67 3.1 Clinical Evaluation of laser-ablated titanium implant 4. Discussion To our knowledge, the current study is the largest published evaluation of wide implants BAHIs in pediatrics and the first study evaluating the clinical outcomes of the new Ponto BHX in children. The present study revealed an implant loss rate of 3.4% in a pediatric population. A previous study on 182 children from BCH using two-stage surgery in 95% of the cases, demonstrated implant failures in 14% of loaded implants (27). In contrast to the present study, 3.75 mm machined implants were used and installed using a split skin graft technique. Moreover, the follow-up time was 15 years. However, the majority of implants were lost during the first 2 years and associated with wound breakdown and significant skin reaction, indicating the influence of implant design and surgical technique on the survival rate. In comparison to other results at our center, outcomes using the previous Ponto wide implant (without a laser ablated surface) showed a 10% implant failure rate in 75 implanted systems (28), indicating a benefit in terms of survival rate using the present implant surface with micro- and nanoscale features. The results from the present study can also be compared with the use of a wide blasted implant (BIA300, Cochlear Nordic AB, Mölnlycke, Sweden) demonstrating 5% implant loss at our center (29). A recent meta-analysis of wide diameter implant systems in the pediatric population demonstrated a 5.9% fixture loss, whereas the corresponding result for the previous narrow BAHI implant was 17.1%, corroborating our findings (19). The reduced revision surgery rate in the present study in comparison with previous results in our center using the small diameter implant, 0% versus 8% (27), is in line with the results in a recent systematic review (19) and far exceeds this center’s experience with the Cochlear BIA300 implant, which demonstrated a significant 77% skin reaction rate and 35% revision rate (29). Taken together, the present study therefore demonstrates significant improvement in the implant loss and revision surgery rates (2.8 and 8.3%) as well as comparable soft tissue complications, compared with previous implant systems utilized. Peri-abutment adverse skin responses are well-known side-effects in pediatric patients (19,27,28). These responses have been linked to hygiene, puberty, skin movement, and medical comorbidities, making children more prone to adverse soft-tissue complications com- pared with adults (19). In children under 5 years old, there is a disproportionate soft tissue complication rate of 15 to 42%, with an associated 10 to 25% revision rate reported (30,31). In our present cohort of 26 children under the age of 5 implanted with 40 BAHIs, two fixture losses were observed (5%) with soft tissue complications (Holgers 2–4) observed in three patients (11.5%). Taken together, the 4.5 mm wide laser ablated titanium bone anchored implant system appears to promote favorable results in this at-risk subgroup compared with the previous
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