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Exploring polyetheretherketone in dental implants and abutments: A focus on biomechanics and finite element methods

  • Eddie Gazo Hanna EMAIL logo , Semaan Amine , Benrose Prasad and Khaled Younes
Published/Copyright: June 17, 2024
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REVIEWS ON ADVANCED MATERIALS SCIENCE
From the journal REVIEWS ON ADVANCED MATERIALS SCIENCE Volume 63 Issue 1

Abstract

This review article investigates the properties and applications of polyetheretherketone (PEEK) in the field of dental implantology. PEEK has emerged as a significant material of interest due to its mechanical strength, biocompatibility, and radiolucency. The article provides a detailed examination of PEEK’s biocompatibility and the various reinforcements that enhance its performance, including PEEK/HA, PEEK/β-TCP–TiO2, and CFR-PEEK. Focusing on dental applications, we discuss PEEK’s use in implant abutments, fixed dental prostheses, implants, and its commercial forms available for dental use. Further, the mechanical behavior of PEEK and its composites is analyzed, including its elastic behavior under various stress conditions and wear resistance. Moreover, the article conducts an integrative systematic review on the stress distribution in dental implants or abutments made from reinforced PEEK composites, assessed through finite element analysis. The aim of this review is to provide insights into the current state of research, the benefits, challenges, and future prospects of PEEK in implantology, and the biomechanical evaluation methods that underpin the development of this promising material.

Keywords: polyetheretherketone; biomaterials; dental implants; abutments; finite element; stress

1 Introduction

Advancements in dentistry involve the evolution of materials. Biocompatibility, aesthetics, low plaque affinity, and characteristics similar to dental structure are among the essential criteria of modern materials used in dentistry [1,2]. Polymers are materials that have allowed significant technological progress in the second half of the twentieth century, although they are now controversial from an environmental standpoint [3–7]. Polyetheretherketone (PEEK) is among the most innovative polymers, described as “high performance.” It was first used in the 1980s in the aerospace and automotive industries [8,9]. Then, due to its remarkable mechanical properties, biocompatibility, and modulus of elasticity similar to human bone, PEEK began to be studied in the field of orthopedic prostheses in the 1990s [6,10–12]. Today, it is expanding in most clinical disciplines of dentistry. Often shaped conventionally, meaning through extrusion, compression, injection, or machining, manufacturers are now turning to 3D printing of PEEK, or additive manufacturing [13–16].

The advancement of dental implant, abutment, and associated materials necessitates adherence to established in vitro and in vivo tests before they are fit for commercial use. Conducting in vivo tests on a substantial number of samples can be lengthy and may pose challenges to animals or patients involved. Moreover, potential inaccuracies in these assessments could lead to misleading outcomes, impacting both the materials and the results of the experiment. Therefore, the finite element method (FEM) emerges as a valuable tool for predicting potential mechanical complications using theoretical models coupled with in vitro tests [17–20]. The finite element analysis (FEA) is frequently used to assess the biomechanical behavior of implantable biomaterials in vitro, whether in orthopedics, traumatology, or oral implantology, a trend is reflected by the increasing number of publications on the subject (Figure 1). This method allows for the evaluation of stress distribution during the load transfer of an implant to the underlying bone structures and typically follows a consistent procedure.

Figure 1 The number of PubMed indexed publications on finite elements used in dental specialties since 2007. Search query: (peek) AND (dental implants) AND (FEA) OR (FEM).
Figure 1

The number of PubMed indexed publications on finite elements used in dental specialties since 2007. Search query: (peek) AND (dental implants) AND (FEA) OR (FEM).

This article delves into the latest advancements in PEEK-based biomaterials for dental applications, highlighting recent improvements in properties and mechanical testing. We will conduct an integrative systematic review focused on analyzing stress distribution across dental implants and abutments made from carbon fiber-reinforced PEEK composites, utilizing FEM studies as a core analytical tool (Figure 1). The investigation is structured around key research questions, aiming to uncover through a systematic approach:

  1. How are PEEK and its composites applied in the dental field, especially as materials for implant abutments and the core of dental implants?

  2. What do mechanical tests, including those for tensile, compression, bending stress, wear resistance, and particularly fatigue tests, reveal about the suitability of PEEK and its composites for dental implant applications?

  3. How does FEA enhance our understanding of stress distribution in dental implants and abutments made from carbon fiber-reinforced PEEK composites?

2 Information sources and search strategy

A literature search on PubMed (via National Library of Medicine) and ScienceDirect (Elsevier BV) was conducted using the following search terms (Table 1):

  • Term 1: (peek) AND (stress analysis, mechanical) AND (dental)

  • Term 2: (peek) AND (dental) AND (mechanical phenomena) AND (stress, mechanical) AND (material testing)

  • Term 3: (peek) AND (dental) AND (finite element) AND (FEA)

Table 1

Electronic search results from PubMed and ScienceDirect databases

Database Results For Total results
Term 1 Term 2 Term 3
PubMed 79 24 78 181
PubMed without duplication 40 13 55 108
ScienceDirect 137 69 69 275
ScienceDirect without duplication 74 45 54 173

The electronic searches described previously contributed to initial grouping:

  • On PubMed: 181 articles

  • On ScienceDirect: 275 articles

After eliminating duplicates, the titles, and abstracts of the articles resulting from the searches, only 45 publications were retained.

A complete reading of the text and an analysis of the relevance of the articles finally led to a final result grouping 25 articles (Table 2). The publication dates of the articles range between 2010 and 2023, except for 1 article.

Table 2

Aim, materials, methods, and key findings derived from the chosen research papers

Articles Type of literature and study design Objectives Methods Types of biomaterials studied and their composition Results
2023
Title: Biomaterials and clinical application of dental implants in relation to bone density – A narrative review Type: Dental/review To assess how implant materials, designs, and surgical techniques impact bone density, focusing on titanium, zirconia, and PEEK implants, and to determine the optimal choices for varying bone densities Analysis of literature on the biomechanical and biological effects of dental implant materials and designs on bone density

  1. PEEK

  2. Zirconia

  3. Titanium

 Titanium is preferred for its reliability, though it presents visibility issues in thin gums and allergy concerns
Author: Khaohoen et al. Zirconia is chosen for aesthetics and metal sensitivity but may fracture more easily
Keywords: biomaterial, bone density, dental implants, … PEEK is promising for its bone-like properties, yet requires further research
Reference: [21] Implant geometry is critical, especially in low-density bone, to enhance stability
2023
Title: Evaluation of stresses on mandible bone and prosthetic parts in fixed prosthesis by utilizing CFR-PEEK, PEKK, and PEEK frameworks Type: Dental/FEA The article aims to assess the impact of using polymeric frameworks instead of titanium on stress distribution within the components of fixed prostheses and surrounding bone tissue, considering the influence of spongy bone density on the success of fixed prosthesis in edentulous patients A FEA assessed stress distribution in an edentulous mandible with fixed prostheses using polymeric materials (CFR-PEEK 60%, CFR-PEEK 30%, PEKK, PEEK) vs titanium, simulating unilateral and bilateral 300 N forces on prostheses in spongy bones of varying densities (normal, low, high)

  1. CFR-PEEK 60%

  2. CFR-PEEK 30%

  3. PEKK

  4. PEEK

 The study showed that the PEEK framework minimized stress on bone tissues and increased mucosa stress, thus reducing bone resorption risk
Author: Shash et al. Frameworks tested (CFR-PEEK 60%, CFR-PEEK 30%, PEKK, PEEK) worked well in normal and high spongy bone densities
Reference: [22]
2023
Title: Evaluation of stress and strain on mandible caused by changing the bar material in hybrid prosthesis utilizing “All-on-Four” technique Type: Dental/FEA The research aimed to explore the viability of using ceramics, polymers, and composites as alternative materials for the bar component in hybrid prostheses, traditionally made of titanium or gold, to address full edentulism and restore the mastication mechanism A 3D mandible model with a hybrid prosthesis was analyzed using various bar materials. The study measured von Mises stress on the prosthesis and mandible, including maximum and minimum principal stresses and strains on the bone. The simulation tested unilateral and bilateral forces to evaluate their impact on cortical and cancellous bones and mucosa stress

  1. Porcelain

  2. Zirconia

  3. Alumina

  4. ZTA

  5. ATZ

  6. PEKK

  7. PEEK

  8. CFR-PEEK

  9. GFR-PEEK

  10. FRR

  11. HA-PEEK

  12. BIOHPP

 A PEEK bar reduced von Mises stresses on cortical and cancellous bones significantly under unilateral and bilateral forces, while slightly increasing mucosa stress, remaining below pain thresholds. Despite these variations, all materials, including ceramics, polymers, and composites, kept bone stresses within safe limits, suggesting they are viable alternatives to titanium for hybrid prosthesis bars
Author: Shash et al.
Reference: [23]
2022
Title: Properties of polyetheretherketone (PEEK) implant abutments: A systematic review Type: Dental/review To know the mechanical and functional properties of PEEK abutment and to find out if it is a potential substitute for titanium abutments The search focused on studies from 2018 to 2020 in English, documented in PROSPERO with ID 274834. Data extraction and quality evaluation adhered to revised CONSORT standards

  1. Titanium (Ti)

  2. PEEK

 The existing data indicate that PEEK implant abutments lack the necessary biomechanical properties to serve as a permanent replacement for titanium abutments. Nonetheless, they are regarded as a suitable temporary option, particularly if placed in the anterior region
Author: Ghazal-Maghras et al.
Keywords: Abutment, polyetheretherketone, titanium, dynamic fatigue, …
Reference: [24]
2022
Title: Influence of different combinations of CAD-CAM crown and customized abutment materials on the force absorption capacity in implant supported restorations – In vitro study Type: Dental/experimental study To assess the capability of implant-supported restorations to absorb force, employing various CAD-CAM materials in the creation of crowns and customized abutments Utilized 12 3D finite element models, 6 implant designs, applied axial loads, and analyzed displacements, stress, and strain in bone tissue

  1. Titanium (Ti) alloy

  2. PEEK

  3. Ti-PEEK composite

 Force curve progression varied by material. Zirconia abutments had highest slopes in ZZ, then EZ, VZ, PZ. PEEK abutments showed least slopes in ZP, EP. PEEK abutments increased slope loss in Zirconia, e.max crowns but not in PEEK, Vita Enamic crowns
Author: Taha et al.
Keywords: customized abutments, force, force absorption, implant prosthetics, …
R eference: [25]
2022
Title: In vitro assessment of PEEK and titanium implant abutments: Screw loosening and microleakage evaluations under dynamic mechanical testing Type: Dental/experimental study This in vitro study aimed to evaluate the mechanical and functional properties of PEEK implant abutments as an aesthetic, non-metallic alternative to traditional titanium abutments, which have aesthetic limitations and are more challenging to customize in clinical settings In this study, 24 PEEK and 24 titanium grade 5 implant abutments fixed to MIS Implants type M4 were tested for screw loosening and microleakage in a 2% methylene blue solution, under static and dynamic conditions following ISO 14801:2016 standards. Observations at 8× magnification and statistical analysis (2-factor ANOVA, chi-square) compared the PEEK and titanium groups

  1. PEEK for manufacturing half of the implant abutments.

  2. Titanium grade 5 for the other half of the implant abutments.

  3. MIS Implants type M4 (3.75 × 16 mm)

 The study showed that titanium implant abutments performed better mechanically than PEEK abutments, with titanium experiencing around 10% torque loss compared to PEEK’s, which is up to 50%. Additionally, 91.6% of titanium abutments had no microleakage, whereas all PEEK abutments did under dynamic loading
Author: Ortega-Martínez et al.
Reference: [26]
2022
Title: Biomaterials and clinical applications of customized healing abutment – A narrative review Type: Dental/review The article aims to assess materials for customized healing abutments used in implant surgery to enhance tissue appearance and reduce treatment and prosthesis fabrication time A literature review was conducted, searching English-language articles on customized healing abutments in Google Scholar, PubMed/MEDLINE, ScienceDirect, and Scopus databases up to August 2022

  1. PEEK

  2. PMMA

  3. Zirconia

  4. Resin composite

  5. Titanium

 All materials—PEEK, PMMA, zirconia, resin composite, and titanium—showed promising results for customized healing abutments. However, more research is needed to compare their effects on peri-implant tissues conclusively
Author: Chokaree et al.
Keywords: PEEK, PMMA, customized healing abutment, …
Reference: [27]
2022
Title: PEEK biomaterial in long-term provisional implant restorations: A review Type: Dental/review The review article examines PEEK as a material for long-term provisional implant restorations in dental implantology, highlighting its growing use in various dental procedures A comprehensive search across Google Scholar, ScienceDirect, PubMed/MEDLINE, and Scopus identified English-language articles on PEEK as a biomaterial for long-term provisional implant restorations, selecting relevant ones for literature review

  1. PEEK

  2. CFR-PEEK

 PEEK, especially when enhanced with 30–50% carbon fibers, is recognized for its broad applicability in implant dentistry, including dental implants, temporary abutments, and various prostheses, indicating its promise for both temporary and long-term provisional restorations. This suggests potential for wider clinical use
Author: Suphangul et al.
Keywords: PEEK, carbon fiber, implant abutment, …
Reference: [28]
2021
Title: Stress distribution around different abutments on titanium and CFR-PEEK implant with different prosthetic crowns under parafunctional loading: A 3D FEA study Type: Dental/FEA Clinical studies linked implant failure to bruxism, while 3D FEA evaluated stress distribution in straight and angled abutments with titanium and CFR-PEEK implants and two crown types under parafunctional loading Twelve 3D bone block models of the maxillary right premolar with osseointegrated implants were divided into CFR-PEEK and titanium groups, each featuring three abutment angles and two crown types. Stresses from 1,000 N vertical and 500 N oblique loads were analyzed using ANSYS software

  1. CFR-PEEK

  2. Titanium

  3. Prosthetic crowns: PFM, and PEEK

 Both CFR-PEEK and titanium implants yielded similar bone stress under vertical and oblique loads, with straight abutments outperforming angled ones, and PEEK crowns inducing less stress than (PFM)
Author: Mourya et al.
Reference: [29]
2021
Title: Biomechanical performance of Ti-PEEK dental implants in bone: An in-silico analysis Type: Dental/experimental study and FEA To compare Ti-PEEK composite dental implants with conventional titanium implants, assessing host bone behavior, especially under conditions of marginal bone loss Utilized 12 3D FEMs, six implant designs, applied axial loads, and analyzed displacements, stress, and strain in bone tissue

  1. Titanium (Ti) alloy

  2. PEEK

  3. Ti-PEEK composite (with the outer layer made of PEEK and inner structures made of Ti)

 Ti-PEEK implants outperformed conventional dense titanium implants (Implant A) in non-bone loss conditions. However, in bone loss scenarios, both Implant A (made entirely of dense titanium) and Implant E (designed with titanium in the upper half and PEEK in the lower half) showed equal effectiveness
Author: Ouldyerou et al.
Keywords: Bone, Composite, Implant, Mechanostat, Ti-PEEK
Reference: [30]
2020
Title: Comparative evaluation of the wear resistance of two different implant abutment materials after cyclic loading Type: Dental/experimental study The paper aims to compare the wear resistance of titanium and PEEK abutment materials when paired with titanium implants after cyclic loading, assessing significant differences in wear resistance under repeated mechanical stress The study involved 20 titanium implants in resin blocks, divided into groups with titanium and PEEK abutments, each undergoing 550,000 cycles of cyclic loading. Surface roughness was measured by profilometry, abutment surfaces imaged by SEM, and elemental analysis conducted using EDS, to evaluate changes at the implant-abutment interface before and after loading

  1. Titanium (Ti): Group I

  2. PEEK: Group II

 The study compared wear resistance of titanium and PEEK abutment materials connected to titanium implants after cyclic loading, finding no significant difference in wear patterns or surface roughness changes between the two, as confirmed by SEM and EDS analyses. Both materials are comparably effective for dental implant abutments, with PEEK offering an aesthetic alternative
Author: Ragupathi et al.
Keywords: Abutment, Polyether ether Ketone, implant-abutment interface, …
Reference: [31]
2019
Title: Effect of different biocompatible implant materials on the mechanical stability of dental implants under excessive oblique load Type: Dental/FEA The study evaluates the impact of replacing traditional titanium with carbon reinforced polyether ether ketone (CRF-PEEK) composites on stress distribution in peri-implant bone under excessive oblique loading, examining if CRF-PEEK’s bone-like mechanical properties can enhance stress distribution and decrease implant failure risks The methodology includes constructing 3D models of a dental implant in the first mandibular molar from CT scans and creating five models using titanium, CRF-PEEK, and lithium disilicate. It employs 3D FEA to assess stress distribution at the implant-bone interface under excessive oblique loads and examines physical interactions, including friction effects between contacting surfaces

  1. Titanium (Ti)

  2. CRF-PEEK

  3. Lithium disilicate

 The study compared wear resistance between titanium and PEEK abutment materials connected to titanium implants post-cyclic loading, revealing only slight and statistically insignificant differences in surface roughness and wear patterns as confirmed by SEM and EDS analyses. Both materials proved comparably effective for dental implant abutments, with PEEK also offering aesthetic benefits
Author: Bataineh et al.
Keywords: CFR-PEEK, biocompatible, biomaterials, deformation, dental implant, …
Reference: [32]
2018
Title: 3D FEA study on implant threading role on selection of implant and crown materials Type: Dental/FEA Examination of the impact of thread design in dental implants and the choice of material on mandibular bone response, considering two distinct crown materials: Translucent zirconia and PFM Two single-piece dental implant designs with a proxy crown were modeled on simplified bone structures in FEA. CAD/CAM software crafted the components, which were assembled and analyzed in ANSYS, applying 100 N compressive and 50 N oblique loads

  1. Reinforced PEKK

  2. PEEK

  3. Titanium

  4. Zirconia

  5. PFM

 In 24 cases, micro-threading slashed the dental implant’s peak Von Mises stress by 50–70% compared to conventional threading. A 50 N oblique force generated 4–5 times the stress on the implant as a 100 N vertical load. Crown material swaps had minimal impact on cortical bone stress, while titanium implants cut stress by 50–100% vs reinforced PEKK or PEEK
Author: Wazeh et al.
Keywords: Dental implant, FEA, PEEK, PEKK, Titanium
Reference: [33]
2018
Title: Computational modelling; damage mechanics; laminated orthopaedic devices; mechanical testing; medical grade carbon fiber reinforced PEEK Type: Dental/FEA The study focuses on the mechanical behavior and failure mechanisms of PEEK-OPTIMA™ Ultra-Reinforced, a unidirectional CFR-PEEK, to develop laminated orthopedic devices and predictive computational models A series of multi-axial experimental tests were conducted, including tension, compression, in-plane shear, and fracture toughness tests, along with the development of a computational failure model that incorporates observed damage mechanisms PEEK-OPTIMA™ Ultra-Reinforced laminates The study identifies three key damage mechanisms: inter-laminar delamination, intra-laminar cracking, and anisotropic plasticity. The computational model effectively predicts these complex failure mechanisms, supporting the design of safe, fiber-reinforced laminated orthopaedic devices
Author: Gallagher et al.
Keywords: computational modelling, damage mechanics, …
Reference: [34]
2018
Title: Effect of different restorative crown and customized abutment materials on stress distribution in single implants and peripheral bone: A three-dimensional FEA study Type: Dental/FEA To evaluate the stress distribution effects of resin-matrix ceramic and PEEK customized abutments on dental implants and adjacent bone using FEA The study used 3D modeling with STL data to create implant systems and abutments, and developed six models combining different restoration materials (TZI, IPS, VTE) and abutments (PEEK, zirconia). These models were subjected to vertical (200 N) and oblique (100 N) loads, analyzing stress distribution via von Mises and principal stress methods

  1. Bone-level implant system

  2. Titanium base abutment

  3. Translucent zirconia (TZI) for restoration

  4. Lithium disilicate glass ceramic (IPS) for restoration

  5. Polymer-infiltrated hybrid ceramic (VTE) for restoration

  6. PEEK for customized abutments

 Oblique loading induced elevated stress in implants, crowns, and cortical bone, with VTE crowns showing lower stress. Zirconia abutments faced greater stress than PEEK ones. Stress patterns in implants and surrounding bone remained consistent across all models
Author: Kaleli et al.
Reference: [35]
2016
Title: Comparison between PEEK and Ti6Al4V concerning micro-scale abrasion wear on dental applications Type: Dental/experimental study The study compared the abrasive wear resistance of PEEK and titanium alloy (Ti6Al4V) under simulated three-body abrasion conditions to mimic wear from food and toothpaste during mastication and tooth brushing The study conducted micro-scale abrasion tests on PEEK and Ti6Al4V cylinders, using varied loads and hydrated silica suspensions, measuring wear volumes and analyzing wear scars with SEM to determine wear mechanisms

  1. PEEK

  2. Ti6Al4V alloy

 The study revealed that under three-body abrasion tests with hydrated silica suspensions, PEEK showed higher volume loss and lower wear resistance than Ti6Al4V, which consistently outperformed PEEK across different abrasive contents and loads
Author: Sampaio et al.
Keywords: Bio-tribology, micro-scale abrasion, PEEK, Ti6Al4V, wear
Reference: [36]
2016
Title: Effects of PEEK veneer thickness on the reciprocating friction and wear behavior of PEEK/Ti6Al4V structures in artificial saliva Type: Dental/FEA The study examines how varying thicknesses of PEEK veneers impact friction, wear rate, and contact stress on Ti6Al4V substrates, crucial for the durability and effectiveness of biomedical materials in oral applications PEEK veneers from 0.1 to 2 mm thick were synthesized on Ti6Al4V substrates, tested for friction and wear against alumina in artificial saliva at 37°C, and analyzed via simulations to study the effect of thickness on contact stress

  1. PEEK

  2. Ti6Al4V alloy

  3. Alumina (Al2O3)

 Thinner PEEK veneers show higher coefficients of friction and wear rates due to increased contact stress, underscoring the importance of considering veneer thickness in designing biomedical devices, particularly for oral applications requiring optimal friction and wear resistance for long-term success
Author: Sampaio et al.
Keywords: Biotribology, Ti6Al4V, PEEK, sliding wear, thickness, FEM model
Reference: [37]
2016
Title: Pressure behavior of different PEEK materials for dental implants Type: Dental/experimental study Evaluate the mechanical properties of different PEEK composites under static pressure Nine PEEK composites (11 applications biomedical, 2 applications industrial) tested under static pressure

  1. VESTAKEEP® M4 R

  2. PEEK-OPTIMA® LT1

  3. PEEK-CLASSIX® BICI

 Mechanical properties: Elastic modulus, yield limit, resistance to compression
Author: Schwitalla et al.
Reference: [38]
2015
Title: FEA of the biomechanical effects of PEEK dental implants on the peri-implant bone Type: Dental/FEA Show the biomechanical behavior differences of three implants (two PEEK vs one titanium)

  1. Endolign®

  2. PEEK

  3. Titanium

 Mechanical properties: Modulus of elasticity, coefficient of Poisson
Author: Schwitalla et al. Stresses at the bone/implant: Ultimate tensile stress, von Mises, deformation and pressure on the peri-implant bone
Reference: [39]
2015
Title: Flexural behavior of PEEK materials for dental application Type: Dental/experimental study Evaluate the mechanical properties of different PEEK composites by the three-point bending test In vitro study: 150 specimens in the form of a bar made from 11 PEEK composites (9 applications biomedical, 2 applications industrial) tested by three-point bending test

  1. VESTAKEEP® M4 R

  2. PEEK-OPTIMA® LT1

  3. PEEK-CLASSIX®

  4. VESTAKEEP®

  5. …

 Mechanical properties: Bending modulus, resistance to flexion
Author: Schwitalla et al.
Reference: [40]
2015
Title: Applications of PEEK in oral implantology and prosthodontics Type: Dental/review Synthesize the results of research conducted on PEEK in dental applications and provide perspectives on the use of PEEK and its potential clinical applications Electronic research of English publications over the last 15 years on PubMed using a combination of keywords “polyetheretherketone” and “dental” and “dentistry”

  1. Unmodified PEEK

  2. CFR-PEEK

  3. Modified PEEK:

    1. PEEK nano-structures

    2. PEEK nano-composites (TiO2 PEEK, HAF-PEEK)

 Mechanical properties: Elastic modulus, resistance to traction
Author: Najeeb et al.
Reference: [41]
2012
Title: Stress shielding and fatigue limits of poly-ether-ether-ketone dental implants Type: Dental/experimental study To evaluate fatigue limits of PEEK and its effects on stress shielding in comparison to traditional titanium dental implants The study used compressive loading tests on GFR-PEEK, CFR-PEEK, and titanium rods, with GFR-PEEK tested as per ISO 14801. FEA involved 3D models of dental implants and bone. PEEK layer coating was applied to implants for further testing and analysis

  1. PEEK

  2. GFR-PEEK

  3. CFR-PEEK

  4. Titanium rods

 GFR-PEEK’s fatigue limit reached 310 N, exceeding static strength. PEEK implants displayed elevated SED near bone. Both GFR and CFR-PEEK implants are suitable for anterior tooth replacement, potentially reducing stress shielding
Author: Lee et al.
Reference: [42]
2010
Title: A “metal free” material in implantology: the Biopik® Type: Dental/Review Presentation of the mechanical and biological properties of “Biopik®“ with a view of its application in implantology Presentation of Biopik® Biopik®: Tricalcium phosphate (TCP) 10% + titanium oxide (TiO2) 10% + PEEK matrix Mechanical properties: Young’s modulus
Author: Cougoulic et al. In vitro study of the interface human osteogenic cells/material
Reference: [43] In vivo study, animal experimentation on osseointegration at 4 weeks
2010
Title: Evaluation of the stress distribution in CFR-PEEK dental implants by the three-dimensional FEM Type: Dental/FEA The stress dispersion around peri-implant bone was evaluated using FEM across four configurations: titanium abutment on titanium implant, CFR-PEEK abutment on titanium implant, titanium abutment on CFR-PEEK implant, and CFR-PEEK abutment on CFR-PEEK implant Cone beam computed tomography was used to create 3D jaw models analyzed via Ansys software for FEM simulations, assessing stress distribution on various abutment-implant configurations in cortical and medullar bone, employing nonlinear simulations with rigid supports to evaluate mechanical response under varied loads

  1. Titanium

  2. CFR-PEEK

  3. Cortical and medullar bone tissues

  4. Feldspathic porcelain for the crown structure

  5. Chrome-cobalt structure within the crown

 The titanium implant distributes the stresses in a more homogenous manner in relation to the CFR-PEEK implant due to the smaller deformation of this material. The CFR-PEEK implant did not present any advantages in relation to the titanium implant regarding stress distribution to the peri-implant bone
Author: Sarot et al.
Reference: [44]
2006
Title: The long-term mechanical integrity of non-reinforced PEEK-OPTIMA polymer for demanding spinal applications: Experimental and finite-element analysis Type: Dntal/experimental study and FEA Compare the biomechanical performances of PEEK and titanium under constraints and analyze their diffusions In vitro study: creep and quasi-static compression tests at one and three times in dry conditions and in saline solution (NaCl) at 37°C on cylindrical specimens of PEEK and titanium

  1. PEEK-OPTIMA® LT1 (Grade 1 LT1R30)

  2. Titanium

 Mechanical properties: Modulus of elasticity, creep
Author: Ferguson et al. Stresses at the bone/implant interface: Analysis of the stress distribution after compression, bending, lateral bending, and axial rotation constraints
Keywords: PEEK, material properties, creep, cages, fusion Finite element study: 3D modeling of vertebrae and simulation of intervertebral cage implant placement based on PEEK and titanium to compare stress diffusion under different constraints
Reference: [45]

A selection tree of articles (as depicted in Figure 2) was therefore made from the 25 articles, including 6 literature reviews (21–24–27–28–41–43), 12 studies for FEA (22–23–29–30–32–33–34–35–37–39–44–45), and 9 in vitro experimental studies (25–26–31–36–38–40–42).

Figure 2 Flow diagram of the search strategy.
Figure 2

Flow diagram of the search strategy.

3 PEEK

The PEEK is a thermally stable semi-crystalline thermoplastic material. Introduced in 1977 by ICI (Imperial Chemical Industries), this material entered the market between 1978 and 1979. It gained traction in the 1980s across orthopedics, traumatology, and spinal surgery, particularly in the creation of interbody cages [46–49]. By the late 1990s, it was recognized as a premier non-metallic counterpart to titanium in these specialties [10]. The literature on implantology began highlighting this material around 1995 [50]. In April 1998, the debut PEEK implant product, branded as PEEK-OPTIMATM and compliant with both European Community and Food and Drug Administration standards, was launched [10,51]. PEEK boasts superior mechanical, physical, and chemical attributes. Notably, it has a hardness rating between 99 and 126 on the Rockwell scale [42,52] and an elasticity modulus (4 GPa) that is more akin to cortical bone (20 GPa) than titanium (110 GPa).

3.1 Biocompatibility

From a biomedical perspective, recent studies assert that the results of various experiments conducted on systemic toxicity, inflammatory response, and genotoxicity tests of PEEK and PEEK composite biomaterials support its biocompatibility [53,54,55]. This blend of biocompatibility and mechanical robustness has solidified PEEK’s standing as a preferred material in medical device manufacturing, including but not limited to, spinal fusion cages and dental implants [10]. However, Najeeb et al. [41], noted that despite the bio-inertia of unmodified PEEK, this does not present any conclusive evidence of osteo-conductive or osteo-inductive effects in vivo and in vitro unlike conventional implant materials (zirconium oxide and titanium). Thus, in its unmodified form, the long-term survival rate of PEEK implants is questionable.

To overcome this gap in osteo-integration and to enhance the biological and physical properties of PEEK, numerous nano-modifications have been explored (Table 3).

Table 3

Nano-modification of PEEK to increase its bioactivity

Nano structured surfaces Bioactive nano-composites
Spin-coating with nano-Hap [66,67] TiO2/PEEK [68–70]
Plasma-gas treatment (O2/Ar, NH4) [71,72]
Plasma electron beam deposition (Ti, TiO2) [54,73] HAF/PEEK [57,70]
Plasma ion immersion implantation (TiO2) [74,75]

Note: TiO2: Titanium dioxide nanoparticles and HAF: Hydroxy-fluorapatite nanoparticles.

3.2 PEEK reinforcement

3.2.1 PEEK/HA

Early investigations to improve PEEK bioactivity focused on the incorporation of hydroxyapatite (HA) particles, a calcium phosphate mineral celebrated for its capacity to facilitate bone attachment and regeneration [56]. By merging HA with PEEK, the aim is to combine PEEK’s structural advantages with the bioactive capabilities of HA, thus amplifying the implant’s potential for successful and durable integration into bone structures [57]. Research around this hybrid material has yielded positive indications, with PEEK-HA dental prosthetics showing improved bone response and superior bonding than their PEEK-only counterparts [58,59,60]. While HA incorporation promotes bioactivity, it might compromise the overall mechanical strength of PEEK, a trade-off that requires careful balance [10,41,61]. Further research is pivotal in establishing the optimal ratio of HA in PEEK to maximize both bioactivity and mechanical integrity.

3.2.2 PEEK/beta-tricalcium phosphate (β-TCP)–TiO2

Studies on the incorporation of beta-tricalcium phosphate into a PEEK matrix has shown that cell proliferation was gradually inhibited when these particles were present. Moreover, the osteo-conduction on the surface of these implants, resulting from the inherent properties of β-TCP, promoted osteo-integration [10].

Cougoulic et al. [43] introduced an implant made from this material, marketed under the name SMARTPIK®, which has received EC marking after meeting the ISO 10993 standard: “Biological Evaluation of Medical Devices.”

In addition to the PEEK matrix, which provides the primary mechanical properties of the implant, and the β-TCP (17%) enhancing its osteoconductive potential, the addition of titanium dioxide (8% TiO2) provides radiopacity. A specific surface treatment optimizes its biological properties[10].

3.2.3 CFR-PEEK

From a biological perspective, CFR-PEEK composites are considered biologically stable, and it has been demonstrated that carbon fibers possess osteo-inductive activity promoting tissue integration and show no toxicity [10,62]. To achieve a strong bond to the matrix, carbon fibers undergo oxidation, allowing them to form a covalent bond robust enough to resist dislocation when a force is applied to the material [63].

The mechanical properties of CFR-PEEK composites can be controlled by the content, dimensions, and orientation of the fibers [64]. The volume percentage of carbon fiber can vary between 30 and 60%. These fibers can be either continuous or short, and they can be unidirectional (oriented parallelly) or multidirectional [38,41,42,64,65]. All authors observe that adding these fibers to PEEK results increased creep, hardness, resistance to compression and fatigue, and also considerably reduced the stress-shielding experienced by the bone since the material’s modulus of elasticity can adjust to that of the bone based on the percentage of fiber incorporated [38,41,42,64,65]. Then, the development of new implants requires adherence to established in vitro and in vivo tests before proceeding to manufacturing.

Due to their adjustable mechanical properties, researchers have suggested through their studies that CFR-PEEK composites are more suitable for use in both orthopedics and oral implantology. Indeed, they are more likely to counteract forces causing stress peaks, ensuring a more uniform distribution of load to the peri-implant bone than the gold-standard implants [38,41,61].

4 PEEK dental applications

As we delve deeper into the applications of PEEK in dentistry, we will explore the use of PEEK in various capacities: as implant abutments, a material for removable partial dentures, a foundation for fixed dental prostheses, and even as the core material for dental implants.

4.1 PEEK implant abutments

In the field of implant dentistry, an abutment serves as the bridge between the prosthetic restoration and the implant itself (Figure 3). Abutments are crafted from a variety of materials, including titanium, gold, zirconium, and ceramics [76]. Recently, there has been an increased utilization of PEEK abutments. Notably, in instances of implant screw damage, PEEK screws offer ease of removal. Studies have shown that PEEK abutments can endure intraoral chewing forces akin to those experienced by titanium abutments. The soft tissue response to PEEK is commendable, often leading to optimal gingival tissue healing [77].

Figure 3 Schematic representation of the structure of a dental implant.
Figure 3

Schematic representation of the structure of a dental implant.

The semi-crystalline nature of PEEK contributes to its reduced brittleness, leading to deformation rather than breakage. Research has shown that when using PEEK for abutments, while the prosthesis remains unharmed, the abutment might deform. Nevertheless, the prosthesis’ functionality can be restored by replacing the deformed abutment [78]. In a study by Koutouzis et al., a randomized controlled clinical trial found negligible differences in bone loss and tissue inflammation between PEEK and titanium abutments (Figure 4). Furthermore, the composition of oral bacteria observed was consistent with that seen with titanium, zirconia, or PMMA abutments [79].

Figure 4 Occlusal view of implants with PEEK abutments (a) following installation and (b) at 3 months. And, occlusal view of implants with titanium abutments (c) following installation and (d) at 3 months [79].
Figure 4

Occlusal view of implants with PEEK abutments (a) following installation and (b) at 3 months. And, occlusal view of implants with titanium abutments (c) following installation and (d) at 3 months [79].

The distribution of occlusal forces and the manner in which stress is distributed during the implant healing period significantly impact the enduring outcomes of implant procedures. In a study by Taha et al. [25], they examined the interplay between various crown-abutment combinations and their impact on the force absorption properties of implant-supported restorations. Their findings indicated that pairing resin-based ceramic crowns with PEEK abutments did not amplify force absorption capabilities. This could be attributed to the notably reduced elastic modulus of PEEK custom abutments, leading to diminished stress within the abutment, but increased stress on the associated crown [35].

Ceramic-reinforced PEEK (RPEEK) is another variant used in implant abutments noted for its good biomechanical properties and biocompatibility, with Al-Rabab’ah et al. [80] reporting stable bone and soft tissue around implants over 2 years.

Otherwise, Al-Zordk et al. discussed the critical aspect of fixation techniques in implant-supported restorations, highlighting the advantages of cement-screws for their superior passive fit, aesthetic appeal, and force distribution [81]. Zarone et al. further asserted that cement-screw systems have a greater load-bearing capability compared to screw-retained systems [82]. Freitas et al. [83] observed that restorations retained by cement and featuring internal connections display enhanced fracture resistance, leading to their preference in Atsu et al.‘s work [84]. Yet, they caution against the potential for peri-implant diseases due to residual cement in the submucosal area, with prevalence rates ranging from 1.9 to 75% in such restorations [81]. The discussion also touches upon physiological bite forces, noting the range of occlusal forces across different teeth types. Atsu et al. reported that titanium abutments exhibit superior fracture toughness (943.67 N) compared to Zr and RPEEK (770.1 N), though the latter two materials show no significant difference in this aspect (p = 0.001). Ortega et al. presented findings on fracture toughness, with titanium abutments at 468.5 N and PEEK at 200.4 N. They noted that PEEK abutments withstand 1.2 million cycles at 140 N without failure, simulating 5 years of function, but fail under increased loads of 160 N after approximately 89,338 cycles, equating to 4–5 months of use [26]. This behavior indicates PEEK’s role as a “sacrificial material,” absorbing deformation to prevent damage to the implant or screw, in contrast to titanium where deformation affects the internal connection, potentially endangering the implant’s longevity [26]. In another study by Mourya et al. [29], the stress distribution around abutments, subjected to both vertical and oblique forces, was assessed for both titanium and carbon-fiber-reinforced PEEK (CF/PEEK) implants. The findings propose that in patients with molar teeth, using straight abutments in conjunction with PEEK crowns could mitigate intraosseous stress levels and potentially avert implant complications.

The available evidence suggests that PEEK abutments may not meet the biomechanical criteria necessary to supplant traditional titanium abutments. Among available options, zirconium is recognized for its superior biocompatibility as an abutment material [85]. Nevertheless, PEEK exhibits particular merits in applications like customized healing abutment [27], provisional restorations [24,28] for patients lacking functional deficiencies, and for shaping emergency contours during surgical interventions, especially relevant for implants in individuals subject to reduced stress loads.

Figure 5 shows the various PEEK abutments. PEEK healing abutment (Figure 5a) is used as an alternative for classic titanium healing abutment [86], and PEEK with titanium base temporary abutment (Figure 5b) is used for long-term interim restoration, especially in areas with aesthetic consideration [87].

Figure 5 PEEK abutments: (a) PEEK healing abutment (GM customizable healing abutment, Neodent, Curitiba, Brazil), (b) PEEK with titanium base temporary abutment (GM PRO PEEK abutment, Neodent, Curitiba, Brazil).
Figure 5

PEEK abutments: (a) PEEK healing abutment (GM customizable healing abutment, Neodent, Curitiba, Brazil), (b) PEEK with titanium base temporary abutment (GM PRO PEEK abutment, Neodent, Curitiba, Brazil).

4.2 PEEK as fixed dental prosthesis

For fixed dental prosthetics, PEEK offers a unique solution with its metal-free crowns and bridges, known for their outstanding biocompatibility and robust mechanical attributes (Figure 6). When assessing PEEK against traditional ceramic and metal materials, it becomes evident that PEEK’s dental bridge infrastructure remains resilient, even when subjected to in vitro aging processes. For implant-linked prosthetic applications, PEEK crowns have showcased effective outcomes [88]. In terms of biocompatibility evaluations, PEEK consistently outperforms many metal-based ceramics. Nevertheless, some experts propose the integration of veneers over PEEK to achieve optimal precision [89]. Given its lightweight nature, PEEK emerges as a promising contender to replace traditional chrome-cobalt prostheses [90–92].

Figure 6 PEEK resin-bonded fixed dental prosthesis: (a) occlusal view and (b) after fixing the teeth [94].
Figure 6

PEEK resin-bonded fixed dental prosthesis: (a) occlusal view and (b) after fixing the teeth [94].

PEEK restorations demonstrate satisfactory resilience against fractures, enduring anterior masticatory forces of around 300 N and forces of 600 N in posterior areas. Extended chewing simulations, replicating up to 5 years of intraoral utilization, revealed no structural damage or debonding incidents in these restorations [77].

4.3 PEEK implants

As mentioned previously, PEEK is emerging as a potential material in implant dentistry, offering a solution to both full and partial tooth loss.

Traditionally, titanium has been the go-to material for dental implants due to its osteoconductive properties. However, PEEK, having elasticity similar to human bone, is now being considered as an alternative to titanium [94]. The stability of an implant can be influenced by several elements, including the occlusal load, bone structure, and potential for bone loss [95]. Khaohoen et al. [21] highlight that PEEK is emerging as a viable option in the realm of dental implantology, countering some of the drawbacks associated with titanium such as aesthetic limitations, allergic reactions, and stress-shielding effects. Despite PEEK’s outstanding biocompatibility and absence of cytotoxic effects, its osseointegration capabilities lag behind those of titanium, marked by a reduced bone-implant contact (BIC) area, diminished osteoblast activity, and lower osteoconductivity. However, enhancing PEEK’s surface hydrophilicity and roughness through nanoscale modifications have been identified as a promising strategy to mitigate these limitations.

Ouldyerou et al. indicated that while standard titanium implants tend to concentrate stress in specific bone areas, those made of a titanium-PEEK combination distribute stress more evenly, potentially reducing bone degradation [30]. Interestingly, studies involving animals have shown that titanium-coated PEEK may support bone formation better than its uncoated counterpart [58]. Pure PEEK, given its hydrophobic nature, might deter initial cell attachment. Yet, some investigations have noted enhanced mechanical bonding between bone and implants when using porous or titanium-coated PEEK, leading to better cellular interaction and integration [96]. Additionally, many studies have reported on methods to increase the bioactivity of PEEK, and various authors have highlighted the need to incorporate bioactive inorganic ceramic particles, such as HA, HAF, β-TCP, and TiO2 to enhance the osteointegration of PEEK implants [10,67,73,97]. Therefore, while PEEK holds promise, comprehensive studies are crucial before its widespread adoption in dental implantology.

4.4 Commercial forms for dental use

Two leading commercial PEEK brands are widely recognized in the dental sector. PEEK-OPTIMA® is the preferred choice within the US, supplied by Invibio Biomaterial Solutions since 1999, and is primarily used for dental applications such as provisional prosthetic abutments and healing screws [98]. In contrast, Europe mainly utilizes BioHPP™ (Figure 7), produced by Bredent GmbH, which is specifically designed for dental applications. It is a modified PEEK material that incorporates ceramic fillers to enhance polishability and is suitable for various dental prostheses and frameworks through injection molding and CAD-CAM processing [99].

Figure 7 PEEK abutment made by BioHPP [99].
Figure 7

PEEK abutment made by BioHPP [99].

5 Mechanical behavior of PEEK and its composites

In this part, we will delve into an in-depth examination of the mechanical behavior properties of PEEK and its associated composites. This analysis will provide a comprehensive understanding of the material’s strengths as well as their ability to withstand force stresses without fracturing or undergoing deformation.

5.1 Elastic behavior under tensile, compression, bending stress, and wear resistance

The tensile, compression, and flexural (bending) tests conducted on PEEK have led to determining its ability to deform after being subjected to a constantly increasing loading process.

The application of tensile forces results in a progressive elongation up to the material’s breaking point and allows for defining many of its mechanical properties. These elastic properties are derived from the interpretation of a stress–strain curve defining both an elastic and a plastic domain. They are directly dependent on the crystallinity of PEEK, reflecting its thermal treatment history [100,101].

5.1.1 Elastic modulus, flexural and tensile strengths of PEEK

In medical and dental fields, the modulus of elasticity stands as a pivotal factor influencing the long-term durability and biocompatibility of a material [102]. Studies have highlighted PEEK’s modulus of elasticity, noting that it does not match that of the human cortical bone but is closer to it than the traditional metals, which positions it as a potential candidate for medical and dental implant applications [103]. Previous studies have shown that rigid implants in Titanium or in zirconia had an elasticity modulus (110 and 210 GPa, respectively) that is 5–14 times greater than cortical bone (17 GPa). This significant difference can lead to bone resorption and loss of osseointegration due to a phenomenon known as “Stress Shielding.” The difference in mechanical behavior between these biomaterials and bone results in poor distribution and uneven diffusion of forces arising from mastication stresses [42,39]. On the other hand, authors have reported values of the modulus of elasticity of the unmodified PEEK (Table 4) ranging between 3 and 4 GPa [104] and, as mentioned previously, this modulus can be increased significantly by reinforcing PEEK with various composite and ceramic materials (hydroxyapatite, glass fiber, carbon fiber, titanium oxide, tricalcium phosphate) to achieve results even more akin to cortical bone [42,104,105,106]. This promotes better stress distribution, preventing high stress peaks at the osseous/implant interface that lead to implant failure [40,42,44,107]. The elastic modulus of CFR-PEEK can reach up to 18 GPa [104,106] while GFR-PEEK can achieve around 12 GPa [42,105]. A comprehensive list of the mechanical properties related to these materials, especially the blended PEEK types, can be found in Table 4.

Table 4

Elastic modulus and the tensile strength of various materials

Material Elastic modulus (GPa) Tensile strength (MPa) Ref.
Titanium 110 954–976 [108]
PMMA 3–5 48–76 [109]
PEEK 3–4 80 [104]
CFR-PEEK 18 120 [104]
GFR-PEEK 12 [110,111]
Cortical bone 14 104–121 [112]
Enamel 40–83 47.5 [113]
Dentin 15–30 104 [114,115]
Ti6Al4V 110–130 976 [111,116]

Schwitalla et al. [38,39] conducted studies on 11 different PEEK materials, assessing them through static compression and three-point flexural tests. Materials included grades of PEEK with various reinforcements, such as titanium dioxide, barium sulfate, carbon fibers, and glass fiber. During testing, specimens were subjected to a load from a wedge-shaped penetrator. The studies highlighted the suitability of these PEEK materials for dental implants, given their capacity to withstand high mastication pressures and compliance with the standard (EN ISO 10477).

Furthermore, Ferguson et al. [45] compared the modulus of elasticity of PEEK OPTIMA® samples through compression tests conducted both in a dry environment at room temperature (22°C) and under saline conditions (NaCl) at 37°C to simulate a natural physiological environment. The results suggested that the modulus of elasticity was 1.8% lower in the aqueous environment, indicating that temperature and humidity had a statistically significant influence on it, even though the difference was relatively small.

Also, Schwitalla et al.’s study [40] employing a three-point flexural approach revealed that PEEK’s strength surpasses the standard benchmark set for plastic materials at 65 MPa. When considering its applications in orthodontics, PEEK sets itself apart by displaying superior flexural strength and minimized creep when compared to other plastics like polyethersulfone and polyvinylidene fluoride [117]. Furthermore, with a tensile strength rating of 80 MPa [104], PEEK’s mechanical properties are close to enamel and dentin [113,114,118], making it an ideal candidate for constructing prosthodontic framework.

5.1.2 Wear resistance

Recent advancements have explored novel PEEK-based composites as potential replacements for traditional metallic materials in biomedical implants and prosthesis. However, the performance of these materials under aggressive oral conditions, particularly in the presence of abrasive particles from toothpaste, remains a critical area of research. A significant study by Sampaio et al. [38] focused on evaluating the abrasive wear resistance of PEEK and Ti6Al4V, which are prevalently utilized in the fabrication of dental prosthetics and implants. The aim of this research was to closely mimic the oral environment, characterized by frequent exposure to abrasive compounds found in both food and dental care products. Such exposure is known to induce wear on the contact surfaces between the prosthetic structures and implants, posing challenges to the longevity and reliability of these materials. The researchers prepared surfaces of both materials and subjected them to micro-scale abrasion tests under varying loads and with different concentrations of hydrated silica, mimicking the abrasive action of chewing and tooth brushing. Their findings revealed that PEEK exhibits a higher volume loss compared to Ti6Al4V under these abrasive conditions, indicating that Ti6Al4V possesses superior wear resistance. The increase in wear for both materials was proportional to the abrasive content and load applied. This suggests that while both materials are susceptible to wear from common abrasive particles in the oral cavity, Ti6Al4V may offer better durability against such challenges.

In a parallel inquiry, Ragupathi et al. [31] conducted a detailed study on the wear characteristics of PEEK in comparison to titanium, specifically focusing on dental abutments subjected to cyclic loading. This method was intended to simulate the wear that occurs over a year of mastication.

Despite the hypothesis suggesting greater wear in PEEK abutments due to their lower elastic modulus, findings revealed minimal difference in wear rates between the two materials. Advanced analytical techniques, including scanning electron microscopy (SEM), were utilized to meticulously evaluate wear patterns, demonstrating that both PEEK and titanium exhibited similar resilience to cyclic stress. This was quantitatively supported by surface roughness measurements before and after loading, indicating no statistically significant wear discrepancy between PEEK and titanium abutments. The study concluded that PEEK’s wear resistance closely matches that of titanium, making it a viable alternative for implant abutments in dental applications. These results highlight PEEK’s potential in dental implantology, although further research is encouraged to validate these findings over longer periods and in varied clinical conditions.

5.2 Mechanical testing

Mechanical testing in dental implants plays a vital role in assessing their robustness and functionality under the conditions of oral cavity. Such tests offer insights into the longevity and stability of these implants when subjected to continuous stress and environmental factors. In the following discussion, we will delve deeper into specific mechanical tests, namely, fatigue tests and wear resistance, to better understand their significance in evaluating dental implant performance.

5.2.1 Fatigue test for PEEK used in implant applications

Implant-supported prosthesis undergo stress from chewing in a wet environment and face sudden temperature changes between 0 and 65°C. Consequently, the materials chosen should meet specific standards concerning their robustness and rigidity. They should also resist against deformation and fatigue fracture [119].

During the chewing process, loads exerted can vary, sometimes remaining below the fracture load. However, even these variations can introduce weaknesses in the structure, resulting in the appearance of fissures and cracks. This is often termed as mechanical fatigue. Over time, these minor imperfections can evolve and spread, leading to a fatigue fracture [120,121]. The fatigue limit or endurance limit is the stress level below which an infinite number of loading cycles can be applied to a material without causing fatigue failure [122].

Lee et al. [42] assessed and compared the fatigue limits of PEEK polymers reinforced with carbon fibers (CFR-PEEK) and others with glass fibers (GFR-PEEK) against titanium for potential dental implant applications. These tests were conducted in accordance with ISO 14801, which outlines the application of cyclic loads under dry conditions and at room temperature on cylindrical specimens with diameters of 4 and 5 mm. This was done to closely replicate the forces transmitted to the implant during chewing: cyclic impacts on the bone/implant over a limited time period. The fatigue limit of GFR-PEEK specimens with a diameter of 4 mm was found to be 310 N, and this was higher than its maximum static compression force of 256 N. According to the authors, this vital phenomenon is due to the fact that the deformation rate can increase the elastic limit of PEEK materials by 30%. This elasticity of PEEK might also explain the high fatigue limits. The authors concluded that implants made of this material could be suitable for replacing anterior teeth where the maximum chewing forces in the incisive zone reach 140–170 N. Otherwise, the fatigue limit of CFR-PEEK specimens with a diameter of 5 mm was found to be 450 N, which was also higher than their maximum static compression force. This material was therefore favored as it appears suitable for the replacement of both anterior and posterior teeth, where the maximum chewing forces in the molar zone range from 200 to 250 N. Dental implants with PEEK polymer coatings or those based on PEEK would thus be advantageous in reducing the effects of “stress shielding.” However, the authors note that the fatigue tests were conducted at room temperature, and even though PEEK is not affected by hydrolysis, concerns are raised regarding its ability to maintain good bonding at the interface between the resin and its reinforcements. There are still too few fatigue tests in saline solution, but the initial results on CFR-PEEK samples seem to indicate good in vivo stability and long-term physical and mechanical properties of PEEK.

6 Finite elements methods

The advancement of dental implant, abutment, and associated materials necessitates adherence to established in vitro and in vivo tests before they are fit for commercial use. Conducting in vivo tests on a substantial number of samples can be lengthy and may pose challenges to animals or patients involved. Moreover, potential inaccuracies in these assessments could lead to misleading outcomes, impacting both the materials and the results of the experiment. Therefore, the FEM emerges as a valuable tool for predicting potential mechanical complications using theoretical models coupled with in vitro tests [22,23,35,39,44,123]. The FEA is frequently used to assess the biomechanical behavior of implantable biomaterials in vitro, whether in orthopedics, traumatology, or oral implantology. This method allows for the evaluation of stress distribution during the load transfer of an implant to the underlying bone structures and typically follows a consistent procedure.

The process involves obtaining a radiographic image of the bone section that will be studied. This image is then converted into a 3D model using computer-aided design (CAD) software. This model becomes the foundation for tests conducted on various models created with each implantable biomaterial.

The articles chosen for this section explore the utilization of FEA in examining the mechanical characteristics of abutments and implants. The process typically involves the creation of a 3D bone model through a CT scan, followed by importing into CAD software such as ANSYS, ABAQUS, SolidWorks, Creo Parametric, or Rhinoceros. A FEA package is then used to generate a 3D mesh which is linked to a suitable mathematical model that captures the properties of the corresponding material. While most of the studies employed ANSYS for simulation [22,23,32,33,39,44], some researchers favored ABAQUS, and CATIA [124–127]. Most of the selected studies assume a linear elastic, isotropic, and homogenous material model. In addition to using fewer parameters, in a linear elastic model, the correlation between these parameters and clinical medical imaging has been well established, which greatly enhances its potential for clinical application [127]. Whereas, an anisotropic material model is found to be more suitable for CFR-PEEK laminates [34]. CFR-PEEK laminates consist of carbon fiber-reinforced PEEK, which exhibits varying stiffness and strength properties in different directions relative to the orientation of the carbon fibers within the laminate. An anisotropic material model can accurately capture these directional dependencies, allowing for more precise simulations and prediction of mechanical behavior. This is particularly crucial in the context of dental implants and abutments, where a comprehensive understanding of material response under diverse loading conditions is essential (Figure 8).

Figure 8 Schematic of an implant-supported prosthesis involving implant, abutment, and a single crown.
Figure 8

Schematic of an implant-supported prosthesis involving implant, abutment, and a single crown.

The mechanical performance of implants, including factors such as von Mises stress, shear stress, contact stress, and stress shielding, is analyzed under varying loading conditions corresponding to clinical scenarios. An integral consideration in FEA methodologies is the assumption of forces to replicate masticatory loads encountered within the oral cavity of patients. However, defining this parameter precisely remains elusive due to its variability among individuals [39]. The magnitude of axial loading in the selected journals ranges widely from 100 to 1,000 N, while oblique loading typically spans from 50 to 500 N [29,33]. Notably, a predominant trend in these studies is the utilization of axial loading within the range of 100 to 150 N. Furthermore, the angle of oblique loading has slight variation, typically falling between 30° and 45°.

The selected journals aimed to investigate the stresses developed in dental implants and bones using various prosthesis materials, including titanium, zirconium, unfilled, and CFR-PEEK, utilized in abutments and implants, and their combinations. Oblique loading typically results in higher stresses in cortical and cancellous bone, implant components, and restorative crowns compared to axial loading across all mentioned studies. The findings of all authors are consistent with each other. A higher stress concentration is generally observed in the cortical bone near the peri-implant region, gradually decreasing towards the cancellous bone under both axial and oblique loading conditions.

Most studies indicate no significant variation in stress distribution at the implant-bone interface for different material models. Mourya et al.’s study of stress distribution in straight and angled abutments supports this conclusion, suggesting similar stress results with CFR-PEEK and titanium implants in both straight and inclined cases [29].

Another study on the performance of titanium/PEEK dental implants simulating different levels of bone loss also indicates that stresses were independent of the implant material [30]. Similarly, Sarot et al.’s work on the stress distribution of CFR-PEEK dental implants concludes that CFR-PEEK implants offer no advantages over titanium implants concerning stress distribution to the peri-implant bone [44]. Shash et al.’s study on fixed prosthesis following the “all on four” framework indicates that 60% CFR-PEEK distributes cortical bone stresses similar to the titanium framework [23] (Figure 9).

Figure 9 The distribution of von Mises stresses (MPa) on the mucosa, cortical and spongy bones, under unilateral force, using Ti and PEEK [27].
Figure 9

The distribution of von Mises stresses (MPa) on the mucosa, cortical and spongy bones, under unilateral force, using Ti and PEEK [27].

Studies by Wazeh et al. [33] and Kaleli et al. [35] agree that crown material does not affect biomechanical behavior concerning stresses in implants and peripheral bone.

However, Mourya et al.‘s findings on stress distribution under parafunctional loading show that the stresses generated in bone with a PEEK crown layered with composite are lower compared to porcelain fused to metal (PFM) crown configurations [29] (Figure 10).

Figure 10 Stress in: (a) CFR-PEEK 15° abutment under vertical loading with PFM crown, (b) CFR-PEEK straight abutment under oblique loading with (PFM) crown, (c) titanium straight abutment under vertical loading with (PFM) crown, and (d) titanium straight abutment under oblique loading with (PFM) crown [29].
Figure 10

Stress in: (a) CFR-PEEK 15° abutment under vertical loading with PFM crown, (b) CFR-PEEK straight abutment under oblique loading with (PFM) crown, (c) titanium straight abutment under vertical loading with (PFM) crown, and (d) titanium straight abutment under oblique loading with (PFM) crown [29].

Implants with micro threads showed a reduction of maximum von Mises stress by 50–70% in peri-implant bone compared to conventional threading [33], as demonstrated by Wazeh et al. Specifically, micro-threaded titanium implants, when used with a zirconia crown, exhibited the lowest cortical bone stress values under vertical loading, approximately 10 MPa. In contrast, implants made of CFR-PEEK with 30% carbon fibers generated notably higher stresses, around 100 MPa, on the cortical bone.

Titanium implants may induce a stress-shielding effect, leading to implant and bone loss due to their high elastic modulus (110 GPa) compared to bone (14 GPa). The stiffness mismatch between bone and implant can result in stress-shielding phenomena, potentially leading to bone resorption during the bone remodeling stage. In vivo, PEEK material possesses biomechanical properties close to human bone, reducing the risk of bone resorption and osteolysis caused by the stress-shielding effect of implants. A study by Ouldyerou et al. found that Ti-PEEK implants outperform conventional Titanium implants in reducing stress shielding and bone resorption [30]. The application of PEEK veneering on dental implants or abutments was also found to diminish the effects of stress shielding, as indicated by studies conducted by Lee et al. and Sampaio et al. [37,42]. Nevertheless, the thickness of PEEK veneering emerged as a critical factor influencing both stress distribution and the strength of hybrid abutments or implants, as highlighted in the research by Sampaio et al. [37].

Implants or abutments made of PEEK containing 30% carbon fiber exhibited increased stiffness compared to unfilled PEEK. The incorporation of such PEEK composites was found to enhance stress distribution and reduce the load concentration throughout the abutment and implant region, as suggested by Sarot et al. [44].

In weaving together, the detailed insights provided by the various studies, it becomes evident that FEA offers a robust framework for simulating and understanding the biomechanical behavior of dental implants and abutments under various conditions. Through meticulous modeling and simulation, FEA enables researchers and practitioners to predict and mitigate potential complications associated with implant materials and designs, thereby facilitating the development of more effective and safer dental restoration solutions. The consensus across studies on the efficacy of materials like CFR-PEEK and the nuances of stress distribution underlines the complexity of dental biomechanics and the indispensable role of FEA in advancing dental implantology. As the field evolves, the ongoing refinement of FEA methodologies and the exploration of new materials will undoubtedly contribute to enhancing the quality and longevity of dental implants, ultimately benefiting patients with more reliable and durable dental restorations.

7 Conclusion

The manuscript thoroughly examines the application and mechanical performance of PEEK and its composites in dental implantology, particularly regarding implant abutments and cores. Through FEA, it highlights PEEK’s pivotal role in advancing dental implant technology.

7.1 Application of PEEK and its composites in dental field

The manuscript discusses PEEK and its composites’ applications in dental implantology, citing their biomechanical compatibility and bioactivity. PEEK emerges as an alternative to titanium for abutments and dental implant cores due to its similar elasticity to bone and ease of removal. It outlines PEEK’s advantages in creating abutments, frameworks, and core materials, including its commendable soft tissue response and customization potential for provisional restorations and shaping emergency contours during surgical interventions.

7.2 Mechanical tests on PEEK

The manuscript extensively explores PEEK’s mechanical properties via tensile, compression, bending stress, wear resistance, and fatigue tests, revealing its robustness and suitability for dental implants. CFR-PEEK and GFR-PEEK composites show increased hardness, compression resistance, and fatigue endurance, reducing stress-shielding in bone. Tests, compliant with ISO 14801, demonstrate their ability to withstand chewing forces, suggesting PEEK-based materials could offer longer lasting implant solutions with more even load distribution.

7.3 Enhancement of understanding through FEA

The manuscript highlights FEA’s crucial role in advancing dental implant technology, allowing simulation of biomechanical behavior and stress distribution analysis in CFR-PEEK implants and abutments. By generating 3D models from radiographic images and using software like ANSYS and ABAQUS, FEA predicts stress distribution during load transfer, crucial for implant-bone interface evaluation. This method effectively assesses CFR-PEEK composites’ mechanical performance, reducing stress concentrations and improving load distribution, essential for implant longevity and success.

In conclusion, the widespread adoption of a new biomaterial is always a slow and cautious process. FEA emerges as a powerful tool in the development and evaluation of dental implants, providing valuable insights into material behavior and design efficacy. The ongoing evolution of this methodology, coupled with advancements in biomaterials, holds the promise of more effective, tailored, and biocompatible implant solutions, ultimately enhancing patient outcomes in dental and orthopedic implantology.

Acknowledgments

We would like to extend our sincere gratitude to the reviewers of this paper for their valuable time, insightful comments, and constructive feedback. Their expertise and meticulous evaluation have significantly contributed to enhancing the quality and clarity of our work.

  1. Funding information: The authors state no funding involved.

  2. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  3. Conflict of interest: The authors state no conflict of interest.

  4. Data availability statement: Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

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Received: 2023-12-14
Revised: 2024-04-22
Accepted: 2024-05-20
Published Online: 2024-06-17

© 2024 the author(s), published by De Gruyter

This work is licensed under the Creative Commons Attribution 4.0 International License.

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https://doi.org/10.1515/rams-2024-0031
Keywords for this article
polyetheretherketone; biomaterials; dental implants; abutments; finite element; stress
Creative Commons
BY 4.0

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  86. Effect of waste crab shell powder on matrix asphalt
  87. Improving effect and mechanism on service performance of asphalt binder modified by PW polymer
  88. Influence of pH on the synthesis of carbon spheres and the application of carbon sphere-based solid catalysts in esterification
  89. Experimenting the compressive performance of low-carbon alkali-activated materials using advanced modeling techniques
  90. Thermogravimetric (TG/DTG) characterization of cold-pressed oil blends and Saccharomyces cerevisiae-based microcapsules obtained with them
  91. Investigation of temperature effect on thermo-mechanical property of carbon fiber/PEEK composites
  92. Computational approaches for structural analysis of wood specimens
  93. Integrated structure–function design of 3D-printed porous polydimethylsiloxane for superhydrophobic engineering
  94. Exploring the impact of seashell powder and nano-silica on ultra-high-performance self-curing concrete: Insights into mechanical strength, durability, and high-temperature resilience
  95. Axial compression damage constitutive model and damage characteristics of fly ash/silica fume modified magnesium phosphate cement after being treated at different temperatures
  96. Integrating testing and modeling methods to examine the feasibility of blended waste materials for the compressive strength of rubberized mortar
  97. Special Issue on 3D and 4D Printing of Advanced Functional Materials - Part II
  98. Energy absorption of gradient triply periodic minimal surface structure manufactured by stereolithography
  99. Marine polymers in tissue bioprinting: Current achievements and challenges
  100. Quick insight into the dynamic dimensions of 4D printing in polymeric composite mechanics
  101. Recent advances in 4D printing of hydrogels
  102. Mechanically sustainable and primary recycled thermo-responsive ABS–PLA polymer composites for 4D printing applications: Fabrication and studies
  103. Special Issue on Materials and Technologies for Low-carbon Biomass Processing and Upgrading
  104. Low-carbon embodied alkali-activated materials for sustainable construction: A comparative study of single and ensemble learners
  105. Study on bending performance of prefabricated glulam-cross laminated timber composite floor
  106. Special Issue on Recent Advancement in Low-carbon Cement-based Materials - Part I
  107. Supplementary cementitious materials-based concrete porosity estimation using modeling approaches: A comparative study of GEP and MEP
  108. Modeling the strength parameters of agro waste-derived geopolymer concrete using advanced machine intelligence techniques
  109. Promoting the sustainable construction: A scientometric review on the utilization of waste glass in concrete
  110. Incorporating geranium plant waste into ultra-high performance concrete prepared with crumb rubber as fine aggregate in the presence of polypropylene fibers
  111. Investigation of nano-basic oxygen furnace slag and nano-banded iron formation on properties of high-performance geopolymer concrete
  112. Effect of incorporating ultrafine palm oil fuel ash on the resistance to corrosion of steel bars embedded in high-strength green concrete
  113. Influence of nanomaterials on properties and durability of ultra-high-performance geopolymer concrete
  114. Influence of palm oil ash and palm oil clinker on the properties of lightweight concrete
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