Assistant Professor Dragana Gabrić, ddm, PhD

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Autor: Assistant Professor Dragana Gabrić, DDM, PhD, Specialist in Oral Surgery,

Department of Oral Surgery, School of Dental Medicine, University of Zagreb

Assistant Professor Dragana Gabrić,


• 2004 Degree, Doctor of Dental Medicine,

University of Zagreb

• 2005 Dean’s Award for Study Success

• 2007 Oral Surgeon Trainee, Department

of Oral Surgery, Clinical Hospital

Center Zagreb

• 2010 PhD Degree, dissertation, field of

experimental laser bone surgery

• 2011 Specialist in Oral Surgery, Department

of Oral Surgery, Clinical Hospital

Center Zagreb,

• 2013 Senior Research Scientist, Department

of Oral Surgery, School of Dental


The usage of dental implants in the

therapy of complete and partial loss

of teeth daily results in a growing

number of complications and cases of

peri-implant diseases, and consequential

loss of implant stability and

osseointegration. According to

Branemark, osseointegration is the

bone ability to bond with the endosteal

implant without soft tissue imposition

(1). The successfulness and

durability of the implant depend on

proper indication, good planning and

execution of prosthetic suprastructure,

the therapist’s skill, but also on

the patient’s oral hygiene (2). Special

attention is paid to general medical

(general condition, nourishment level,

age, current medication, metabolic

diseases, hematologic diseases,

heart and vascular system condition,

bone metabolism problems, collagenosis,

implant as a potential bacterial

focus) and intraoral (anatomically

unfavourable inter-jaw relation, changed

occlusal and functional relations,

pathological finding in jaw-bone, pathological

changes of mucous membrane,

xerotomia, macroglossia,

untreated remaining teeth, poor oral

hygiene) contraindications that have

to be recognised during diagnostic

and preparatory procedure. There are

also time-limited contraindications

(acute inflammatory disease and infection,

pregnancy, temporary usage

of certain medications, stressful situations

of body and mind) and mentally

conditioned contraindications

(insufficient co-operation of the patient

and failure to understand the

therapy plan, alcohol or drug consumption,

smoking, neuroses and

psychoses, problematic patients) that

also have to be taken into consideration

(3). Although in numerous clinical

cases implant placement results in

long-term success, it does not guarantee

absolute lack of complications, so

it is necessary to consider the fact that

complications are possible even after

a successful implant placement. With

regard to the course and maintenance

of implants, which primarily means

osseointegration of the implant and

the patient’s oral hygiene, biological

complications occur in the form of

peri-implant mucositis and peri-implantitis,

as well as inflammations of

soft and hard tissue (4).


Failure in therapy with dental implants

can be divided into early, which

occurs immediately after implantation,

and late which occurs when the

restoration supported by the implant

is put in function. Early failure of the

implant can be caused by: improper

site preparation, bacterial contamination

and extensive inflammation of

the wound, unfavourable mechanical

stability of the implant after placement

and premature or inadequate

implant burden. Late failures occur

when there is a loss of osseointegration

of previously stable and functional

implant and it is a result of

excessive burdening or infection (5).

Prevalence of peri-implant diseases is

difficult to determine because of the

variation from 2 to 10 per cent of the

cases of all implant insertions (5). The

published research mentions the prevalence

of peri-implant mucositis up

to 48 per cent during the monitoring

period from 9 to 14 years (6). There are

numerous risk factors that can lead to

the development of peri-implant mucositis

and peri-implantitis. Some of

these factors are the following: previous

periodontal disease, poor plaque

control, residual cement,

smoking, genetic factors, diabetes,

occlusal overload, alcohol consumption

and connective tissue diseases (7-



Peri-implant mucositis is a reversible

inflammation restricted to soft tissue

surrounding the implant, without signs

of any loss of the supporting

bone, which results from plaque accumulation.

39.4 per cent to 80 per cent

of persons with dental implants experience

it (22-24). Gingiva and mucosa

around the implant respond to the

colonisation of microbiota by developing

apparent lesions i.e. by the infiltration

of leukocytes in connective

tissue. In comparison with a natural

tooth, mucous membrane lesions

spread more and progress apically,

since the mucous membrane surrounding

the implant contains less fibroblasts.

The mucous membrane

surrounding the implant is less efficient

in restricting lesions connected

with the plaque. A small number of fibroblasts

fail to produce sufficient

collagen and matrix during the reparatory

stage which results in further

advancement and spreading of inflamed

infiltrate in the membrane surrounding

the implant (5).


Peri-implantitis is defined as an inflammatory

process that affects the

tissue surrounding osseointegrated

implant in function and results in the

loss of the supporting bone, and it is a

consequence of the progression of

peri-implant mucositis. Peri-implant

tissue, unlike the tissue surrounding a

healthy tooth, is organised more poorly,

so progressive lesions connected

with plaque are more difficult to stop


It occurs as a consequence of overheating

during osteotomy, implant overload

following the implant-prosthetic

rehabilitation and contamination of

dental implant during the production

or insertion. Radiolucency is radiologically

visible in the coronal part of

the implant, and it further progresses

towards the top of the implant (5).

Retrograde peri-implantitis

Retrograde peri-implantitis is defined

as a clinically symptomatic periapical

lesion diagnosed as a radiolucency

that develops shortly after implant insertion,

and the coronal portion of the

implant sustains a normal bone-to-

-implant interface (25). This condition

was first described by McAllister et al

(26). The etiology of the condition

may be attributed to several causes

and includes pre-existing inflammation

of a residual root top or adjacent

tooth, foreign body within bone tissue

or insertion of a dental implant in

an infected maxillary sinus (27).


Therapy of already existing conditions

in peri-implant diseases is extremely

complicated and is conducted in several

stages. Considering the known

causes of peri-implant diseases, a

combination of systemic therapy by

antibiotics and some of surgical or

non-surgical methods (debridement,

detoxification and guided bone regeneration)

are applied in their treatment.

It is important to note that the

treatment of any peri-implant disease

is difficult, and the success and clinical

results are uncertain. After the insertion

of dental implants and the conclusion

of implant-prosthetic therapy,

the patients have to be informed

about the importance of proper oral

hygiene. Additionally, during regular

follow-ups it is necessary to conduct

professional removal of soft and hard

plaque with the aim of removing present

bacteria as the lead factor in the

occurrence of peri-implant diseases


One of the most prominent and recent

theories about the occurrence of

peri-implant diseases is based on reinfection

of peri-implant tissue from the

inside of the implant (29). Between

implants and suprastructure there is a

gap that can be minimised, but not

completely removed. According to

the literature, marginal area amounts

to 14 to 160 micrones and is usually

unable to resist infiltration of germs

from the mouth cavity, because pathogenic

microorganisms are regularly

several times smaller than the

existing gap between the implant surface

and suprastructure. The colonisation

of microorganisms occurs

immediately after the fixation of cover

screw or prosthetic suprastructures,

whereas the heat and moist conditions

within the implant enable the

growth of microbes. During chewing,

due to capillary forces and micromovements,

an exchange of fluids occurs

between the inside of the implant and

peri-implant tissue. This mechanism

leads to permanent reinfection which

is the most frequent cause of peri-implantitis.

Even the highest level of precision

in the implant making cannot

fully eliminate the need to add some

materials into the implant in order to

compensate for the rough surface of

the implant and suprastructure (28).

Primarily because of that some preparations

appeared on the market to fill

the gap and thus contribute to the

prevention of peri-implant diseases:

gold foil, self-hardening silicon materials,

vaseline, antibiotic gels, chlorhexidine

gel, Paldur® and Ledermix®.

Regardless of which of the afore mentioned

preparations is used for the

treatment of this important area, it

should be emphasised that they are

unstable and that the prevention of

this type is a short-term one and needs

to be repeated. Due to that, based

on the past ten years of experimental

and clinical work at the University of

Düsseldorf, the material called Gap-

Seal® has been developed (Hager &

Werken, Duisburg, Germany). The material

is based on essential components

from high viscose silicone basis

and an ingredient combination complex

with bactericidal, fungicidal, virucidal

properties , which enables

long-term softness and efficient sealing

on implant gap. Considering

that it is not possible to remove by rinsing,

but it has to be done mechanically,

it is the only material that ensures

long-term protection from reinfection

from the inside of the implant. It is

packed in prefilled sterile tips, with

the applicator that can be autoclaved,

and that makes the application fast

and simple. The application is indicated

in all stages of dental implant insertion,

in the fixation of the cover

screw of the implant, fixation of gingiva

formers and final prosthetic construction.

Since the largest number of peri-implant

diseases occurs as a result of

peri-implant tissue reinfection from

the inside of the implant, it seems reasonable

to attempt to prevent peri-

-implant diseases by using recent

sealants of gaps based on high viscose

silicones between the implant surface

and prosthetic suprastructure with

the aim of preventing and disabling

mechanisms of reinfection of peri-implant


1. Branemark PI. Osseointegration and its experimental

background. J Prosthet Dent. 1983


2. Aurer A. Periimplantatne bolesti. Medix.


3. Ćelić R, Pandurić J, Klaić B. Razumijevanje okluzije

– ključ za uspjeh oseointegracije. Medix.


4. Academy report. Peri-implant mucositis and peri-

-implantitis: a current understanding of their diagnoses

and clinical implications. J Periodontol.


5. Lindhe J, Karring TH, Lang NP. Klinička parodontologija

i dentalna implantologija. Zagreb: Globus;


6. Roos-Jansaker AM, Lindahl C, Renvert H, Renvert

S. Nine- to fourteen-year follow-up of implant

treatment. Part II: Presence of peri-implant lesions.

J Clin Periodontol. 2006;33(4):290-5.

7. Klokkevold PR, Han TJ. How do smoking, diabetes,

and periodontitis affect outcomes of implant

treatment? Int J Oral Maxillofac Implants.


8. Serino G, Strom C. Peri-implantitis in partially

edentulous patients: Association with inadequate

plaque control. Clin Oral Implants Res.


9. Wilson TG Jr. The positive relationship between

excess cement and peri-implant disease: A prospective

clinical endoscopic study. J Periodontol.

2009; 80(9):1388-92.

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L, Apse P. Does residual cement around implantsupported

restorations cause peri-implant disease?

A retrospective case analysis. Clin Oral

Implants Res. 2013;24(11):1179-84.

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B, Kuchler I. Smoking interferes with the prognosis

of dental implant treatment: A systematic

review and meta-analysis. J Clin Periodontol.


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Yamauchi E, Miyamoto Y. Influence of smoking on

osseointegrated implant failure: A meta-analysis.

Clin Oral Implants Res. 2006;17(4):473-8.

13. Heitz-Mayfield LJ, Huynh-Ba G. History of treated

periodontitis and smoking as risks for implant

therapy. Int J Oral Maxillofac Implants.


14. Bormann KH, Stühmer C, Z’Graggen M, Kokemöller

H, Rücker M, Gellrich NC. IL-1 polymorphism

and peri-implantitis. A literature review. Schweiz

Monatsschr Zahnmed. 2010;120(6):510-20.

15. Bornstein MM, Cionca N, Mombelli A. Systemic

conditions and treatments as risks for implant

therapy. Int J Oral Maxillofac Implants.


16. Mombelli A, Cionca N. Systemic diseases affecting

osseointegration therapy. Clin Oral Implants Res.

2006;17(Suppl 2):97-103.

17. Salvi GE, Carollo-Bittel B, Lang NP. Effects of diabetes

mellitus on periodontal and peri-implant conditions:

Update on associations and risks. J Clin

Periodontol. 2008;35(8):398-409.

18. Stanford CM, Brand RA. Toward an understanding

of implant occlusion and strain adaptive bone

modeling and remodeling. J Prosthet Dent


19. Fu JH, Hsu YT, Wang HL. Identifying occlusal overload

and how to deal with it to avoid marginal

bone loss around implants. Eur J Oral Implantol.


20. Krennmair G, Seemann R, Piehslinger E. Dental

implants in patients with rheumatoid arthritis:

Clinical outcome and peri-implant findings. J Clin

Periodontol. 2010;37(10):928-36.

21. Galindo-Moreno P, Fauri M, Avila-Ortiz G, Fernandez-

Barbero JE, Cabrera-Leon A, Sanchez-Fernandez

E. Influence of alcohol and tobacco habits

on peri-implant marginal bone loss: A prospective

study. Clin Oral Implants Res. 2005;16(5):579-


22. Rinke S, Ohl S, Ziebolz D, Lange K, Eickholz P. Prevalence

of peri-implant disease in partially edentulous

patients: a practice-based cross-sectional

study. Clin Oral Implants Res. 2011;22(8):826-33.

23. Koldsland OC, Scheie AA, Aass AM. Prevalence of

peri-implantitis related to severity of the disease

with different degrees of bone loss. J Periodontol.

2010; 81(2):231-8.

24. Zitzmann NU, Berglundh T. Definition and prevalence

of peri-implant diseases. J Clin Periodontol.

25. Quirynen M, Gijbels F, Jacobs R. An infected

jawbone site which compromised a successful

osseointegration. Periodontol 2000. 2003;33:129-


26. McAllister BS, Masters D, Meffert RM. The treatment

of the implants which demonstrated periapical

radiolucencies. Pract Periodontics Aesthet

Dent. 1992;4(9):37-41.

27. Zhou W, Han C, Li D, Li Y, Song Y, Zhao Y. The endodontic

treatment of teeth induces retrograde

peri-implantitis. Clin Oral Implants Res.

2009;20(12):1326-32. 2008; 35(8):286-91.

28. Laney WR, Tolman DE. Tissue Integration in Oral,

Orthopedic & Maxillofacial Reconstruction, Mayo

Medical Center Rochester, Minnesota, 1990.

29. Fritzemeier CU. Peri-implantitis prophylaxis by

sealing implant gaps and hollow spaces. Implants

2013 (3) 41-43

Hager & Werken GmbH & Co. KG

Ackerstraße 1, 47269 Duisburg

Tel. +49 (203) 99269-0 · Fax +49 (203) 299283 ·
GapSeal Set (applicator with 10 Tips) REF 152 041

GapSeal Refill Pack (10 Tips à 0,06 ml) REF 152 040

Applicator separately REF 152 042

Fig. 1: GapSeal® (Hager & Werken, Duisburg,

Germany) disposable sterile tips with applicator.
Fig. 2: Simple insertion of carpule into the applicator.
Fig. 3: Application of the material into the osseointegrated

dental implant.

Fig. 4: Application of the material during fixation

of the cover screw.

Fig. 5: Fixation of the cover screw after application

of GapSeal®.

Fig. 6: Application of the material for the prothetic


Fig. 7: Application of the material into the inside

of the dental implant.

Fig. 8: Final clinical aspect after fixation of the

prosthetic suprastructure

Fig. 9: Mechanism of reinfection from the inside

of the implant. (Courtesy of Hager & Werken,

Duisburg, Germany)

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