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

Journal of Oral Implantology 743

PEEK Dental Implants
Care Policy and Research.15 Furthermore, the stress
distribution of a zirconia implant to the surrounding
bone could be associated with even higher stress
peaks compared to titanium, due to the higher
elastic modulus of zirconia of 210 GPa.25
Another biocompatible material with an elastic
modulus of 3.6 GPa, which is closer to that of bone,
is polyetheretherketone (PEEK).26 Its modulus can
be modified by reinforcing it with carbon fibers, for
example, to achieve a modulus of 18 GPa, similar to
that of cortical bone.27
Since PEEK showed resistance to degradation in
vivo, it was offered commercially in April 1998 as a
biomaterial for long-term implants (Invibio Ltd,
Thornton-Cleveleys, UK).28 Since then, PEEK has
demonstrated to be a high-performance thermo-
plastic polymer able to replace metallic implant
components in the field of orthopedics29,30 and
traumatology.31,32 Also, calvarial reconstructions
with PEEK implants were described.33 These find-
ings suggest that PEEK could substitute titanium as
material for dental endosseous implants.
The current review pertains to literature pub-
lished prior to December 1, 2010. The aim was to
figure out whether there are existing studies about
dental implants from PEEK, which probably under-
line the theory that PEEK could be considered as a
viable alternative material for dental implants.
MATERIALS AND METHODS
Literature search
The articles for the current review were found using the
PubMed search engine and searching for references
cited within these articles. All articles published until
December 2010 were reviewed. The following search
terms were used together: ‘‘dental implant PEEK.’’
Inclusion criteria
Only articles about dental implants from PEEK or
modified PEEK published until December 2010 were
included, regardless of the kind of investigation (in
vivo or in vitro), implant design, surface modifica-
tions, year of publication, and language.
RESULTS
The search yielded 5 articles, of which 3 were
included in the review.11,34,35 Two articles were
744 Vol. XXXIX /No. Six /2013
excluded, because they did not report on dental
implants of PEEK.36,37
Of the included articles, 2 reported on animal
investigations34,35 and 1 on an in vitro finite
element study.11
The aim of the 3-dimensional finite element
study was to compare the stress distribution to the
peri-implant bone in 4 distinct testing models
consisting of either a titanium or a carbon fiber–
reinforced PEEK (CFR-PEEK) implant, containing 30%
carbon fibers to obtain an elastic modulus of 17.4
GPa similar to that of cortical bone,27 each in
combination with a titanium and a CFR-PEEK
abutment, completed with a cemented artificial
crown (Table 1).
The CFR-PEEK implants presented a higher load
concentration in the cervical area and at the cortical
bone than the titanium implants, whereas the
titanium implants presented equivalent stress peaks
in the cervical portion and a more homogenous
load distribution throughout the whole implant
body (Table 1).
The authors admit that the higher stress
concentrations of the PEEK implant were not
expected. A more homogenous stress distribution
was intended to diminish stress peaks at the
implant-bone interface. So, they conclude that the
CFR-PEEK implant did not present any advantages
in comparison to the titanium implant.
This material was also used for cylindrical
implants in an animal experiment, which compared
the bone-implant contact (BIC) and shear strength
of 20 titanium-coated implants to 20 uncoated
implants.35 In this study 5 implants were inserted in
each femur of 4 mongrel dogs, 5 uncoated on one
side and 5 titanium-coated on the other side. After 4
and 8 weeks of healing, 2 dogs were sacrificed. Of
each femur, 3 implants underwent pull-out testing
to determine the mechanical integrity of the
interface. The other 2 implants of each femur were
reserved for intact histologic evaluation.
The coated implants showed significantly BIC
values after a healing period of both 4 (P ¼ .0014)
and 8 weeks (P ¼ .0261), whereas the BIC of both
the uncoated and the coated implants generally
decreased from 4 to 8 weeks. The shear strength for
the uncoated implants was significantly higher after
4 (P ¼ .0107) and lower after 8 weeks (P ¼ .2496)
(Table 2). The authors conclude that the addition of
the titanium coating apparently increases the
 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.

Journal of Oral Implantology

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
BIC ratio as a parameter for the grade of osseointe-
gration, it can be stated that both CFR-PEEK
implants (coated and uncoated) presented a
desirable osseointegration in comparison to the
BIC values of the titanium implants (40.91 6
10.11%) of the second animal experiment34 (Table
2). The aim of that study was to evaluate
osseointegration of 1-piece zirconia vs titanium
implants depending on their insertion depths after
a healing period of 4 months due to a split-mouth
design (submerged vs nonsubmerged healing).
Therefore, the test implants made from zirconia
and coated zirconia (covered by a calcium-liberating
titanium oxide [TiO2] sol-gel layer) were compared
to a control implant made from titanium. Addition-
ally, an experimental implant of PEEK was inserted.
All implants had the same design, only differing in
their biomaterials. In this study, the PEEK implants
reached BIC rates of 26 6 8.9%.
In neither of the 2 animal investigations were
signs of inflammation or foreign body reactions
observed.
DISCUSSION
Referring to a 3-dimensional finite element analysis
of a CFR-PEEK and a titanium implant (Table 1), the
authors concluded that due to its higher stress
concentrations, the CFR-PEEK implant could not be
recommended.11
This deformation rate could probably be dimin-
ished by an inner stiffening of the implant, for
example, by an abutment connection bolt which
extends to the apical region of the implant, whereas
the complete biomechanical behavior of a PEEK
implant has to be tested experimentally to achieve
accurate data.
Because CFR-PEEK is black due to the carbon
fibers, its use could be unfavorable, especially in
esthetic zones.
In an animal investigation from 1995, the BIC
and shear strength of titanium-coated and uncoat-
ed CFR-PEEK implants were evaluated.35 The shear
strength of the uncoated implants was significantly
higher after 4 and insignificantly lower after 8 weeks
of healing, although the BIC rate of the coated
implants was always significantly higher (Table 2).
The surface roughness as an important factor
was not assessed, so this phenomenon is difficult to
interpret.
Considering potential hypersensitivities to tita-
nium, in such cases a titanium coating might
provoke hypersensitive inflammatory reactions.
The aim of the second animal experiment was to
evaluate osseointegration of 1-piece implants made
from zirconia, coated zirconia (coated by a calcium-
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
period of 4 months due to a split-mouth design
(submerged vs nonsubmerged healing).34 Regretta-
bly, the resulting BIC values of both the submerged
and the nonsubmerged implant groups of this
study were summarized to a mean value (Table 2).
The different types of healing could have had an
influence on the BIC values, due to different
exposures of the implants to masticatory loads
and oral flora.
For histomorphometric analysis, the bone level
(BL) between the uppermost thread and the crestal
bone level was subdivided into 2 sections. One
section described the bone-related BL, ranging from
the crestal bone level to the uppermost BIC. The
other section was named implant-related BL,
measured from the uppermost thread to the
uppermost level of BIC. The level of the uppermost
BIC was localized between the uppermost thread
and the crestal bone level. All results, however, were
expressed as negative values (Table 3). The authors
argue that the bone levels in general presented
higher values in the group of the submerged
implants due to higher insertion depths, which
were defined neither before nor while the implants
were inserted. To get the mean insertion depths of
the uppermost threads in relation to the crestal
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,
Mean Insertion Depths
From Table 3, mm
Zirconia 2.15
Coated zirconia 2.56
Titanium 2.02
PEEK 1.74
*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
the original article and added them together (Table
3). Then, we evaluated the differences in these
calculated insertion depths for the nonsubmerged
and the submerged implants to see how much
deeper the submerged implants were inserted
compared to the nonsubmerged (Table 4). The
value of the difference was positive when the result
revealed a greater insertion depth for the sub-
merged implants and negative if the insertion
depth of the submerged implants was less deep.
In this way, we calculated the following values: for
the submerged implants of zirconia þ0.47 mm, of
coated zirconia 0.31 mm, of titanium þ0.6 mm,
and of PEEK þ0.81 mm (Table 4). These findings
contradict the statement of the authors that the
submerged implants in general were inserted
deeper than the nonsubmerged implants.
Another finding in the article states that the
PEEK nonsubmerged implants showed significantly
lower bone-related BL than the nonsubmerged
coated zirconia and titanium implants (P ¼ .046,
.028). There is no evidence mentioned, if the mean
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-
related BL, as the PEEK implants of the non-
submerged group presented the lowest mean
insertion depth (Table 3).
Neither of the 2 animal investigations observed
inflammation signs or foreign body reactions, which
emphasizes the evidenced biocompatibility of PEEK.
Another in vitro study demonstrated attachment of
a collagen gel to PEEK by enzyme-induced mineral
deposition.38 If this kind of coating could be used to
anchor a PEEK implant in the alveolar bone by
collagen fibers like a natural tooth, this could
748 Vol. XXXIX /No. Six /2013
Submerged Implants,
Mean Insertion Depths Differences in the
From Table 3, mm Mean Insertion Depths, mm*
2.62 þ0.47
2.25 0.31
2.62 þ0.6
2.55 þ0.81
represent another advantage of PEEK over titanium,
giving back the physiologic tensile load to the
bone.
CONCLUSION
Literature reporting on dental implants made from
PEEK demonstrate that PEEK is basically osseointe-
grated as biocompatible material in vivo. Further
investigations are necessary to find ways to improve
the biomechanical behavior to achieve a more
homogenous stress distribution to the surrounding
bone, which has not yet been experimentally
proven. Long-term investigations of loaded PEEK
implants in vitro and in vivo are necessary.
Experimental modulations of the surface are need-
ed as well to achieve the highest possible grade of
osseointegration. The design of a 2-piece implant
made from PEEK, which allows the submerged
healing method, has to be developed. PEEK used for
a dental implant should have a light translucency
similar to a natural tooth to achieve favorable
esthetic results.
ABBREVIATIONS
BIC: bone-implant contact
BL: bone level
CFR-PEEK: carbon fiber–reinforced PEEK
PEEK: polyetheretherketone
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