Introduction 17 1 Skin reactions require special consideration in the paediatric population. Pubertal hormonal changes result in sebaceous hypertrophy and an associated skin overgrowth which may require a longer abutment [40]. There is also an acceptance that the lifestyle and behaviour of children can result in an anticipated proportion of abutment loss secondary to trauma [41]. This underlies the philosophy of sleeper fixture insertion at the time of the primary procedure. Any fixture loss can be replaced quickly without any delay associated with waiting for osseointegration of a new implant. Physiological factors and Osseointegration Successful implantation is dependent upon osseointegration of the implanted fixture with the surrounding bone which occurs during wound healing, and is defined by three factors; (i) the formation of a stable support and absence of relative motion between the implant and surrounding tissues, (ii) the apposition of bone to the implant without intervening soft tissue, and (iii) the tissues closest to the implant surface are identified as normal bone and marrow constituents (at light and electron microscopic levels [42]. These factors are in turn influenced by implant geometry (macro, micro and nano scale), drilling protocol, osteotomy configuration, surface, and material properties, surrounding bone quality as well as systemic and local characteristics of the host [43]. Patient-related conditions such as high BMI, diabetes, osteogenesis imperfecta, previous radiotherapy of the temporal bone, various co-morbidities and smoking have been implicated in higher rates of implant loss [44,45,46]. For this reason, despite the overall low incidence of implant failure, there is a need to further enhance the implant stability and osseointegration, and thereby survival rates. Furthermore, some centres advocate early or even immediate loading of processors in adults [47,48,49,50] and at 6 weeks in children [51]. This too, leads to increased demands on implant stability and accelerated osseointegration. The common strategy for addressing these challenges, both for dental, orthopaedic and BAHI applications, have been two-fold, (i) increased implant diameter and primary implantto-bone contact and (ii) application of surface modification to the implant. The use of wider diameter implants was shown to improve outcomes in dental implantation with lower implant failure rates [52,53]. Application of wide diameter BAHI (4.5 mm diameter) has been found to have comparable adverse skin reaction rates to the previous generation implants (3.75mm diameter) and associated with increased survival [54,55,56,57]. The wider diameter increases the surface area contact between the implant and temporal bone thereby providing a greater primary stability with the aim to promote a reduction in
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