{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T09:48:41Z","timestamp":1791971321151,"version":"4.3.4"},"update-to":[{"DOI":"10.12688\/f1000research.170095.1","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2026,5,7]],"date-time":"2026-05-07T00:00:00Z","timestamp":1778112000000}},{"DOI":"10.12688\/f1000research.170095.2","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2026,5,7]],"date-time":"2026-05-07T00:00:00Z","timestamp":1778112000000}},{"DOI":"10.12688\/f1000research.170095.3","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2026,5,7]],"date-time":"2026-05-07T00:00:00Z","timestamp":1778112000000}}],"reference-count":41,"publisher":"F1000 Research Ltd","license":[{"start":{"date-parts":[[2026,5,7]],"date-time":"2026-05-07T00:00:00Z","timestamp":1778112000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["f1000research.com"],"crossmark-restriction":false},"short-container-title":["F1000Res"],"abstract":"<ns3:p>\n                    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\u201340 years and had 6\u201310 years of experience. Orthodontists accounted for 65.2% of the respondents, with oral and maxillofacial surgeons at 34.8%. While most treated 1\u20134 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\n                    <ns3:sup>2<\/ns3:sup>\n                    = 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.\n                  <\/ns3:p>","DOI":"10.12688\/f1000research.170095.4","type":"journal-article","created":{"date-parts":[[2026,5,7]],"date-time":"2026-05-07T07:54:07Z","timestamp":1778140447000},"page":"1001","update-policy":"https:\/\/doi.org\/10.12688\/f1000research.crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontists and Oral and Maxillofacial Surgeons"],"prefix":"10.12688","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1940-7359","authenticated-orcid":false,"given":"Ahmad","family":"Salem Assari","sequence":"first","affiliation":[{"name":"Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, College of Medicine and Dentistry Riyadh Riyadh Province Riyadh Elm University"},{"name":"Department of Dentistry Riyadh King Faisal Specialist Hospital and Research Centre"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6497-0984","authenticated-orcid":false,"given":"Muslat","family":"A Bin Rubaia\u2019an","sequence":"additional","affiliation":[{"name":"Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, College of Medicine and Dentistry Riyadh Riyadh Province Riyadh Elm University"},{"name":"Department of Maxillofacial Surgery Riyadh Riyadh Province Prince Sultan Military Medical City"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Diaa","family":"Taisir Al-Marhoun","sequence":"additional","affiliation":[{"name":"Riyadh Dental Clinic"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hayat","family":"Arafah","sequence":"additional","affiliation":[{"name":"Riyadh Alwattan medical complex 3"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"AlAnood","family":"N Bin Saedan","sequence":"additional","affiliation":[{"name":"Saudi Board in Periodontics, College of Medicine and Dentistry Riyadh Riyadh Province Riyadh Elm University"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hajar","family":"Dar Salamah","sequence":"additional","affiliation":[{"name":"Riyadh Dental Clinic"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Raneem","family":"Mohammed Aljomiey","sequence":"additional","affiliation":[{"name":"Riyadh Dental Clinic"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"2560","published-online":{"date-parts":[[2026,5,7]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"1488-1491","DOI":"10.1097\/SCS.0000000000005572","article-title":"Comparing Outcomes in Orthognathic Surgery Using Clear Aligners Versus Conventional Fixed Appliances.","volume":"30","author":"H Kankam","year":"2019 Jul","journal-title":"J. Craniofac. Surg."},{"key":"ref2","doi-asserted-by":"publisher","first-page":"133-136","DOI":"10.1055\/s-0033-1357109","article-title":"Orthognathic surgery: general considerations.","volume":"27","author":"D Khechoyan","year":"2013 Aug","journal-title":"Semin. Plast. Surg."},{"key":"ref3","first-page":"230","article-title":"Orthodontic Retainers-A Critical Review.","volume":"10","author":"I Lyros","year":"2023 Jan 28","journal-title":"Children (Basel)."},{"key":"ref4","doi-asserted-by":"publisher","first-page":"ZC26-ZC28","DOI":"10.7860\/JCDR\/2015\/13496.6086","article-title":"A Unique Bonding Technique for Immediate Orthognathic Surgery.","volume":"9","author":"B Padmaprabha","year":"2015 Jun","journal-title":"J. Clin. Diagn. Res."},{"key":"ref5","article-title":"Measuring Orthognathic Surgery Satisfaction in Orthodontic Patients \u2013 A Questionnaire Survey.","volume":"6","author":"S Banu","year":"2021"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"8932770","DOI":"10.1155\/2022\/8932770","article-title":"Clear Aligner Treatments in Orthoperio Patients.","volume":"2022","author":"G Mampieri","year":"2022","journal-title":"Case Rep. Dent."},{"key":"ref7","doi-asserted-by":"publisher","first-page":"1071.e1-1071.e8","DOI":"10.1016\/j.joms.2018.12.012","article-title":"Clear Aligner Orthognathic Splints.","volume":"77","author":"M Caminiti","year":"2019 May","journal-title":"J. Oral Maxillofac. Surg."},{"key":"ref8","doi-asserted-by":"publisher","first-page":"247275122094940","DOI":"10.1177\/2472751220949405","article-title":"Orthognathic Surgery in a Patient With Clear Aligners and Veneers: Options for Interim Fixation and Early Elastic Physiotherapy\u2014Case Report.","volume":"5","author":"N Naung","year":"2020 Jan 1","journal-title":"Craniomaxillofacial Trauma & Reconstruction Open."},{"key":"ref9","doi-asserted-by":"publisher","first-page":"485-490","DOI":"10.2319\/122919-844.1","article-title":"Outcome assessment of orthodontic clear aligner vs fixed appliance treatment in a teenage population with mild malocclusions.","volume":"90","author":"A Borda","year":"2020 Jul 1","journal-title":"Angle Orthod."},{"key":"ref10","doi-asserted-by":"publisher","first-page":"58-62","DOI":"10.1111\/adj.12480","article-title":"Clear aligners in orthodontic treatment.","volume":"62","author":"T Weir","year":"2017 Mar","journal-title":"Aust. Dent. J."},{"key":"ref11","doi-asserted-by":"publisher","first-page":"229-239","DOI":"10.1016\/j.xaor.2022.03.001","article-title":"Considerations for treatment of patients undergoing orthognathic surgery using clear aligners.","volume":"2","author":"M Moshiri","year":"2022 Jun 1 cited 2025 Jun 16","journal-title":"AJO-DO Clinical Companion."},{"key":"ref12","doi-asserted-by":"publisher","first-page":"e40173","DOI":"10.7759\/cureus.40173","article-title":"Impact of Orthodontic Appliances on Hiring Prospects in Saudi Arabia: A Cross-Sectional Study.","volume":"15","author":"S Alsaeed","year":"2023 Jun","journal-title":"Cureus."},{"key":"ref13","doi-asserted-by":"publisher","first-page":"2395-2403","DOI":"10.18203\/2394-6040.ijcmph20241299","article-title":"Trends and patterns of orthognathic surgery in Saudi Arabia: a visualized bibliometric analysis of research output.","volume":"11","author":"M Alsulaimani","year":"2024 May 14 cited 2025 Jul 12","journal-title":"Int. J. Commun. Med. Public Health."},{"key":"ref14","doi-asserted-by":"publisher","first-page":"10","DOI":"10.1186\/s40510-019-0263-3","article-title":"Clear aligner treatment: different perspectives between orthodontists and general dentists.","volume":"20","author":"F d\u2019Apuzzo","year":"2019 Mar 11 cited 2025 Jun 16","journal-title":"Prog. Orthod."},{"key":"ref15","article-title":"First 4-years orthognathic surgery audit of a Saudi teaching hospital - PubMed.","year":"cited 2025 Jul 13"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"270-274","DOI":"10.5005\/jp-journals-10015-1646","article-title":"Health-related Quality of Life and Satisfaction of the Patient Following Orthognathic Surgery in Kingdom of Saudi Arabia.","volume":"10","author":"G Duhduh","year":"2019 Aug cited 2025 Jul 13","journal-title":"World J. Dent."},{"key":"ref17","doi-asserted-by":"publisher","first-page":"762-769","DOI":"10.1007\/s12663-023-02066-4","article-title":"Patient Satisfaction Following Orthognathic Surgery: A Systematic Review.","volume":"22","author":"U Uppada","year":"2023 Dec cited 2025 Jul 13","journal-title":"J. Maxillofac Oral Surg."},{"key":"ref18","article-title":"Considerations to Planning Orthognathic Surgery in Different Regions of Saudi and the Middle East.","year":"cited 2025 Jul 13"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"1208-1216","DOI":"10.1016\/j.jsps.2017.09.005","article-title":"The characteristics and distribution of dentist workforce in Saudi Arabia: A descriptive cross-sectional study.","volume":"25","author":"A AlBaker","year":"2017 Dec cited 2025 Jul 13","journal-title":"Saudi Pharm J."},{"key":"ref20","doi-asserted-by":"publisher","first-page":"417-426","DOI":"10.2319\/101022-694.1","article-title":"Insight into clear aligner therapy protocols and preferences among members of the American Association of Orthodontists in the United States and Canada.","volume":"93","author":"S Abu-Arqub","year":"2023 Jul 1","journal-title":"Angle Orthod."},{"key":"ref21","doi-asserted-by":"publisher","first-page":"120-129","DOI":"10.1177\/14653125231204889","article-title":"Clear aligner therapy practice among orthodontists in the United Kingdom and the Republic of Ireland: A cross-sectional survey of the British Orthodontic Society membership.","volume":"51","author":"M Meade","year":"2024 Jun","journal-title":"J. Orthod."},{"key":"ref22","doi-asserted-by":"publisher","first-page":"105061","DOI":"10.1016\/j.jdent.2024.105061","article-title":"Advancements in computer-assisted orthognathic surgery: A comprehensive review and clinical application in South Korea.","volume":"146","author":"S On","year":"2024 Jul 1 cited 2025 Jun 16","journal-title":"J. Dent."},{"key":"ref39","doi-asserted-by":"publisher","first-page":"2353-2370","DOI":"10.1007\/s00784-021-04361-1","article-title":"Clinical effectiveness of clear aligner treatment compared to fixed appliance treatment: an overview of systematic reviews.","volume":"26","author":"Y Yassir","year":"2022","journal-title":"Clinical Oral Investigations."},{"key":"ref40","doi-asserted-by":"publisher","DOI":"10.3390\/app132111675","article-title":"Comparative Evaluation of Postoperative Facial Swelling and Occlusion in Orthognathic Treatment with Clear Aligners versus Fixed Orthodontic Appliances: A Systematic Review.","volume":"13","author":"S Rosenberg","year":"2023","journal-title":"Applied Sciences."},{"key":"ref41","doi-asserted-by":"publisher","first-page":"133-142","DOI":"10.1111\/ocr.12353","article-title":"Effectiveness of clear aligner therapy for orthodontic treatment: A systematic review.","volume":"23","author":"L Robertson","year":"2020","journal-title":"Orthodontics & craniofacial research."},{"key":"ref23","doi-asserted-by":"publisher","first-page":"100098","DOI":"10.1016\/j.dentre.2024.100098","article-title":"Use of Clear Aligners with a Surgery-First Approach for Treatment of the Anterior Open Bite: A Systematic Review and Comparison with Conventional Fixed Appliances.","volume":"4","author":"J Stewart","year":"2024 Sep 1 cited 2025 Jun 16","journal-title":"Dentistry Review."},{"key":"ref24","doi-asserted-by":"publisher","first-page":"104052","DOI":"10.1016\/j.jdent.2022.104052","article-title":"The current state of computer assisted orthognathic surgery: A narrative review.","volume":"119","author":"D Apostolakis","year":"2022 Apr","journal-title":"J. Dent."},{"key":"ref25","doi-asserted-by":"publisher","first-page":"334-346","DOI":"10.1053\/j.sodo.2022.12.002","article-title":"Clinical application of Clear Aligner Treatment (CAT) in the Surgery-First Orthognathic Approach (SFOA).","volume":"28","author":"W Sabouni","year":"2022 Dec cited 2025 Jun 16","journal-title":"Semin. Orthod."},{"key":"ref26","doi-asserted-by":"publisher","first-page":"635-643","DOI":"10.1111\/joor.13459","article-title":"Effects of short-term motor training on accuracy and precision of simple jaw and finger movements after orthodontic treatment and orthognathic surgery: A case-control study.","volume":"50","author":"J Liu","year":"2023 Aug","journal-title":"J. Oral Rehabil."},{"key":"ref27","first-page":"e46348","article-title":"Assessment of Awareness and Perceptions of Healthcare Professional Graduates Regarding the Use of Clear Aligners in Orthodontic Treatment.","volume":"15","author":"V Shivlani","year":"cited 2025 Jun 16","journal-title":"Cureus."},{"key":"ref28","article-title":"Dentist\u2019s Knowledge and Attitude towards Using Invisalign in Orthodontic Treatment.","volume":"10","author":"M Zakirulla","year":"2022","journal-title":"Journal of Research in Medical and Dental Science."},{"key":"ref29","first-page":"973-981","article-title":"Aligners- The Choice of New Generation: A Questionnaire Based Survey of Dental Students on Aligner Treatment Protocol.","volume":"6","author":"D Shah","year":"2022 Sep 1 cited 2025 Jun 16","journal-title":"Journal of Positive School Psychology."},{"key":"ref30","doi-asserted-by":"publisher","first-page":"38-45","DOI":"10.25259\/APOS_127_2022","article-title":"Public perception of Invisalign\u00ae clear aligner treatment: A cross-sectional survey-based study.","volume":"13","author":"N Almotairy","year":"2023 Jan 30","journal-title":"APOS Trends in Orthodontics."},{"key":"ref31","doi-asserted-by":"publisher","first-page":"27","DOI":"10.1186\/s40510-024-00525-3","article-title":"Clear aligner therapy practices among orthodontists practicing in Canada.","volume":"25","author":"E Miranda","year":"2024 Jul 8","journal-title":"Prog. Orthod."},{"key":"ref32","doi-asserted-by":"publisher","first-page":"400-409","DOI":"10.1016\/j.ajodo.2019.09.014","article-title":"Esthetic perception of clear aligner therapy attachments using eye-tracking technology.","volume":"158","author":"J Thai","year":"2020 Sep","journal-title":"Am. J. Orthod. Dentofacial Orthop."},{"key":"ref33","doi-asserted-by":"publisher","first-page":"1512838","DOI":"10.3389\/froh.2024.1512838","article-title":"Effects of clear aligners treatment in growing patients: a systematic review.","volume":"5","author":"V D\u2019Ant\u00f2","year":"2024","journal-title":"Front Oral Health."},{"key":"ref34","doi-asserted-by":"publisher","first-page":"312","DOI":"10.1186\/s12903-020-01300-6","article-title":"An objective system for appraising clear aligner treatment difficulty: clear aligner treatment complexity assessment tool (CAT-CAT).","volume":"20","author":"H Long","year":"2020 Nov 10","journal-title":"BMC Oral Health."},{"key":"ref35","doi-asserted-by":"publisher","first-page":"3672","DOI":"10.3390\/jcm13133672","article-title":"Predicting Outcome in Clear Aligner Treatment: A Machine Learning Analysis.","volume":"13","author":"D Wolf","year":"2024 Jun 24","journal-title":"J. Clin. Med."},{"key":"ref36","doi-asserted-by":"publisher","first-page":"e52038","DOI":"10.7759\/cureus.52038","article-title":"Stability and Success of Clear Aligners in Orthodontics: A Narrative Review.","volume":"16","author":"H Katib","year":"2024 Jan","journal-title":"Cureus."},{"key":"ref37","doi-asserted-by":"publisher","first-page":"127-133","DOI":"10.1111\/ocr.12177","article-title":"Efficiency, effectiveness and treatment stability of clear aligners: A systematic review and meta-analysis.","volume":"20","author":"M Zheng","year":"2017 Aug","journal-title":"Orthod. Craniofac. Res."},{"key":"ref38","doi-asserted-by":"publisher","first-page":"274-285","DOI":"10.1055\/s-0041-1739441","article-title":"Does Clear Aligner Treatment Result in Different Patient Perceptions of Treatment Process and Outcomes Compared to Conventional\/Traditional Fixed Appliance Treatment: A Literature Review.","volume":"16","author":"A Ben Gassem","year":"2021 Dec 22 cited 2025 Jun 16","journal-title":"Eur. J. Dent."}],"updated-by":[{"DOI":"10.12688\/f1000research.170095.5","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T00:00:00Z","timestamp":1791936000000}}],"container-title":["F1000Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/f1000research.com\/articles\/14-1001\/v4\/xml","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/f1000research.com\/articles\/14-1001\/v4\/pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/f1000research.com\/articles\/14-1001\/v4\/iparadigms","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T08:59:09Z","timestamp":1791968349000},"score":1,"resource":{"primary":{"URL":"https:\/\/f1000research.com\/articles\/14-1001\/v4"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,7]]},"references-count":41,"URL":"https:\/\/doi.org\/10.12688\/f1000research.170095.4","relation":{"has-version":[{"id-type":"doi","id":"10.12688\/f1000research.170095.3","asserted-by":"subject"},{"id-type":"doi","id":"10.12688\/f1000research.170095.2","asserted-by":"subject"},{"id-type":"doi","id":"10.12688\/f1000research.170095.1","asserted-by":"subject"}],"has-review":[{"id-type":"doi","id":"10.5256\/f1000research.200348.r482398","asserted-by":"subject"},{"id-type":"doi","id":"10.5256\/f1000research.200348.r482399","asserted-by":"subject"},{"id-type":"doi","id":"10.5256\/f1000research.200348.r482399","asserted-by":"object"},{"id-type":"doi","id":"10.5256\/f1000research.200348.r482398","asserted-by":"object"}],"is-version-of":[{"id-type":"doi","id":"10.12688\/f1000research.170095.5","asserted-by":"object"}]},"ISSN":["2046-1402"],"issn-type":[{"value":"2046-1402","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,7]]},"assertion":[{"value":"Approved, Approved with reservations","URL":"https:\/\/f1000research.com\/articles\/14-1001\/v4#article-reports","order":0,"name":"referee-status","label":"Referee status","group":{"name":"current-referee-status","label":"Current Referee Status"}},{"value":"10.5256\/f1000research.200348.r482398, Abdelrahman MA Mohamed, Orthodontics, Royal College of Surgeons of Edinburgh, Edinburgh, 09 May 2026, version 4, 1 approved, 1 approved with reservations","URL":"https:\/\/f1000research.com\/articles\/14-1001\/v4#referee-response-482398","order":0,"name":"referee-response-482398","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Ahmad Assari<\/b>; \n<i>Posted: 13 May 2026<\/i>; \n<b>Response to Reviewer<\/b> We sincerely thank the reviewer for the careful evaluation of our manuscript and for the constructive suggestions. We also appreciate the overall positive assessment that the manuscript is generally acceptable after revision. We have carefully addressed each point raised, as detailed below. \n<b>1. Results: Tables S1 and S2 definitions in the footnote need to be added (P value, CI).<\/b> \n<b>Response:<\/b> We agree and thank the reviewer for identifying this issue. In the revised version, we added clear footnote definitions for the statistical abbreviations used in Supplementary Tables S1 and S2, including CI and p-value, to improve clarity and consistency of presentation. \n<b>Changes made:<\/b>  Added footnote definitions to Supplementary Tables S1 and S2 as follows: CI, confidence interval; p-value, probability value.  \n<b>2. Discussion and Limitations sections are overly long and contain repeated information under different subheadings, leading to unnecessary redundancy.<\/b> \n<b>Response:<\/b> We agree with this important comment. In the revised manuscript, both the Discussion and Limitations sections were substantially streamlined to improve focus, reduce redundancy, and enhance readability. Repeated statements regarding sample size, response rate, exploratory interpretation, and generalizability were consolidated. Several discussion subsections that were more narrative or repetitive in nature were removed or merged, and the revised Discussion now focuses more directly on the study findings, their cautious interpretation, and implications for future research and training. The Limitations section was also revised so that each major limitation is stated once in a more concise and organized manner. \n<b>Changes made:<\/b>  Shortened and reorganized the Discussion section. Removed repeated or overlapping discussion content across multiple subheadings. Consolidated cautionary statements regarding the exploratory nature of the study. Streamlined the Limitations section to reduce redundancy and improve clarity.  \n<b>3. 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.<\/b> \n<b>Response:<\/b> We appreciate this observation. In the revised manuscript, we further emphasized that the study should be interpreted strictly as exploratory, given the small achieved sample size and low response rate. This cautious framing has been maintained consistently across the Abstract, Methods, Statistical Analysis, Results, Discussion, Limitations, and Conclusion. We also revised the organization of the Discussion to improve overall flow and reduce redundancy, while ensuring that the implications of the sample size and response rate remain clearly acknowledged. \n<b>Changes made:<\/b>  Further reinforced the exploratory nature of the study throughout the manuscript. Maintained explicit acknowledgment of the limitations related to the small achieved sample size and low response rate. Improved the organization and readability of the Discussion section.   We thank the reviewer again for these valuable comments, which helped improve the clarity, structure, and overall presentation of the manuscript.","URL":"https:\/\/f1000research.com\/articles\/14-1001\/v4#referee-comment-16191","order":1,"name":"referee-comment-16191","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.5256\/f1000research.200348.r482399, Tiago Fialho, Department of Orthodontics, Bauru Dental School, S\u00e3o Paulo University, Bauru, SP, 08 May 2026, version 4, 1 approved, 1 approved with reservations","URL":"https:\/\/f1000research.com\/articles\/14-1001\/v4#referee-response-482399","order":2,"name":"referee-response-482399","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Ahmad Assari<\/b>; \n<i>Posted: 13 May 2026<\/i>; \n<b>Response to Reviewer<\/b> We sincerely thank the reviewer for the careful, thoughtful, and constructive evaluation of our revised manuscript. We greatly appreciate the recognition that the manuscript has improved substantially compared with the previous versions, particularly in terms of methodological transparency, clarification of study limitations, restructuring of the discussion, and clearer positioning of the work as exploratory in nature. We also appreciate the reviewer\u2019s acknowledgement of the clinical relevance and timeliness of the topic, as well as the value of providing preliminary regional data from Saudi Arabia. We carefully considered all comments and revised the manuscript accordingly. Our detailed point-by-point responses are provided below. \n<b><b>1. Reviewer comment<\/b><\/b> \n<b>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.<\/b> \n<b>Response:<\/b> We sincerely thank the reviewer for this encouraging assessment. We are grateful that the revisions made in response to earlier comments have improved the transparency, balance, and scientific caution of the manuscript. We have continued to refine the revised version to ensure that the study is consistently presented as exploratory and that its limitations are clearly and transparently acknowledged throughout. \n<b><b>2. <\/b><b>Reviewer comment<\/b><\/b> \n<b>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.<\/b> \n<b>Response:<\/b> We thank the reviewer for highlighting the clinical relevance and timeliness of this topic. We agree that the evolving role of CAT in orthognathic workflows warrants investigation, particularly in regions where evidence remains limited. We have retained this contextual relevance in the Introduction and Discussion while ensuring that our findings are framed appropriately as preliminary regional observations rather than definitive conclusions. \n<b><b>3. Reviewer comment<\/b><\/b> \n<b>Nevertheless, several methodological and statistical concerns persist and should be acknowledged as important limitations of the study.<\/b> \n<b>Response:<\/b> We agree. In the revised manuscript, we have further strengthened the acknowledgment of methodological and statistical limitations. These are now stated more explicitly in the Methods, Statistical Analysis, Discussion, and Limitations sections, including the low achieved sample size, limited statistical power, exploratory nature of inferential testing, potential selection bias, and limited external validity. \n<b>4. Reviewer comment<\/b> 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. \n<b>Response:<\/b> We fully agree. In the revised manuscript, we have further clarified that the final sample size was substantially below the calculated target and that this limited statistical power, precision, and inferential robustness. We now emphasize more consistently that all inferential analyses were conducted for exploratory purposes only and should not be interpreted as confirmatory. We also reduced interpretive emphasis on inferential findings throughout the manuscript. Changes made:  Revised the Abstract, Discussion, Limitations, and Conclusion to emphasize the exploratory and hypothesis-generating nature of the study. Added clearer wording in the Statistical Analysis section indicating that inferential analyses were exploratory only. Reduced the interpretive weight given to chi-square and regression findings in the Results and Discussion.  \n<b>5. Reviewer comment<\/b> 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\u2019s exact test or purely descriptive reporting would likely have been more appropriate. \n<b>Response:<\/b> We thank the reviewer for this important observation and agree that the statistical presentation required further clarification and restraint. In the revised manuscript, descriptive statistics are now clearly presented as the primary analytical framework. We have revised the Statistical Analysis section to state explicitly that chi-square or Fisher\u2019s exact tests were applied only for selected exploratory comparisons between categorical variables, depending on expected cell frequencies and data distribution. We also now define the null hypothesis for these analyses and clarify that any reported p-values are exploratory rather than confirmatory. Changes made:  Clarified that descriptive statistics constitute the primary analytical approach. Revised the Statistical Analysis section to specify that chi-square or Fisher\u2019s exact tests were used only where exploratory categorical comparisons were considered clinically relevant. Added the statement that the null hypothesis for these exploratory analyses was that no association existed between the variables being compared. Added explicit caution that p-values should be interpreted as exploratory only. Reduced unnecessary inferential emphasis in tables and text.  \n<b>6. Reviewer comment<\/b> Similarly, the regression analysis should be interpreted with substantial caution. The manuscript does not fully explain how the composite \u201cCAT usage score\u201d was constructed or validated, and the limited sample size raises concerns regarding model stability, overfitting, and reliability of the reported R&sup2; 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. \n<b>Response:<\/b> We agree. In the revised manuscript, we clarified that the CAT usage score was derived from questionnaire responses reflecting reported CAT-related experience in orthognathic surgery and that it was created specifically for the purposes of this survey. We now explicitly state that this score is not a previously validated scale. We also further softened the interpretation of regression findings and removed wording that could imply stable explanatory power. The manuscript now clearly states that regression findings are exploratory, vulnerable to instability and overfitting, and should be viewed only as preliminary patterns to inform future studies. Changes made:  Added a clearer explanation of the CAT usage score in the Statistical Analysis section. Stated explicitly that the score was survey-derived and not externally validated. Added caution regarding limited sample size, sparse data structure, model instability, and overfitting risk. Revised Results and Discussion text to avoid overstating explanatory power and to caution interpretation of reported R&sup2; values.  \n<b>7. Reviewer comment<\/b> 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. \n<b>Response:<\/b> We appreciate this important comment and agree. In the revised manuscript, we have further shortened and refocused the Discussion to align more closely with the actual survey findings. Sections that were excessively narrative have been streamlined, and speculative statements regarding clinician behavior, digital workflow adoption, and broader regional trends have been reduced, softened, or removed unless directly supported by the data. The revised Discussion now places greater emphasis on cautious interpretation of the collected findings and their preliminary implications. Changes made:  Reduced the overall length of the Discussion. Streamlined literature-heavy sections that were more narrative than interpretive. Removed or softened speculative statements not directly supported by the study methodology or findings. Refocused the section on interpretation of the observed survey results within an exploratory framework.  \n<b>8. Reviewer comment<\/b> 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. \n<b>Response:<\/b> We agree and thank the reviewer for highlighting this conceptual limitation. In the revised manuscript, we now explicitly acknowledge that the questionnaire was designed to provide a broad exploratory overview of clinician perspectives and did not distinguish all orthognathic CAT-related protocols with sufficient analytical precision. We also note that future research should evaluate these treatment scenarios separately to allow more protocol-specific interpretation. Changes made:  Added this issue to the questionnaire description in the Methods. Added this limitation explicitly to the Limitations section. Included a recommendation in the Discussion for future protocol-specific investigations.  \n<b><b>9. Reviewer comment<\/b><\/b> \n<b>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.<\/b> \n<b>Response:<\/b> We sincerely thank the reviewer for this positive assessment. We believe transparency regarding study weaknesses is essential, especially in exploratory work with limited sample size. We have maintained and further clarified these limitations in the revised manuscript and retained the open data statement to support transparency, reproducibility, and future secondary analysis. \n<b><b>10. Reviewer comment<\/b><\/b> \n<b>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.<\/b> \n<b>Response:<\/b> We fully agree. The revised manuscript now consistently presents the study as an exploratory survey offering preliminary insight rather than definitive evidence. We have strengthened this wording in the Abstract, Discussion, Limitations, and Conclusion. We also agree that the current work may serve as an initial foundation for future multicenter studies with stronger methodological design and adequate statistical power. \n<b><b>11. Reviewer comment<\/b><\/b> \n<b>Based on the improvements introduced in Version 4 and considering the remaining limitations described above, my recommendation is:<\/b> \n<b>Response:<\/b> We sincerely thank the reviewer for the careful reassessment of Version 4 and for considering the manuscript acceptable in light of the revisions made and the limitations transparently acknowledged. \n<b><b>12. Reviewer comment<\/b><\/b> \n<b>Approved with Reservations.<\/b> \n<b>Response:<\/b> We are grateful to the reviewer for this recommendation and for the constructive guidance that helped us improve the manuscript substantially. We have carefully addressed the remaining concerns to the best extent possible within the scope and design of the present study. \n<b><b>13. Reviewer comment<\/b><\/b> \n<b>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.<\/b> \n<b>Response:<\/b> We appreciate this valuable recommendation and have incorporated further refinements in the current revision. Specifically, we improved the statistical presentation by clarifying the exploratory nature of all inferential analyses, defining the null hypothesis for categorical comparisons, specifying the use of chi-square or Fisher\u2019s exact tests as appropriate, and providing clearer caution regarding interpretation of regression findings and R&sup2; values. We also further reduced speculative and narrative elements within the Discussion. We agree that these areas will remain important considerations in future related publications. We again thank the reviewer for the constructive, balanced, and thoughtful feedback. These comments were highly valuable in strengthening the manuscript, particularly with respect to statistical caution, interpretive restraint, and clearer acknowledgment of conceptual and methodological limitations.","URL":"https:\/\/f1000research.com\/articles\/14-1001\/v4#referee-comment-16192","order":3,"name":"referee-comment-16192","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"The author(s) declared that no grants were involved in supporting this work","order":4,"name":"grant-information","label":"Grant Information"},{"value":"This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.","order":0,"name":"copyright-info","label":"Copyright"}]}}