LITERATURE REVIEW

PEEK Dental Implants: A Review of the Literature

Andreas Schwitalla, DDS1*
Wolf-Dieter Müller, PhD2

The insertion of dental implants containing titanium can be associated with various complications (eg,
hypersensitivity to titanium). The aim of this article is to evaluate whether there are existing studies reporting on
PEEK (polyetheretherketone) as an alternative material for dental implants. A systematic literature search of
PubMed until December 2010 yielded 3 articles reporting on dental implants made from PEEK. One article
analyzed stress distribution in carbon fiber-reinforced PEEK (CFR-PEEK) dental implants by the 3-dimensional
finite element method, demonstrating higher stress peaks due to a reduced stiffness compared to titanium. Two
articles reported on investigations in mongrel dogs. The first article compared CFR-PEEK to titanium-coated CFR-
PEEK implants, which were inserted into the femurs and evaluated after 4 and 8 weeks. The titanium-coated
implants showed significantly higher bone-implant contact (BIC) rates. In a second study, implants of pure PEEK
were inserted into the mandibles beside implants made from titanium and zirconia and evaluated after 4
months, where PEEK presented the lowest BIC. The existing articles reporting on PEEK dental implants indicate
that PEEK could represent a viable alternative material for dental implants. However, further experimental
studies on the chemical modulation of PEEK seem to be necessary, mainly to increase the BIC ratio and to
minimize the stress distribution to the peri-implant bone.

Key Words: PEEK, dental implants, finite element method, animal experiments, osseointegration

INTRODUCTION implant bone loss.12,13 Also, titanium can cause

esthetic problems due to its lack of light transmis-

D
ental implants increase the quality of
sion.14 This can provoke a dark shimmer of the peri-
life for many patients with tooth
implant soft tissue in cases of thin biotype mucosa
loss.1 The material of choice for oral
and/or mucosa recession around a titanium implant.
endosseous implants is pure titani-
This can be problematic especially in the presence of
um, introduced at the end of the
a high smile line.15,16 Additionally, an increasing
1960s by Branemark.2 Although implants based on
number of patients are demanding dental recon-
titanium and titanium alloys, such as Ti-6Al-7Nb and structions of completely metal-free materials.15 As an
Ti- 6Al-4V,3,4 are well evidence-based, it was demon- alternative to titanium, ceramic implants are pro-
strated that their use can be correlated with a range posed, which were first introduced about 40 years
of problems. One problem is a potential hypersen- ago and were made from aluminum oxide.17–22 Due
sitivity to titanium.5–9 Another problem could occur to frequent fracture incidence, this material was
due to the gradient difference in the elastic moduli of substituted by titanium.23 Nowadays, ceramic dental
a titanium implant and its surrounding bone. This implants are made of zirconia, which seems to be a
may cause stress in the implant-bone interface better suitable alternative to titanium because of its
during load transfer,10,11 probably resulting in peri- tooth-like color, mechanical properties, biocompat-
ibility, and low plaque affinity.24 But a systematic
1
Department of Oral and Maxillofacial Surgery, Clinical Naviga- review of the literature by Andreiotelli et al15 from
tion and Robotics, Charité-Campus Virchow Clinic, Berlin, 2009 concludes that the scientific clinical data are not
Germany.
2
Department for Dental Materials and Biomaterial Research, yet sufficient to recommend ceramic implants for
School of Dentistry, Charité-Campus Benjamin Franklin, Berlin, routine clinical use. This corresponds to a grade C
Germany.
* Corresponding author, e-mail: [email protected] recommendation of the definitions of types of
DOI: 10.1563/AAID-JOI-D-11-00002 evidence originating from the US Agency for Health

Journal of Oral Implantology 743

PEEK Dental Implants

Care Policy and Research.15 Furthermore, the stress excluded, because they did not report on dental
distribution of a zirconia implant to the surrounding implants of PEEK.36,37
bone could be associated with even higher stress Of the included articles, 2 reported on animal
peaks compared to titanium, due to the higher investigations34,35 and 1 on an in vitro finite
elastic modulus of zirconia of 210 GPa.25 element study.11
Another biocompatible material with an elastic The aim of the 3-dimensional finite element
modulus of 3.6 GPa, which is closer to that of bone, study was to compare the stress distribution to the
is polyetheretherketone (PEEK).26 Its modulus can peri-implant bone in 4 distinct testing models
be modified by reinforcing it with carbon fibers, for consisting of either a titanium or a carbon fiber–
example, to achieve a modulus of 18 GPa, similar to reinforced PEEK (CFR-PEEK) implant, containing 30%
that of cortical bone.27 carbon fibers to obtain an elastic modulus of 17.4
Since PEEK showed resistance to degradation in GPa similar to that of cortical bone,27 each in
vivo, it was offered commercially in April 1998 as a combination with a titanium and a CFR-PEEK
biomaterial for long-term implants (Invibio Ltd, abutment, completed with a cemented artificial
Thornton-Cleveleys, UK).28 Since then, PEEK has crown (Table 1).
demonstrated to be a high-performance thermo- The CFR-PEEK implants presented a higher load
plastic polymer able to replace metallic implant concentration in the cervical area and at the cortical
components in the field of orthopedics29,30 and bone than the titanium implants, whereas the
traumatology.31,32 Also, calvarial reconstructions titanium implants presented equivalent stress peaks
with PEEK implants were described.33 These find- in the cervical portion and a more homogenous
ings suggest that PEEK could substitute titanium as load distribution throughout the whole implant
material for dental endosseous implants. body (Table 1).
The current review pertains to literature pub- The authors admit that the higher stress
lished prior to December 1, 2010. The aim was to concentrations of the PEEK implant were not
figure out whether there are existing studies about expected. A more homogenous stress distribution
dental implants from PEEK, which probably under- was intended to diminish stress peaks at the
line the theory that PEEK could be considered as a implant-bone interface. So, they conclude that the
viable alternative material for dental implants. CFR-PEEK implant did not present any advantages
in comparison to the titanium implant.
This material was also used for cylindrical
MATERIALS AND METHODS implants in an animal experiment, which compared
Literature search the bone-implant contact (BIC) and shear strength
of 20 titanium-coated implants to 20 uncoated
The articles for the current review were found using the
implants.35 In this study 5 implants were inserted in
PubMed search engine and searching for references
each femur of 4 mongrel dogs, 5 uncoated on one
cited within these articles. All articles published until
side and 5 titanium-coated on the other side. After 4
December 2010 were reviewed. The following search
and 8 weeks of healing, 2 dogs were sacrificed. Of
terms were used together: ‘‘dental implant PEEK.’’
each femur, 3 implants underwent pull-out testing
Inclusion criteria to determine the mechanical integrity of the
interface. The other 2 implants of each femur were
Only articles about dental implants from PEEK or reserved for intact histologic evaluation.
modified PEEK published until December 2010 were The coated implants showed significantly BIC
included, regardless of the kind of investigation (in values after a healing period of both 4 (P ¼ .0014)
vivo or in vitro), implant design, surface modifica- and 8 weeks (P ¼ .0261), whereas the BIC of both
tions, year of publication, and language. the uncoated and the coated implants generally
decreased from 4 to 8 weeks. The shear strength for
the uncoated implants was significantly higher after
RESULTS
4 (P ¼ .0107) and lower after 8 weeks (P ¼ .2496)
The search yielded 5 articles, of which 3 were (Table 2). The authors conclude that the addition of
included in the review.11,34,35 Two articles were the titanium coating apparently increases the

744 Vol. XXXIX /No. Six /2013

 TABLE 1
Overview of an in vitro 3-dimensional finite element study*
Author Sarot et al11
Year of publication 2009
Implantation site Virtual 3-dimensional model of a lower jaw of region 35, based on a randomly chosen computerized tomography scan with a total
of 212 transversal slices with 0.25 mm in length, consisting of medullar bone covered by a 1.0-mm thick layer of cortical bone,
designed with the software Ansys DesignModeler v11 (ANSYS Inc, Canonsburg, Pa)
Simulation software Ansys Workbench V11 finite elements simulation software (ANSYS Inc)
Implant design Screwed cylindrical implant with a hexagon connection
Implant dimensions, mm Diameter: 4.1; length: 10
Surface modification N.R.
Roughness RA, lm N.R.
Abutment design Outer hexagon
Abutment dimensions, mm 4.1, bottom platform with upper conic portion
Connection abutment/implant Titanium bolt with screws in the lower third
Prosthesis Chrome-cobalt structure with a thickness of at least 0.3 mm, covered by a feldspathic porcelain with coronary shape; an
approximately 0.1-mm thick line of zinc phosphate cement was located between prosthesis and abutment
Implant material Titanium CFR-PEEK with 30% carbon fiber
Elastic modulus, GPa 110 18
Poisson ratio 0.35 0.39
Abutment material Titanium CFR-PEEK Titanium CFR-PEEK
Stress peaks in the different structures von Mises implant 76.46; von Mises implant 74.70; von von Mises implant 85.54; von von Mises implant 86.61; von
with vertical loads in relation to the von Mises abutment 41.76; Mises abutment 33.82; Mises abutment 41.32; Mises abutment 33.96;
long axis of the tooth with 100 N in tensile cortical/medullar tensile cortical/medullar tensile cortical/medullar tensile cortical/medullar
magnitude, MPa 32.70/2.48, 32.70/2.47, compression 27.77/4.22, compression 27.90/4.2, compression
compression cortical/ cortical/medullar 81.04/3.19 cortical/medullar 89.47/3.58 cortical/medullar 86.57/3.6
medullar 81.14/3.19
Tension peaks in the different von Mises implant 171.42; von Mises implant 172.02; von von Mises implant 188.95; von von Mises implant 189.72; von
structures with oblique load von Mises abutment 84.82; Mises abutment 69.96; Mises abutment 84.17; Mises abutment 69.41;
direction (308) in relation to the long tensile cortical/medullar tensile cortical/medullar tensile cortical/medullar tensile cortical/medullar
axis of the tooth with 100 N in 22.02/2.65, 21.85/2.65, compression 58.82/4.90, compression 57.53/4.89, compression
magnitude, MPa compression cortical/ cortical/medullar 146.04/ cortical/medullar 177.81/ cortical/medullar 177.58/
medullar 146.26/3.95 3.96 6.42 6.44

*N.R. indicates not reported.

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745
Schwitalla and Müller
PEEK Dental Implants

TABLE 2
Overview of 2 in vivo animal investigations*
Author Cook and Rust-Dawicki35
Year of publication 1995
Number of animals 4 (mongrel dogs)
Number of implants 40
Number of implants/animal 10
Implantation site Femur
Healing period 4 weeks (n ¼ 2); 8 weeks (n ¼ 2)
Implant design Cylindrical
Healing method Submerged/unloaded
Implant material Chopped CFR-PEEK
Implant dimensions, mm Diameter: 4; length: 10
Surface modification Ti-coated uncoated

Roughness RA, lm N.R. N.R.

Elastic modulus, GPa N.R. N.R.
Shear strength, MPa 5.62 6 1.97 (n ¼ 10; 4 wk), 8.12 6 1.74 (n ¼ 10; 4 wk),
8.41 6 2.67 (n ¼ 10; 8 wk) 6.81 6 1.80 (n ¼ 10; 8 wk)
BIC, % 66.7 6 21.76 (4 wk), 54.83 6 21.36 (4 wk),
60.18 6 24.48 (8 wk) 51.55 6 21.21 (8 wk)

*N.R. indicates not reported.

biocompatibility of the implant surface. Using the concentrations, the CFR-PEEK implant could not be
BIC ratio as a parameter for the grade of osseointe- recommended.11
gration, it can be stated that both CFR-PEEK This deformation rate could probably be dimin-
implants (coated and uncoated) presented a ished by an inner stiffening of the implant, for
desirable osseointegration in comparison to the example, by an abutment connection bolt which
BIC values of the titanium implants (40.91 6 extends to the apical region of the implant, whereas
10.11%) of the second animal experiment34 (Table the complete biomechanical behavior of a PEEK
2). The aim of that study was to evaluate implant has to be tested experimentally to achieve
osseointegration of 1-piece zirconia vs titanium accurate data.
implants depending on their insertion depths after Because CFR-PEEK is black due to the carbon
a healing period of 4 months due to a split-mouth fibers, its use could be unfavorable, especially in
design (submerged vs nonsubmerged healing). esthetic zones.
Therefore, the test implants made from zirconia In an animal investigation from 1995, the BIC
and coated zirconia (covered by a calcium-liberating and shear strength of titanium-coated and uncoat-
titanium oxide [TiO2] sol-gel layer) were compared ed CFR-PEEK implants were evaluated.35 The shear
to a control implant made from titanium. Addition- strength of the uncoated implants was significantly
ally, an experimental implant of PEEK was inserted. higher after 4 and insignificantly lower after 8 weeks
All implants had the same design, only differing in of healing, although the BIC rate of the coated
their biomaterials. In this study, the PEEK implants implants was always significantly higher (Table 2).
reached BIC rates of 26 6 8.9%. The surface roughness as an important factor
In neither of the 2 animal investigations were was not assessed, so this phenomenon is difficult to
signs of inflammation or foreign body reactions interpret.
observed. Considering potential hypersensitivities to tita-
nium, in such cases a titanium coating might
provoke hypersensitive inflammatory reactions.
DISCUSSION
The aim of the second animal experiment was to
Referring to a 3-dimensional finite element analysis evaluate osseointegration of 1-piece implants made
of a CFR-PEEK and a titanium implant (Table 1), the from zirconia, coated zirconia (coated by a calcium-
authors concluded that due to its higher stress liberating TiO2 sol-gel layer), titanium, and PEEK

746 Vol. XXXIX /No. Six /2013

 Schwitalla and Müller

TABLE 2
Extended
34
Koch et al
2010
6 (mongrel dogs)
48
8
Mandible (split-mouth design)
4 months
Screwed 1-piece implant (all groups identical)
Submerged/unloaded Nonsubmerged/unloaded, with antagonistic teeth remained
Titanium zirconia zirconia PEEK Titanium zirconia zirconia PEEK
N.R. N.R. N.R. N.R. N.R. N.R. N.R. N.R.
Caliberating TiO2 Caliberating TiO2
sol-gel layer sol-gel layer
1.5–3 1.5–3 1.5–3 1.5–3 1.5–3 1.5–3 1.5–3 1.5–3
110 200–220 200–220 .3 110 200–220 200–220 .3
N.R. N.R. N.R. N.R. N.R. N.R. N.R. N.R.

40.91 6 10.11 59.11 6 7.45 55.83 6 13.92 26 6 8.9 40.91 6 10.11 59.11 6 7.45 55.83 6 13.92 26 6 8.9

depending on their insertion depths after a healing the crestal bone level to the uppermost BIC. The
period of 4 months due to a split-mouth design other section was named implant-related BL,
(submerged vs nonsubmerged healing).34 Regretta- measured from the uppermost thread to the
bly, the resulting BIC values of both the submerged uppermost level of BIC. The level of the uppermost
and the nonsubmerged implant groups of this BIC was localized between the uppermost thread
study were summarized to a mean value (Table 2). and the crestal bone level. All results, however, were
The different types of healing could have had an expressed as negative values (Table 3). The authors
influence on the BIC values, due to different argue that the bone levels in general presented
exposures of the implants to masticatory loads higher values in the group of the submerged
and oral flora. implants due to higher insertion depths, which
For histomorphometric analysis, the bone level were defined neither before nor while the implants
(BL) between the uppermost thread and the crestal were inserted. To get the mean insertion depths of
bone level was subdivided into 2 sections. One the uppermost threads in relation to the crestal
section described the bone-related BL, ranging from bone level, we took the values of the mean bone-

TABLE 3
Mean values of bone-related and implant-related bone level (BL) (Koch et al34) and the mean insertion depths
Mean Bone-Related BL, mm Mean Implant-Related BL, mm Mean Insertion Depth, mm*
Nonsubmerged
Zirconia 0.53 1.62 2.15
Coated zirconia 0.59 1.97 2.56
Titanium 0.37 1.65 2.02
PEEK 1.3 0.44 1.74
Submerged
Zirconia 0.76 1.86 2.62
Coated zirconia 0 2.25 2.25
Titanium 0.59 2.03 2.62
PEEK 0.58 1.97 2.55

*Distance from the crestal BL to the uppermost implant thread, calculated by the authors of the current review by adding
bone-related BL and implant-related BL.

Journal of Oral Implantology 747

PEEK Dental Implants

TABLE 4
Differences in the mean insertion depths between submerged and nonsubmerged implants from Table 3
Nonsubmerged Implants, Submerged Implants,
Mean Insertion Depths Mean Insertion Depths Differences in the
From Table 3, mm From Table 3, mm Mean Insertion Depths, mm*
Zirconia 2.15 2.62 þ0.47
Coated zirconia 2.56 2.25 0.31
Titanium 2.02 2.62 þ0.6
PEEK 1.74 2.55 þ0.81

*Values calculated by the authors of this review by subtracting the values of the submerged implants from the values of
the nonsubmerged implants.

related BL and the mean implant-related BL from represent another advantage of PEEK over titanium,
the original article and added them together (Table giving back the physiologic tensile load to the
3). Then, we evaluated the differences in these bone.
calculated insertion depths for the nonsubmerged
and the submerged implants to see how much
deeper the submerged implants were inserted CONCLUSION
compared to the nonsubmerged (Table 4). The Literature reporting on dental implants made from
value of the difference was positive when the result PEEK demonstrate that PEEK is basically osseointe-
revealed a greater insertion depth for the sub- grated as biocompatible material in vivo. Further
merged implants and negative if the insertion investigations are necessary to find ways to improve
depth of the submerged implants was less deep. the biomechanical behavior to achieve a more
In this way, we calculated the following values: for homogenous stress distribution to the surrounding
the submerged implants of zirconia þ0.47 mm, of bone, which has not yet been experimentally
coated zirconia 0.31 mm, of titanium þ0.6 mm, proven. Long-term investigations of loaded PEEK
and of PEEK þ0.81 mm (Table 4). These findings implants in vitro and in vivo are necessary.
contradict the statement of the authors that the Experimental modulations of the surface are need-
submerged implants in general were inserted ed as well to achieve the highest possible grade of
deeper than the nonsubmerged implants. osseointegration. The design of a 2-piece implant
Another finding in the article states that the made from PEEK, which allows the submerged
PEEK nonsubmerged implants showed significantly healing method, has to be developed. PEEK used for
lower bone-related BL than the nonsubmerged a dental implant should have a light translucency
coated zirconia and titanium implants (P ¼ .046, similar to a natural tooth to achieve favorable
.028). There is no evidence mentioned, if the mean esthetic results.
insertion depths of the coated zirconia (2.56 mm),
the titanium (2.02 mm), and the PEEK implants (1.74
mm) could play an influencing role for the bone- ABBREVIATIONS
related BL, as the PEEK implants of the non-
BIC: bone-implant contact
submerged group presented the lowest mean
insertion depth (Table 3). BL: bone level
Neither of the 2 animal investigations observed CFR-PEEK: carbon fiber–reinforced PEEK
inflammation signs or foreign body reactions, which PEEK: polyetheretherketone
emphasizes the evidenced biocompatibility of PEEK.
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