integration of CAT into surgery-first workflows. However, even there, broader clinical use is constrained by cost, the need for validation, and specialized training. 22 Globally, while enthusiasm for CAT is rising, systematic reviews suggest continued caution in surgical applications due to unresolved concerns about long-term stability, workflow complexity, and lack of standardized protocols. 26 , 27 The absence of significant knowledge differences between orthodontists and surgeons aligns with literature showing both groups have similar exposure to CAT protocols, especially in digitally supported workflows like 3D planning and simulation. 28 These observations should be interpreted cautiously because the exploratory nature of the study and the limited sample size restrict the ability to generalize the findings to the broader clinician population. Comparative knowledge across specialties This reflects global literature showing that both groups have similar exposure to digital workflows, particularly where interdisciplinary planning is emphasized. 29 According to published literature, while orthodontists and oral and maxillofacial surgeons agree on the benefits of CAT particularly for patient esthetic and comfort they also remain critical of the stability and control during IMF, as well as the accuracy of postoperative occlusion. 7 , 27 Particularly in surgery, first workup, digital planning along with coordination of appliances are challenging and require greater interdisciplinary collaboration. 28 Local clinicians have expressed high confidence in static CAOS tools for CAT, but have only limited adaptability to the full integration of such systems because of the cost and education base. 22 Long-term evidence and universal protocols remain insufficient, reinforcing the need for cautious optimism. 27 Awareness across populations The awareness and perception of health professional graduates regarding the use of clear aligners in orthodontics ranged from moderate to low. 30 Furthermore, several other studies have evaluated awareness of clear aligners among various groups, including dentists, dental graduates, the general public, and orthodontists. For instance, a study in Saudi Arabia examined dentists’ knowledge of clear aligners, revealing moderate awareness, with most respondents not opting for this treatment option for their patients. 31 Another study performed in India, found that 93.5% of dental interns and 83.6% of dental undergraduates were aware of clear aligners, 32 while another study was performed in Saudi Arabia and reported that only 19.6% of the general public, out of 934 respondents, were aware of clear aligners. 33 CAT is increasingly adopted in routine orthodontic practice; however, its application in orthognathic surgery remains limited, as also reflected in the present study findings. Attitudes toward CAT vs fixed appliances A study performed in Canada and almost half of the orthodontists (47%) combined CAT with fixed appliances. 34 Across regions, CAT is generally perceived as more comfortable and aesthetically appealing than traditional fixed appliances. In East Asia, for example, social media influence, digital marketing, and cultural emphasis on facial harmony contribute to higher aligner demand, especially among younger adults. 35 In areas with an emphasis on precision of the treatment (e.g., parts of Europe and North America), clinicians continue to be skeptical of CAT’s capacity to address complex orthodontic mechanics. This concern is especially prevalent in the area of surgery, where clinicians expect outcomes to be highly predictable, and are slow to embrace aligners in the absence of clearly defined protocols and long-term success rates. Here, traditional braces remain more common due to their lower cost and widespread familiarity. Demographic trends in usage This may be attributed to greater exposure to digital workflows and CAT protocols during training. Increased comfort with new technologies, and responsiveness to patient demand for esthetic and metal-free treatments. These clinicians are especially confident using CAT in mild to moderate adult malocclusions, where case complexity remains manageable. 20 Conversely, in parts of the Middle East and Asia, CAT use is more common among experienced clinicians. Here, senior practitioners often dominate surgical orthodontics, and their adoption of CAT is shaped more by clinical judgment and accumulated experience than by early exposure during training. Still, adoption among younger practitioners is rising, driven by evolving patient expectations, improved curriculum, and broader access to aligner systems. Across all regions, adults remain the primary demographic for CAT, particularly working professionals who prioritize aesthetics and convenience. Studies also highlight increasing use of CAT in adolescents and even children for dentoalveolar changes, although evidence for skeletal correction is less conclusive. 36 Clinician experience also directly affects treatment outcomes: those using structured case selection protocols or assessment tools like the CAT-CAT index report improved predictability and fewer refinements. 37 Emerging technologies such as machine learning models that predict treatment refinement needs are poised to further assist both novice and experienced practitioners in case planning. 38 Socioeconomic factors also influence usage trends. In high-income countries, access to advanced 3D printing and aligner software enhances usage across age groups. However, in low-resource settings, cost and access barriers can limit the use of aligners, even among trained professionals. Multinational providers and mobile digital scanning platforms have helped expand aligner availability globally, yet disparities in access remain, particularly in underserved or rural regions. Because the statistical analyses were exploratory and conducted on a limited sample, the observed association between age and CAT usage should be interpreted as a hypothesis-generating observation requiring confirmation in larger studies. Regional and global public/Professional awareness Our study’s findings regarding professional awareness among Saudi orthodontists and oral surgeons appear to align with the limited public awareness reported in prior regional research. A recent study by Alsaeed et al. (2023) reported that only 19.6% of the general Saudi public were aware of clear aligner options for orthodontic care. 12 This figure contrasts with awareness levels among Indian dental interns, which were as high as 93.5%, suggesting that educational exposure during undergraduate training may significantly enhance familiarity and confidence in CAT. This discrepancy underscores a potential gap between rising aesthetic-driven patient demand and limited public awareness. Unlike in digitally-saturated markets, consumers may be less likely to proactively seek CAT unless informed by a clinician, suggesting a need for targeted public education campaigns and greater integration of CAT discussions during consultations. Bridging this gap may require collaboration between dental professionals, academic institutions, and aligner manufacturers to promote evidence-based awareness and ensure patients receive comprehensive treatment information. Clinical challenges and workflow uncertainties Respondents in the present study did not have a clear stance regarding whether CAT takes longer pre-surgical time or not. They believe CAT pre-surgical outcomes are similar to those of fixed appliance treatment. Respondents’ uncertainty regarding whether CAT requires more time before surgery. This may be attributed to differences in the complexity of the case and the treatment goals of the patient. Compared to fixed appliances that have a long history of treating a wide variety of complex malocclusions, CAT is still new, and its effectiveness may vary considering the malocclusion type, requirement in tooth movement, and the orthodontist’s experience in using technology. 39 A few clinicians stated that CAT can lead to pre-surgical lag because of the repetitive modifications of digital treatment plans, or challenges associated with achieving final tooth position where aligner refinements are required. Moreover, patient comfort and compliance in terms of aligner wear, which can vary widely, can affect these time perceptions. 7 , 10 , 11 In our Saudi orthodontists and oral maxillofacial survey, many of the respondents expressed anxiousness about workflow interference which has been blocking the best integration of the CAT with the orthognathic protocols. Critical factors were pre-surgical treatment delay, phase II with multiple aligner fits and aligner mechanics’ limitations in masking complex skeletal discrepancies. These results confirm the observations of international literature where it is underlined how contemporary CAT systems are frequently unable to make sufficiently complex orthognathic cases without the adoption of hybrid protocols. For instance, 3D digital planning workflows integrated with computer-aided technology (CAT) custom titanium plates have been performed by North American surgeons has improved surgical predictability and postoperative management. 28 Although promising, these approaches need dedicated software, additional coordination at the chairside, and higher costs, which diminishes their applicability under low-resource settings. In Europe, similar challenges are addressed through adjunctive techniques, such as temporary anchorage devices (TADs) and segmental surgery, to supplement CAT in treating skeletal Class III deformities and asymmetries, especially in surgery-first approaches. 26 – 28 Our findings appear to align with international observations suggesting that CAT may represent a promising but technically challenging modality that demands interdisciplinary teamwork, strong digital infrastructure and flexible case-by-case planning. Practice preferences and treatment decision factors The current study highlights that clinicians in Saudi Arabia prioritize case complexity, patient demand, and comfort when selecting between Clear Aligner Therapy (CAT) and traditional fixed appliances. Survey responses showed that esthetic-driven demand, particularly among younger adults, plays a growing role in treatment planning. Nevertheless, clinicians remained cautious about using CAT in complex skeletal cases, especially those requiring precise post-surgical occlusion and long-term stability. Although final refinements post-surgery were not widely reported as problematic, achieving ideal occlusion remains a key concern. Factors such as patient cooperation, 8 treatment cost and duration, 9 and coordination with oral surgeons often influence treatment selection. Some clinicians opt for hybrid protocols, combining CAT with fixed appliances or adjunctive tools like Temporary Anchorage Devices (TADs) in post-surgical phases. 7 Skepticism toward CAT for skeletal discrepancies stems from its original design for dental malocclusions rather than orthognathic correction. 1 Limitations in tooth movement control, especially without mid-course corrections, and short-term clinical experience further compound uncertainty. 10 Globally, similar patterns emerge. In Europe, clinicians often adapt to patient demands for removable appliances even in less complex cases, balancing esthetic preferences with biomechanical viability. 40 , 41 In contrast, Asian clinicians emphasize predictability and long-term outcomes, favoring fixed or hybrid options for skeletal corrections. 22 – 28 These regional nuances underscore that CAT adoption is shaped by clinical culture, economic context, and patient expectations. 35 It is important to note that the convenience sampling strategy and relatively small number of respondents may limit the generalizability of these findings to the broader population of orthodontists and oral and maxillofacial surgeons in Saudi Arabia. Future studies with larger, multicenter samples are required to confirm these observations. Implications for clinical protocols and training The results of this investigation highlight an urgent need for evidence-based, standardized clinical protocols for the application of Clear Aligner Therapy (CAT) in orthognathic procedures. The present clinical ambiguities, particularly case selection, treatment sequence, digital treatment planning, and appliance modification in surgery-first protocols, reveal notable deficiencies in defined criteria and predictable results. And this gap is not specific locally. Others overseas report similar struggles, and in places like North America and Europe, hybrid models of providing care are slowly starting to take off. These commonly incorporate 3D surgical planning, Temporary Anchorage Devices (TADs) and segmental surgeries to enhance predictability, stability and control for CAT-based interventions. 28 Even though there has been progress on this field, the lack of standardized protocols is still a big limitation; and especially for more complex skeletal deformities. Overcoming these implementation barriers will require major training reforms. In light of the study findings, several practical and educational recommendations can be drawn. For orthodontists, postgraduate and continuing education programs should include structured modules on digital workflows, aligner biomechanics, case selection, and integration of hybrid treatment strategies when CAT alone may be insufficient. These competencies are essential to improve confidence and predictability in managing complex surgical orthodontic cases. For oral and maxillofacial surgeons, the training focus should be different—centered on understanding the surgical coordination aspects of CAT, including splint adaptation, intermaxillary fixation (IMF), and postoperative elastic management. Rather than orthodontic biomechanics, surgeons primarily need awareness of CAT’s surgical limitations and its implications for occlusal stability and intraoperative workflow. To translate these findings into practice, two key recommendations can be proposed: 1. Educational integration: Incorporation of CAT and digital workflow training into orthodontic and surgical training programs, supported by structured courses and continuing professional development initiatives. 2. Interdisciplinary and research collaboration: Promotion of collaborative case planning through interdisciplinary workshops, alongside multicenter and international research efforts to develop standardized, evidence-based clinical protocols. These strategies would help standardize CAT use in surgical orthodontics, enhance interdisciplinary coordination, and align training in Saudi Arabia with international standards for digitally driven, patient-centered care. Overall, the findings of this study should be considered preliminary and serve primarily to highlight areas requiring further investigation in larger, adequately powered studies. Limitations Despite providing valuable insights into clinician perspectives on clear aligner therapy (CAT) in orthognathic surgery, this study is not without limitations. First, the sample size was relatively small, with only 46 responses obtained out of 278 invitations, resulting in a response rate of 16.5%. While this rate is comparable to similar professional surveys, it is substantially lower than the calculated minimum required sample size (n = 302) and therefore limits the statistical power of the study. This increases the risk of both Type II error (failure to detect true associations) and Type I error (false-positive findings due to multiple testing), and restricts the generalizability of the findings across the broader population of orthodontists and surgeons in Saudi Arabia. The low participation rate also raises the possibility of non-response bias (selection bias), where clinicians more familiar with or interested in CAT may have been more likely to respond. Although a formal non-responder analysis could not be conducted due to participant anonymity, this potential self-selection bias should be acknowledged, as it may have led to an overrepresentation of clinicians with prior interest or familiarity with CAT. Given the limited sample size, the statistical analyses—including chi-square testing and univariate regression—should be interpreted strictly as exploratory. Although the regression model demonstrated a moderate R 2 value (0.38), this finding should be considered hypothesis-generating rather than confirmatory. Future studies with larger, randomized samples are necessary to confirm and expand upon these findings. The study employed a non-probability convenience sampling approach, which, while pragmatic and commonly used in exploratory healthcare research, limits the representativeness of the sample and further constrains external validity. This constraint may affect the generalizability of findings to the entire population of orthodontists and oral and maxillofacial surgeons in Saudi Arabia. limits the representativeness of the sample and further constrains external validity. Second, while the study draws on international comparisons to contextualize findings, these should be interpreted with caution. Variations in aligner systems (e.g., Invisalign, Clarity, AngelAlign), digital infrastructure, and regulatory environments can impact workflows, confidence, and adoption, complicating direct cross-country comparisons. Third, the study relied on self-reported data, which may be subject to recall bias or overestimation of familiarity and competence with CAT protocols. This is particularly relevant in areas where structured CAT training is lacking or inconsistently delivered. Despite these limitations, the study adds to the global understanding of CAT implementation and highlights important educational and clinical gaps that can be addressed in future research and policy reforms. Given the complex, multidisciplinary nature of surgical orthodontics, ongoing collaboration and mutual learning between orthodontists and surgeons are essential to address evolving clinical expectations. Literature increasingly supports collaborative CAT planning, especially for protocols such as surgery-first, which require coordinated efforts in digital planning, appliance design, and clinical workflow. 28 A standardized protocol and education effort may help mitigate current clinical uncertainties and enhance patient’s outcomes. The establishment of a standardized clinical protocol and a consolidated training program may be an approach to overcome these inconsistencies and improve the prognosis of patients undergoing complex surgical procedures. Conclusion This exploratory survey suggests limited clinical experience with clear aligner therapy (CAT) in orthognathic surgery among Saudi orthodontists and oral and maxillofacial surgeons, along with concerns regarding its predictability and surgical application. Clinicians reported challenges in both orthodontic phases (e.g., pre-surgical alignment) and surgical procedures, including intraoperative fixation, splint use, and intermaxillary elastics. Given that the achieved sample size (n = 46) was substantially lower than the calculated requirement (n = 302), the findings should be interpreted as preliminary. Further large-scale, multicenter studies are needed to validate these observations and support the development of standardized protocols for CAT-assisted orthognathic treatment. Underlying data Repository name: The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontics and Oral and Maxillofacial Surgeons. https://doi.org/10.5281/zenodo.16977338 The project contains the following underlying data: FINAL The use of clear aligner therapy for orthognathic surgery patients (Responses)-3.xlsx (raw). Supplementary Tables.docx (Tables). Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication). Software availability The statistical analysis for this study was performed using the Statistical Package for the Social Sciences (SPSS), version 27 (SPSS Inc., Chicago, IL, USA). The software used for digital treatment planning and data collection, including the Google Forms platform for survey distribution, are freely available for public use. No specialized or proprietary software was required for the completion of this study beyond those mentioned above. Acknowledgments The authors are thankful to all the associated personnel who contributed to this study by any means. Supplementary materials The complete survey questionnaire used in this study is provided in Supplementary Table S1. It includes all sections used to assess demographics, clinical experience, knowledge, and attitudes toward the use of clear aligner therapy (CAT) in orthognathic surgery. 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PubMed Abstract | Publisher Full Text Reference Source Comments on this article Comments (0) Version 4 VERSION 4 PUBLISHED 29 Sep 2025 ADD YOUR COMMENT Comment Author details Author details 1 Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, College of Medicine and Dentistry, Riyadh Elm University, Riyadh, Riyadh Province, Saudi Arabia 2 Department of Dentistry, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia 3 Department of Maxillofacial Surgery, Prince Sultan Military Medical City, Riyadh, Riyadh Province, Saudi Arabia 4 Dental Clinic, Riyadh, Saudi Arabia 5 Alwattan medical complex 3, Riyadh, Saudi Arabia 6 Saudi Board in Periodontics, College of Medicine and Dentistry, Riyadh Elm University, Riyadh, Riyadh Province, Saudi Arabia Ahmad Salem Assari Roles: Conceptualization, Methodology, Project Administration, Supervision, Writing – Review & Editing Muslat A Bin Rubaia’an Roles: Methodology, Resources, Supervision, Writing – Review & Editing Diaa Taisir Al-Marhoun Roles: Data Curation, Formal Analysis, Investigation, Writing – Original Draft Preparation Hayat Arafah Roles: Data Curation, Formal Analysis, Investigation, Writing – Original Draft Preparation AlAnood N Bin Saedan Roles: Data Curation, Formal Analysis, Investigation, Writing – Original Draft Preparation Hajar Dar Salamah Roles: Data Curation, Formal Analysis, Investigation, Writing – Original Draft Preparation Raneem Mohammed Aljomiey Roles: Data Curation, Formal Analysis, Investigation, Writing – Original Draft Preparation Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (4) version 4 Revised Published: 07 May 2026, 14:1001 https://doi.org/10.12688/f1000research.170095.4 version 3 Revised Published: 15 Apr 2026, 14:1001 https://doi.org/10.12688/f1000research.170095.3 version 2 Revised Published: 14 Feb 2026, 14:1001 https://doi.org/10.12688/f1000research.170095.2 version 1 Published: 29 Sep 2025, 14:1001 https://doi.org/10.12688/f1000research.170095.1 Copyright © 2026 Salem Assari A et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Salem Assari A, A Bin Rubaia’an M, Taisir Al-Marhoun D et al. The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons [version 4; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 14 :1001 ( https://doi.org/10.12688/f1000research.170095.4 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 4 VERSION 4 PUBLISHED 07 May 2026 Revised Views 0 Cite How to cite this report: Mohamed AM. Reviewer Report For: The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons [version 4; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 14 :1001 ( https://doi.org/10.5256/f1000research.200348.r482398 ) The direct URL for this report is: https://f1000research.com/articles/14-1001/v4#referee-response-482398 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 09 May 2026 Abdelrahman MA Mohamed , Orthodontics, Royal College of Surgeons of Edinburgh, Edinburgh, UK Approved VIEWS 0 https://doi.org/10.5256/f1000research.200348.r482398 I would like to thank the editor very much for giving me the opportunity to review this paper. 1. Results: Tables s1 and s2 definitions in the footprint need to be added ( P value, CI). 2. ... Continue reading READ ALL I would like to thank the editor very much for giving me the opportunity to review this paper. 1. Results: Tables s1 and s2 definitions in the footprint need to be added ( P value, CI). 2. Discussion and Limitations sections are overly long and contains repeated information under different subheadings, leading to unnecessary redundancy. The manuscript is generally acceptable after revision; however, an additional reviewer opinion may help strengthen the editorial assessment, particularly regarding the sample size, response rate, and the organization and redundancy within the Discussion section. Competing Interests: No competing interests were disclosed. Reviewer Expertise: Orthodontics. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Mohamed AM. Reviewer Report For: The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons [version 4; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 14 :1001 ( https://doi.org/10.5256/f1000research.200348.r482398 ) The direct URL for this report is: https://f1000research.com/articles/14-1001/v4#referee-response-482398 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Fialho T. Reviewer Report For: The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons [version 4; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 14 :1001 ( https://doi.org/10.5256/f1000research.200348.r482399 ) The direct URL for this report is: https://f1000research.com/articles/14-1001/v4#referee-response-482399 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 08 May 2026 Tiago Fialho , Department of Orthodontics, Bauru Dental School, São Paulo University, Bauru, SP, Brazil Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.200348.r482399 The revised manuscript demonstrates substantial improvement compared with the previous versions. The authors have clearly made significant efforts to address prior reviewer comments, particularly regarding transparency of methodology, clarification of study limitations, restructuring of the discussion, and repositioning of ... Continue reading READ ALL The revised manuscript demonstrates substantial improvement compared with the previous versions. The authors have clearly made significant efforts to address prior reviewer comments, particularly regarding transparency of methodology, clarification of study limitations, restructuring of the discussion, and repositioning of the study as exploratory in nature. The manuscript now presents a more balanced and scientifically cautious interpretation of the findings, which considerably strengthens its overall credibility. The topic remains clinically relevant and timely, particularly considering the increasing global interest in the integration of Clear Aligner Therapy (CAT) into orthognathic surgery workflows. The manuscript also contributes preliminary regional data from Saudi Arabia, where evidence on this topic remains limited. Nevertheless, several methodological and statistical concerns persist and should be acknowledged as important limitations of the study. The principal limitation remains the substantially insufficient sample size. Although the authors appropriately calculated a minimum required sample of 302 participants, only 46 complete responses were ultimately obtained. While the authors correctly reframed the study as exploratory and acknowledged the reduced statistical power, the manuscript still includes inferential analyses that may overextend the interpretability of the data. Specifically, the use of multiple chi-square analyses and univariate linear regression models appears methodologically fragile considering the small sample size and low cell frequencies observed in several tables. In Tables 1 through 6, p-values are repeatedly presented without a clearly defined null hypothesis or clinically meaningful comparative framework. In several instances, the statistical purpose of the chi-square analyses is unclear, particularly because many of the presented variables are descriptive in nature rather than comparative. Additionally, the small expected frequencies in multiple categories may violate assumptions required for chi-square testing. In this context, either Fisher’s exact test or purely descriptive reporting would likely have been more appropriate. Similarly, the regression analysis should be interpreted with substantial caution. The manuscript does not fully explain how the composite “CAT usage score” was constructed or validated, and the limited sample size raises concerns regarding model stability, overfitting, and reliability of the reported R² values. Although the authors appropriately characterize these findings as exploratory, some statements regarding explanatory power remain somewhat stronger than the available data can robustly support. The discussion section is considerably improved; however, it remains somewhat lengthy and occasionally extends beyond the direct findings of the study. Certain sections resemble a narrative literature review rather than a focused interpretation of the collected data. Some speculative statements regarding clinician behavior, digital workflow adoption, and regional sociocultural trends are not directly supported by the study methodology and should therefore be interpreted cautiously. Another conceptual limitation is the broad inclusion of different orthognathic protocols involving CAT, including surgery-first approaches, hybrid protocols, adjunctive TAD usage, and combined fixed appliance mechanics. The questionnaire appears to group these clinical scenarios together without sufficiently distinguishing between them, which may limit the precision of the conclusions. Despite these limitations, the authors should be commended for explicitly acknowledging most methodological weaknesses, including selection bias, low response rate, limited external validity, and the exploratory nature of the statistical analyses. The availability of open data and the transparent reporting of limitations further strengthen the integrity of the work. Overall, this manuscript should not be interpreted as providing definitive evidence regarding the use of CAT in orthognathic surgery. However, within the context of an exploratory survey study and considering the publication model of F1000Research, the work provides useful preliminary insights and may serve as a valuable foundation for future multicenter investigations with adequate statistical power. Based on the improvements introduced in Version 4 and considering the remaining limitations described above, my recommendation is: Approved with Reservations. I encourage the authors to consider additional refinement of the statistical presentation and further reduction of speculative discussion sections in future revisions or subsequent related publications. Competing Interests: No competing interests were disclosed. Reviewer Expertise: Orthodontics; Orthodontic Aligners, Orthodontic mechanics I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Fialho T. Reviewer Report For: The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons [version 4; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 14 :1001 ( https://doi.org/10.5256/f1000research.200348.r482399 ) The direct URL for this report is: https://f1000research.com/articles/14-1001/v4#referee-response-482399 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 3 VERSION 3 PUBLISHED 15 Apr 2026 Revised Views 0 Cite How to cite this report: Mohamed AM. Reviewer Report For: The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons [version 4; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 14 :1001 ( https://doi.org/10.5256/f1000research.198023.r475308 ) The direct URL for this report is: https://f1000research.com/articles/14-1001/v3#referee-response-475308 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 24 Apr 2026 Abdelrahman MA Mohamed , Orthodontics, Royal College of Surgeons of Edinburgh, Edinburgh, UK Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.198023.r475308 I would like to thank the editor very much for giving me the opportunity to review this paper. Below are my comments and suggestions to strengthen the manuscript. The authors did a great effort to enhance the ... Continue reading READ ALL I would like to thank the editor very much for giving me the opportunity to review this paper. Below are my comments and suggestions to strengthen the manuscript. The authors did a great effort to enhance the manuscript, however Title still need to be modified to explain the aim of the study, my suggestion: Awareness and Clinical Experience with Clear Aligners in Orthognathic Surgery: A Saudi Multispecialty Exploratory Survey Results: Author need to define the exact place or better add the link of the Tables s1 and s2 to make it easier for the readers to reach it or add it as normal tables 8 and 9 to the manuscript, also definitions of these table in the footprint need to be added. 3. Discussion: The Discussion section is overly long and contains repeated information under different subheadings, leading to unnecessary redundancy. I recommend revising it to be more concise and better organized. The Limitations section has a similar issue as discussion. Competing Interests: No competing interests were disclosed. Reviewer Expertise: Orthodontics. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Mohamed AM. Reviewer Report For: The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons [version 4; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 14 :1001 ( https://doi.org/10.5256/f1000research.198023.r475308 ) The direct URL for this report is: https://f1000research.com/articles/14-1001/v3#referee-response-475308 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 27 Apr 2026 Ahmad Assari , Department of Dentistry, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia 27 Apr 2026 Author Response We sincerely thank the reviewer for their valuable feedback and constructive suggestions to improve the manuscript. Comment 1: The title needs modification to better reflect the aim of the study. ... Continue reading We sincerely thank the reviewer for their valuable feedback and constructive suggestions to improve the manuscript. Comment 1: The title needs modification to better reflect the aim of the study. Response: Thank you for this suggestion. The title has been revised to better reflect the scope and aim of the study, emphasizing clinician awareness and clinical experience, as well as the exploratory nature of the investigation. Comment 2: Clarify the location or accessibility of Supplementary Tables S1 and S2. Response: We appreciate this important comment. The manuscript has been revised to clearly label “Table S1” and “Table S2” as Supplementary Tables S1 and S2 throughout the text. A dedicated Supplementary Materials section has been added, and references to these tables in the Results section have been clarified to guide readers. Additionally, appropriate explanatory footnotes have been included. Comment 3: The Discussion section is overly long and contains repeated information; the Limitations section has similar issues. Response: Thank you for this constructive observation. The Discussion section has been carefully revised to improve conciseness, reduce redundancy, and enhance overall organization. Repetitive statements have been removed, and the content has been streamlined to focus more directly on interpretation of the study findings in relation to existing literature. Similarly, the Limitations section has been substantially revised to eliminate duplication, improve clarity, and present the study constraints in a more concise and structured manner. Redundant phrases related to generalizability and sampling limitations have been removed, and the section has been refined to clearly highlight key methodological limitations, including sample size, exploratory statistical analysis, and potential biases. We thank the reviewer again for their insightful comments, which have significantly improved the clarity, structure, and scientific quality of the manuscript. We sincerely thank the reviewer for their valuable feedback and constructive suggestions to improve the manuscript. Comment 1: The title needs modification to better reflect the aim of the study. Response: Thank you for this suggestion. The title has been revised to better reflect the scope and aim of the study, emphasizing clinician awareness and clinical experience, as well as the exploratory nature of the investigation. Comment 2: Clarify the location or accessibility of Supplementary Tables S1 and S2. Response: We appreciate this important comment. The manuscript has been revised to clearly label “Table S1” and “Table S2” as Supplementary Tables S1 and S2 throughout the text. A dedicated Supplementary Materials section has been added, and references to these tables in the Results section have been clarified to guide readers. Additionally, appropriate explanatory footnotes have been included. Comment 3: The Discussion section is overly long and contains repeated information; the Limitations section has similar issues. Response: Thank you for this constructive observation. The Discussion section has been carefully revised to improve conciseness, reduce redundancy, and enhance overall organization. Repetitive statements have been removed, and the content has been streamlined to focus more directly on interpretation of the study findings in relation to existing literature. Similarly, the Limitations section has been substantially revised to eliminate duplication, improve clarity, and present the study constraints in a more concise and structured manner. Redundant phrases related to generalizability and sampling limitations have been removed, and the section has been refined to clearly highlight key methodological limitations, including sample size, exploratory statistical analysis, and potential biases. We thank the reviewer again for their insightful comments, which have significantly improved the clarity, structure, and scientific quality of the manuscript. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 27 Apr 2026 Ahmad Assari , Department of Dentistry, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia 27 Apr 2026 Author Response We sincerely thank the reviewer for their valuable feedback and constructive suggestions to improve the manuscript. Comment 1: The title needs modification to better reflect the aim of the study. ... Continue reading We sincerely thank the reviewer for their valuable feedback and constructive suggestions to improve the manuscript. Comment 1: The title needs modification to better reflect the aim of the study. Response: Thank you for this suggestion. The title has been revised to better reflect the scope and aim of the study, emphasizing clinician awareness and clinical experience, as well as the exploratory nature of the investigation. Comment 2: Clarify the location or accessibility of Supplementary Tables S1 and S2. Response: We appreciate this important comment. The manuscript has been revised to clearly label “Table S1” and “Table S2” as Supplementary Tables S1 and S2 throughout the text. A dedicated Supplementary Materials section has been added, and references to these tables in the Results section have been clarified to guide readers. Additionally, appropriate explanatory footnotes have been included. Comment 3: The Discussion section is overly long and contains repeated information; the Limitations section has similar issues. Response: Thank you for this constructive observation. The Discussion section has been carefully revised to improve conciseness, reduce redundancy, and enhance overall organization. Repetitive statements have been removed, and the content has been streamlined to focus more directly on interpretation of the study findings in relation to existing literature. Similarly, the Limitations section has been substantially revised to eliminate duplication, improve clarity, and present the study constraints in a more concise and structured manner. Redundant phrases related to generalizability and sampling limitations have been removed, and the section has been refined to clearly highlight key methodological limitations, including sample size, exploratory statistical analysis, and potential biases. We thank the reviewer again for their insightful comments, which have significantly improved the clarity, structure, and scientific quality of the manuscript. We sincerely thank the reviewer for their valuable feedback and constructive suggestions to improve the manuscript. Comment 1: The title needs modification to better reflect the aim of the study. Response: Thank you for this suggestion. The title has been revised to better reflect the scope and aim of the study, emphasizing clinician awareness and clinical experience, as well as the exploratory nature of the investigation. Comment 2: Clarify the location or accessibility of Supplementary Tables S1 and S2. Response: We appreciate this important comment. The manuscript has been revised to clearly label “Table S1” and “Table S2” as Supplementary Tables S1 and S2 throughout the text. A dedicated Supplementary Materials section has been added, and references to these tables in the Results section have been clarified to guide readers. Additionally, appropriate explanatory footnotes have been included. Comment 3: The Discussion section is overly long and contains repeated information; the Limitations section has similar issues. Response: Thank you for this constructive observation. The Discussion section has been carefully revised to improve conciseness, reduce redundancy, and enhance overall organization. Repetitive statements have been removed, and the content has been streamlined to focus more directly on interpretation of the study findings in relation to existing literature. Similarly, the Limitations section has been substantially revised to eliminate duplication, improve clarity, and present the study constraints in a more concise and structured manner. Redundant phrases related to generalizability and sampling limitations have been removed, and the section has been refined to clearly highlight key methodological limitations, including sample size, exploratory statistical analysis, and potential biases. We thank the reviewer again for their insightful comments, which have significantly improved the clarity, structure, and scientific quality of the manuscript. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Fialho T. Reviewer Report For: The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons [version 4; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 14 :1001 ( https://doi.org/10.5256/f1000research.198023.r475309 ) The direct URL for this report is: https://f1000research.com/articles/14-1001/v3#referee-response-475309 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 16 Apr 2026 Tiago Fialho , Department of Orthodontics, Bauru Dental School, São Paulo University, Bauru, SP, Brazil Approved VIEWS 0 https://doi.org/10.5256/f1000research.198023.r475309 I have carefully reviewed the third version (V3) of the manuscript entitled "The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons." After evaluating the amendments made by the ... Continue reading READ ALL I have carefully reviewed the third version (V3) of the manuscript entitled "The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons." After evaluating the amendments made by the authors in response to previous peer-review rounds, I would like to offer the following assessment regarding its current status and suitability for indexing. Firstly, I commend the authors for their diligent efforts in addressing the terminological and structural concerns raised. The correction of the title to "Orthodontists" and the refinement of "dental anomaly" to "dentofacial deformity" in the introduction significantly enhance the academic precision of the text. Furthermore, the inclusion of a detailed flowchart (Figure 1) and the explicit statement of the response rate (16.5%) provide the necessary transparency regarding the study’s recruitment process, which was a point of concern in earlier versions. The standardization of tables, including the proper definition of statistical abbreviations and p-values in the footnotes, has also improved the readability and technical quality of the data presentation. Regarding the discussion and conclusions, the authors have successfully integrated a more nuanced interpretation of the findings. The clearer distinction between the training needs of orthodontists versus oral surgeons, particularly concerning biomechanics and intermaxillary fixation, adds depth to the study's clinical implications. The conclusion now effectively summarizes the quantitative findings rather than offering generalized statements, which is a vital improvement. However, a critical limitation remains: the sample size ($n=46$). Despite the authors' efforts to increase recruitment, the final cohort remains substantially below the initially calculated power requirement ($n=302$). This limitation inherently restricts the generalizability of the findings and the robustness of the inferential statistics. In the F1000Research model, which prioritizes transparency and the publication of all sound scientific work—including exploratory and preliminary data—this does not necessarily preclude publication. The authors have acted appropriately by reframing the study as an "exploratory survey" and being candid about these limitations in the discussion section. In conclusion, I believe that the authors have addressed the major technical and editorial queries to the best of their ability within the constraints of their recruitment environment. The manuscript now provides a clear, transparent, and honest account of a preliminary investigation into an emerging clinical field in Saudi Arabia. While the small sample size remains a "reservation," the transparency of the reporting and the open-access availability of the underlying dataset (via Zenodo) align with the journal's standards. Therefore, I recommend that the article be considered for approval, provided that readers continue to interpret the statistical findings with the caution warranted by the exploratory nature of the study. Competing Interests: No competing interests were disclosed. Reviewer Expertise: Orthodontics; Orthodontic Aligners, Orthodontic mechanics I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Fialho T. Reviewer Report For: The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons [version 4; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 14 :1001 ( https://doi.org/10.5256/f1000research.198023.r475309 ) The direct URL for this report is: https://f1000research.com/articles/14-1001/v3#referee-response-475309 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 07 May 2026 Ahmad Assari , Department of Dentistry, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia 07 May 2026 Author Response We sincerely thank the reviewer for their careful evaluation of Version 3 of our manuscript and for recognizing the substantial improvements made in response to previous review rounds. We appreciate ... Continue reading We sincerely thank the reviewer for their careful evaluation of Version 3 of our manuscript and for recognizing the substantial improvements made in response to previous review rounds. We appreciate the reviewer’s positive feedback regarding the refinement of terminology, improved clarity of the introduction, inclusion of the recruitment flowchart, and enhanced transparency in reporting the response rate and data availability. We are also grateful for the acknowledgment of improvements in table presentation, discussion structure, and the strengthened conclusions. Regarding the key concern about the sample size (n = 46 vs. calculated n = 302), we fully agree that this represents a major methodological limitation. In response, we have made the following revisions throughout the manuscript: The study has been explicitly repositioned as an exploratory survey in the Abstract, Methods, Results, Discussion, and Conclusion. The discrepancy between the calculated and achieved sample size has been clearly stated and consistently emphasized. The implications of the small sample size on statistical power, risk of Type I/II errors, and generalizability have been explicitly discussed in the Limitations section. All inferential analyses (chi-square and regression) have been clearly described as exploratory, and their interpretation has been appropriately tempered. The observed association between age and CAT usage has been reframed as a hypothesis-generating observation rather than a definitive finding. We have also explicitly clarified that the findings may not be generalizable due to the small sample size and the use of a convenience sampling approach. Additionally, the nature of the dependent variable and the exploratory purpose of the regression model have been clarified to ensure appropriate interpretation. We have also acknowledged potential limitations related to statistical assumptions (e.g., small expected cell counts) and interpreted these analyses with caution. In addition, we have strengthened the discussion of sampling limitations, including the use of convenience sampling and the potential for self-selection bias, and we have ensured that all conclusions are aligned with the exploratory nature of the study. We appreciate the reviewer’s recognition that the study meets the principles of transparency and open science, particularly through the public availability of the dataset and survey instrument. In conclusion, we believe the manuscript now provides a transparent and appropriately cautious account of a preliminary investigation into an emerging clinical topic. We thank the reviewer for their valuable feedback and recommendation for approval with reservations. We sincerely thank the reviewer for their careful evaluation of Version 3 of our manuscript and for recognizing the substantial improvements made in response to previous review rounds. We appreciate the reviewer’s positive feedback regarding the refinement of terminology, improved clarity of the introduction, inclusion of the recruitment flowchart, and enhanced transparency in reporting the response rate and data availability. We are also grateful for the acknowledgment of improvements in table presentation, discussion structure, and the strengthened conclusions. Regarding the key concern about the sample size (n = 46 vs. calculated n = 302), we fully agree that this represents a major methodological limitation. In response, we have made the following revisions throughout the manuscript: The study has been explicitly repositioned as an exploratory survey in the Abstract, Methods, Results, Discussion, and Conclusion. The discrepancy between the calculated and achieved sample size has been clearly stated and consistently emphasized. The implications of the small sample size on statistical power, risk of Type I/II errors, and generalizability have been explicitly discussed in the Limitations section. All inferential analyses (chi-square and regression) have been clearly described as exploratory, and their interpretation has been appropriately tempered. The observed association between age and CAT usage has been reframed as a hypothesis-generating observation rather than a definitive finding. We have also explicitly clarified that the findings may not be generalizable due to the small sample size and the use of a convenience sampling approach. Additionally, the nature of the dependent variable and the exploratory purpose of the regression model have been clarified to ensure appropriate interpretation. We have also acknowledged potential limitations related to statistical assumptions (e.g., small expected cell counts) and interpreted these analyses with caution. In addition, we have strengthened the discussion of sampling limitations, including the use of convenience sampling and the potential for self-selection bias, and we have ensured that all conclusions are aligned with the exploratory nature of the study. We appreciate the reviewer’s recognition that the study meets the principles of transparency and open science, particularly through the public availability of the dataset and survey instrument. In conclusion, we believe the manuscript now provides a transparent and appropriately cautious account of a preliminary investigation into an emerging clinical topic. We thank the reviewer for their valuable feedback and recommendation for approval with reservations. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 07 May 2026 Ahmad Assari , Department of Dentistry, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia 07 May 2026 Author Response We sincerely thank the reviewer for their careful evaluation of Version 3 of our manuscript and for recognizing the substantial improvements made in response to previous review rounds. We appreciate ... Continue reading We sincerely thank the reviewer for their careful evaluation of Version 3 of our manuscript and for recognizing the substantial improvements made in response to previous review rounds. We appreciate the reviewer’s positive feedback regarding the refinement of terminology, improved clarity of the introduction, inclusion of the recruitment flowchart, and enhanced transparency in reporting the response rate and data availability. We are also grateful for the acknowledgment of improvements in table presentation, discussion structure, and the strengthened conclusions. Regarding the key concern about the sample size (n = 46 vs. calculated n = 302), we fully agree that this represents a major methodological limitation. In response, we have made the following revisions throughout the manuscript: The study has been explicitly repositioned as an exploratory survey in the Abstract, Methods, Results, Discussion, and Conclusion. The discrepancy between the calculated and achieved sample size has been clearly stated and consistently emphasized. The implications of the small sample size on statistical power, risk of Type I/II errors, and generalizability have been explicitly discussed in the Limitations section. All inferential analyses (chi-square and regression) have been clearly described as exploratory, and their interpretation has been appropriately tempered. The observed association between age and CAT usage has been reframed as a hypothesis-generating observation rather than a definitive finding. We have also explicitly clarified that the findings may not be generalizable due to the small sample size and the use of a convenience sampling approach. Additionally, the nature of the dependent variable and the exploratory purpose of the regression model have been clarified to ensure appropriate interpretation. We have also acknowledged potential limitations related to statistical assumptions (e.g., small expected cell counts) and interpreted these analyses with caution. In addition, we have strengthened the discussion of sampling limitations, including the use of convenience sampling and the potential for self-selection bias, and we have ensured that all conclusions are aligned with the exploratory nature of the study. We appreciate the reviewer’s recognition that the study meets the principles of transparency and open science, particularly through the public availability of the dataset and survey instrument. In conclusion, we believe the manuscript now provides a transparent and appropriately cautious account of a preliminary investigation into an emerging clinical topic. We thank the reviewer for their valuable feedback and recommendation for approval with reservations. We sincerely thank the reviewer for their careful evaluation of Version 3 of our manuscript and for recognizing the substantial improvements made in response to previous review rounds. We appreciate the reviewer’s positive feedback regarding the refinement of terminology, improved clarity of the introduction, inclusion of the recruitment flowchart, and enhanced transparency in reporting the response rate and data availability. We are also grateful for the acknowledgment of improvements in table presentation, discussion structure, and the strengthened conclusions. Regarding the key concern about the sample size (n = 46 vs. calculated n = 302), we fully agree that this represents a major methodological limitation. In response, we have made the following revisions throughout the manuscript: The study has been explicitly repositioned as an exploratory survey in the Abstract, Methods, Results, Discussion, and Conclusion. The discrepancy between the calculated and achieved sample size has been clearly stated and consistently emphasized. The implications of the small sample size on statistical power, risk of Type I/II errors, and generalizability have been explicitly discussed in the Limitations section. All inferential analyses (chi-square and regression) have been clearly described as exploratory, and their interpretation has been appropriately tempered. The observed association between age and CAT usage has been reframed as a hypothesis-generating observation rather than a definitive finding. We have also explicitly clarified that the findings may not be generalizable due to the small sample size and the use of a convenience sampling approach. Additionally, the nature of the dependent variable and the exploratory purpose of the regression model have been clarified to ensure appropriate interpretation. We have also acknowledged potential limitations related to statistical assumptions (e.g., small expected cell counts) and interpreted these analyses with caution. In addition, we have strengthened the discussion of sampling limitations, including the use of convenience sampling and the potential for self-selection bias, and we have ensured that all conclusions are aligned with the exploratory nature of the study. We appreciate the reviewer’s recognition that the study meets the principles of transparency and open science, particularly through the public availability of the dataset and survey instrument. In conclusion, we believe the manuscript now provides a transparent and appropriately cautious account of a preliminary investigation into an emerging clinical topic. We thank the reviewer for their valuable feedback and recommendation for approval with reservations. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Version 2 VERSION 2 PUBLISHED 14 Feb 2026 Revised Views 0 Cite How to cite this report: Mohamed AM. Reviewer Report For: The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons [version 4; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 14 :1001 ( https://doi.org/10.5256/f1000research.191604.r458561 ) The direct URL for this report is: https://f1000research.com/articles/14-1001/v2#referee-response-458561 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 10 Mar 2026 Abdelrahman MA Mohamed , Orthodontics, Royal College of Surgeons of Edinburgh, Edinburgh, UK Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.191604.r458561 I would like to thank the editor very much for giving me the opportunity to review this paper. Below are my comments and suggestions to strengthen the manuscript. Title need to explain the aim of ... Continue reading READ ALL I would like to thank the editor very much for giving me the opportunity to review this paper. Below are my comments and suggestions to strengthen the manuscript. Title need to explain the aim of the study Introduction : The authors need to mention that they are talking abut orthodontic 1 st and not surgery 1 st technique, as if it was the surgery 1 st , there will be no need to revaluate surgeon response. Material and Methods : Sample size are very small , less than the minimum base on sample size calculation 302 , but the author only included 46 which is much less than the required , especially for the orthognathic surgeons. This needs to be highlighted in the abstract and in conclusion. Results: I suggest to change the aim to be also the experience of orthodontist in treatment of orthognathic surgery cases also, even with this, the reliability and external validity of the study are compromised. WHAT ARE TABLE S1 AND TABLE S2??? IS IT A WRITING MISTAKE OR WHAT???? The error still exists Discussion: - Please Share the reference of this sentence: (Systematic reviews confirm that while CAT is increasingly effective for mild-to-moderate malocclusions, evidence for its use in surgical orthodontics remains limited and largely anecdotal.)? - author put facts that do not come from the current study without citing a reference for it, e.g. (Besides, CAT is considered as a popular treatment choice among many orthodontists, however not a common treatment for orthognathic surgery patients.). - Discussion writing is not organized, some have large paragraph and some part just have small 1 line sentences. DISCUSSION STILL VERY LONG AND NOT INTERESTING and not majorly focuses on interpreting the results. - I see the recommendations have 5 points which can be merged on 2 points. Conclusion : - please make the conclusion shorter. Competing Interests: No competing interests were disclosed. Reviewer Expertise: Orthodontics. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Mohamed AM. Reviewer Report For: The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons [version 4; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 14 :1001 ( https://doi.org/10.5256/f1000research.191604.r458561 ) The direct URL for this report is: https://f1000research.com/articles/14-1001/v2#referee-response-458561 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 15 Apr 2026 Ahmad Assari , Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, College of Medicine and Dentistry, Riyadh Elm University, Riyadh, Saudi Arabia 15 Apr 2026 Author Response Response to Reviewer Comment: Title need to explain the aim of the study Response: Thank you for this valuable suggestion. The title has been revised to more clearly reflect the ... Continue reading Response to Reviewer Comment: Title need to explain the aim of the study Response: Thank you for this valuable suggestion. The title has been revised to more clearly reflect the aim of the study by explicitly including the assessment of knowledge, attitudes, and clinical practices, as well as indicating the exploratory nature of the investigation. Comment: Introduction : The authors need to mention that they are talking about orthodontic 1 st and not surgery 1 st technique, as if it was the surgery 1 st , there will be no need to revaluate surgeon response. Response: Its use in combination with surgery is emerging; however, its role differs between orthodontics-first and surgery-first protocols. In orthodontics-first approaches, CAT may be used in pre- and post-surgical phases, whereas in surgery-first protocols its role is more limited and evolving. Comment: Material and Methods : Sample size are very small , less than the minimum base on sample size calculation 302 , but the author only included 46 which is much less than the required , especially for the orthognathic surgeons. This needs to be highlighted in the abstract and in conclusion. Response: Thank you for this important observation. We have revised both the Abstract and Conclusion to explicitly highlight the discrepancy between the calculated minimum sample size (n = 302) and the achieved sample (n = 46). We have also emphasized that this limitation reduces statistical power and affects the robustness of subgroup analyses, particularly for oral and maxillofacial surgeons. The findings are now clearly presented as exploratory and preliminary in nature. Comment: Results: I suggest to change the aim to be also the experience of orthodontist in treatment of orthognathic surgery cases also, even with this, the reliability and external validity of the study are compromised. WHAT ARE TABLE S1 AND TABLE S2??? IS IT A WRITING MISTAKE OR WHAT???? The error still exists Response: Thank you for this valuable feedback. The study aim has been revised in both the Introduction and Abstract to explicitly include clinical experience alongside knowledge, attitudes, and practices. Thank you for highlighting this issue. We apologize for the lack of clarity. “Table S1” and “Table S2” refer to Supplementary Tables, which contain detailed demographic and clinical data. In the revised manuscript, these have been clearly labeled as “Supplementary Table S1” and “Supplementary Table S2”, and a dedicated Supplementary Material section has been added to improve clarity and accessibility. We have also further emphasized the limitations related to sample size and external validity in the revised manuscript to ensure appropriate interpretation of the findings. Comment: Discussion: - Please Share the reference of this sentence: (Systematic reviews confirm that while CAT is increasingly effective for mild-to-moderate malocclusions, evidence for its use in surgical orthodontics remains limited and largely anecdotal.)? - author put facts that do not come from the current study without citing a reference for it, e.g. (Besides, CAT is considered as a popular treatment choice among many orthodontists, however not a common treatment for orthognathic surgery patients.). - Discussion writing is not organized, some have large paragraph and some part just have small 1 line sentences. DISCUSSION STILL VERY LONG AND NOT INTERESTING and not majorly focuses on interpreting the results. - I see the recommendations have 5 points which can be merged on 2 points. Response: Thank you for these valuable suggestions. We have revised the Discussion section accordingly: The previously uncited statement regarding systematic reviews has now been supported with appropriate references. Unsupported general statements have been revised or linked directly to the findings of the current study. The Discussion has been reorganized to improve flow, reduce redundancy, and place greater emphasis on interpreting the study findings in relation to existing literature. Long and fragmented sections have been streamlined for clarity and readability. The recommendations section has been condensed from five points into two concise and structured recommendations to improve clarity and impact. Comment: Conclusion : - please make the conclusion shorter. Response: Thank you for this suggestion. The Conclusion section has been revised to improve conciseness while retaining the key findings and clinical implications. Redundant statements have been removed, and the section now presents a clearer and more focused summary of the study outcomes and future research directions. Response to Reviewer Comment: Title need to explain the aim of the study Response: Thank you for this valuable suggestion. The title has been revised to more clearly reflect the aim of the study by explicitly including the assessment of knowledge, attitudes, and clinical practices, as well as indicating the exploratory nature of the investigation. Comment: Introduction : The authors need to mention that they are talking about orthodontic 1 st and not surgery 1 st technique, as if it was the surgery 1 st , there will be no need to revaluate surgeon response. Response: Its use in combination with surgery is emerging; however, its role differs between orthodontics-first and surgery-first protocols. In orthodontics-first approaches, CAT may be used in pre- and post-surgical phases, whereas in surgery-first protocols its role is more limited and evolving. Comment: Material and Methods : Sample size are very small , less than the minimum base on sample size calculation 302 , but the author only included 46 which is much less than the required , especially for the orthognathic surgeons. This needs to be highlighted in the abstract and in conclusion. Response: Thank you for this important observation. We have revised both the Abstract and Conclusion to explicitly highlight the discrepancy between the calculated minimum sample size (n = 302) and the achieved sample (n = 46). We have also emphasized that this limitation reduces statistical power and affects the robustness of subgroup analyses, particularly for oral and maxillofacial surgeons. The findings are now clearly presented as exploratory and preliminary in nature. Comment: Results: I suggest to change the aim to be also the experience of orthodontist in treatment of orthognathic surgery cases also, even with this, the reliability and external validity of the study are compromised. WHAT ARE TABLE S1 AND TABLE S2??? IS IT A WRITING MISTAKE OR WHAT???? The error still exists Response: Thank you for this valuable feedback. The study aim has been revised in both the Introduction and Abstract to explicitly include clinical experience alongside knowledge, attitudes, and practices. Thank you for highlighting this issue. We apologize for the lack of clarity. “Table S1” and “Table S2” refer to Supplementary Tables, which contain detailed demographic and clinical data. In the revised manuscript, these have been clearly labeled as “Supplementary Table S1” and “Supplementary Table S2”, and a dedicated Supplementary Material section has been added to improve clarity and accessibility. We have also further emphasized the limitations related to sample size and external validity in the revised manuscript to ensure appropriate interpretation of the findings. Comment: Discussion: - Please Share the reference of this sentence: (Systematic reviews confirm that while CAT is increasingly effective for mild-to-moderate malocclusions, evidence for its use in surgical orthodontics remains limited and largely anecdotal.)? - author put facts that do not come from the current study without citing a reference for it, e.g. (Besides, CAT is considered as a popular treatment choice among many orthodontists, however not a common treatment for orthognathic surgery patients.). - Discussion writing is not organized, some have large paragraph and some part just have small 1 line sentences. DISCUSSION STILL VERY LONG AND NOT INTERESTING and not majorly focuses on interpreting the results. - I see the recommendations have 5 points which can be merged on 2 points. Response: Thank you for these valuable suggestions. We have revised the Discussion section accordingly: The previously uncited statement regarding systematic reviews has now been supported with appropriate references. Unsupported general statements have been revised or linked directly to the findings of the current study. The Discussion has been reorganized to improve flow, reduce redundancy, and place greater emphasis on interpreting the study findings in relation to existing literature. Long and fragmented sections have been streamlined for clarity and readability. The recommendations section has been condensed from five points into two concise and structured recommendations to improve clarity and impact. Comment: Conclusion : - please make the conclusion shorter. Response: Thank you for this suggestion. The Conclusion section has been revised to improve conciseness while retaining the key findings and clinical implications. Redundant statements have been removed, and the section now presents a clearer and more focused summary of the study outcomes and future research directions. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 15 Apr 2026 Ahmad Assari , Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, College of Medicine and Dentistry, Riyadh Elm University, Riyadh, Saudi Arabia 15 Apr 2026 Author Response Response to Reviewer Comment: Title need to explain the aim of the study Response: Thank you for this valuable suggestion. The title has been revised to more clearly reflect the ... Continue reading Response to Reviewer Comment: Title need to explain the aim of the study Response: Thank you for this valuable suggestion. The title has been revised to more clearly reflect the aim of the study by explicitly including the assessment of knowledge, attitudes, and clinical practices, as well as indicating the exploratory nature of the investigation. Comment: Introduction : The authors need to mention that they are talking about orthodontic 1 st and not surgery 1 st technique, as if it was the surgery 1 st , there will be no need to revaluate surgeon response. Response: Its use in combination with surgery is emerging; however, its role differs between orthodontics-first and surgery-first protocols. In orthodontics-first approaches, CAT may be used in pre- and post-surgical phases, whereas in surgery-first protocols its role is more limited and evolving. Comment: Material and Methods : Sample size are very small , less than the minimum base on sample size calculation 302 , but the author only included 46 which is much less than the required , especially for the orthognathic surgeons. This needs to be highlighted in the abstract and in conclusion. Response: Thank you for this important observation. We have revised both the Abstract and Conclusion to explicitly highlight the discrepancy between the calculated minimum sample size (n = 302) and the achieved sample (n = 46). We have also emphasized that this limitation reduces statistical power and affects the robustness of subgroup analyses, particularly for oral and maxillofacial surgeons. The findings are now clearly presented as exploratory and preliminary in nature. Comment: Results: I suggest to change the aim to be also the experience of orthodontist in treatment of orthognathic surgery cases also, even with this, the reliability and external validity of the study are compromised. WHAT ARE TABLE S1 AND TABLE S2??? IS IT A WRITING MISTAKE OR WHAT???? The error still exists Response: Thank you for this valuable feedback. The study aim has been revised in both the Introduction and Abstract to explicitly include clinical experience alongside knowledge, attitudes, and practices. Thank you for highlighting this issue. We apologize for the lack of clarity. “Table S1” and “Table S2” refer to Supplementary Tables, which contain detailed demographic and clinical data. In the revised manuscript, these have been clearly labeled as “Supplementary Table S1” and “Supplementary Table S2”, and a dedicated Supplementary Material section has been added to improve clarity and accessibility. We have also further emphasized the limitations related to sample size and external validity in the revised manuscript to ensure appropriate interpretation of the findings. Comment: Discussion: - Please Share the reference of this sentence: (Systematic reviews confirm that while CAT is increasingly effective for mild-to-moderate malocclusions, evidence for its use in surgical orthodontics remains limited and largely anecdotal.)? - author put facts that do not come from the current study without citing a reference for it, e.g. (Besides, CAT is considered as a popular treatment choice among many orthodontists, however not a common treatment for orthognathic surgery patients.). - Discussion writing is not organized, some have large paragraph and some part just have small 1 line sentences. DISCUSSION STILL VERY LONG AND NOT INTERESTING and not majorly focuses on interpreting the results. - I see the recommendations have 5 points which can be merged on 2 points. Response: Thank you for these valuable suggestions. We have revised the Discussion section accordingly: The previously uncited statement regarding systematic reviews has now been supported with appropriate references. Unsupported general statements have been revised or linked directly to the findings of the current study. The Discussion has been reorganized to improve flow, reduce redundancy, and place greater emphasis on interpreting the study findings in relation to existing literature. Long and fragmented sections have been streamlined for clarity and readability. The recommendations section has been condensed from five points into two concise and structured recommendations to improve clarity and impact. Comment: Conclusion : - please make the conclusion shorter. Response: Thank you for this suggestion. The Conclusion section has been revised to improve conciseness while retaining the key findings and clinical implications. Redundant statements have been removed, and the section now presents a clearer and more focused summary of the study outcomes and future research directions. Response to Reviewer Comment: Title need to explain the aim of the study Response: Thank you for this valuable suggestion. The title has been revised to more clearly reflect the aim of the study by explicitly including the assessment of knowledge, attitudes, and clinical practices, as well as indicating the exploratory nature of the investigation. Comment: Introduction : The authors need to mention that they are talking about orthodontic 1 st and not surgery 1 st technique, as if it was the surgery 1 st , there will be no need to revaluate surgeon response. Response: Its use in combination with surgery is emerging; however, its role differs between orthodontics-first and surgery-first protocols. In orthodontics-first approaches, CAT may be used in pre- and post-surgical phases, whereas in surgery-first protocols its role is more limited and evolving. Comment: Material and Methods : Sample size are very small , less than the minimum base on sample size calculation 302 , but the author only included 46 which is much less than the required , especially for the orthognathic surgeons. This needs to be highlighted in the abstract and in conclusion. Response: Thank you for this important observation. We have revised both the Abstract and Conclusion to explicitly highlight the discrepancy between the calculated minimum sample size (n = 302) and the achieved sample (n = 46). We have also emphasized that this limitation reduces statistical power and affects the robustness of subgroup analyses, particularly for oral and maxillofacial surgeons. The findings are now clearly presented as exploratory and preliminary in nature. Comment: Results: I suggest to change the aim to be also the experience of orthodontist in treatment of orthognathic surgery cases also, even with this, the reliability and external validity of the study are compromised. WHAT ARE TABLE S1 AND TABLE S2??? IS IT A WRITING MISTAKE OR WHAT???? The error still exists Response: Thank you for this valuable feedback. The study aim has been revised in both the Introduction and Abstract to explicitly include clinical experience alongside knowledge, attitudes, and practices. Thank you for highlighting this issue. We apologize for the lack of clarity. “Table S1” and “Table S2” refer to Supplementary Tables, which contain detailed demographic and clinical data. In the revised manuscript, these have been clearly labeled as “Supplementary Table S1” and “Supplementary Table S2”, and a dedicated Supplementary Material section has been added to improve clarity and accessibility. We have also further emphasized the limitations related to sample size and external validity in the revised manuscript to ensure appropriate interpretation of the findings. Comment: Discussion: - Please Share the reference of this sentence: (Systematic reviews confirm that while CAT is increasingly effective for mild-to-moderate malocclusions, evidence for its use in surgical orthodontics remains limited and largely anecdotal.)? - author put facts that do not come from the current study without citing a reference for it, e.g. (Besides, CAT is considered as a popular treatment choice among many orthodontists, however not a common treatment for orthognathic surgery patients.). - Discussion writing is not organized, some have large paragraph and some part just have small 1 line sentences. DISCUSSION STILL VERY LONG AND NOT INTERESTING and not majorly focuses on interpreting the results. - I see the recommendations have 5 points which can be merged on 2 points. Response: Thank you for these valuable suggestions. We have revised the Discussion section accordingly: The previously uncited statement regarding systematic reviews has now been supported with appropriate references. Unsupported general statements have been revised or linked directly to the findings of the current study. The Discussion has been reorganized to improve flow, reduce redundancy, and place greater emphasis on interpreting the study findings in relation to existing literature. Long and fragmented sections have been streamlined for clarity and readability. The recommendations section has been condensed from five points into two concise and structured recommendations to improve clarity and impact. Comment: Conclusion : - please make the conclusion shorter. Response: Thank you for this suggestion. The Conclusion section has been revised to improve conciseness while retaining the key findings and clinical implications. Redundant statements have been removed, and the section now presents a clearer and more focused summary of the study outcomes and future research directions. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Fialho T. Reviewer Report For: The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons [version 4; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 14 :1001 ( https://doi.org/10.5256/f1000research.191604.r461487 ) The direct URL for this report is: https://f1000research.com/articles/14-1001/v2#referee-response-461487 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 25 Feb 2026 Tiago Fialho , Department of Orthodontics, Bauru Dental School, São Paulo University, Bauru, SP, Brazil Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.191604.r461487 Thank you for the opportunity to review the revised version of this manuscript. The topic is timely and clinically relevant, particularly given the growing incorporation of clear aligner therapy (CAT) into orthognathic surgery protocols. The authors have made appreciable ... Continue reading READ ALL Thank you for the opportunity to review the revised version of this manuscript. The topic is timely and clinically relevant, particularly given the growing incorporation of clear aligner therapy (CAT) into orthognathic surgery protocols. The authors have made appreciable efforts to address prior reviewer comments, especially regarding ethical approval, questionnaire validation, and data transparency. The availability of the dataset and survey instrument is a notable strength and aligns well with the open science principles of the journal. Despite these improvements, important methodological and statistical concerns remain that limit the robustness of the conclusions. The manuscript reports a calculated minimum sample size of 302 participants; however, only 46 valid responses were ultimately analyzed. Although the authors attribute this to a limited specialist pool, the manuscript also states that approximately 1,400 eligible professionals exist in the target population. This creates an inconsistency between the theoretical sampling framework and the achieved sample. Most importantly, the final sample size is substantially below the calculated requirement, rendering the study underpowered for inferential statistical testing. Under such conditions, p-values become unstable, and the risk of both Type I and Type II errors increases considerably. If the authors were unable to realistically achieve the required sample size, the study should be explicitly repositioned as an exploratory or pilot investigation, and the inferential claims should be substantially tempered. Related to this issue is the use of multiple inferential statistical tests in a small dataset. The manuscript employs several chi-square analyses and univariate linear regression. With a final sample of 46 respondents, there is a high probability that assumptions underlying chi-square tests—particularly minimum expected cell counts—may not be satisfied. Additionally, multiple comparisons are conducted without correction, increasing the risk of false-positive findings. Given the limited sample size, the statistical analysis would be more appropriately framed as primarily descriptive. Inferential modeling, if retained, should be explicitly described as exploratory and interpreted with considerable caution. The use of univariate linear regression to assess the association between age and CAT usage also warrants clarification. It is not sufficiently clear whether the dependent variable representing CAT use is continuous, ordinal, or binary. If the outcome is binary or categorical, linear regression is not the appropriate analytical approach, and logistic regression would be methodologically preferable. The reported R² value appears relatively high given the small sample size, which further underscores the need for clarification regarding model specification, variable coding, and assumption testing. Without this clarification, the validity of the regression findings remains uncertain. The sampling strategy also limits external validity. The study relied on convenience sampling through online distribution and professional networks, with a response rate of 16.5%. While such an approach is common in survey research, it introduces self-selection bias and may disproportionately attract clinicians already interested in or favorable toward CAT. Although the authors acknowledge this limitation, its implications for generalizability should be more explicitly emphasized in both the discussion and conclusion. Statements regarding trends in CAT adoption should be presented cautiously and framed within the context of these sampling constraints. The conclusion that age may influence CAT adoption should be reformulated as a hypothesis-generating observation rather than a definitive finding. Given the limited sample size and statistical fragility, the results should be interpreted as preliminary and in need of confirmation through adequately powered studies. Strengthening the distinction between descriptive observations and inferential claims would improve the internal coherence of the manuscript. In summary, the study addresses a relevant and underexplored topic, and its transparency in data reporting is commendable. However, methodological and statistical inconsistencies currently limit the strength of the conclusions. I would recommend approval with reservations contingent upon substantial clarification of the statistical modeling, reconsideration or reframing of the inferential analyses, explicit repositioning of the study as exploratory if appropriate, and a more cautious interpretation of the findings. With these revisions, the manuscript would more accurately reflect the evidentiary weight of the data and would be suitable for publication as an exploratory survey study. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Orthodontics; Orthodontic Aligners, Orthodontic mechanics I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Fialho T. Reviewer Report For: The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons [version 4; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 14 :1001 ( https://doi.org/10.5256/f1000research.191604.r461487 ) The direct URL for this report is: https://f1000research.com/articles/14-1001/v2#referee-response-461487 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 15 Apr 2026 Ahmad Assari , Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, College of Medicine and Dentistry, Riyadh Elm University, Riyadh, Saudi Arabia 15 Apr 2026 Author Response We sincerely thank the reviewer for their thorough and constructive evaluation of our manuscript. We appreciate the recognition of the study’s relevance, transparency, and data availability. We have carefully addressed ... Continue reading We sincerely thank the reviewer for their thorough and constructive evaluation of our manuscript. We appreciate the recognition of the study’s relevance, transparency, and data availability. We have carefully addressed all methodological and statistical concerns raised and have revised the manuscript accordingly. Our responses are detailed below. 1. Sample size and underpowered study Reviewer comment: The manuscript reports a calculated minimum sample size of 302 participants; however, only 46 valid responses were ultimately analyzed. Although the authors attribute this to a limited specialist pool, the manuscript also states that approximately 1,400 eligible professionals exist in the target population. This creates an inconsistency between the theoretical sampling framework and the achieved sample. Most importantly, the final sample size is substantially below the calculated requirement, rendering the study underpowered for inferential statistical testing. Under such conditions, p-values become unstable, and the risk of both Type I and Type II errors increases considerably. If the authors were unable to realistically achieve the required sample size, the study should be explicitly repositioned as an exploratory or pilot investigation, and the inferential claims should be substantially tempered. Response: We fully agree with this important observation. The manuscript has been revised to explicitly acknowledge the discrepancy between the calculated and achieved sample size. We have now clearly repositioned the study as an exploratory survey investigation rather than a confirmatory or inferential study. This clarification has been added to the Abstract, Methods, Results, Discussion, and Conclusion. We have explicitly stated that the limited sample size reduces statistical power and increases the risk of both Type I and Type II errors. 2. Use of inferential statistical tests in a small dataset Reviewer comment: Related to this issue is the use of multiple inferential statistical tests in a small dataset. The manuscript employs several chi-square analyses and univariate linear regression. With a final sample of 46 respondents, there is a high probability that assumptions underlying chi-square tests—particularly minimum expected cell counts—may not be satisfied. Additionally, multiple comparisons are conducted without correction, increasing the risk of false-positive findings. Given the limited sample size, the statistical analysis would be more appropriately framed as primarily descriptive. Inferential modeling, if retained, should be explicitly described as exploratory and interpreted with considerable caution. Response: We agree and have revised the manuscript accordingly: All inferential analyses are now explicitly described as exploratory. The Results section has been revised to emphasize descriptive findings, with reduced reliance on p-values. A clear statement has been added indicating that inferential results should be interpreted as hypothesis-generating rather than confirmatory. The limitations of chi-square testing in small samples (including expected cell counts) are now explicitly acknowledged. 3. Clarification of regression analysis and Sampling strategy and external validity Reviewer comment: The use of univariate linear regression to assess the association between age and CAT usage also warrants clarification. It is not sufficiently clear whether the dependent variable representing CAT use is continuous, ordinal, or binary. If the outcome is binary or categorical, linear regression is not the appropriate analytical approach, and logistic regression would be methodologically preferable. The reported R² value appears relatively high given the small sample size, which further underscores the need for clarification regarding model specification, variable coding, and assumption testing. Without this clarification, the validity of the regression findings remains uncertain. The sampling strategy also limits external validity. The study relied on convenience sampling through online distribution and professional networks, with a response rate of 16.5%. While such an approach is common in survey research, it introduces self-selection bias and may disproportionately attract clinicians already interested in or favorable toward CAT. Although the authors acknowledge this limitation, its implications for generalizability should be more explicitly emphasized in both the discussion and conclusion. Statements regarding trends in CAT adoption should be presented cautiously and framed within the context of these sampling constraints. Response: We have clarified the regression methodology in the Statistical Analysis section: The dependent variable (CAT usage) is now explicitly described as a continuous composite score derived from questionnaire responses. The rationale for using linear regression has been clarified. The interpretation of the regression model has been substantially tempered, and results are now presented as exploratory observations rather than definitive findings. Convenience sampling and low response rate introduce bias and limit generalizability. Response: We agree and have strengthened this aspect: The implications of self-selection bias and non-response bias are now explicitly discussed. We have clarified that clinicians with prior interest in CAT may have been overrepresented. Statements regarding trends and adoption have been reworded cautiously. Limitations in external validity and generalizability are now clearly emphasized in both the Discussion and Conclusion. 4. Interpretation of age as a predictor Reviewer comment: The conclusion that age may influence CAT adoption should be reformulated as a hypothesis-generating observation rather than a definitive finding. Given the limited sample size and statistical fragility, the results should be interpreted as preliminary and in need of confirmation through adequately powered studies. Strengthening the distinction between descriptive observations and inferential claims would improve the internal coherence of the manuscript. Response: This has been revised throughout the manuscript: The association between age and CAT usage is now described as exploratory and hypothesis-generating. Any language suggesting a definitive relationship has been removed. The need for validation in larger, adequately powered studies has been emphasized. We have made the following changes: The Results section is now primarily descriptive. Inferential findings are clearly labelled as exploratory. The Discussion and Conclusion have been revised to ensure cautious interpretation and avoid overgeneralization. 5. Overall revision In response to the reviewer’s recommendations, the manuscript has been comprehensively revised to: Reposition the study as an exploratory survey Strengthen transparency regarding methodological limitations Improve clarity of statistical methods Ensure appropriate interpretation of findings We are grateful for the reviewer’s insightful feedback, which has significantly improved the methodological clarity and scientific rigor of the manuscript. We believe the revised version now more accurately reflects the exploratory nature of the study and provides a balanced and cautious interpretation of the findings. We sincerely thank the reviewer for their thorough and constructive evaluation of our manuscript. We appreciate the recognition of the study’s relevance, transparency, and data availability. We have carefully addressed all methodological and statistical concerns raised and have revised the manuscript accordingly. Our responses are detailed below. 1. Sample size and underpowered study Reviewer comment: The manuscript reports a calculated minimum sample size of 302 participants; however, only 46 valid responses were ultimately analyzed. Although the authors attribute this to a limited specialist pool, the manuscript also states that approximately 1,400 eligible professionals exist in the target population. This creates an inconsistency between the theoretical sampling framework and the achieved sample. Most importantly, the final sample size is substantially below the calculated requirement, rendering the study underpowered for inferential statistical testing. Under such conditions, p-values become unstable, and the risk of both Type I and Type II errors increases considerably. If the authors were unable to realistically achieve the required sample size, the study should be explicitly repositioned as an exploratory or pilot investigation, and the inferential claims should be substantially tempered. Response: We fully agree with this important observation. The manuscript has been revised to explicitly acknowledge the discrepancy between the calculated and achieved sample size. We have now clearly repositioned the study as an exploratory survey investigation rather than a confirmatory or inferential study. This clarification has been added to the Abstract, Methods, Results, Discussion, and Conclusion. We have explicitly stated that the limited sample size reduces statistical power and increases the risk of both Type I and Type II errors. 2. Use of inferential statistical tests in a small dataset Reviewer comment: Related to this issue is the use of multiple inferential statistical tests in a small dataset. The manuscript employs several chi-square analyses and univariate linear regression. With a final sample of 46 respondents, there is a high probability that assumptions underlying chi-square tests—particularly minimum expected cell counts—may not be satisfied. Additionally, multiple comparisons are conducted without correction, increasing the risk of false-positive findings. Given the limited sample size, the statistical analysis would be more appropriately framed as primarily descriptive. Inferential modeling, if retained, should be explicitly described as exploratory and interpreted with considerable caution. Response: We agree and have revised the manuscript accordingly: All inferential analyses are now explicitly described as exploratory. The Results section has been revised to emphasize descriptive findings, with reduced reliance on p-values. A clear statement has been added indicating that inferential results should be interpreted as hypothesis-generating rather than confirmatory. The limitations of chi-square testing in small samples (including expected cell counts) are now explicitly acknowledged. 3. Clarification of regression analysis and Sampling strategy and external validity Reviewer comment: The use of univariate linear regression to assess the association between age and CAT usage also warrants clarification. It is not sufficiently clear whether the dependent variable representing CAT use is continuous, ordinal, or binary. If the outcome is binary or categorical, linear regression is not the appropriate analytical approach, and logistic regression would be methodologically preferable. The reported R² value appears relatively high given the small sample size, which further underscores the need for clarification regarding model specification, variable coding, and assumption testing. Without this clarification, the validity of the regression findings remains uncertain. The sampling strategy also limits external validity. The study relied on convenience sampling through online distribution and professional networks, with a response rate of 16.5%. While such an approach is common in survey research, it introduces self-selection bias and may disproportionately attract clinicians already interested in or favorable toward CAT. Although the authors acknowledge this limitation, its implications for generalizability should be more explicitly emphasized in both the discussion and conclusion. Statements regarding trends in CAT adoption should be presented cautiously and framed within the context of these sampling constraints. Response: We have clarified the regression methodology in the Statistical Analysis section: The dependent variable (CAT usage) is now explicitly described as a continuous composite score derived from questionnaire responses. The rationale for using linear regression has been clarified. The interpretation of the regression model has been substantially tempered, and results are now presented as exploratory observations rather than definitive findings. Convenience sampling and low response rate introduce bias and limit generalizability. Response: We agree and have strengthened this aspect: The implications of self-selection bias and non-response bias are now explicitly discussed. We have clarified that clinicians with prior interest in CAT may have been overrepresented. Statements regarding trends and adoption have been reworded cautiously. Limitations in external validity and generalizability are now clearly emphasized in both the Discussion and Conclusion. 4. Interpretation of age as a predictor Reviewer comment: The conclusion that age may influence CAT adoption should be reformulated as a hypothesis-generating observation rather than a definitive finding. Given the limited sample size and statistical fragility, the results should be interpreted as preliminary and in need of confirmation through adequately powered studies. Strengthening the distinction between descriptive observations and inferential claims would improve the internal coherence of the manuscript. Response: This has been revised throughout the manuscript: The association between age and CAT usage is now described as exploratory and hypothesis-generating. Any language suggesting a definitive relationship has been removed. The need for validation in larger, adequately powered studies has been emphasized. We have made the following changes: The Results section is now primarily descriptive. Inferential findings are clearly labelled as exploratory. The Discussion and Conclusion have been revised to ensure cautious interpretation and avoid overgeneralization. 5. Overall revision In response to the reviewer’s recommendations, the manuscript has been comprehensively revised to: Reposition the study as an exploratory survey Strengthen transparency regarding methodological limitations Improve clarity of statistical methods Ensure appropriate interpretation of findings We are grateful for the reviewer’s insightful feedback, which has significantly improved the methodological clarity and scientific rigor of the manuscript. We believe the revised version now more accurately reflects the exploratory nature of the study and provides a balanced and cautious interpretation of the findings. Competing Interests: None Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 15 Apr 2026 Ahmad Assari , Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, College of Medicine and Dentistry, Riyadh Elm University, Riyadh, Saudi Arabia 15 Apr 2026 Author Response We sincerely thank the reviewer for their thorough and constructive evaluation of our manuscript. We appreciate the recognition of the study’s relevance, transparency, and data availability. We have carefully addressed ... Continue reading We sincerely thank the reviewer for their thorough and constructive evaluation of our manuscript. We appreciate the recognition of the study’s relevance, transparency, and data availability. We have carefully addressed all methodological and statistical concerns raised and have revised the manuscript accordingly. Our responses are detailed below. 1. Sample size and underpowered study Reviewer comment: The manuscript reports a calculated minimum sample size of 302 participants; however, only 46 valid responses were ultimately analyzed. Although the authors attribute this to a limited specialist pool, the manuscript also states that approximately 1,400 eligible professionals exist in the target population. This creates an inconsistency between the theoretical sampling framework and the achieved sample. Most importantly, the final sample size is substantially below the calculated requirement, rendering the study underpowered for inferential statistical testing. Under such conditions, p-values become unstable, and the risk of both Type I and Type II errors increases considerably. If the authors were unable to realistically achieve the required sample size, the study should be explicitly repositioned as an exploratory or pilot investigation, and the inferential claims should be substantially tempered. Response: We fully agree with this important observation. The manuscript has been revised to explicitly acknowledge the discrepancy between the calculated and achieved sample size. We have now clearly repositioned the study as an exploratory survey investigation rather than a confirmatory or inferential study. This clarification has been added to the Abstract, Methods, Results, Discussion, and Conclusion. We have explicitly stated that the limited sample size reduces statistical power and increases the risk of both Type I and Type II errors. 2. Use of inferential statistical tests in a small dataset Reviewer comment: Related to this issue is the use of multiple inferential statistical tests in a small dataset. The manuscript employs several chi-square analyses and univariate linear regression. With a final sample of 46 respondents, there is a high probability that assumptions underlying chi-square tests—particularly minimum expected cell counts—may not be satisfied. Additionally, multiple comparisons are conducted without correction, increasing the risk of false-positive findings. Given the limited sample size, the statistical analysis would be more appropriately framed as primarily descriptive. Inferential modeling, if retained, should be explicitly described as exploratory and interpreted with considerable caution. Response: We agree and have revised the manuscript accordingly: All inferential analyses are now explicitly described as exploratory. The Results section has been revised to emphasize descriptive findings, with reduced reliance on p-values. A clear statement has been added indicating that inferential results should be interpreted as hypothesis-generating rather than confirmatory. The limitations of chi-square testing in small samples (including expected cell counts) are now explicitly acknowledged. 3. Clarification of regression analysis and Sampling strategy and external validity Reviewer comment: The use of univariate linear regression to assess the association between age and CAT usage also warrants clarification. It is not sufficiently clear whether the dependent variable representing CAT use is continuous, ordinal, or binary. If the outcome is binary or categorical, linear regression is not the appropriate analytical approach, and logistic regression would be methodologically preferable. The reported R² value appears relatively high given the small sample size, which further underscores the need for clarification regarding model specification, variable coding, and assumption testing. Without this clarification, the validity of the regression findings remains uncertain. The sampling strategy also limits external validity. The study relied on convenience sampling through online distribution and professional networks, with a response rate of 16.5%. While such an approach is common in survey research, it introduces self-selection bias and may disproportionately attract clinicians already interested in or favorable toward CAT. Although the authors acknowledge this limitation, its implications for generalizability should be more explicitly emphasized in both the discussion and conclusion. Statements regarding trends in CAT adoption should be presented cautiously and framed within the context of these sampling constraints. Response: We have clarified the regression methodology in the Statistical Analysis section: The dependent variable (CAT usage) is now explicitly described as a continuous composite score derived from questionnaire responses. The rationale for using linear regression has been clarified. The interpretation of the regression model has been substantially tempered, and results are now presented as exploratory observations rather than definitive findings. Convenience sampling and low response rate introduce bias and limit generalizability. Response: We agree and have strengthened this aspect: The implications of self-selection bias and non-response bias are now explicitly discussed. We have clarified that clinicians with prior interest in CAT may have been overrepresented. Statements regarding trends and adoption have been reworded cautiously. Limitations in external validity and generalizability are now clearly emphasized in both the Discussion and Conclusion. 4. Interpretation of age as a predictor Reviewer comment: The conclusion that age may influence CAT adoption should be reformulated as a hypothesis-generating observation rather than a definitive finding. Given the limited sample size and statistical fragility, the results should be interpreted as preliminary and in need of confirmation through adequately powered studies. Strengthening the distinction between descriptive observations and inferential claims would improve the internal coherence of the manuscript. Response: This has been revised throughout the manuscript: The association between age and CAT usage is now described as exploratory and hypothesis-generating. Any language suggesting a definitive relationship has been removed. The need for validation in larger, adequately powered studies has been emphasized. We have made the following changes: The Results section is now primarily descriptive. Inferential findings are clearly labelled as exploratory. The Discussion and Conclusion have been revised to ensure cautious interpretation and avoid overgeneralization. 5. Overall revision In response to the reviewer’s recommendations, the manuscript has been comprehensively revised to: Reposition the study as an exploratory survey Strengthen transparency regarding methodological limitations Improve clarity of statistical methods Ensure appropriate interpretation of findings We are grateful for the reviewer’s insightful feedback, which has significantly improved the methodological clarity and scientific rigor of the manuscript. We believe the revised version now more accurately reflects the exploratory nature of the study and provides a balanced and cautious interpretation of the findings. We sincerely thank the reviewer for their thorough and constructive evaluation of our manuscript. We appreciate the recognition of the study’s relevance, transparency, and data availability. We have carefully addressed all methodological and statistical concerns raised and have revised the manuscript accordingly. Our responses are detailed below. 1. Sample size and underpowered study Reviewer comment: The manuscript reports a calculated minimum sample size of 302 participants; however, only 46 valid responses were ultimately analyzed. Although the authors attribute this to a limited specialist pool, the manuscript also states that approximately 1,400 eligible professionals exist in the target population. This creates an inconsistency between the theoretical sampling framework and the achieved sample. Most importantly, the final sample size is substantially below the calculated requirement, rendering the study underpowered for inferential statistical testing. Under such conditions, p-values become unstable, and the risk of both Type I and Type II errors increases considerably. If the authors were unable to realistically achieve the required sample size, the study should be explicitly repositioned as an exploratory or pilot investigation, and the inferential claims should be substantially tempered. Response: We fully agree with this important observation. The manuscript has been revised to explicitly acknowledge the discrepancy between the calculated and achieved sample size. We have now clearly repositioned the study as an exploratory survey investigation rather than a confirmatory or inferential study. This clarification has been added to the Abstract, Methods, Results, Discussion, and Conclusion. We have explicitly stated that the limited sample size reduces statistical power and increases the risk of both Type I and Type II errors. 2. Use of inferential statistical tests in a small dataset Reviewer comment: Related to this issue is the use of multiple inferential statistical tests in a small dataset. The manuscript employs several chi-square analyses and univariate linear regression. With a final sample of 46 respondents, there is a high probability that assumptions underlying chi-square tests—particularly minimum expected cell counts—may not be satisfied. Additionally, multiple comparisons are conducted without correction, increasing the risk of false-positive findings. Given the limited sample size, the statistical analysis would be more appropriately framed as primarily descriptive. Inferential modeling, if retained, should be explicitly described as exploratory and interpreted with considerable caution. Response: We agree and have revised the manuscript accordingly: All inferential analyses are now explicitly described as exploratory. The Results section has been revised to emphasize descriptive findings, with reduced reliance on p-values. A clear statement has been added indicating that inferential results should be interpreted as hypothesis-generating rather than confirmatory. The limitations of chi-square testing in small samples (including expected cell counts) are now explicitly acknowledged. 3. Clarification of regression analysis and Sampling strategy and external validity Reviewer comment: The use of univariate linear regression to assess the association between age and CAT usage also warrants clarification. It is not sufficiently clear whether the dependent variable representing CAT use is continuous, ordinal, or binary. If the outcome is binary or categorical, linear regression is not the appropriate analytical approach, and logistic regression would be methodologically preferable. The reported R² value appears relatively high given the small sample size, which further underscores the need for clarification regarding model specification, variable coding, and assumption testing. Without this clarification, the validity of the regression findings remains uncertain. The sampling strategy also limits external validity. The study relied on convenience sampling through online distribution and professional networks, with a response rate of 16.5%. While such an approach is common in survey research, it introduces self-selection bias and may disproportionately attract clinicians already interested in or favorable toward CAT. Although the authors acknowledge this limitation, its implications for generalizability should be more explicitly emphasized in both the discussion and conclusion. Statements regarding trends in CAT adoption should be presented cautiously and framed within the context of these sampling constraints. Response: We have clarified the regression methodology in the Statistical Analysis section: The dependent variable (CAT usage) is now explicitly described as a continuous composite score derived from questionnaire responses. The rationale for using linear regression has been clarified. The interpretation of the regression model has been substantially tempered, and results are now presented as exploratory observations rather than definitive findings. Convenience sampling and low response rate introduce bias and limit generalizability. Response: We agree and have strengthened this aspect: The implications of self-selection bias and non-response bias are now explicitly discussed. We have clarified that clinicians with prior interest in CAT may have been overrepresented. Statements regarding trends and adoption have been reworded cautiously. Limitations in external validity and generalizability are now clearly emphasized in both the Discussion and Conclusion. 4. Interpretation of age as a predictor Reviewer comment: The conclusion that age may influence CAT adoption should be reformulated as a hypothesis-generating observation rather than a definitive finding. Given the limited sample size and statistical fragility, the results should be interpreted as preliminary and in need of confirmation through adequately powered studies. Strengthening the distinction between descriptive observations and inferential claims would improve the internal coherence of the manuscript. Response: This has been revised throughout the manuscript: The association between age and CAT usage is now described as exploratory and hypothesis-generating. Any language suggesting a definitive relationship has been removed. The need for validation in larger, adequately powered studies has been emphasized. We have made the following changes: The Results section is now primarily descriptive. Inferential findings are clearly labelled as exploratory. The Discussion and Conclusion have been revised to ensure cautious interpretation and avoid overgeneralization. 5. Overall revision In response to the reviewer’s recommendations, the manuscript has been comprehensively revised to: Reposition the study as an exploratory survey Strengthen transparency regarding methodological limitations Improve clarity of statistical methods Ensure appropriate interpretation of findings We are grateful for the reviewer’s insightful feedback, which has significantly improved the methodological clarity and scientific rigor of the manuscript. We believe the revised version now more accurately reflects the exploratory nature of the study and provides a balanced and cautious interpretation of the findings. Competing Interests: None Close Report a concern COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 29 Sep 2025 Views 0 Cite How to cite this report: Mohamed AM. Reviewer Report For: The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons [version 4; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 14 :1001 ( https://doi.org/10.5256/f1000research.187514.r419152 ) The direct URL for this report is: https://f1000research.com/articles/14-1001/v1#referee-response-419152 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 22 Oct 2025 Abdelrahman MA Mohamed , Orthodontics, Royal College of Surgeons of Edinburgh, Edinburgh, UK Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.187514.r419152 I would like to thank the editor very much for giving me the opportunity to review this paper. Below are my comments and suggestions to strengthen the manuscript. Title : It should be ... Continue reading READ ALL I would like to thank the editor very much for giving me the opportunity to review this paper. Below are my comments and suggestions to strengthen the manuscript. Title : It should be orthodontists, not orthodontics . Abstract: The response rate percentage (16.5%) should appear in the results. Introduction : The authors in the 1 st line mentioned ‘ dental anomaly’ it would be better to change it with ‘dentofacial’ as they are talking about skeletal deformities and orthognathic surgery. focus more on the gap in literature concerning CAT in orthognathic surgery. Material and Methods : Better to put the ethical consideration at the beginning of the methods section and merge it with the study design and setting. Ethical approval is mentioned twice ( in methods and before the references with slight variation in details) better to be accurately mentioned once. How participants were recruited? (email list? Saudi Orthodontic society? Or how?). Can the author put the equation used in the Sample size calculation? Sample size are very small especially for the orthognathic surgeons. Author did not mention how to handle the bias came from the very low response rate (16.5%). The authors mentioned that the sample size required is 278, but they only included 46, this is too small sample size compared to the actual needed sample based on the authors calculation. This can extremely weaken the study by: Reduced statistical power (less ability to detect real effects). Increased risk of Type II error (failing to detect a difference that exists). - Many orthodontist don’t treat the cases with orthodontic-orthognathic surgery, how about even treated these cases with CAT technology, this required a good experience in orthodontic-orthognathic surgery cases. It would be better to chooses expert orthodontist and maxillo-facial surgeons in this field in the inclusion exclusion criteria. - In the statistical step, authors mentioned that 4 participants did not complete their response, can the author give the actual number of participants whom completed the response and included in the study? - Why did the authors used Mann-Whitney U test and not independent samples t-test? Did they performed the normal distribution analysis and found that the data are non-parametric ( not normally distributed) please explain. - It is better to explain the program used in the statistics SPSS in the beginning and not the end of the statistical analysis. - In the statistical analysis: author should mention the type of statistical test used above each table and cite each statistical test to the corresponding table. Results: Ensure all abbreviations are defined in table footnotes ( p-value, CI, etc). What are Table S1 and Table S2??? Is it a writing mistake or what? Many sentences in the 1 st paragraph are not cited and linked to any tables, better to arrange it in a table. Discussion: - At the end of the discussion, the author mention that: ‘ Orthodontists and oral & maxillofacial surgeons should have catered CATs in their postgraduate training. They should expand on digital workflows, aligner biomechanics, and technology integration, and allocate time to the importance of interdisciplinary cooperation, clinical sequencing, and the utility of hybrid approaches when CAT alone may prove inadequate’ I think this paragraph is not accurate, this is correct for orthodontist but not for orthognathic surgeons to know the biomechanics at all, clinical sequence nor utility of hybrid approach, it is much simple for orthognathic surgeon in this field just to know basks and to know hot to apply the inter-maxillary elastics after surgery for patient wearing CAT. - Beside the discussion looks long, it give a little explanation of the founded result. I recommend the author to focus more on the discussion section in explanation of the finding of the results and compare it more with other studies and findings in the literature. - Put practical recommendations (e.g., training courses, inclusion of CAT in residency programs). Conclusion : - Generally,the conclusions, seems giving no real benefit, the author should also mention the difficulties during orthognathic surgery when used with CAT, e.g. the maxillary fixation, how to use the heavy intermaxillary elastics, splints etc., not only mentioning the orthodontic difficulties. - Should summarize major quantitative findings and their implications e.g.: “Most orthodontists and surgeons surveyed had limited experience with CAT in orthognathic cases, indicating the need for enhanced clinical training and interdisciplinary collaboration.” References : - The introduction started with an odd statement that not linked to the study , and in return the selected reference are not linked to the study at all ???!!! ref no. 1-3. - Where did the author cite reference no. 43? Also this reference almost have same idea , patient of the current study? Tables: - Table 1 is unclear and it’s column 2 is not defined. - Many variables ( rows) in table 2 seems not linked to the CAT with surgery, it is only related to CAT and orthodontics. e.g.: row 3: It is challenging to achieve the needed pre surgical space closure, row 4 Minor grammar and style edits are recommended. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? No Are the conclusions drawn adequately supported by the results? No Competing Interests: No competing interests were disclosed. Reviewer Expertise: Orthodontics. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Mohamed AM. Reviewer Report For: The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons [version 4; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 14 :1001 ( https://doi.org/10.5256/f1000research.187514.r419152 ) The direct URL for this report is: https://f1000research.com/articles/14-1001/v1#referee-response-419152 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 14 Feb 2026 Ahmad Assari , Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, College of Medicine and Dentistry, Riyadh Elm University, Riyadh, Saudi Arabia 14 Feb 2026 Author Response Title : It should be orthodontists, not orthodontics . Response: done Abstract : The response rate percentage (16.5%) should appear in the results. Response: done ... Continue reading Title : It should be orthodontists, not orthodontics . Response: done Abstract : The response rate percentage (16.5%) should appear in the results. Response: done Introduction : The authors in the 1 st line mentioned ‘dental anomaly’ it would be better to change it with ‘dentofacial’ as they are talking about skeletal deformities and orthognathic surgery. Response: We thank the reviewer for this helpful suggestion. The term “dental anomaly” has been replaced with “dentofacial anomaly” to more accurately reflect the skeletal and facial components relevant to orthognathic surgery. This modification ensures better alignment between the introductory context and the study’s clinical focus. focus more on the gap in literature concerning CAT in orthognathic surgery. Response: done Response: We agree with the reviewer’s observation and have revised the final paragraph of the Introduction to better highlight the literature gap on the use of Clear Aligner Therapy (CAT) in orthognathic surgery. The new text emphasizes that, although CAT has gained global popularity in orthodontics, there is a lack of empirical data regarding its application, feasibility, and clinician readiness in surgical orthodontic contexts, especially within the Saudi population. This strengthened focus now clearly establishes the rationale for conducting the present study. Material and Methods : Better to put the ethical consideration at the beginning of the methods section and merge it with the study design and setting. Response: We appreciate the reviewer’s recommendation. The Ethical Consideration subsection has now been moved and merged with the Study Design and Setting subsection at the beginning of the Methods section to improve logical flow and eliminate redundancy. Ethical approval is mentioned twice ( in methods and before the references with slight variation in details) better to be accurately mentioned once. Response: We thank the reviewer for identifying this duplication. The repeated ethical statement before the References section has been removed , and only the version integrated within the Study Design and Setting subsection has been retained for accuracy and consistency. How were participants recruited? (email list? Saudi Orthodontic society? Or how?). Response: Thank you for this important clarification. The participant recruitment process has now been described in detail. The revised text specifies that survey invitations were distributed through professional email lists , the Saudi Orthodontic Society , academic institutions , and social media platforms (e.g., WhatsApp and LinkedIn) to maximize geographic and professional reach. Can the author put the equation used in the Sample size calculation? Response: We appreciate the suggestion. The finite population sample size equation has now been added to the Sample Size and Population subsection, including variable definitions for clarity. Sample size are very small especially for the orthognathic surgeons. Response: We agree with the reviewer. A statement has been added acknowledging the small subgroup size of oral and maxillofacial surgeons, attributing it to their limited national representation and demanding clinical schedules. The revision also clarifies that while the sample size limits inferential generalization, it provides valuable pilot data for future multicenter and higher-powered studies. Author did not mention how to handle the bias came from the very low response rate (16.5%). Response: We thank the reviewer for noting this. A paragraph addressing potential non-response and self-selection bias has been added to the Sample Size and Population subsection. The revised text explains measures taken to minimize bias (multi-channel recruitment, anonymity assurance, and non-parametric analysis) and justifies interpreting results within an exploratory framework rather than population-level inference. The authors mentioned that the sample size required is 278, but they only included 46, this is too small sample size compared to the actual needed sample based on the authors calculation. This can extremely weaken the study by: Reduced statistical power (less ability to detect real effects). Increased risk of Type II error (failing to detect a difference that exists). Response: We acknowledge this limitation and have now included an explicit statement describing the impact of reduced sample size on statistical power and Type II error . This limitation is now clearly discussed in the Sample Size and Population subsection and reiterated in the Limitations section, clarifying that this study was exploratory and intended to provide pilot-level evidence to guide larger-scale future research. - Many orthodontist don’t treat the cases with orthodontic-orthognathic surgery, how about even treated these cases with CAT technology, this required a good experience in orthodontic-orthognathic surgery cases. It would be better to chooses expert orthodontist and maxillo-facial surgeons in this field in the inclusion exclusion criteria. Response: We thank the reviewer for this insightful observation. We have now clarified the inclusion criteria to emphasize that the study targeted licensed orthodontists and oral and maxillofacial surgeons actively practicing in Saudi Arabia , regardless of their level of experience with orthognathic surgery. However, to address the reviewer’s concern, we have added a statement specifying that future studies should consider recruiting only experienced clinicians or specialists who regularly perform orthognathic treatments , to ensure deeper insight into expert practices. This note has been added to the Limitations section to acknowledge the potential variability in participant expertise. - In the statistical step, authors mentioned that 4 participants did not complete their response, can the author give the actual number of participants whom completed the response and included in the study? Response: We appreciate this request for clarity. The total number of participants who completed the questionnaire in full and were included in the final analysis was 46 , after excluding 4 incomplete responses from the original 50 submissions. This has been explicitly stated in the Statistical Analysis subsection. - Why did the authors used Mann-Whitney U test and not independent samples t-test? Did they performed the normal distribution analysis and found that the data are non-parametric ( not normally distributed) please explain. Response: We thank the reviewer for highlighting this point. The Mann–Whitney U test was used because the normality assumption was not met for the knowledge score data. This indicates that the data were non-normally distributed , making the Mann–Whitney U test a more appropriate non-parametric alternative to the independent samples t-test. This clarification has been added to the Statistical Analysis section to ensure transparency regarding the choice of statistical test. - It is better to explain the program used in the statistics SPSS in the beginning and not the end of the statistical analysis. Response: We agree with the reviewer. The mention of the statistical software ( IBM SPSS Statistics version 27, Chicago, IL, USA ) has been relocated to the beginning of the Statistical Analysis section for improved readability and consistency with journal standards. - In the statistical analysis: author should mention the type of statistical test used above each table and cite each statistical test to the corresponding table. Response: We appreciate this helpful suggestion. The type of statistical test used in each analysis has now been explicitly indicated above every table in the Results section (e.g., Statistical test: Chi-square test , Statistical test: Mann–Whitney U test , Statistical test: Univariate linear regression analysis ). Additionally, cross-references have been added in the Statistical Analysis section to identify which test corresponds to which table for greater clarity and transparency. Results: Ensure all abbreviations are defined in table footnotes ( p-value, CI, etc). Response: We appreciate the reviewer’s careful attention to detail. All abbreviations, including p-value (probability value) and CI (confidence interval), have now been clearly defined in the footnotes of all tables (Tables 1–7) to ensure clarity and uniformity. What are Table S1 and Table S2??? Is it a writing mistake or what? Response: We thank the reviewer for pointing out this issue. The mention of “Table S1” and “Table S2” was an inadvertent labeling error carried over from an earlier draft where supplementary tables were planned but later merged into the main text. These have now been corrected and relabeled as Table 1 and Table 2 , respectively, ensuring consistency throughout the Results section and in-text citations. All references to “S1” and “S2” have been deleted and replaced with “Table 1” and “Table 2.” Many sentences in the 1 st paragraph are not cited and linked to any tables, better to arrange it in a table. Response: We appreciate this constructive comment. The first paragraph of the Results section has been restructured for clarity . Quantitative findings that were previously written narratively are now directly linked to their corresponding tables , and where appropriate, data have been reorganized into concise tabular form. Each descriptive statement now includes the relevant table reference in parentheses, e.g., “(Table 1)” or “(Table 2),” to allow readers to easily cross-check findings. This restructuring improves logical flow, clarity, and data traceability. Discussion: - At the end of the discussion, the author mention that: ‘ Orthodontists and oral & maxillofacial surgeons should have catered CATs in their postgraduate training. They should expand on digital workflows, aligner biomechanics, and technology integration, and allocate time to the importance of interdisciplinary cooperation, clinical sequencing, and the utility of hybrid approaches when CAT alone may prove inadequate’ I think this paragraph is not accurate, this is correct for orthodontist but not for orthognathic surgeons to know the biomechanics at all, clinical sequence nor utility of hybrid approach, it is much simple for orthognathic surgeon in this field just to know basks and to know hot to apply the inter-maxillary elastics after surgery for patient wearing CAT. Response: We thank the reviewer for this precise and valuable clarification. We agree that the original statement overstated the training requirements for oral and maxillofacial surgeons. The paragraph has been revised to clearly distinguish between the educational needs of orthodontists and surgeons. Orthodontists’ training recommendations remain focused on digital workflows, biomechanics, and case sequencing , while the surgeons’ component now emphasizes understanding splint adaptation, intermaxillary fixation (IMF), and postoperative elastic management . - Beside the discussion looks long, it give a little explanation of the founded result. I recommend the author to focus more on the discussion section in explanation of the finding of the results and compare it more with other studies and findings in the literature. Response: We appreciate this insightful feedback. The Discussion section has been condensed and refocused to emphasize interpretation of our main results rather than general literature review. - Put practical recommendations (e.g., training courses, inclusion of CAT in residency programs). Response: Thank you for this excellent suggestion. We have incorporated a new “Practical Recommendations” paragraph at the end of the Discussion, explicitly outlining actionable educational and clinical strategies. These include integrating CAT education into orthodontic and surgical residency curricula, conducting continuing professional training workshops, and fostering national and international collaboration. Conclusion : - Generally,the conclusions, seems giving no real benefit, the author should also mention the difficulties during orthognathic surgery when used with CAT, e.g. the maxillary fixation, how to use the heavy intermaxillary elastics, splints etc., not only mentioning the orthodontic difficulties. Response: We thank the reviewer for this valuable feedback. We have revised the Conclusion to provide a more comprehensive and clinically relevant summary that acknowledges both orthodontic and surgical challenges associated with Clear Aligner Therapy (CAT) in orthognathic surgery. The revised version now includes mention of intraoperative and postoperative challenges , such as maxillary fixation, splint adaptation, and management of intermaxillary elastics in CAT-treated patients, to ensure that both specialties’ perspectives are reflected. - Should summarize major quantitative findings and their implications e.g.: “Most orthodontists and surgeons surveyed had limited experience with CAT in orthognathic cases, indicating the need for enhanced clinical training and interdisciplinary collaboration.” Response: We fully agree with this suggestion. The revised conclusion now incorporates quantitative summary statements (e.g., the low response rate, limited experience levels, and lack of significant knowledge difference between specialties) and their broader implications for clinical practice and training . The final paragraph also emphasizes the importance of interdisciplinary collaboration , standardized training , and evidence-based clinical integration of CAT into surgical orthodontics. References : - The introduction started with an odd statement that not linked to the study , and in return the selected reference are not linked to the study at all ???!!! ref no. 1-3. Response: We thank the reviewer for this observation. We respectfully clarify that References 1–3 were intentionally included to provide epidemiological context regarding the prevalence of dentofacial anomalies , which are the underlying conditions often treated through orthognathic surgery —the core topic of this study. However, to improve clarity and ensure stronger linkage between these references and the study focus, the opening paragraph of the Introduction was revised to better connect the cited data on dentofacial anomalies to the relevance of orthognathic surgery and, subsequently, to Clear Aligner Therapy (CAT). - Where did the author cite reference no. 43? Also this reference almost have same idea , patient of the current study? Response: We thank the reviewer for this valuable observation. Reference no. 43 refers to the Zenodo data repository containing the dataset that supports the findings of the current study, rather than to a separate research article or independent sample. Tables: - Table 1 is unclear and it’s column 2 is not defined. Response: We thank the reviewer for identifying this oversight. The second column in Table 1 has now been properly labeled to specify its content. - Many variables ( rows) in table 2 seems not linked to the CAT with surgery, it is only related to CAT and orthodontics. e.g.: row 3: It is challenging to achieve the needed pre surgical space closure, row 4 Response: We appreciate the reviewer’s observation. We agree that certain items in Table 2 appeared more related to general orthodontic CAT practice rather than surgical applications . Title : It should be orthodontists, not orthodontics . Response: done Abstract : The response rate percentage (16.5%) should appear in the results. Response: done Introduction : The authors in the 1 st line mentioned ‘dental anomaly’ it would be better to change it with ‘dentofacial’ as they are talking about skeletal deformities and orthognathic surgery. Response: We thank the reviewer for this helpful suggestion. The term “dental anomaly” has been replaced with “dentofacial anomaly” to more accurately reflect the skeletal and facial components relevant to orthognathic surgery. This modification ensures better alignment between the introductory context and the study’s clinical focus. focus more on the gap in literature concerning CAT in orthognathic surgery. Response: done Response: We agree with the reviewer’s observation and have revised the final paragraph of the Introduction to better highlight the literature gap on the use of Clear Aligner Therapy (CAT) in orthognathic surgery. The new text emphasizes that, although CAT has gained global popularity in orthodontics, there is a lack of empirical data regarding its application, feasibility, and clinician readiness in surgical orthodontic contexts, especially within the Saudi population. This strengthened focus now clearly establishes the rationale for conducting the present study. Material and Methods : Better to put the ethical consideration at the beginning of the methods section and merge it with the study design and setting. Response: We appreciate the reviewer’s recommendation. The Ethical Consideration subsection has now been moved and merged with the Study Design and Setting subsection at the beginning of the Methods section to improve logical flow and eliminate redundancy. Ethical approval is mentioned twice ( in methods and before the references with slight variation in details) better to be accurately mentioned once. Response: We thank the reviewer for identifying this duplication. The repeated ethical statement before the References section has been removed , and only the version integrated within the Study Design and Setting subsection has been retained for accuracy and consistency. How were participants recruited? (email list? Saudi Orthodontic society? Or how?). Response: Thank you for this important clarification. The participant recruitment process has now been described in detail. The revised text specifies that survey invitations were distributed through professional email lists , the Saudi Orthodontic Society , academic institutions , and social media platforms (e.g., WhatsApp and LinkedIn) to maximize geographic and professional reach. Can the author put the equation used in the Sample size calculation? Response: We appreciate the suggestion. The finite population sample size equation has now been added to the Sample Size and Population subsection, including variable definitions for clarity. Sample size are very small especially for the orthognathic surgeons. Response: We agree with the reviewer. A statement has been added acknowledging the small subgroup size of oral and maxillofacial surgeons, attributing it to their limited national representation and demanding clinical schedules. The revision also clarifies that while the sample size limits inferential generalization, it provides valuable pilot data for future multicenter and higher-powered studies. Author did not mention how to handle the bias came from the very low response rate (16.5%). Response: We thank the reviewer for noting this. A paragraph addressing potential non-response and self-selection bias has been added to the Sample Size and Population subsection. The revised text explains measures taken to minimize bias (multi-channel recruitment, anonymity assurance, and non-parametric analysis) and justifies interpreting results within an exploratory framework rather than population-level inference. The authors mentioned that the sample size required is 278, but they only included 46, this is too small sample size compared to the actual needed sample based on the authors calculation. This can extremely weaken the study by: Reduced statistical power (less ability to detect real effects). Increased risk of Type II error (failing to detect a difference that exists). Response: We acknowledge this limitation and have now included an explicit statement describing the impact of reduced sample size on statistical power and Type II error . This limitation is now clearly discussed in the Sample Size and Population subsection and reiterated in the Limitations section, clarifying that this study was exploratory and intended to provide pilot-level evidence to guide larger-scale future research. - Many orthodontist don’t treat the cases with orthodontic-orthognathic surgery, how about even treated these cases with CAT technology, this required a good experience in orthodontic-orthognathic surgery cases. It would be better to chooses expert orthodontist and maxillo-facial surgeons in this field in the inclusion exclusion criteria. Response: We thank the reviewer for this insightful observation. We have now clarified the inclusion criteria to emphasize that the study targeted licensed orthodontists and oral and maxillofacial surgeons actively practicing in Saudi Arabia , regardless of their level of experience with orthognathic surgery. However, to address the reviewer’s concern, we have added a statement specifying that future studies should consider recruiting only experienced clinicians or specialists who regularly perform orthognathic treatments , to ensure deeper insight into expert practices. This note has been added to the Limitations section to acknowledge the potential variability in participant expertise. - In the statistical step, authors mentioned that 4 participants did not complete their response, can the author give the actual number of participants whom completed the response and included in the study? Response: We appreciate this request for clarity. The total number of participants who completed the questionnaire in full and were included in the final analysis was 46 , after excluding 4 incomplete responses from the original 50 submissions. This has been explicitly stated in the Statistical Analysis subsection. - Why did the authors used Mann-Whitney U test and not independent samples t-test? Did they performed the normal distribution analysis and found that the data are non-parametric ( not normally distributed) please explain. Response: We thank the reviewer for highlighting this point. The Mann–Whitney U test was used because the normality assumption was not met for the knowledge score data. This indicates that the data were non-normally distributed , making the Mann–Whitney U test a more appropriate non-parametric alternative to the independent samples t-test. This clarification has been added to the Statistical Analysis section to ensure transparency regarding the choice of statistical test. - It is better to explain the program used in the statistics SPSS in the beginning and not the end of the statistical analysis. Response: We agree with the reviewer. The mention of the statistical software ( IBM SPSS Statistics version 27, Chicago, IL, USA ) has been relocated to the beginning of the Statistical Analysis section for improved readability and consistency with journal standards. - In the statistical analysis: author should mention the type of statistical test used above each table and cite each statistical test to the corresponding table. Response: We appreciate this helpful suggestion. The type of statistical test used in each analysis has now been explicitly indicated above every table in the Results section (e.g., Statistical test: Chi-square test , Statistical test: Mann–Whitney U test , Statistical test: Univariate linear regression analysis ). Additionally, cross-references have been added in the Statistical Analysis section to identify which test corresponds to which table for greater clarity and transparency. Results: Ensure all abbreviations are defined in table footnotes ( p-value, CI, etc). Response: We appreciate the reviewer’s careful attention to detail. All abbreviations, including p-value (probability value) and CI (confidence interval), have now been clearly defined in the footnotes of all tables (Tables 1–7) to ensure clarity and uniformity. What are Table S1 and Table S2??? Is it a writing mistake or what? Response: We thank the reviewer for pointing out this issue. The mention of “Table S1” and “Table S2” was an inadvertent labeling error carried over from an earlier draft where supplementary tables were planned but later merged into the main text. These have now been corrected and relabeled as Table 1 and Table 2 , respectively, ensuring consistency throughout the Results section and in-text citations. All references to “S1” and “S2” have been deleted and replaced with “Table 1” and “Table 2.” Many sentences in the 1 st paragraph are not cited and linked to any tables, better to arrange it in a table. Response: We appreciate this constructive comment. The first paragraph of the Results section has been restructured for clarity . Quantitative findings that were previously written narratively are now directly linked to their corresponding tables , and where appropriate, data have been reorganized into concise tabular form. Each descriptive statement now includes the relevant table reference in parentheses, e.g., “(Table 1)” or “(Table 2),” to allow readers to easily cross-check findings. This restructuring improves logical flow, clarity, and data traceability. Discussion: - At the end of the discussion, the author mention that: ‘ Orthodontists and oral & maxillofacial surgeons should have catered CATs in their postgraduate training. They should expand on digital workflows, aligner biomechanics, and technology integration, and allocate time to the importance of interdisciplinary cooperation, clinical sequencing, and the utility of hybrid approaches when CAT alone may prove inadequate’ I think this paragraph is not accurate, this is correct for orthodontist but not for orthognathic surgeons to know the biomechanics at all, clinical sequence nor utility of hybrid approach, it is much simple for orthognathic surgeon in this field just to know basks and to know hot to apply the inter-maxillary elastics after surgery for patient wearing CAT. Response: We thank the reviewer for this precise and valuable clarification. We agree that the original statement overstated the training requirements for oral and maxillofacial surgeons. The paragraph has been revised to clearly distinguish between the educational needs of orthodontists and surgeons. Orthodontists’ training recommendations remain focused on digital workflows, biomechanics, and case sequencing , while the surgeons’ component now emphasizes understanding splint adaptation, intermaxillary fixation (IMF), and postoperative elastic management . - Beside the discussion looks long, it give a little explanation of the founded result. I recommend the author to focus more on the discussion section in explanation of the finding of the results and compare it more with other studies and findings in the literature. Response: We appreciate this insightful feedback. The Discussion section has been condensed and refocused to emphasize interpretation of our main results rather than general literature review. - Put practical recommendations (e.g., training courses, inclusion of CAT in residency programs). Response: Thank you for this excellent suggestion. We have incorporated a new “Practical Recommendations” paragraph at the end of the Discussion, explicitly outlining actionable educational and clinical strategies. These include integrating CAT education into orthodontic and surgical residency curricula, conducting continuing professional training workshops, and fostering national and international collaboration. Conclusion : - Generally,the conclusions, seems giving no real benefit, the author should also mention the difficulties during orthognathic surgery when used with CAT, e.g. the maxillary fixation, how to use the heavy intermaxillary elastics, splints etc., not only mentioning the orthodontic difficulties. Response: We thank the reviewer for this valuable feedback. We have revised the Conclusion to provide a more comprehensive and clinically relevant summary that acknowledges both orthodontic and surgical challenges associated with Clear Aligner Therapy (CAT) in orthognathic surgery. The revised version now includes mention of intraoperative and postoperative challenges , such as maxillary fixation, splint adaptation, and management of intermaxillary elastics in CAT-treated patients, to ensure that both specialties’ perspectives are reflected. - Should summarize major quantitative findings and their implications e.g.: “Most orthodontists and surgeons surveyed had limited experience with CAT in orthognathic cases, indicating the need for enhanced clinical training and interdisciplinary collaboration.” Response: We fully agree with this suggestion. The revised conclusion now incorporates quantitative summary statements (e.g., the low response rate, limited experience levels, and lack of significant knowledge difference between specialties) and their broader implications for clinical practice and training . The final paragraph also emphasizes the importance of interdisciplinary collaboration , standardized training , and evidence-based clinical integration of CAT into surgical orthodontics. References : - The introduction started with an odd statement that not linked to the study , and in return the selected reference are not linked to the study at all ???!!! ref no. 1-3. Response: We thank the reviewer for this observation. We respectfully clarify that References 1–3 were intentionally included to provide epidemiological context regarding the prevalence of dentofacial anomalies , which are the underlying conditions often treated through orthognathic surgery —the core topic of this study. However, to improve clarity and ensure stronger linkage between these references and the study focus, the opening paragraph of the Introduction was revised to better connect the cited data on dentofacial anomalies to the relevance of orthognathic surgery and, subsequently, to Clear Aligner Therapy (CAT). - Where did the author cite reference no. 43? Also this reference almost have same idea , patient of the current study? Response: We thank the reviewer for this valuable observation. Reference no. 43 refers to the Zenodo data repository containing the dataset that supports the findings of the current study, rather than to a separate research article or independent sample. Tables: - Table 1 is unclear and it’s column 2 is not defined. Response: We thank the reviewer for identifying this oversight. The second column in Table 1 has now been properly labeled to specify its content. - Many variables ( rows) in table 2 seems not linked to the CAT with surgery, it is only related to CAT and orthodontics. e.g.: row 3: It is challenging to achieve the needed pre surgical space closure, row 4 Response: We appreciate the reviewer’s observation. We agree that certain items in Table 2 appeared more related to general orthodontic CAT practice rather than surgical applications . Competing Interests: no competing interests to disclose. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 14 Feb 2026 Ahmad Assari , Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, College of Medicine and Dentistry, Riyadh Elm University, Riyadh, Saudi Arabia 14 Feb 2026 Author Response Title : It should be orthodontists, not orthodontics . Response: done Abstract : The response rate percentage (16.5%) should appear in the results. Response: done ... Continue reading Title : It should be orthodontists, not orthodontics . Response: done Abstract : The response rate percentage (16.5%) should appear in the results. Response: done Introduction : The authors in the 1 st line mentioned ‘dental anomaly’ it would be better to change it with ‘dentofacial’ as they are talking about skeletal deformities and orthognathic surgery. Response: We thank the reviewer for this helpful suggestion. The term “dental anomaly” has been replaced with “dentofacial anomaly” to more accurately reflect the skeletal and facial components relevant to orthognathic surgery. This modification ensures better alignment between the introductory context and the study’s clinical focus. focus more on the gap in literature concerning CAT in orthognathic surgery. Response: done Response: We agree with the reviewer’s observation and have revised the final paragraph of the Introduction to better highlight the literature gap on the use of Clear Aligner Therapy (CAT) in orthognathic surgery. The new text emphasizes that, although CAT has gained global popularity in orthodontics, there is a lack of empirical data regarding its application, feasibility, and clinician readiness in surgical orthodontic contexts, especially within the Saudi population. This strengthened focus now clearly establishes the rationale for conducting the present study. Material and Methods : Better to put the ethical consideration at the beginning of the methods section and merge it with the study design and setting. Response: We appreciate the reviewer’s recommendation. The Ethical Consideration subsection has now been moved and merged with the Study Design and Setting subsection at the beginning of the Methods section to improve logical flow and eliminate redundancy. Ethical approval is mentioned twice ( in methods and before the references with slight variation in details) better to be accurately mentioned once. Response: We thank the reviewer for identifying this duplication. The repeated ethical statement before the References section has been removed , and only the version integrated within the Study Design and Setting subsection has been retained for accuracy and consistency. How were participants recruited? (email list? Saudi Orthodontic society? Or how?). Response: Thank you for this important clarification. The participant recruitment process has now been described in detail. The revised text specifies that survey invitations were distributed through professional email lists , the Saudi Orthodontic Society , academic institutions , and social media platforms (e.g., WhatsApp and LinkedIn) to maximize geographic and professional reach. Can the author put the equation used in the Sample size calculation? Response: We appreciate the suggestion. The finite population sample size equation has now been added to the Sample Size and Population subsection, including variable definitions for clarity. Sample size are very small especially for the orthognathic surgeons. Response: We agree with the reviewer. A statement has been added acknowledging the small subgroup size of oral and maxillofacial surgeons, attributing it to their limited national representation and demanding clinical schedules. The revision also clarifies that while the sample size limits inferential generalization, it provides valuable pilot data for future multicenter and higher-powered studies. Author did not mention how to handle the bias came from the very low response rate (16.5%). Response: We thank the reviewer for noting this. A paragraph addressing potential non-response and self-selection bias has been added to the Sample Size and Population subsection. The revised text explains measures taken to minimize bias (multi-channel recruitment, anonymity assurance, and non-parametric analysis) and justifies interpreting results within an exploratory framework rather than population-level inference. The authors mentioned that the sample size required is 278, but they only included 46, this is too small sample size compared to the actual needed sample based on the authors calculation. This can extremely weaken the study by: Reduced statistical power (less ability to detect real effects). Increased risk of Type II error (failing to detect a difference that exists). Response: We acknowledge this limitation and have now included an explicit statement describing the impact of reduced sample size on statistical power and Type II error . This limitation is now clearly discussed in the Sample Size and Population subsection and reiterated in the Limitations section, clarifying that this study was exploratory and intended to provide pilot-level evidence to guide larger-scale future research. - Many orthodontist don’t treat the cases with orthodontic-orthognathic surgery, how about even treated these cases with CAT technology, this required a good experience in orthodontic-orthognathic surgery cases. It would be better to chooses expert orthodontist and maxillo-facial surgeons in this field in the inclusion exclusion criteria. Response: We thank the reviewer for this insightful observation. We have now clarified the inclusion criteria to emphasize that the study targeted licensed orthodontists and oral and maxillofacial surgeons actively practicing in Saudi Arabia , regardless of their level of experience with orthognathic surgery. However, to address the reviewer’s concern, we have added a statement specifying that future studies should consider recruiting only experienced clinicians or specialists who regularly perform orthognathic treatments , to ensure deeper insight into expert practices. This note has been added to the Limitations section to acknowledge the potential variability in participant expertise. - In the statistical step, authors mentioned that 4 participants did not complete their response, can the author give the actual number of participants whom completed the response and included in the study? Response: We appreciate this request for clarity. The total number of participants who completed the questionnaire in full and were included in the final analysis was 46 , after excluding 4 incomplete responses from the original 50 submissions. This has been explicitly stated in the Statistical Analysis subsection. - Why did the authors used Mann-Whitney U test and not independent samples t-test? Did they performed the normal distribution analysis and found that the data are non-parametric ( not normally distributed) please explain. Response: We thank the reviewer for highlighting this point. The Mann–Whitney U test was used because the normality assumption was not met for the knowledge score data. This indicates that the data were non-normally distributed , making the Mann–Whitney U test a more appropriate non-parametric alternative to the independent samples t-test. This clarification has been added to the Statistical Analysis section to ensure transparency regarding the choice of statistical test. - It is better to explain the program used in the statistics SPSS in the beginning and not the end of the statistical analysis. Response: We agree with the reviewer. The mention of the statistical software ( IBM SPSS Statistics version 27, Chicago, IL, USA ) has been relocated to the beginning of the Statistical Analysis section for improved readability and consistency with journal standards. - In the statistical analysis: author should mention the type of statistical test used above each table and cite each statistical test to the corresponding table. Response: We appreciate this helpful suggestion. The type of statistical test used in each analysis has now been explicitly indicated above every table in the Results section (e.g., Statistical test: Chi-square test , Statistical test: Mann–Whitney U test , Statistical test: Univariate linear regression analysis ). Additionally, cross-references have been added in the Statistical Analysis section to identify which test corresponds to which table for greater clarity and transparency. Results: Ensure all abbreviations are defined in table footnotes ( p-value, CI, etc). Response: We appreciate the reviewer’s careful attention to detail. All abbreviations, including p-value (probability value) and CI (confidence interval), have now been clearly defined in the footnotes of all tables (Tables 1–7) to ensure clarity and uniformity. What are Table S1 and Table S2??? Is it a writing mistake or what? Response: We thank the reviewer for pointing out this issue. The mention of “Table S1” and “Table S2” was an inadvertent labeling error carried over from an earlier draft where supplementary tables were planned but later merged into the main text. These have now been corrected and relabeled as Table 1 and Table 2 , respectively, ensuring consistency throughout the Results section and in-text citations. All references to “S1” and “S2” have been deleted and replaced with “Table 1” and “Table 2.” Many sentences in the 1 st paragraph are not cited and linked to any tables, better to arrange it in a table. Response: We appreciate this constructive comment. The first paragraph of the Results section has been restructured for clarity . Quantitative findings that were previously written narratively are now directly linked to their corresponding tables , and where appropriate, data have been reorganized into concise tabular form. Each descriptive statement now includes the relevant table reference in parentheses, e.g., “(Table 1)” or “(Table 2),” to allow readers to easily cross-check findings. This restructuring improves logical flow, clarity, and data traceability. Discussion: - At the end of the discussion, the author mention that: ‘ Orthodontists and oral & maxillofacial surgeons should have catered CATs in their postgraduate training. They should expand on digital workflows, aligner biomechanics, and technology integration, and allocate time to the importance of interdisciplinary cooperation, clinical sequencing, and the utility of hybrid approaches when CAT alone may prove inadequate’ I think this paragraph is not accurate, this is correct for orthodontist but not for orthognathic surgeons to know the biomechanics at all, clinical sequence nor utility of hybrid approach, it is much simple for orthognathic surgeon in this field just to know basks and to know hot to apply the inter-maxillary elastics after surgery for patient wearing CAT. Response: We thank the reviewer for this precise and valuable clarification. We agree that the original statement overstated the training requirements for oral and maxillofacial surgeons. The paragraph has been revised to clearly distinguish between the educational needs of orthodontists and surgeons. Orthodontists’ training recommendations remain focused on digital workflows, biomechanics, and case sequencing , while the surgeons’ component now emphasizes understanding splint adaptation, intermaxillary fixation (IMF), and postoperative elastic management . - Beside the discussion looks long, it give a little explanation of the founded result. I recommend the author to focus more on the discussion section in explanation of the finding of the results and compare it more with other studies and findings in the literature. Response: We appreciate this insightful feedback. The Discussion section has been condensed and refocused to emphasize interpretation of our main results rather than general literature review. - Put practical recommendations (e.g., training courses, inclusion of CAT in residency programs). Response: Thank you for this excellent suggestion. We have incorporated a new “Practical Recommendations” paragraph at the end of the Discussion, explicitly outlining actionable educational and clinical strategies. These include integrating CAT education into orthodontic and surgical residency curricula, conducting continuing professional training workshops, and fostering national and international collaboration. Conclusion : - Generally,the conclusions, seems giving no real benefit, the author should also mention the difficulties during orthognathic surgery when used with CAT, e.g. the maxillary fixation, how to use the heavy intermaxillary elastics, splints etc., not only mentioning the orthodontic difficulties. Response: We thank the reviewer for this valuable feedback. We have revised the Conclusion to provide a more comprehensive and clinically relevant summary that acknowledges both orthodontic and surgical challenges associated with Clear Aligner Therapy (CAT) in orthognathic surgery. The revised version now includes mention of intraoperative and postoperative challenges , such as maxillary fixation, splint adaptation, and management of intermaxillary elastics in CAT-treated patients, to ensure that both specialties’ perspectives are reflected. - Should summarize major quantitative findings and their implications e.g.: “Most orthodontists and surgeons surveyed had limited experience with CAT in orthognathic cases, indicating the need for enhanced clinical training and interdisciplinary collaboration.” Response: We fully agree with this suggestion. The revised conclusion now incorporates quantitative summary statements (e.g., the low response rate, limited experience levels, and lack of significant knowledge difference between specialties) and their broader implications for clinical practice and training . The final paragraph also emphasizes the importance of interdisciplinary collaboration , standardized training , and evidence-based clinical integration of CAT into surgical orthodontics. References : - The introduction started with an odd statement that not linked to the study , and in return the selected reference are not linked to the study at all ???!!! ref no. 1-3. Response: We thank the reviewer for this observation. We respectfully clarify that References 1–3 were intentionally included to provide epidemiological context regarding the prevalence of dentofacial anomalies , which are the underlying conditions often treated through orthognathic surgery —the core topic of this study. However, to improve clarity and ensure stronger linkage between these references and the study focus, the opening paragraph of the Introduction was revised to better connect the cited data on dentofacial anomalies to the relevance of orthognathic surgery and, subsequently, to Clear Aligner Therapy (CAT). - Where did the author cite reference no. 43? Also this reference almost have same idea , patient of the current study? Response: We thank the reviewer for this valuable observation. Reference no. 43 refers to the Zenodo data repository containing the dataset that supports the findings of the current study, rather than to a separate research article or independent sample. Tables: - Table 1 is unclear and it’s column 2 is not defined. Response: We thank the reviewer for identifying this oversight. The second column in Table 1 has now been properly labeled to specify its content. - Many variables ( rows) in table 2 seems not linked to the CAT with surgery, it is only related to CAT and orthodontics. e.g.: row 3: It is challenging to achieve the needed pre surgical space closure, row 4 Response: We appreciate the reviewer’s observation. We agree that certain items in Table 2 appeared more related to general orthodontic CAT practice rather than surgical applications . Title : It should be orthodontists, not orthodontics . Response: done Abstract : The response rate percentage (16.5%) should appear in the results. Response: done Introduction : The authors in the 1 st line mentioned ‘dental anomaly’ it would be better to change it with ‘dentofacial’ as they are talking about skeletal deformities and orthognathic surgery. Response: We thank the reviewer for this helpful suggestion. The term “dental anomaly” has been replaced with “dentofacial anomaly” to more accurately reflect the skeletal and facial components relevant to orthognathic surgery. This modification ensures better alignment between the introductory context and the study’s clinical focus. focus more on the gap in literature concerning CAT in orthognathic surgery. Response: done Response: We agree with the reviewer’s observation and have revised the final paragraph of the Introduction to better highlight the literature gap on the use of Clear Aligner Therapy (CAT) in orthognathic surgery. The new text emphasizes that, although CAT has gained global popularity in orthodontics, there is a lack of empirical data regarding its application, feasibility, and clinician readiness in surgical orthodontic contexts, especially within the Saudi population. This strengthened focus now clearly establishes the rationale for conducting the present study. Material and Methods : Better to put the ethical consideration at the beginning of the methods section and merge it with the study design and setting. Response: We appreciate the reviewer’s recommendation. The Ethical Consideration subsection has now been moved and merged with the Study Design and Setting subsection at the beginning of the Methods section to improve logical flow and eliminate redundancy. Ethical approval is mentioned twice ( in methods and before the references with slight variation in details) better to be accurately mentioned once. Response: We thank the reviewer for identifying this duplication. The repeated ethical statement before the References section has been removed , and only the version integrated within the Study Design and Setting subsection has been retained for accuracy and consistency. How were participants recruited? (email list? Saudi Orthodontic society? Or how?). Response: Thank you for this important clarification. The participant recruitment process has now been described in detail. The revised text specifies that survey invitations were distributed through professional email lists , the Saudi Orthodontic Society , academic institutions , and social media platforms (e.g., WhatsApp and LinkedIn) to maximize geographic and professional reach. Can the author put the equation used in the Sample size calculation? Response: We appreciate the suggestion. The finite population sample size equation has now been added to the Sample Size and Population subsection, including variable definitions for clarity. Sample size are very small especially for the orthognathic surgeons. Response: We agree with the reviewer. A statement has been added acknowledging the small subgroup size of oral and maxillofacial surgeons, attributing it to their limited national representation and demanding clinical schedules. The revision also clarifies that while the sample size limits inferential generalization, it provides valuable pilot data for future multicenter and higher-powered studies. Author did not mention how to handle the bias came from the very low response rate (16.5%). Response: We thank the reviewer for noting this. A paragraph addressing potential non-response and self-selection bias has been added to the Sample Size and Population subsection. The revised text explains measures taken to minimize bias (multi-channel recruitment, anonymity assurance, and non-parametric analysis) and justifies interpreting results within an exploratory framework rather than population-level inference. The authors mentioned that the sample size required is 278, but they only included 46, this is too small sample size compared to the actual needed sample based on the authors calculation. This can extremely weaken the study by: Reduced statistical power (less ability to detect real effects). Increased risk of Type II error (failing to detect a difference that exists). Response: We acknowledge this limitation and have now included an explicit statement describing the impact of reduced sample size on statistical power and Type II error . This limitation is now clearly discussed in the Sample Size and Population subsection and reiterated in the Limitations section, clarifying that this study was exploratory and intended to provide pilot-level evidence to guide larger-scale future research. - Many orthodontist don’t treat the cases with orthodontic-orthognathic surgery, how about even treated these cases with CAT technology, this required a good experience in orthodontic-orthognathic surgery cases. It would be better to chooses expert orthodontist and maxillo-facial surgeons in this field in the inclusion exclusion criteria. Response: We thank the reviewer for this insightful observation. We have now clarified the inclusion criteria to emphasize that the study targeted licensed orthodontists and oral and maxillofacial surgeons actively practicing in Saudi Arabia , regardless of their level of experience with orthognathic surgery. However, to address the reviewer’s concern, we have added a statement specifying that future studies should consider recruiting only experienced clinicians or specialists who regularly perform orthognathic treatments , to ensure deeper insight into expert practices. This note has been added to the Limitations section to acknowledge the potential variability in participant expertise. - In the statistical step, authors mentioned that 4 participants did not complete their response, can the author give the actual number of participants whom completed the response and included in the study? Response: We appreciate this request for clarity. The total number of participants who completed the questionnaire in full and were included in the final analysis was 46 , after excluding 4 incomplete responses from the original 50 submissions. This has been explicitly stated in the Statistical Analysis subsection. - Why did the authors used Mann-Whitney U test and not independent samples t-test? Did they performed the normal distribution analysis and found that the data are non-parametric ( not normally distributed) please explain. Response: We thank the reviewer for highlighting this point. The Mann–Whitney U test was used because the normality assumption was not met for the knowledge score data. This indicates that the data were non-normally distributed , making the Mann–Whitney U test a more appropriate non-parametric alternative to the independent samples t-test. This clarification has been added to the Statistical Analysis section to ensure transparency regarding the choice of statistical test. - It is better to explain the program used in the statistics SPSS in the beginning and not the end of the statistical analysis. Response: We agree with the reviewer. The mention of the statistical software ( IBM SPSS Statistics version 27, Chicago, IL, USA ) has been relocated to the beginning of the Statistical Analysis section for improved readability and consistency with journal standards. - In the statistical analysis: author should mention the type of statistical test used above each table and cite each statistical test to the corresponding table. Response: We appreciate this helpful suggestion. The type of statistical test used in each analysis has now been explicitly indicated above every table in the Results section (e.g., Statistical test: Chi-square test , Statistical test: Mann–Whitney U test , Statistical test: Univariate linear regression analysis ). Additionally, cross-references have been added in the Statistical Analysis section to identify which test corresponds to which table for greater clarity and transparency. Results: Ensure all abbreviations are defined in table footnotes ( p-value, CI, etc). Response: We appreciate the reviewer’s careful attention to detail. All abbreviations, including p-value (probability value) and CI (confidence interval), have now been clearly defined in the footnotes of all tables (Tables 1–7) to ensure clarity and uniformity. What are Table S1 and Table S2??? Is it a writing mistake or what? Response: We thank the reviewer for pointing out this issue. The mention of “Table S1” and “Table S2” was an inadvertent labeling error carried over from an earlier draft where supplementary tables were planned but later merged into the main text. These have now been corrected and relabeled as Table 1 and Table 2 , respectively, ensuring consistency throughout the Results section and in-text citations. All references to “S1” and “S2” have been deleted and replaced with “Table 1” and “Table 2.” Many sentences in the 1 st paragraph are not cited and linked to any tables, better to arrange it in a table. Response: We appreciate this constructive comment. The first paragraph of the Results section has been restructured for clarity . Quantitative findings that were previously written narratively are now directly linked to their corresponding tables , and where appropriate, data have been reorganized into concise tabular form. Each descriptive statement now includes the relevant table reference in parentheses, e.g., “(Table 1)” or “(Table 2),” to allow readers to easily cross-check findings. This restructuring improves logical flow, clarity, and data traceability. Discussion: - At the end of the discussion, the author mention that: ‘ Orthodontists and oral & maxillofacial surgeons should have catered CATs in their postgraduate training. They should expand on digital workflows, aligner biomechanics, and technology integration, and allocate time to the importance of interdisciplinary cooperation, clinical sequencing, and the utility of hybrid approaches when CAT alone may prove inadequate’ I think this paragraph is not accurate, this is correct for orthodontist but not for orthognathic surgeons to know the biomechanics at all, clinical sequence nor utility of hybrid approach, it is much simple for orthognathic surgeon in this field just to know basks and to know hot to apply the inter-maxillary elastics after surgery for patient wearing CAT. Response: We thank the reviewer for this precise and valuable clarification. We agree that the original statement overstated the training requirements for oral and maxillofacial surgeons. The paragraph has been revised to clearly distinguish between the educational needs of orthodontists and surgeons. Orthodontists’ training recommendations remain focused on digital workflows, biomechanics, and case sequencing , while the surgeons’ component now emphasizes understanding splint adaptation, intermaxillary fixation (IMF), and postoperative elastic management . - Beside the discussion looks long, it give a little explanation of the founded result. I recommend the author to focus more on the discussion section in explanation of the finding of the results and compare it more with other studies and findings in the literature. Response: We appreciate this insightful feedback. The Discussion section has been condensed and refocused to emphasize interpretation of our main results rather than general literature review. - Put practical recommendations (e.g., training courses, inclusion of CAT in residency programs). Response: Thank you for this excellent suggestion. We have incorporated a new “Practical Recommendations” paragraph at the end of the Discussion, explicitly outlining actionable educational and clinical strategies. These include integrating CAT education into orthodontic and surgical residency curricula, conducting continuing professional training workshops, and fostering national and international collaboration. Conclusion : - Generally,the conclusions, seems giving no real benefit, the author should also mention the difficulties during orthognathic surgery when used with CAT, e.g. the maxillary fixation, how to use the heavy intermaxillary elastics, splints etc., not only mentioning the orthodontic difficulties. Response: We thank the reviewer for this valuable feedback. We have revised the Conclusion to provide a more comprehensive and clinically relevant summary that acknowledges both orthodontic and surgical challenges associated with Clear Aligner Therapy (CAT) in orthognathic surgery. The revised version now includes mention of intraoperative and postoperative challenges , such as maxillary fixation, splint adaptation, and management of intermaxillary elastics in CAT-treated patients, to ensure that both specialties’ perspectives are reflected. - Should summarize major quantitative findings and their implications e.g.: “Most orthodontists and surgeons surveyed had limited experience with CAT in orthognathic cases, indicating the need for enhanced clinical training and interdisciplinary collaboration.” Response: We fully agree with this suggestion. The revised conclusion now incorporates quantitative summary statements (e.g., the low response rate, limited experience levels, and lack of significant knowledge difference between specialties) and their broader implications for clinical practice and training . The final paragraph also emphasizes the importance of interdisciplinary collaboration , standardized training , and evidence-based clinical integration of CAT into surgical orthodontics. References : - The introduction started with an odd statement that not linked to the study , and in return the selected reference are not linked to the study at all ???!!! ref no. 1-3. Response: We thank the reviewer for this observation. We respectfully clarify that References 1–3 were intentionally included to provide epidemiological context regarding the prevalence of dentofacial anomalies , which are the underlying conditions often treated through orthognathic surgery —the core topic of this study. However, to improve clarity and ensure stronger linkage between these references and the study focus, the opening paragraph of the Introduction was revised to better connect the cited data on dentofacial anomalies to the relevance of orthognathic surgery and, subsequently, to Clear Aligner Therapy (CAT). - Where did the author cite reference no. 43? Also this reference almost have same idea , patient of the current study? Response: We thank the reviewer for this valuable observation. Reference no. 43 refers to the Zenodo data repository containing the dataset that supports the findings of the current study, rather than to a separate research article or independent sample. Tables: - Table 1 is unclear and it’s column 2 is not defined. Response: We thank the reviewer for identifying this oversight. The second column in Table 1 has now been properly labeled to specify its content. - Many variables ( rows) in table 2 seems not linked to the CAT with surgery, it is only related to CAT and orthodontics. e.g.: row 3: It is challenging to achieve the needed pre surgical space closure, row 4 Response: We appreciate the reviewer’s observation. We agree that certain items in Table 2 appeared more related to general orthodontic CAT practice rather than surgical applications . Competing Interests: no competing interests to disclose. Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 4 VERSION 4 PUBLISHED 29 Sep 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 4 (revision) 07 May 26 read read Version 3 (revision) 15 Apr 26 read read Version 2 (revision) 14 Feb 26 read read Version 1 29 Sep 25 read Abdelrahman MA Mohamed , Royal College of Surgeons of Edinburgh, Edinburgh, UK Tiago Fialho , Bauru Dental School, São Paulo University, Bauru, Brazil Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Mohamed A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 09 May 2026 | for Version 4 Abdelrahman MA Mohamed , Orthodontics, Royal College of Surgeons of Edinburgh, Edinburgh, UK 0 Views copyright © 2026 Mohamed A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions I would like to thank the editor very much for giving me the opportunity to review this paper. 1. Results: Tables s1 and s2 definitions in the footprint need to be added ( P value, CI). 2. Discussion and Limitations sections are overly long and contains repeated information under different subheadings, leading to unnecessary redundancy. The manuscript is generally acceptable after revision; however, an additional reviewer opinion may help strengthen the editorial assessment, particularly regarding the sample size, response rate, and the organization and redundancy within the Discussion section. Competing Interests No competing interests were disclosed. Reviewer Expertise Orthodontics. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Mohamed AM. Peer Review Report For: The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons [version 4; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 14 :1001 ( https://doi.org/10.5256/f1000research.200348.r482398) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-1001/v4#referee-response-482398 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Fialho T. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 08 May 2026 | for Version 4 Tiago Fialho , Department of Orthodontics, Bauru Dental School, São Paulo University, Bauru, SP, Brazil 0 Views copyright © 2026 Fialho T. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The revised manuscript demonstrates substantial improvement compared with the previous versions. The authors have clearly made significant efforts to address prior reviewer comments, particularly regarding transparency of methodology, clarification of study limitations, restructuring of the discussion, and repositioning of the study as exploratory in nature. The manuscript now presents a more balanced and scientifically cautious interpretation of the findings, which considerably strengthens its overall credibility. The topic remains clinically relevant and timely, particularly considering the increasing global interest in the integration of Clear Aligner Therapy (CAT) into orthognathic surgery workflows. The manuscript also contributes preliminary regional data from Saudi Arabia, where evidence on this topic remains limited. Nevertheless, several methodological and statistical concerns persist and should be acknowledged as important limitations of the study. The principal limitation remains the substantially insufficient sample size. Although the authors appropriately calculated a minimum required sample of 302 participants, only 46 complete responses were ultimately obtained. While the authors correctly reframed the study as exploratory and acknowledged the reduced statistical power, the manuscript still includes inferential analyses that may overextend the interpretability of the data. Specifically, the use of multiple chi-square analyses and univariate linear regression models appears methodologically fragile considering the small sample size and low cell frequencies observed in several tables. In Tables 1 through 6, p-values are repeatedly presented without a clearly defined null hypothesis or clinically meaningful comparative framework. In several instances, the statistical purpose of the chi-square analyses is unclear, particularly because many of the presented variables are descriptive in nature rather than comparative. Additionally, the small expected frequencies in multiple categories may violate assumptions required for chi-square testing. In this context, either Fisher’s exact test or purely descriptive reporting would likely have been more appropriate. Similarly, the regression analysis should be interpreted with substantial caution. The manuscript does not fully explain how the composite “CAT usage score” was constructed or validated, and the limited sample size raises concerns regarding model stability, overfitting, and reliability of the reported R² values. Although the authors appropriately characterize these findings as exploratory, some statements regarding explanatory power remain somewhat stronger than the available data can robustly support. The discussion section is considerably improved; however, it remains somewhat lengthy and occasionally extends beyond the direct findings of the study. Certain sections resemble a narrative literature review rather than a focused interpretation of the collected data. Some speculative statements regarding clinician behavior, digital workflow adoption, and regional sociocultural trends are not directly supported by the study methodology and should therefore be interpreted cautiously. Another conceptual limitation is the broad inclusion of different orthognathic protocols involving CAT, including surgery-first approaches, hybrid protocols, adjunctive TAD usage, and combined fixed appliance mechanics. The questionnaire appears to group these clinical scenarios together without sufficiently distinguishing between them, which may limit the precision of the conclusions. Despite these limitations, the authors should be commended for explicitly acknowledging most methodological weaknesses, including selection bias, low response rate, limited external validity, and the exploratory nature of the statistical analyses. The availability of open data and the transparent reporting of limitations further strengthen the integrity of the work. Overall, this manuscript should not be interpreted as providing definitive evidence regarding the use of CAT in orthognathic surgery. However, within the context of an exploratory survey study and considering the publication model of F1000Research, the work provides useful preliminary insights and may serve as a valuable foundation for future multicenter investigations with adequate statistical power. Based on the improvements introduced in Version 4 and considering the remaining limitations described above, my recommendation is: Approved with Reservations. I encourage the authors to consider additional refinement of the statistical presentation and further reduction of speculative discussion sections in future revisions or subsequent related publications. Competing Interests No competing interests were disclosed. Reviewer Expertise Orthodontics; Orthodontic Aligners, Orthodontic mechanics I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Fialho T. Peer Review Report For: The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons [version 4; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 14 :1001 ( https://doi.org/10.5256/f1000research.200348.r482399) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-1001/v4#referee-response-482399 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Mohamed A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 24 Apr 2026 | for Version 3 Abdelrahman MA Mohamed , Orthodontics, Royal College of Surgeons of Edinburgh, Edinburgh, UK 0 Views copyright © 2026 Mohamed A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions I would like to thank the editor very much for giving me the opportunity to review this paper. Below are my comments and suggestions to strengthen the manuscript. The authors did a great effort to enhance the manuscript, however Title still need to be modified to explain the aim of the study, my suggestion: Awareness and Clinical Experience with Clear Aligners in Orthognathic Surgery: A Saudi Multispecialty Exploratory Survey Results: Author need to define the exact place or better add the link of the Tables s1 and s2 to make it easier for the readers to reach it or add it as normal tables 8 and 9 to the manuscript, also definitions of these table in the footprint need to be added. 3. Discussion: The Discussion section is overly long and contains repeated information under different subheadings, leading to unnecessary redundancy. I recommend revising it to be more concise and better organized. The Limitations section has a similar issue as discussion. Competing Interests No competing interests were disclosed. Reviewer Expertise Orthodontics. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 27 Apr 2026 Ahmad Assari, Department of Dentistry, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia We sincerely thank the reviewer for their valuable feedback and constructive suggestions to improve the manuscript. Comment 1: The title needs modification to better reflect the aim of the study. Response: Thank you for this suggestion. The title has been revised to better reflect the scope and aim of the study, emphasizing clinician awareness and clinical experience, as well as the exploratory nature of the investigation. Comment 2: Clarify the location or accessibility of Supplementary Tables S1 and S2. Response: We appreciate this important comment. The manuscript has been revised to clearly label “Table S1” and “Table S2” as Supplementary Tables S1 and S2 throughout the text. A dedicated Supplementary Materials section has been added, and references to these tables in the Results section have been clarified to guide readers. Additionally, appropriate explanatory footnotes have been included. Comment 3: The Discussion section is overly long and contains repeated information; the Limitations section has similar issues. Response: Thank you for this constructive observation. The Discussion section has been carefully revised to improve conciseness, reduce redundancy, and enhance overall organization. Repetitive statements have been removed, and the content has been streamlined to focus more directly on interpretation of the study findings in relation to existing literature. Similarly, the Limitations section has been substantially revised to eliminate duplication, improve clarity, and present the study constraints in a more concise and structured manner. Redundant phrases related to generalizability and sampling limitations have been removed, and the section has been refined to clearly highlight key methodological limitations, including sample size, exploratory statistical analysis, and potential biases. We thank the reviewer again for their insightful comments, which have significantly improved the clarity, structure, and scientific quality of the manuscript. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Mohamed AM. Peer Review Report For: The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons [version 4; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 14 :1001 ( https://doi.org/10.5256/f1000research.198023.r475308) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-1001/v3#referee-response-475308 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Fialho T. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 16 Apr 2026 | for Version 3 Tiago Fialho , Department of Orthodontics, Bauru Dental School, São Paulo University, Bauru, SP, Brazil 0 Views copyright © 2026 Fialho T. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions I have carefully reviewed the third version (V3) of the manuscript entitled "The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons." After evaluating the amendments made by the authors in response to previous peer-review rounds, I would like to offer the following assessment regarding its current status and suitability for indexing. Firstly, I commend the authors for their diligent efforts in addressing the terminological and structural concerns raised. The correction of the title to "Orthodontists" and the refinement of "dental anomaly" to "dentofacial deformity" in the introduction significantly enhance the academic precision of the text. Furthermore, the inclusion of a detailed flowchart (Figure 1) and the explicit statement of the response rate (16.5%) provide the necessary transparency regarding the study’s recruitment process, which was a point of concern in earlier versions. The standardization of tables, including the proper definition of statistical abbreviations and p-values in the footnotes, has also improved the readability and technical quality of the data presentation. Regarding the discussion and conclusions, the authors have successfully integrated a more nuanced interpretation of the findings. The clearer distinction between the training needs of orthodontists versus oral surgeons, particularly concerning biomechanics and intermaxillary fixation, adds depth to the study's clinical implications. The conclusion now effectively summarizes the quantitative findings rather than offering generalized statements, which is a vital improvement. However, a critical limitation remains: the sample size ($n=46$). Despite the authors' efforts to increase recruitment, the final cohort remains substantially below the initially calculated power requirement ($n=302$). This limitation inherently restricts the generalizability of the findings and the robustness of the inferential statistics. In the F1000Research model, which prioritizes transparency and the publication of all sound scientific work—including exploratory and preliminary data—this does not necessarily preclude publication. The authors have acted appropriately by reframing the study as an "exploratory survey" and being candid about these limitations in the discussion section. In conclusion, I believe that the authors have addressed the major technical and editorial queries to the best of their ability within the constraints of their recruitment environment. The manuscript now provides a clear, transparent, and honest account of a preliminary investigation into an emerging clinical field in Saudi Arabia. While the small sample size remains a "reservation," the transparency of the reporting and the open-access availability of the underlying dataset (via Zenodo) align with the journal's standards. Therefore, I recommend that the article be considered for approval, provided that readers continue to interpret the statistical findings with the caution warranted by the exploratory nature of the study. Competing Interests No competing interests were disclosed. Reviewer Expertise Orthodontics; Orthodontic Aligners, Orthodontic mechanics I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (1) Author Response 07 May 2026 Ahmad Assari, Department of Dentistry, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia We sincerely thank the reviewer for their careful evaluation of Version 3 of our manuscript and for recognizing the substantial improvements made in response to previous review rounds. We appreciate the reviewer’s positive feedback regarding the refinement of terminology, improved clarity of the introduction, inclusion of the recruitment flowchart, and enhanced transparency in reporting the response rate and data availability. We are also grateful for the acknowledgment of improvements in table presentation, discussion structure, and the strengthened conclusions. Regarding the key concern about the sample size (n = 46 vs. calculated n = 302), we fully agree that this represents a major methodological limitation. In response, we have made the following revisions throughout the manuscript: The study has been explicitly repositioned as an exploratory survey in the Abstract, Methods, Results, Discussion, and Conclusion. The discrepancy between the calculated and achieved sample size has been clearly stated and consistently emphasized. The implications of the small sample size on statistical power, risk of Type I/II errors, and generalizability have been explicitly discussed in the Limitations section. All inferential analyses (chi-square and regression) have been clearly described as exploratory, and their interpretation has been appropriately tempered. The observed association between age and CAT usage has been reframed as a hypothesis-generating observation rather than a definitive finding. We have also explicitly clarified that the findings may not be generalizable due to the small sample size and the use of a convenience sampling approach. Additionally, the nature of the dependent variable and the exploratory purpose of the regression model have been clarified to ensure appropriate interpretation. We have also acknowledged potential limitations related to statistical assumptions (e.g., small expected cell counts) and interpreted these analyses with caution. In addition, we have strengthened the discussion of sampling limitations, including the use of convenience sampling and the potential for self-selection bias, and we have ensured that all conclusions are aligned with the exploratory nature of the study. We appreciate the reviewer’s recognition that the study meets the principles of transparency and open science, particularly through the public availability of the dataset and survey instrument. In conclusion, we believe the manuscript now provides a transparent and appropriately cautious account of a preliminary investigation into an emerging clinical topic. We thank the reviewer for their valuable feedback and recommendation for approval with reservations. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Fialho T. Peer Review Report For: The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons [version 4; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 14 :1001 ( https://doi.org/10.5256/f1000research.198023.r475309) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-1001/v3#referee-response-475309 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Mohamed A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 10 Mar 2026 | for Version 2 Abdelrahman MA Mohamed , Orthodontics, Royal College of Surgeons of Edinburgh, Edinburgh, UK 0 Views copyright © 2026 Mohamed A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions I would like to thank the editor very much for giving me the opportunity to review this paper. Below are my comments and suggestions to strengthen the manuscript. Title need to explain the aim of the study Introduction : The authors need to mention that they are talking abut orthodontic 1 st and not surgery 1 st technique, as if it was the surgery 1 st , there will be no need to revaluate surgeon response. Material and Methods : Sample size are very small , less than the minimum base on sample size calculation 302 , but the author only included 46 which is much less than the required , especially for the orthognathic surgeons. This needs to be highlighted in the abstract and in conclusion. Results: I suggest to change the aim to be also the experience of orthodontist in treatment of orthognathic surgery cases also, even with this, the reliability and external validity of the study are compromised. WHAT ARE TABLE S1 AND TABLE S2??? IS IT A WRITING MISTAKE OR WHAT???? The error still exists Discussion: - Please Share the reference of this sentence: (Systematic reviews confirm that while CAT is increasingly effective for mild-to-moderate malocclusions, evidence for its use in surgical orthodontics remains limited and largely anecdotal.)? - author put facts that do not come from the current study without citing a reference for it, e.g. (Besides, CAT is considered as a popular treatment choice among many orthodontists, however not a common treatment for orthognathic surgery patients.). - Discussion writing is not organized, some have large paragraph and some part just have small 1 line sentences. DISCUSSION STILL VERY LONG AND NOT INTERESTING and not majorly focuses on interpreting the results. - I see the recommendations have 5 points which can be merged on 2 points. Conclusion : - please make the conclusion shorter. Competing Interests No competing interests were disclosed. Reviewer Expertise Orthodontics. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 15 Apr 2026 Ahmad Assari, Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, College of Medicine and Dentistry, Riyadh Elm University, Riyadh, Saudi Arabia Response to Reviewer Comment: Title need to explain the aim of the study Response: Thank you for this valuable suggestion. The title has been revised to more clearly reflect the aim of the study by explicitly including the assessment of knowledge, attitudes, and clinical practices, as well as indicating the exploratory nature of the investigation. Comment: Introduction : The authors need to mention that they are talking about orthodontic 1 st and not surgery 1 st technique, as if it was the surgery 1 st , there will be no need to revaluate surgeon response. Response: Its use in combination with surgery is emerging; however, its role differs between orthodontics-first and surgery-first protocols. In orthodontics-first approaches, CAT may be used in pre- and post-surgical phases, whereas in surgery-first protocols its role is more limited and evolving. Comment: Material and Methods : Sample size are very small , less than the minimum base on sample size calculation 302 , but the author only included 46 which is much less than the required , especially for the orthognathic surgeons. This needs to be highlighted in the abstract and in conclusion. Response: Thank you for this important observation. We have revised both the Abstract and Conclusion to explicitly highlight the discrepancy between the calculated minimum sample size (n = 302) and the achieved sample (n = 46). We have also emphasized that this limitation reduces statistical power and affects the robustness of subgroup analyses, particularly for oral and maxillofacial surgeons. The findings are now clearly presented as exploratory and preliminary in nature. Comment: Results: I suggest to change the aim to be also the experience of orthodontist in treatment of orthognathic surgery cases also, even with this, the reliability and external validity of the study are compromised. WHAT ARE TABLE S1 AND TABLE S2??? IS IT A WRITING MISTAKE OR WHAT???? The error still exists Response: Thank you for this valuable feedback. The study aim has been revised in both the Introduction and Abstract to explicitly include clinical experience alongside knowledge, attitudes, and practices. Thank you for highlighting this issue. We apologize for the lack of clarity. “Table S1” and “Table S2” refer to Supplementary Tables, which contain detailed demographic and clinical data. In the revised manuscript, these have been clearly labeled as “Supplementary Table S1” and “Supplementary Table S2”, and a dedicated Supplementary Material section has been added to improve clarity and accessibility. We have also further emphasized the limitations related to sample size and external validity in the revised manuscript to ensure appropriate interpretation of the findings. Comment: Discussion: - Please Share the reference of this sentence: (Systematic reviews confirm that while CAT is increasingly effective for mild-to-moderate malocclusions, evidence for its use in surgical orthodontics remains limited and largely anecdotal.)? - author put facts that do not come from the current study without citing a reference for it, e.g. (Besides, CAT is considered as a popular treatment choice among many orthodontists, however not a common treatment for orthognathic surgery patients.). - Discussion writing is not organized, some have large paragraph and some part just have small 1 line sentences. DISCUSSION STILL VERY LONG AND NOT INTERESTING and not majorly focuses on interpreting the results. - I see the recommendations have 5 points which can be merged on 2 points. Response: Thank you for these valuable suggestions. We have revised the Discussion section accordingly: The previously uncited statement regarding systematic reviews has now been supported with appropriate references. Unsupported general statements have been revised or linked directly to the findings of the current study. The Discussion has been reorganized to improve flow, reduce redundancy, and place greater emphasis on interpreting the study findings in relation to existing literature. Long and fragmented sections have been streamlined for clarity and readability. The recommendations section has been condensed from five points into two concise and structured recommendations to improve clarity and impact. Comment: Conclusion : - please make the conclusion shorter. Response: Thank you for this suggestion. The Conclusion section has been revised to improve conciseness while retaining the key findings and clinical implications. Redundant statements have been removed, and the section now presents a clearer and more focused summary of the study outcomes and future research directions. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Mohamed AM. Peer Review Report For: The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons [version 4; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 14 :1001 ( https://doi.org/10.5256/f1000research.191604.r458561) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-1001/v2#referee-response-458561 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Fialho T. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 25 Feb 2026 | for Version 2 Tiago Fialho , Department of Orthodontics, Bauru Dental School, São Paulo University, Bauru, SP, Brazil 0 Views copyright © 2026 Fialho T. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Thank you for the opportunity to review the revised version of this manuscript. The topic is timely and clinically relevant, particularly given the growing incorporation of clear aligner therapy (CAT) into orthognathic surgery protocols. The authors have made appreciable efforts to address prior reviewer comments, especially regarding ethical approval, questionnaire validation, and data transparency. The availability of the dataset and survey instrument is a notable strength and aligns well with the open science principles of the journal. Despite these improvements, important methodological and statistical concerns remain that limit the robustness of the conclusions. The manuscript reports a calculated minimum sample size of 302 participants; however, only 46 valid responses were ultimately analyzed. Although the authors attribute this to a limited specialist pool, the manuscript also states that approximately 1,400 eligible professionals exist in the target population. This creates an inconsistency between the theoretical sampling framework and the achieved sample. Most importantly, the final sample size is substantially below the calculated requirement, rendering the study underpowered for inferential statistical testing. Under such conditions, p-values become unstable, and the risk of both Type I and Type II errors increases considerably. If the authors were unable to realistically achieve the required sample size, the study should be explicitly repositioned as an exploratory or pilot investigation, and the inferential claims should be substantially tempered. Related to this issue is the use of multiple inferential statistical tests in a small dataset. The manuscript employs several chi-square analyses and univariate linear regression. With a final sample of 46 respondents, there is a high probability that assumptions underlying chi-square tests—particularly minimum expected cell counts—may not be satisfied. Additionally, multiple comparisons are conducted without correction, increasing the risk of false-positive findings. Given the limited sample size, the statistical analysis would be more appropriately framed as primarily descriptive. Inferential modeling, if retained, should be explicitly described as exploratory and interpreted with considerable caution. The use of univariate linear regression to assess the association between age and CAT usage also warrants clarification. It is not sufficiently clear whether the dependent variable representing CAT use is continuous, ordinal, or binary. If the outcome is binary or categorical, linear regression is not the appropriate analytical approach, and logistic regression would be methodologically preferable. The reported R² value appears relatively high given the small sample size, which further underscores the need for clarification regarding model specification, variable coding, and assumption testing. Without this clarification, the validity of the regression findings remains uncertain. The sampling strategy also limits external validity. The study relied on convenience sampling through online distribution and professional networks, with a response rate of 16.5%. While such an approach is common in survey research, it introduces self-selection bias and may disproportionately attract clinicians already interested in or favorable toward CAT. Although the authors acknowledge this limitation, its implications for generalizability should be more explicitly emphasized in both the discussion and conclusion. Statements regarding trends in CAT adoption should be presented cautiously and framed within the context of these sampling constraints. The conclusion that age may influence CAT adoption should be reformulated as a hypothesis-generating observation rather than a definitive finding. Given the limited sample size and statistical fragility, the results should be interpreted as preliminary and in need of confirmation through adequately powered studies. Strengthening the distinction between descriptive observations and inferential claims would improve the internal coherence of the manuscript. In summary, the study addresses a relevant and underexplored topic, and its transparency in data reporting is commendable. However, methodological and statistical inconsistencies currently limit the strength of the conclusions. I would recommend approval with reservations contingent upon substantial clarification of the statistical modeling, reconsideration or reframing of the inferential analyses, explicit repositioning of the study as exploratory if appropriate, and a more cautious interpretation of the findings. With these revisions, the manuscript would more accurately reflect the evidentiary weight of the data and would be suitable for publication as an exploratory survey study. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise Orthodontics; Orthodontic Aligners, Orthodontic mechanics I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 15 Apr 2026 Ahmad Assari, Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, College of Medicine and Dentistry, Riyadh Elm University, Riyadh, Saudi Arabia We sincerely thank the reviewer for their thorough and constructive evaluation of our manuscript. We appreciate the recognition of the study’s relevance, transparency, and data availability. We have carefully addressed all methodological and statistical concerns raised and have revised the manuscript accordingly. Our responses are detailed below. 1. Sample size and underpowered study Reviewer comment: The manuscript reports a calculated minimum sample size of 302 participants; however, only 46 valid responses were ultimately analyzed. Although the authors attribute this to a limited specialist pool, the manuscript also states that approximately 1,400 eligible professionals exist in the target population. This creates an inconsistency between the theoretical sampling framework and the achieved sample. Most importantly, the final sample size is substantially below the calculated requirement, rendering the study underpowered for inferential statistical testing. Under such conditions, p-values become unstable, and the risk of both Type I and Type II errors increases considerably. If the authors were unable to realistically achieve the required sample size, the study should be explicitly repositioned as an exploratory or pilot investigation, and the inferential claims should be substantially tempered. Response: We fully agree with this important observation. The manuscript has been revised to explicitly acknowledge the discrepancy between the calculated and achieved sample size. We have now clearly repositioned the study as an exploratory survey investigation rather than a confirmatory or inferential study. This clarification has been added to the Abstract, Methods, Results, Discussion, and Conclusion. We have explicitly stated that the limited sample size reduces statistical power and increases the risk of both Type I and Type II errors. 2. Use of inferential statistical tests in a small dataset Reviewer comment: Related to this issue is the use of multiple inferential statistical tests in a small dataset. The manuscript employs several chi-square analyses and univariate linear regression. With a final sample of 46 respondents, there is a high probability that assumptions underlying chi-square tests—particularly minimum expected cell counts—may not be satisfied. Additionally, multiple comparisons are conducted without correction, increasing the risk of false-positive findings. Given the limited sample size, the statistical analysis would be more appropriately framed as primarily descriptive. Inferential modeling, if retained, should be explicitly described as exploratory and interpreted with considerable caution. Response: We agree and have revised the manuscript accordingly: All inferential analyses are now explicitly described as exploratory. The Results section has been revised to emphasize descriptive findings, with reduced reliance on p-values. A clear statement has been added indicating that inferential results should be interpreted as hypothesis-generating rather than confirmatory. The limitations of chi-square testing in small samples (including expected cell counts) are now explicitly acknowledged. 3. Clarification of regression analysis and Sampling strategy and external validity Reviewer comment: The use of univariate linear regression to assess the association between age and CAT usage also warrants clarification. It is not sufficiently clear whether the dependent variable representing CAT use is continuous, ordinal, or binary. If the outcome is binary or categorical, linear regression is not the appropriate analytical approach, and logistic regression would be methodologically preferable. The reported R² value appears relatively high given the small sample size, which further underscores the need for clarification regarding model specification, variable coding, and assumption testing. Without this clarification, the validity of the regression findings remains uncertain. The sampling strategy also limits external validity. The study relied on convenience sampling through online distribution and professional networks, with a response rate of 16.5%. While such an approach is common in survey research, it introduces self-selection bias and may disproportionately attract clinicians already interested in or favorable toward CAT. Although the authors acknowledge this limitation, its implications for generalizability should be more explicitly emphasized in both the discussion and conclusion. Statements regarding trends in CAT adoption should be presented cautiously and framed within the context of these sampling constraints. Response: We have clarified the regression methodology in the Statistical Analysis section: The dependent variable (CAT usage) is now explicitly described as a continuous composite score derived from questionnaire responses. The rationale for using linear regression has been clarified. The interpretation of the regression model has been substantially tempered, and results are now presented as exploratory observations rather than definitive findings. Convenience sampling and low response rate introduce bias and limit generalizability. Response: We agree and have strengthened this aspect: The implications of self-selection bias and non-response bias are now explicitly discussed. We have clarified that clinicians with prior interest in CAT may have been overrepresented. Statements regarding trends and adoption have been reworded cautiously. Limitations in external validity and generalizability are now clearly emphasized in both the Discussion and Conclusion. 4. Interpretation of age as a predictor Reviewer comment: The conclusion that age may influence CAT adoption should be reformulated as a hypothesis-generating observation rather than a definitive finding. Given the limited sample size and statistical fragility, the results should be interpreted as preliminary and in need of confirmation through adequately powered studies. Strengthening the distinction between descriptive observations and inferential claims would improve the internal coherence of the manuscript. Response: This has been revised throughout the manuscript: The association between age and CAT usage is now described as exploratory and hypothesis-generating. Any language suggesting a definitive relationship has been removed. The need for validation in larger, adequately powered studies has been emphasized. We have made the following changes: The Results section is now primarily descriptive. Inferential findings are clearly labelled as exploratory. The Discussion and Conclusion have been revised to ensure cautious interpretation and avoid overgeneralization. 5. Overall revision In response to the reviewer’s recommendations, the manuscript has been comprehensively revised to: Reposition the study as an exploratory survey Strengthen transparency regarding methodological limitations Improve clarity of statistical methods Ensure appropriate interpretation of findings We are grateful for the reviewer’s insightful feedback, which has significantly improved the methodological clarity and scientific rigor of the manuscript. We believe the revised version now more accurately reflects the exploratory nature of the study and provides a balanced and cautious interpretation of the findings. View more View less Competing Interests None reply Respond Report a concern Fialho T. Peer Review Report For: The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons [version 4; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 14 :1001 ( https://doi.org/10.5256/f1000research.191604.r461487) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-1001/v2#referee-response-461487 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Mohamed A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 22 Oct 2025 | for Version 1 Abdelrahman MA Mohamed , Orthodontics, Royal College of Surgeons of Edinburgh, Edinburgh, UK 0 Views copyright © 2025 Mohamed A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions I would like to thank the editor very much for giving me the opportunity to review this paper. Below are my comments and suggestions to strengthen the manuscript. Title : It should be orthodontists, not orthodontics . Abstract: The response rate percentage (16.5%) should appear in the results. Introduction : The authors in the 1 st line mentioned ‘ dental anomaly’ it would be better to change it with ‘dentofacial’ as they are talking about skeletal deformities and orthognathic surgery. focus more on the gap in literature concerning CAT in orthognathic surgery. Material and Methods : Better to put the ethical consideration at the beginning of the methods section and merge it with the study design and setting. Ethical approval is mentioned twice ( in methods and before the references with slight variation in details) better to be accurately mentioned once. How participants were recruited? (email list? Saudi Orthodontic society? Or how?). Can the author put the equation used in the Sample size calculation? Sample size are very small especially for the orthognathic surgeons. Author did not mention how to handle the bias came from the very low response rate (16.5%). The authors mentioned that the sample size required is 278, but they only included 46, this is too small sample size compared to the actual needed sample based on the authors calculation. This can extremely weaken the study by: Reduced statistical power (less ability to detect real effects). Increased risk of Type II error (failing to detect a difference that exists). - Many orthodontist don’t treat the cases with orthodontic-orthognathic surgery, how about even treated these cases with CAT technology, this required a good experience in orthodontic-orthognathic surgery cases. It would be better to chooses expert orthodontist and maxillo-facial surgeons in this field in the inclusion exclusion criteria. - In the statistical step, authors mentioned that 4 participants did not complete their response, can the author give the actual number of participants whom completed the response and included in the study? - Why did the authors used Mann-Whitney U test and not independent samples t-test? Did they performed the normal distribution analysis and found that the data are non-parametric ( not normally distributed) please explain. - It is better to explain the program used in the statistics SPSS in the beginning and not the end of the statistical analysis. - In the statistical analysis: author should mention the type of statistical test used above each table and cite each statistical test to the corresponding table. Results: Ensure all abbreviations are defined in table footnotes ( p-value, CI, etc). What are Table S1 and Table S2??? Is it a writing mistake or what? Many sentences in the 1 st paragraph are not cited and linked to any tables, better to arrange it in a table. Discussion: - At the end of the discussion, the author mention that: ‘ Orthodontists and oral & maxillofacial surgeons should have catered CATs in their postgraduate training. They should expand on digital workflows, aligner biomechanics, and technology integration, and allocate time to the importance of interdisciplinary cooperation, clinical sequencing, and the utility of hybrid approaches when CAT alone may prove inadequate’ I think this paragraph is not accurate, this is correct for orthodontist but not for orthognathic surgeons to know the biomechanics at all, clinical sequence nor utility of hybrid approach, it is much simple for orthognathic surgeon in this field just to know basks and to know hot to apply the inter-maxillary elastics after surgery for patient wearing CAT. - Beside the discussion looks long, it give a little explanation of the founded result. I recommend the author to focus more on the discussion section in explanation of the finding of the results and compare it more with other studies and findings in the literature. - Put practical recommendations (e.g., training courses, inclusion of CAT in residency programs). Conclusion : - Generally,the conclusions, seems giving no real benefit, the author should also mention the difficulties during orthognathic surgery when used with CAT, e.g. the maxillary fixation, how to use the heavy intermaxillary elastics, splints etc., not only mentioning the orthodontic difficulties. - Should summarize major quantitative findings and their implications e.g.: “Most orthodontists and surgeons surveyed had limited experience with CAT in orthognathic cases, indicating the need for enhanced clinical training and interdisciplinary collaboration.” References : - The introduction started with an odd statement that not linked to the study , and in return the selected reference are not linked to the study at all ???!!! ref no. 1-3. - Where did the author cite reference no. 43? Also this reference almost have same idea , patient of the current study? Tables: - Table 1 is unclear and it’s column 2 is not defined. - Many variables ( rows) in table 2 seems not linked to the CAT with surgery, it is only related to CAT and orthodontics. e.g.: row 3: It is challenging to achieve the needed pre surgical space closure, row 4 Minor grammar and style edits are recommended. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? No Are the conclusions drawn adequately supported by the results? No Competing Interests No competing interests were disclosed. Reviewer Expertise Orthodontics. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 14 Feb 2026 Ahmad Assari, Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, College of Medicine and Dentistry, Riyadh Elm University, Riyadh, Saudi Arabia Title : It should be orthodontists, not orthodontics . Response: done Abstract : The response rate percentage (16.5%) should appear in the results. Response: done Introduction : The authors in the 1 st line mentioned ‘dental anomaly’ it would be better to change it with ‘dentofacial’ as they are talking about skeletal deformities and orthognathic surgery. Response: We thank the reviewer for this helpful suggestion. The term “dental anomaly” has been replaced with “dentofacial anomaly” to more accurately reflect the skeletal and facial components relevant to orthognathic surgery. This modification ensures better alignment between the introductory context and the study’s clinical focus. focus more on the gap in literature concerning CAT in orthognathic surgery. Response: done Response: We agree with the reviewer’s observation and have revised the final paragraph of the Introduction to better highlight the literature gap on the use of Clear Aligner Therapy (CAT) in orthognathic surgery. The new text emphasizes that, although CAT has gained global popularity in orthodontics, there is a lack of empirical data regarding its application, feasibility, and clinician readiness in surgical orthodontic contexts, especially within the Saudi population. This strengthened focus now clearly establishes the rationale for conducting the present study. Material and Methods : Better to put the ethical consideration at the beginning of the methods section and merge it with the study design and setting. Response: We appreciate the reviewer’s recommendation. The Ethical Consideration subsection has now been moved and merged with the Study Design and Setting subsection at the beginning of the Methods section to improve logical flow and eliminate redundancy. Ethical approval is mentioned twice ( in methods and before the references with slight variation in details) better to be accurately mentioned once. Response: We thank the reviewer for identifying this duplication. The repeated ethical statement before the References section has been removed , and only the version integrated within the Study Design and Setting subsection has been retained for accuracy and consistency. How were participants recruited? (email list? Saudi Orthodontic society? Or how?). Response: Thank you for this important clarification. The participant recruitment process has now been described in detail. The revised text specifies that survey invitations were distributed through professional email lists , the Saudi Orthodontic Society , academic institutions , and social media platforms (e.g., WhatsApp and LinkedIn) to maximize geographic and professional reach. Can the author put the equation used in the Sample size calculation? Response: We appreciate the suggestion. The finite population sample size equation has now been added to the Sample Size and Population subsection, including variable definitions for clarity. Sample size are very small especially for the orthognathic surgeons. Response: We agree with the reviewer. A statement has been added acknowledging the small subgroup size of oral and maxillofacial surgeons, attributing it to their limited national representation and demanding clinical schedules. The revision also clarifies that while the sample size limits inferential generalization, it provides valuable pilot data for future multicenter and higher-powered studies. Author did not mention how to handle the bias came from the very low response rate (16.5%). Response: We thank the reviewer for noting this. A paragraph addressing potential non-response and self-selection bias has been added to the Sample Size and Population subsection. The revised text explains measures taken to minimize bias (multi-channel recruitment, anonymity assurance, and non-parametric analysis) and justifies interpreting results within an exploratory framework rather than population-level inference. The authors mentioned that the sample size required is 278, but they only included 46, this is too small sample size compared to the actual needed sample based on the authors calculation. This can extremely weaken the study by: Reduced statistical power (less ability to detect real effects). Increased risk of Type II error (failing to detect a difference that exists). Response: We acknowledge this limitation and have now included an explicit statement describing the impact of reduced sample size on statistical power and Type II error . This limitation is now clearly discussed in the Sample Size and Population subsection and reiterated in the Limitations section, clarifying that this study was exploratory and intended to provide pilot-level evidence to guide larger-scale future research. - Many orthodontist don’t treat the cases with orthodontic-orthognathic surgery, how about even treated these cases with CAT technology, this required a good experience in orthodontic-orthognathic surgery cases. It would be better to chooses expert orthodontist and maxillo-facial surgeons in this field in the inclusion exclusion criteria. Response: We thank the reviewer for this insightful observation. We have now clarified the inclusion criteria to emphasize that the study targeted licensed orthodontists and oral and maxillofacial surgeons actively practicing in Saudi Arabia , regardless of their level of experience with orthognathic surgery. However, to address the reviewer’s concern, we have added a statement specifying that future studies should consider recruiting only experienced clinicians or specialists who regularly perform orthognathic treatments , to ensure deeper insight into expert practices. This note has been added to the Limitations section to acknowledge the potential variability in participant expertise. - In the statistical step, authors mentioned that 4 participants did not complete their response, can the author give the actual number of participants whom completed the response and included in the study? Response: We appreciate this request for clarity. The total number of participants who completed the questionnaire in full and were included in the final analysis was 46 , after excluding 4 incomplete responses from the original 50 submissions. This has been explicitly stated in the Statistical Analysis subsection. - Why did the authors used Mann-Whitney U test and not independent samples t-test? Did they performed the normal distribution analysis and found that the data are non-parametric ( not normally distributed) please explain. Response: We thank the reviewer for highlighting this point. The Mann–Whitney U test was used because the normality assumption was not met for the knowledge score data. This indicates that the data were non-normally distributed , making the Mann–Whitney U test a more appropriate non-parametric alternative to the independent samples t-test. This clarification has been added to the Statistical Analysis section to ensure transparency regarding the choice of statistical test. - It is better to explain the program used in the statistics SPSS in the beginning and not the end of the statistical analysis. Response: We agree with the reviewer. The mention of the statistical software ( IBM SPSS Statistics version 27, Chicago, IL, USA ) has been relocated to the beginning of the Statistical Analysis section for improved readability and consistency with journal standards. - In the statistical analysis: author should mention the type of statistical test used above each table and cite each statistical test to the corresponding table. Response: We appreciate this helpful suggestion. The type of statistical test used in each analysis has now been explicitly indicated above every table in the Results section (e.g., Statistical test: Chi-square test , Statistical test: Mann–Whitney U test , Statistical test: Univariate linear regression analysis ). Additionally, cross-references have been added in the Statistical Analysis section to identify which test corresponds to which table for greater clarity and transparency. Results: Ensure all abbreviations are defined in table footnotes ( p-value, CI, etc). Response: We appreciate the reviewer’s careful attention to detail. All abbreviations, including p-value (probability value) and CI (confidence interval), have now been clearly defined in the footnotes of all tables (Tables 1–7) to ensure clarity and uniformity. What are Table S1 and Table S2??? Is it a writing mistake or what? Response: We thank the reviewer for pointing out this issue. The mention of “Table S1” and “Table S2” was an inadvertent labeling error carried over from an earlier draft where supplementary tables were planned but later merged into the main text. These have now been corrected and relabeled as Table 1 and Table 2 , respectively, ensuring consistency throughout the Results section and in-text citations. All references to “S1” and “S2” have been deleted and replaced with “Table 1” and “Table 2.” Many sentences in the 1 st paragraph are not cited and linked to any tables, better to arrange it in a table. Response: We appreciate this constructive comment. The first paragraph of the Results section has been restructured for clarity . Quantitative findings that were previously written narratively are now directly linked to their corresponding tables , and where appropriate, data have been reorganized into concise tabular form. Each descriptive statement now includes the relevant table reference in parentheses, e.g., “(Table 1)” or “(Table 2),” to allow readers to easily cross-check findings. This restructuring improves logical flow, clarity, and data traceability. Discussion: - At the end of the discussion, the author mention that: ‘ Orthodontists and oral & maxillofacial surgeons should have catered CATs in their postgraduate training. They should expand on digital workflows, aligner biomechanics, and technology integration, and allocate time to the importance of interdisciplinary cooperation, clinical sequencing, and the utility of hybrid approaches when CAT alone may prove inadequate’ I think this paragraph is not accurate, this is correct for orthodontist but not for orthognathic surgeons to know the biomechanics at all, clinical sequence nor utility of hybrid approach, it is much simple for orthognathic surgeon in this field just to know basks and to know hot to apply the inter-maxillary elastics after surgery for patient wearing CAT. Response: We thank the reviewer for this precise and valuable clarification. We agree that the original statement overstated the training requirements for oral and maxillofacial surgeons. The paragraph has been revised to clearly distinguish between the educational needs of orthodontists and surgeons. Orthodontists’ training recommendations remain focused on digital workflows, biomechanics, and case sequencing , while the surgeons’ component now emphasizes understanding splint adaptation, intermaxillary fixation (IMF), and postoperative elastic management . - Beside the discussion looks long, it give a little explanation of the founded result. I recommend the author to focus more on the discussion section in explanation of the finding of the results and compare it more with other studies and findings in the literature. Response: We appreciate this insightful feedback. The Discussion section has been condensed and refocused to emphasize interpretation of our main results rather than general literature review. - Put practical recommendations (e.g., training courses, inclusion of CAT in residency programs). Response: Thank you for this excellent suggestion. We have incorporated a new “Practical Recommendations” paragraph at the end of the Discussion, explicitly outlining actionable educational and clinical strategies. These include integrating CAT education into orthodontic and surgical residency curricula, conducting continuing professional training workshops, and fostering national and international collaboration. Conclusion : - Generally,the conclusions, seems giving no real benefit, the author should also mention the difficulties during orthognathic surgery when used with CAT, e.g. the maxillary fixation, how to use the heavy intermaxillary elastics, splints etc., not only mentioning the orthodontic difficulties. Response: We thank the reviewer for this valuable feedback. We have revised the Conclusion to provide a more comprehensive and clinically relevant summary that acknowledges both orthodontic and surgical challenges associated with Clear Aligner Therapy (CAT) in orthognathic surgery. The revised version now includes mention of intraoperative and postoperative challenges , such as maxillary fixation, splint adaptation, and management of intermaxillary elastics in CAT-treated patients, to ensure that both specialties’ perspectives are reflected. - Should summarize major quantitative findings and their implications e.g.: “Most orthodontists and surgeons surveyed had limited experience with CAT in orthognathic cases, indicating the need for enhanced clinical training and interdisciplinary collaboration.” Response: We fully agree with this suggestion. The revised conclusion now incorporates quantitative summary statements (e.g., the low response rate, limited experience levels, and lack of significant knowledge difference between specialties) and their broader implications for clinical practice and training . The final paragraph also emphasizes the importance of interdisciplinary collaboration , standardized training , and evidence-based clinical integration of CAT into surgical orthodontics. References : - The introduction started with an odd statement that not linked to the study , and in return the selected reference are not linked to the study at all ???!!! ref no. 1-3. Response: We thank the reviewer for this observation. We respectfully clarify that References 1–3 were intentionally included to provide epidemiological context regarding the prevalence of dentofacial anomalies , which are the underlying conditions often treated through orthognathic surgery —the core topic of this study. However, to improve clarity and ensure stronger linkage between these references and the study focus, the opening paragraph of the Introduction was revised to better connect the cited data on dentofacial anomalies to the relevance of orthognathic surgery and, subsequently, to Clear Aligner Therapy (CAT). - Where did the author cite reference no. 43? Also this reference almost have same idea , patient of the current study? Response: We thank the reviewer for this valuable observation. Reference no. 43 refers to the Zenodo data repository containing the dataset that supports the findings of the current study, rather than to a separate research article or independent sample. Tables: - Table 1 is unclear and it’s column 2 is not defined. Response: We thank the reviewer for identifying this oversight. The second column in Table 1 has now been properly labeled to specify its content. - Many variables ( rows) in table 2 seems not linked to the CAT with surgery, it is only related to CAT and orthodontics. e.g.: row 3: It is challenging to achieve the needed pre surgical space closure, row 4 Response: We appreciate the reviewer’s observation. We agree that certain items in Table 2 appeared more related to general orthodontic CAT practice rather than surgical applications . View more View less Competing Interests no competing interests to disclose. reply Respond Report a concern Mohamed AM. Peer Review Report For: The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons [version 4; peer review: 1 approved, 1 approved with reservations] . 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