Mechanical and biological characteristics of diamond-like carbon coated poly aryl-ether-ether-ketone

The research status and future direction of polyetheretherketone in dental implant -A comprehensive review

Currently, dental implants primarily rely on the use of titanium and titanium alloys. However, the extensive utilization of these materials in clinical practice has unveiled various problems including stress shielding, corrosion, allergic reactions, cytotoxicity, and image artifacts. As a result, polyetheretherketone (PEEK) has emerged as a notable alternative due to its favorable mechanical properties, corrosion resistance, wear resistance, biocompatibility, radiation penetrability and MRI compatibility. Meanwhile, the advancement and extensive application of 3D printing technology has expanded the range of medical applications for PEEK, including artificial spines, skulls, ribs, shinbones, hip joints, and temporomandibular joints. In this review, we aim to assess the advantages and disadvantages of PEEK as a dental implant material, summarize the measures taken to address its shortcomings and their effects, and provide insight into the future potential of PEEK in dental implant applications, with the goal of offering guidance and reference for future research endeavors.

Bone Regeneration and Polyetheretherketone Implants in Maxillo-Facial Surgery and Neurosurgery: A Multidisciplinary Study

Polyetheretherketone (PEEK) in the last few years has emerged as an exceedingly promising material for craniofacial defects due to its biocompatibility and mechanical properties. However, its utilization remains controversial due to its inertness and low osteoinductivity. This study aimed to investigate the postoperative outcomes of patients undergoing maxillo-facial and neurosurgical procedures with PEEK implants. The focus is on evaluating bone regrowth on the surface and edges of the implant, periosteal reactions, and implant positioning. A retrospective analysis of 12 maxillo-facial surgery patients and 10 neurosurgery patients who received PEEK implants was conducted. CT scans performed at least one year post operation were examined for bone regrowth, periosteal reactions, and implant positioning. In maxillo-facial cases, the analysis included mandibular angle and fronto-orbital reconstruction, while neurosurgical cases involved cranioplasty. In maxillofacial surgery, 11 out of 12 patients showed radiological evidence of bone regrowth around PEEK implants, with favorable outcomes observed in craniofacial reconstruction. In neurosurgery, 9 out of 10 patients exhibited minimal or none bone regrowth, while one case demonstrated notable bone regeneration beneath the PEEK implant interface. The study highlights the importance of implant design and patient-specific factors in achieving successful outcomes, providing valuable insights for future implant-based procedures.

Mechanical Integrity of All-on-Four Dental Implant Systems: Finite Element Simulation of Material Properties of Zirconia, Titanium, and PEEK

Background

Dental implants are critical for restoring functionality and aesthetics in patients with missing teeth. The all-on-four treatment concept utilizes four dental implants to support a full-arch prosthesis. Material choice for these implants plays a crucial role in the long-term success of the treatment, affecting everything from biomechanical stability to osseointegration and patient comfort.

Aim

The purpose of this study is to analyze the biomechanical performance of three different materials used in all-on-four dental implant designs through finite element analysis (FEA). The aim is to determine which material optimally balances stress and deformation under various loading conditions.

Objective

The main objective of this research is to evaluate the effects of stress, strain, and deformation on all-on-four dental implants made from titanium, zirconia, and polyether ether ketone (PEEK). The study seeks to identify which material demonstrates the best mechanical properties under simulated functional loads.

Methods

A 3D model simulating the dental implants integrated with cancellous and cortical bone was developed. Finite element analysis was conducted to assess the biomechanical performance of the implants made from titanium, zirconia, and PEEK. A perpendicular load of 100 N was applied to the tips of the implants, followed by an oblique load of 100 N at a 30-degree angle, to simulate different chewing forces.

Results

The deformation analysis indicated that implants made of zirconia exhibited significantly lower maximum and average deformation compared to those made from titanium and PEEK. Although PEEK implants showed lower maximum and average stress, they did not perform well in stress dissipation compared to zirconia. Similar patterns of stress and deformation were observed under both perpendicular and oblique loading conditions.

Conclusion

Zirconia implants outperformed titanium and PEEK in terms of deformation and stress distribution under simulated loading conditions. This suggests that zirconia could be a superior material for all-on-four dental implants, offering better mechanical stability and potentially enhancing the longevity and success of dental restorations. Further clinical trials are recommended to validate these findings and assess the long-term outcomes of zirconia-based implants.

Role of Polyetheretherketone in Prosthodontics: A Literature Review

Implant prostheses and other fixed and removable metal prostheses have led to an increase in demand for the development of new and efficient materials such as high-performance polymers polyetheretherketone (PEEK) over titanium and other metals because of their further complications in the human body. PEEK is a polymer that is nontoxic and has a modulus of elasticity that is comparable to that of human bone. PEEK implants provide benefits over metal implants, such as reducing the stress shielding effect, simple processing, and color resemblance to natural teeth. And it is a fantastic alternative to titanium for dental and orthopedic implants. The current review is undertaken to understand the properties of this PEEK material to weigh its benefits and drawbacks for potential use in dental implants and other prostheses.

Synergistic Effect of Physical and Chemical Cross-Linkers Enhances Shape Fidelity and Mechanical Properties of 3D Printable Low-Modulus Polyesters

Three-dimensional (3D) printing is becoming increasingly prevalent in tissue engineering, driving the demand for low-modulus, high-performance, biodegradable, and biocompatible polymers. Extrusion-based direct-write (EDW) 3D printing enables printing and customization of low-modulus materials, ranging from cell-free printing to cell-laden bioinks that closely resemble natural tissue. While EDW holds promise, the requirement for soft materials with excellent printability and shape fidelity postprinting remains unmet. The development of new synthetic materials for 3D printing applications has been relatively slow, and only a small polymer library is available for tissue engineering applications. Furthermore, most of these polymers require high temperature (FDM) or additives and solvents (DLP/SLA) to enable printability. In this study, we present low-modulus 3D printable polyester inks that enable low-temperature printing without the need for solvents or additives. To maintain shape fidelity, we incorporate physical and chemical cross-linkers. These 3D printable polyester inks contain pendant amide groups as the physical cross-linker and coumarin pendant groups as the photochemical cross-linker. Molecular dynamics simulations further confirm the presence of physical interactions between different pendants, including hydrogen bonding and hydrophobic interactions. The combination of the two types of cross-linkers enhances the zero-shear viscosity and hence provides good printability and shape fidelity.

Enhancing cell adhesive and antibacterial activities of glass-fibre-reinforced polyetherketoneketone through Mg and Ag PIII

Glass-fibre-reinforced polyetherketoneketone (PEKK-GF) shows great potential for application as a dental implant restoration material; however, its surface bioinertness and poor antibacterial properties limit its integration with peri-implant soft tissue, which is critical in the long-term success of implant restoration. Herein, functional magnesium (Mg) and silver (Ag) ions were introduced into PEKK-GF by plasma immersion ion implantation (PIII). Surface characterization confirmed that the surface morphology of PEKK-GF was not visibly affected by PIII treatment. Further tests revealed that PIII changed the wettability and electrochemical environment of the PEKK-GF surface and enabled the release of Mg²⁺ and Ag⁺ modulated by Giavanni effect. In vitro experiments showed that Mg/Ag PIII-treated PEKK-GF promoted the proliferation and adhesion of human gingival fibroblasts and upregulated the expression of adhesion-related genes and proteins. In addition, the treated samples inhibited the metabolic viability and adhesion of Streptococcus mutans and Porphyromonas gingivalis on their surfaces, distorting bacterial morphology. Mg/Ag PIII surface treatment improved the soft tissue integration and antibacterial activities of PEKK-GF, which will further support and broaden its adoption in dentistry.

Description of Poly(aryl-ether-ketone) Materials (PAEKs), Polyetheretherketone (PEEK) and Polyetherketoneketone (PEKK) for Application as a Dental Material: A Materials Science Review

Poly(aryl-ether-ketone) materials (PAEKs), a class of high-performance polymers comprised of polyetheretherketone (PEEK) and polyetherketoneketone (PEKK), have attracted interest in standard dental procedures due to their inherent characteristics in terms of mechanical and biological properties. Polyetheretherketone (PEEK) is a restorative dental material widely used for prosthetic frameworks due to its superior physical, mechanical, aesthetic, and handling features. Meanwhile, polyetherketoneketone (PEKK) is a semi-crystalline thermoplastic embraced in the additive manufacturing market. In the present review study, a new way to fabricate high-performance polymers, particularly PEEK and PEKK, is demonstrated using additive manufacturing digital dental technology, or 3-dimensional (3D) printing. The focus in this literature review will encompass an investigation of the chemical, mechanical, and biological properties of HPPs, particularly PEEK and PEKK, along with their application particularly in dentistry. High-performance polymers have gained popularity in denture prosthesis in advance dentistry due to their flexibility in terms of manufacturing and the growing interest in utilizing additive manufacturing in denture fabrication. Further, this review also explores the literature regarding the properties of high-performance polymers (HPP) compared to previous reported polymers in terms of the dental material along with the current advancement of the digital designing and manufacturing.

Surface Modifications of High-Performance Polymer Polyetheretherketone (PEEK) to Improve Its Biological Performance in Dentistry

This comprehensive review focuses on polyetheretherketone (PEEK), a synthetic thermoplastic polymer, for applications in dentistry. As a high-performance polymer, PEEK is intrinsically robust yet biocompatible, making it an ideal substitute for titanium-the current gold standard in dentistry. PEEK, however, is also inert due to its low surface energy and brings challenges when employed in dentistry. Inert PEEK often falls short of achieving a few critical requirements of clinical dental materials, such as adhesiveness, osseoconductivity, antibacterial properties, and resistance to tribocorrosion. This study aims to review these properties and explore the various surface modification strategies that enhance the performance of PEEK. Literatures searches were conducted on Google Scholar, Research Gate, and PubMed databases using PEEK, polyetheretherketone, osseointegration of PEEK, PEEK in dentistry, tribology of PEEK, surface modifications, dental applications, bonding strength, surface topography, adhesive in dentistry, and dental implant as keywords. Literature on the topics of surface modification to increase adhesiveness, tribology, and osseointegration of PEEK were included in the review. The unavailability of full texts was considered when excluding literature. Surface modifications via chemical strategies (such as sulfonation, plasma treatment, UV treatment, surface coating, surface polymerization, etc.) and/or physical approaches (such as sandblasting, laser treatment, accelerated neutral atom beam, layer-by-layer assembly, particle leaching, etc.) discussed in the literature are summarized and compared. Further, approaches such as the incorporation of bioactive materials, e.g., osteogenic agents, antibacterial agents, etc., to enhance the abovementioned desired properties are explored. This review presents surface modification as a critical and essential approach to enhance the biological performance of PEEK in dentistry by retaining its mechanical robustness.

Immunohistochemical analysis of soft tissue response to polyetheretherketone (PEEK) and titanium healing abutments on dental implants: a randomized pilot clinical study

Background

The data on polyetheretherketone (PEEK) influence on the peri-implant soft tissues in clinical settings are deficient. The aims of this pilot study were to analyze and compare soft tissues’ response to PEEK and titanium (Ti) healing abutments (HA) by means of histological and immunohistochemical analyses.

Methods

A total of 22 implants with PEEK or Ti HA were placed in 11 patients, applying the “split-mouth” study design. Three months later, soft tissue specimens were harvested from 20 implants for histology in order to qualitatively detect the inflammatory cells’ presence, to semi-qualitatively analyze the inflammation intensity and to assess the inflammatory responses type by immunohistochemical analysis using LCA, CD3, CD20 and CD68 antibodies.

Results

Epithelial infiltrate followed by an intensive inflammation in sub-epithelium was observed in 100% around PEEK HA. A number of LCA+ and CD 68+ cells was significantly higher in PEEK comparing to Ti group (p = 0.001 and p = 0.020, respectively), while CD 20+ and CD3+ counted cells were found in a significantly higher amount in Ti than in PEEK group (p = 0.006 and p = 0.010, respectively).

Conclusion

PEEK HA seems to evoke the more intense tissue inflammatory response demonstrated predominantly by histocytes’ and plasmacytes’ activation, while Ti HA triggers the inflammatory reaction of lower intensity, dominantly mediated by B-cells.

Trial registration

The study registered at ClinicalTrials.gov (NCT04436939).

Mechanical Properties of Fused Deposition Modeling of Polyetheretherketone (PEEK) and Interest for Dental Restorations: A Systematic Review

The aim of this systematic review was to determine the optimal printing parameters for the producing of fused deposition modeling (FDM) 3D-printed polyetheretherketone (PEEK) elements with mechanical properties suitable for dental restorations. Indeed, the mechanical properties are a critical prerequisite for the study of other parameters, such as physical, aesthetic and biological properties. An exhaustive electronic search was carried out in the PubMed, Embase and Web of knowledge databases to gather all the studies evaluating the influence of the printing parameters on the obtained mechanical properties of FDM 3D-printed PEEK elements were selected. Initially, the search resulted in 614 eligible papers. Independent screenings of the abstracts were performed by two authors to identify the articles related to the question. Twenty-nine studies were selected, of which eleven were further excluded after reading of the full text, and finally, eighteen articles were included in this review. The studies were difficult to compare due to the variability of the printing parameters and the types of PEEK. However, it seems interesting to use a high infill rate, a high chamber temperature close to that of the printing temperature and a heat post-treatment to obtain 3D PEEK elements presenting properties adapted to use as dental restorations. The analysis of the available literature suggested that the properties of PEEK could make it an interesting material in dental restorations to be performed with FDM additive manufacturing.

Low-Temperature Printed Hierarchically Porous Induced-Biomineralization Polyaryletherketone Scaffold for Bone Tissue Engineering

Polyetheretherketone (PEEK) as a popular orthopaedic implant is usually fabricated into a hierarchically porous structure for improving osteogenic activity. However, the applications are limited due to the excessively high processing temperature and uncontrollably tedious modification routes. Here, an amorphous polyaryletherketone with carboxyl groups (PAEK-COOH) is synthesized and fabricated to the hierarchically controllable porous scaffolds via a low-temperature 3D-printing process. The prepared PAEK-COOH scaffolds present controllable porous structures ranging from nano- to micro-scale, and their mechanical strengths are comparable to that of trabecular bone. More importantly, the in vitro experiments show that the nanoporous surface is conducive to promoting cellular adhesion, and carboxyl groups can induce hydroxyapatite mineralization via electrostatic interaction. The in vivo experiments demonstrate that the PAEK-COOH scaffolds offer much better osseointegration without additional active ingredients, compared to that of PEEK. Therefore, this work will not only develop a promising candidate for bone tissue engineering, but provide a viable method to design PAEK biomaterials.

Osteocompatibility of Si3N4-coated carbon fiber-reinforced polyetheretherketone (CFRP) and hydroxyapatite-coated CFRP with antibiotics and antithrombotic drugs

This study used a rabbit model to investigate the osteocompatibility of Si₃N₄-coated carbon fiber-reinforced polyetheretherketone (CFRP) and hydroxyapatite (HA)-coated CFRP with antibiotics (vancomycin [VCM]) and antithrombotic drugs (polyvinylpyrrolidone [PVP]). HA-coated cylindrical CFRP implants were used as the controls (HA), and HA-coated implants treated with VCM and PVP were prepared (HA-VP) as the test groups; a cylindrical CFRP coated with Si₃N₄ was also prepared (SiN). Ten implants from each group were randomly inserted into the femoral diaphysis of rabbits. The pull-out test, radiological analysis using micro-computed tomography (µ-CT), and histological analysis were performed. The pull-out strength of the SiN group was lower than that of the HA group. µ-CT analysis revealed that the amount of bone formation around the implant in the SiN group was inferior to that in the HA group. Conversely, the HA-VP group had equivalent pull-out strength and bone formation as analyzed by µ-CT compared to the HA group. In conclusion, the additional surface treatment of the HA-coated CFRP with VCM and PVP provided sufficient bone fixation and formation.

Nd:YVO4 laser groove treatment can improve the shear bond strength between dental PEEK and adhesive resin cement with an adhesive system

The purpose of this study was to investigate the effect of various surface treatments on the shear bond strength between dental polyetheretherketone (PEEK) and adhesive resin cement. Two hundred and forty specimens were randomly classified into four groups: no treatment, sandblasted, sulfuric-acid-etched, and laser-grooved treatment. Each group was classified into two adhesive resin cement subgroups. Surface roughness, water contact angle, shear bond strength, and failure mode were measured; SEM and XPS results were obtained. The data were statistically analyzed using one-way or two-way analysis of variance and Tukey's honest significant difference test (α=0.05). Laser-grooved PEEK surface showed regular grooves and carbonization by thermal degradation; the surface roughness as well as water contact angle of were the highest in all groups. Shear bond strength values were significantly higher in the laser-groove-treated and sulfuric-acid-etched groups. Laser-groove-treated specimens showed cohesive failure. Laser-grooved treatment can improve shear bond strength between PEEK and adhesive resin cement.

Modification of polyether ether ketone for the repairing of bone defects

Bone damage as a consequence of disease or trauma is a common global occurrence. For bone damage treatment - bone implant materials are necessary across three classifications of surgical intervention (i.e. fixation, repair, and replacement). Many types of bone implant materials have been developed to meet the requirements of bone repair. Among them, polyether ether ketone (PEEK) has been considered as one of the next generation of bone implant materials, owing to its advantages related to good biocompatibility, chemical stability, X-ray permeability, elastic modulus comparable to natural bone, as well as the ease of processing and modification. However, as PEEK is a naturally bioinert material, some modification is needed to improve its integration with adjacent bones after implantation. Therefore, it has become a very hot topic of biomaterials research and various strategies for the modification of PEEK including blending, 3D printing, coating, chemical modification and the introduction of bioactive and/or antibacterial substances have been proposed. In this systematic review, the recent advances in modification of PEEK and its application prospect as bone implants are summarized, and the remaining challenges are also discussed.

PEEK Biomaterial in Long-Term Provisional Implant Restorations: A Review

Polyetheretherketone (PEEK) has become a useful polymeric biomaterial due to its superior properties and has been increasingly used in dentistry, especially in prosthetic dentistry and dental implantology. Promising applications of PEEK in dentistry are dental implants, temporary abutment, implant-supported provisional crowns, fixed prosthesis, removable denture framework, and finger prosthesis. PEEK as a long-term provisional implant restoration has not been studied much. Hence, this review article aims to review PEEK as a long-term provisional implant restoration for applications focusing on implant dentistry. Articles published in English on PEEK biomaterial for long-term provisional implant restoration were searched in Google Scholar, ScienceDirect, PubMed/MEDLINE, and Scopus. Then, relevant articles were selected and included in this literature review. PEEK presents suitable properties for various implant components in implant dentistry, including temporary and long-term provisional restorations. The modifications of PEEK result in wider applications in clinical dentistry. The PEEK reinforced by 30-50% carbon fibers can be a suitable material for the various implant components in dentistry.

Antibacterial activity, bio-compatibility and osteogenic differentiation of graphene oxide coating on 3D-network poly-ether-ether-ketone for orthopaedic implants

Poly-ether-ether-ketone (PEEK) has attracted increasing attention as a promising orthopaedic implant material owing to its excellent mechanical properties and biocompatibility. However, its antibacterial properties must be improved as an implant material. In this study, PEEK was sulfonated to obtain a porous surface, and graphene oxide (GO) was deposited to form a coating with antibacterial activity and biocompatibility. After PEEK was sulfonated for different durations, GO was deposited on the surface to prepare the coating (SPEEK-GO), which was then characterised using scanning electron microscopy (SEM), Raman spectroscopy, and contact angle measurements. The in vitro study included antimicrobial and cellular tests. The results showed that the PEEK sulfonated using a 10-min treatment exhibited a uniform porous structure and provided a better basal surface for the deposition of GO. The SPEEK-GO coating displayed strong antibacterial activity against two common dental pathogens. It exhibited good adhesion and proliferation of MC3T3-E1. Moreover, it showed osteogenic differentiation as bone implant material.

Programmed surface on poly(aryl-ether-ether-ketone) initiating immune mediation and fulfilling bone regeneration sequentially

The immune responses are involved in every stage after implantation but the reported immune-regulated materials only work at the beginning without fully considering the different phases of bone healing. Here, poly(aryl-ether-ether-ketone) (PEEK) is coated with a programmed surface, which rapidly releases interleukin-10 (IL-10) in the first week and slowly delivers dexamethasone (DEX) up to 4 weeks. Owing to the synergistic effects of IL-10 and DEX, an aptly weak inflammation is triggered within the first week, followed by significant M2 polarization of macrophages and upregulation of the autophagy-related factors. The suitable immunomodulatory activities pave the way for osteogenesis and the steady release of DEX facilitates bone regeneration thereafter. The sequential immune-mediated process is also validated by an 8-week implementation on a rat model. This is the first attempt to construct implants by taking advantage of both immune-mediated modulation and sequential regulation spanning all bone regeneration phases, which provides insights into the fabrication of advanced biomaterials for tissue engineering and immunological therapeutics.

•

A programed surface is designed and fabricated for immune-mediated osteogenesis

•

The degradation of PTMC coating enables a sequential release of IL-10 and DEX

•

Initially, osteoimmunomodulation is achieved by IL-10 and a small amount of DEX

•

Afterwards, sustained release of DEX fosters the peri-implant bone regeneration

The Impact of Instrumentation and Implant Surface Technology on Cervical and Thoracolumbar Fusion

Spinal fusion has undergone significant evolution and improvement over the past 50 yr. Historically, spine fusion was noninstrumented and arthrodesis was based entirely on autograft. Improved understanding of spinal anatomy and materials science ushered in a new era of spinal fusion equipped with screw-based technologies and various interbody devices. Osteobiologics is another important realm of spine fusion, and the evolution of various osteobiologics has perhaps undergone the most change within the past 20 yr. A new element to spinal instrumentation has recently gained traction-namely, surface technology. New data suggest that surface treatments play an increasingly well-recognized role in inducing osteogenesis and successful fusion. Until now, however, there has yet to be a unified resource summarizing the existing data and a lack of consensus exists on superior technology. Here, authors provide an in-depth review on surface technology and its impact on spinal arthrodesis.

One-step mild preparation of tough and thermo-reversible poly(vinyl alcohol) hydrogels induced by small molecules

To overcome shortcomings of the traditional freeze-thaw method for PVA hydrogel preparation, we develop a one-step mild method, which induces PVA crystallization to form hydrogels through small molecules containing hydroxyl and carboxyl groups. The obtained hydrogels showed high mechanical properties, untypical plasticity with short gelation time and repeatable sol-gel transformation.

Bioactivity of PEEK GRF30 and Ti6Al4V SLM in Simulated Body Fluid and Hank's Balanced Salt Solution

In recent years, scientists have defined two main paths for orthopedic implant fabrication: searching for new materials with properties closest to natural bone in order to reduce the stress-shielding effect or creating individually adapted geometry of the implant with the use and Rapid Prototyping methods. Therefore, materials such as PEEK GRF30 and Ti6Al4V selective laser melting (SLM) are of interest. They are defined as materials suitable for implants, however, the knowledge of their bioactivity, a feature which is one of the most desirable properties of biomaterials, is still insufficient. Using Simulated Body Fluid and Hank's Balanced Salt Solution, the bioactivity of PEEK GRF30 and Ti6Al4V SLM was assessed, as well as commercial Ti6Al4V as a reference material. Ten cylindrical samples of each material were prepared and immersed in solutions per period from 2 to 28 days at 37 °C. Optical analysis of the changes on the examined surfaces suggested that right after 2-day crystals with different morphologies were formed on each material. Further analysis of the chemical composition of the altered surfaces confirmed the formation of a calcium phosphate layer on them, however, the Ca/P ratio was slightly different from 1.67. On the basis of the obtained results, it can be concluded that both PEEK GRF30 and Ti6Al4V SLM are characterized by appropriate-comparable to Ti6Al4V-bioactivity.

The Impact of Dental Implant Surface Modifications on Osseointegration and Biofilm Formation

Implant surface design has evolved to meet oral rehabilitation challenges in both healthy and compromised bone. For example, to conquer the most common dental implant-related complications, peri-implantitis, and subsequent implant loss, implant surfaces have been modified to introduce desired properties to a dental implant and thus increase the implant success rate and expand their indications. Until now, a diversity of implant surface modifications, including different physical, chemical, and biological techniques, have been applied to a broad range of materials, such as titanium, zirconia, and polyether ether ketone, to achieve these goals. Ideal modifications enhance the interaction between the implant's surface and its surrounding bone which will facilitate osseointegration while minimizing the bacterial colonization to reduce the risk of biofilm formation. This review article aims to comprehensively discuss currently available implant surface modifications commonly used in implantology in terms of their impact on osseointegration and biofilm formation, which is critical for clinicians to choose the most suitable materials to improve the success and survival of implantation.

Review on Development and Dental Applications of Polyetheretherketone-Based Biomaterials and Restorations

Polyetheretherketone (PEEK) is an important high-performance thermoplastic. Its excellent strength, stiffness, toughness, fatigue resistance, biocompatibility, chemical stability and radiolucency have made PEEK attractive in dental and orthopedic applications. However, PEEK has an inherently hydrophobic and chemically inert surface, which has restricted its widespread use in clinical applications, especially in bonding with dental resin composites. Cutting edge research on novel methods to improve PEEK applications in dentistry, including oral implant, prosthodontics and orthodontics, is reviewed in this article. In addition, this article also discusses innovative surface modifications of PEEK, which are a focus area of active investigations. Furthermore, this article also discusses the necessary future studies and clinical trials for the use of PEEK in the human oral environment to investigate its feasibility and long-term performance.

Bioinspired Modifications of PEEK Implants for Bone Tissue Engineering

In recent years, polyetheretherketone (PEEK) has been increasingly employed as an implant material in clinical applications. Although PEEK is biocompatible, chemically stable, and radiolucent and has an elastic modulus similar to that of natural bone, it suffers from poor integration with surrounding bone tissue after implantation. To improve the bioactivity of PEEK, numerous strategies for functionalizing the PEEK surface and changing the PEEK structure have been proposed. Inspired by the components, structure, and function of bone tissue, this review discusses strategies to enhance the biocompatibility of PEEK implants and provides direction for fabricating multifunctional implants in the future.

Modern Porous Polymer Implants: Synthesis, Properties, and Application

Abstract

The needs of modern surgery triggered the intensive development of transplantology, medical materials science, and tissue engineering. These directions require the use of innovative materials, among which porous polymers occupy one of the leading positions. The use of natural and synthetic polymers makes it possible to adjust the structure and combination of properties of a material to its particular application. This review generalizes and systematizes the results of recent studies describing requirements imposed on the structure and properties of synthetic (or artificial) porous polymer materials and implants on their basis and the advantages and limitations of synthesis methods. The most extensively employed, promising initial materials are considered, and the possible areas of application of polymer implants based on these materials are highlighted.

Evaluation of the Bioactivity of Surface Modified Polyetheretherketone (PEEK) as an Implant Material: An In Vitro Study

Purpose

The purpose of this study was to evaluate the bioactivity of polyetheretherketone (PEEK) used as an implant material after surface modification by electron beam deposition of titanium.

Materials and Methods

Twenty-two samples of PEEK were obtained from a single manufacturer, water jet sectioned, and divided randomly into two groups of eleven each (Group I and Group II). Eleven PEEK samples from Group II were coated with Grade II commercially pure titanium by electron beam deposition technique. One representative sample from each group was evaluated for surface roughness, topography and composition using three dimensional surface profilometer, scanning electron microscope coupled with energy dispersive X-ray (SEM-EDX) analysis. Simulated body fluid (SBF) was prepared and calcium (Ca) content in it was quantitatively analyzed by inductively coupled plasma mass spectrometry (ICP-MS) technique. Ten samples from each group were then immersed in SBF for a period of 21 days and amount of calcium depletion was analyzed to determine the bioactivity of two groups. Surface characteristics and elemental composition of immersed samples were analyzed by SEM-EDX and correlated with results of ICP-MS tests. The data obtained were then subjected to statistical analysis using independent t-test.

Results

Group II samples showed a significant increase in surface roughness compared to Group I (P < 0.02). There were significant differences in Ca depletion of Group I and Group II samples when compared to preimmersion Ca content (P < 0.001). When compared between two Groups, Group II samples showed higher Ca depletion (P < 0.001).

Conclusion

Within the limitations of this study, it was concluded that PEEK dental implants which were surface modified by electron beam deposition of titanium had enhanced bioactivity when compared to unmodified PEEK. Hence, they can serve as a valuable alternative to conventional dental implant materials.

Rapid construction of polyetheretherketone (PEEK) biological implants incorporated with brushite (CaHPO4·2H2O) and antibiotics for anti-infection and enhanced osseointegration

Polyetheretherketone (PEEK) is an ideal implant material for orthopedic and dental application due to its high biocompatibility and mechanical property. However, biological inertness of PEEK hinders the effective clinical applications in treating bone defect, especially in the situation accompanied by bacterial infection. In this study, a layer-by-layer (LBL) deposition method with controlled cycles was developed to rapidly construct brushite (CaHPO₄·2H₂O) (CaP) layers containing gentamicin sulfate (GS) on PEEK to obtain CaP-and-GS modified PEEK, named as PEEK/CaP-GS. Different PEEK/CaP-GS, like PEEK/CaP-GS*3, PEEK/CaP-GS*6 and PEEK/CaP-GS*9 were conveniently prepared by repeating the LBL cycles to 3, 6 and 9 times, respectively. The morphology, structure and surface property of the fabricated PEEK/CaP-GS were carefully characterized. In vitro antibacterial experiments illustrated that all of the PEEK/CaP-GS samples had excellent and sustained antibacterial property. Cell proliferation experiments revealed the acceptable biocompatibility and cell osteogenic differentiation of PEEK/CaP-GS, especially in PEEK/CaP-GS*6. X-ray, μ-CT, and histological analysis showed that PEEK/CaP-GS exhibited in vivo antibacterial activity and osseointegration ability in the treatment of bone defect with infection. In both the in vitro and the in vivo experiments, PEEK/CaP-GS*6 prepared from the 6 LBL cycles exhibited the best antibacterial and osseointegration ability for bone healing. This work opens new avenue of the facile and effective modification of PEEK with special biological functions for clinical application, especially for the implants requiring excellent antibacterial and osseointegration ability.

In vitro study of surface alterations to polyetheretherketone and titanium and their effect upon human gingival fibroblasts

STATEMENT OF PROBLEM

Soft-tissue attachment to different surfaces may play a pivotal role in the long-term success of dental implants. However, studies on the issue, especially on newer materials, are sparse.

PURPOSE

The purpose of this in vitro study was to evaluate the viability and adhesion of human gingival fibroblasts (HGFs) on different implant abutment materials with specific surface modifications.

MATERIAL AND METHODS

One hundred and fifty specimens in 6 experimental groups were evaluated: smooth-machined titanium alloy (Ti), laser-modified titanium (TiL), smooth-machined polyetheretherketone (PEEK) (P), laser-modified PEEK (PL), plasma-treated PEEK (PP), laser- and plasma-treated PEEK (PLP). Machined Ti was considered as the control group. Surface roughness (S_a), water contact angle (WCA), and X-ray photoelectron spectroscopy (XPS) were measured. HGF attachment and proliferation were observed at 1, 3, and 7 days after cell seeding. Comparison of the means among the groups was performed with 1-way analysis of variance (ANOVA) with post hoc comparison using the Tukey test (α=.05).

RESULTS

S_a values of the laser modified groups were significantly higher than those of the nonmodified (smooth-machined) groups (P<.001). WCAs were significantly different among PEEK groups, and plasma-sprayed groups had the lowest WCAs. XPS analysis of both Ti and PEEK groups showed laser treatment did not have any significant effect on the surface composition of the PEEK as the same bonds with similar ratio/fraction were detected in the spectrum of the modified specimens. Scanning electron microscopy (SEM) revealed more functionally oriented HGF cells on the laser-grooved surfaces. On the first, third, and seventh day of proliferation, the titanium groups showed no significant differences (P>.05). On the first and third days of proliferation, the plasma sprayed groups (PP, PLP) showed significantly greater proliferation than all experimental groups (P<.001). On the seventh day of proliferation, statistically significant differences were observed between all PEEK groups and between all PEEK groups and the Ti group (P<.001), with the exception of the PL and P groups and the PLP and Ti groups (P>.05).

CONCLUSIONS

Laser-modified titanium and PEEK surfaces led to guided gingival fibroblast attachment. Plasma treatment of PEEK surfaces increased the wettability of this polymer and improved proliferation of HGF.

Osteogenesis regulation of mesenchymal stem cells via autophagy induced by silica–titanium composite surfaces with different mechanical moduli

The high surface elastic modulus of the titanium (Ti) implant is one of the critical factors causing poor osteointegration between the implant surface and surrounding bone tissue.

Surface sulfonation and nitrification enhance the biological activity and osteogenesis of polyetheretherketone by forming an irregular nano-porous monolayer

Polyether-ether-ketone (PEEK) is becoming a popular component of clinical spinal and orthopedic applications, but its practical use suffers from several limitations. In this study, irregular nano-porous monolayer with differently functional groups was formed on the surface of PEEK through sulfonation and nitrification. The surface characteristics were detected by field-emission scanning electron microscopy, atomic force microscopy, energy-dispersive X-ray spectrometry, water contact angle measurements and Fourier transform infrared spectroscopy. In vitro cellular behaviors were evaluated by cell adhesion, morphological changes, proliferation, alkalinity, phosphatase activity, real-time RT-PCR and western blot analyses. In vivo osseointegration was examined through micro-CT and histological assessments. Our results reveal that the irregular nano-porous of PEEK affect the biological properties. High-temperature hydrothermal NP treatment induced early osteogenic differentiation and early osteogenesis. Modification by sulfonation and nitrification can broaden the use of PEEK in orthopedic and dental applications. This study provides a theoretical basis for the wider clinical application of PEEK. a To obtain a uniform porous structure, PEEK samples were treated by concentrated sulfuric acid and fuming nitric acid (82-80%) with magnetic stirring sequentially. b Effects of nanopores on biological behavior of bMSCS.

Biomimetic polyetheretherketone microcarriers with specific surface topography and self-secreted extracellular matrix for large-scale cell expansion

Reusable microcarriers with appropriate surface topography, mechanical properties, as well as biological modification through decellularization facilitating repeated cell culture are crucial for tissue engineering applications. Herein, we report the preparation of topological polyetheretherketone (PEEK) microcarriers via gas-driven and solvent exchange method followed by hydrothermal treatment at high temperature and pressure. After hydrothermal treated for 8 h, the resulting topological PEEK microcarriers exhibit walnut-like surface topography and good sphericity as well as uniform size distribution of 350.24 ± 19.44 µm. And the average width between ravine-patterned surface of PEEK microcarriers is 780 ± 290 nm. After repeated steam sterilization by autoclaving for three times, topological PEEK microcarriers show nearly identical results compared with previous ones indicating strong tolerance to high temperature and pressure. This is a unique advantage for large-scale cell expansion and clinical applications. Moreover, PEEK microcarriers with special topography possess higher protein adsorption efficiency. In addition, the reutilization and biofunctionalization with repeated decellularization of topological PEEK microcarriers show highly beneficial for cell adhesion and proliferation. Therefore, our study is of great importance for new generation microcarriers with micro-and nano-scale surface feature for a broad application prospect in tissue engineering.

Clinical outcomes after carbon-plate osteosynthesis in patients with distal radius fractures

Background

Surgical implant material has changed over time, from metal to stainless steel to titanium. In recent decades a new material, carbon-fibre-reinforced polyether ether ketone, has been introduced. The aim of this study was to assess the clinical and radiological feasibility and functional outcome after treatment of distal radius fractures with this new implant.

Methods

Inclusion criteria: AO type B distal radius fractures treated with 2.7 mm CF/PEEK plates at one Level 1 trauma centre between 2016 and 2017. Follow-up period 1 year, measurement of range of motion and radiographic assessment, histological analysis of debris only after plate removal.

Results

Out of 112 eligible patients, 10 (8.9%) patients were included. Mean operation time was 65 ± 10 min. Radiographic healing was confirmed by radiologists at 6 weeks follow-up. During one-year follow-up, no adverse events were reported and functionality and patients subjective satisfaction improved significantly (p < 0.05). Only one plate was removed, with no histological signs of inflammation or allergic reaction.

Conclusions

The 2.7 mm CF/PEEK plate osteosynthesis appears to be a reliable and safe implant for certain types of distal radius fracture. Assessment of fracture union is substantially more practical and functionality improved significantly over 1 year.

First Clinical Experience with a Carbon Fibre Reinforced PEEK Composite Plating System for Anterior Cervical Discectomy and Fusion

Carbon fibre reinforced polyether ether ketone (CFR-PEEK) is a suitable material to replace metal implants in orthopaedic surgery. The radiolucency of CFR-PEEK allows an optimal visualisation of the bone and soft tissue structures. We aimed to assess the performance and radiological and clinical outcomes of anterior cervical discectomy and fusion (ACDF) with CFR-PEEK anterior cervical plating (ACP) under first use clinical conditions. We retrospectively studied the prospectively-collected data of 42 patients who underwent ACDF with CFR-PEEK ACP between 2011 and 2016. We assessed clinical outcome (Odom's criteria, complications) and radiological parameters (global and segmental cervical lordosis, Bridwell score for fusion, adjacent segment degeneration) preoperatively, immediately post-operatively, and after a 12-month follow-up period. Patients' satisfaction was excellent, good, fair, and poor in 12, 19, 3, and 1 patients, respectively. Two patients developed dysphagia. No hardware failure occurred. Compared with preoperative radiographs, we observed a gain of global cervical lordosis and segmental lordosis (7.4 ± 10.1 and 5.6 ± 7.1 degrees, respectively) at the 12-month follow-up. Bridwell IF grades I, II, and III were observed in 22, 6, and 7 patients, respectively. The 12-month adjacent segment degeneration-free and adjacent segment disease-free survival rates were 93.1% and 96.3%, respectively. We observed a dysphagia rate of 5.7% and a reoperation rate of 4.8%. In conclusion, CFR-PEEK ACP shows positive outcomes in terms of implant safety, restoration of cervical lordosis, and functional recovery, and is suitable for ACDF.

Highly Effective Bone Fusion Induced by the Interbody Cage Made of Calcium Silicate/Polyetheretherketone in a Goat Model

Interbody fusion surgery is often used to settle matters such as degenerative disc disease or disc herniation in clinical orthopedics. Considering the deficiencies of the current treatment methods, we developed an interbody fusion cage made of calcium silicate (CS)/polyetheretherketone (PEEK) and hoped that the bioactive cage could exhibit great fusion ability and maintain stable mechanical function. In the goat model of cervical interbody fusion, the CS/PEEK cage showed stronger interbody fusion at 12 and 26 weeks compared with pure PEEK cage based on the X-ray analysis. The micro-CT scanning and analysis indicated that the CS/PEEK cage induced more new bone ingrowth than the PEEK cage and led to nearly complete interbody fusion at 26 weeks. Moreover, the CS/PEEK group showed excellent mechanical stability and stiffness as evaluated by the spine kinematic assay at the time points. The histological assessment showed the rapid osseointegration and mineralized bone formation around the CS/PEEK cage. This study confirmed that the bioactive CS/PEEK cage is capable of inducing highly effective bone fusion and has high potential to be used in the clinics of spine surgery.

Tuning the tribofilm nanostructures of polymer-on-metal joint replacements for simultaneously enhancing anti-wear performance and corrosion resistance

Total joint replacement is currently the most successful clinical treatment for improving the life quality of individuals afflicted with end-stage osteoarthritis of knee or hip joints. However, release of wear and corrosion products from the prostheses is a critical issue causing adverse physiological responses of local issues. β-SiC nanoparticles were dispersed into polyetheretherketone (PEEK) materials and their role in tribocorrosion performance of PEEK-steel joints exposed to simulated body fluid was investigated. It is demonstrated that β-SiC nanoparticles increase greatly the wear resistance of the PEEK materials, and meanwhile mitigate significantly corrosion of the steel counterpart. It is revealed that tribochemical reactions of β-SiC nanoparticles promoted formation of a robust tribofilm having complex structures providing protection and shielding effects. The present work proposes a strategy for developing high-performance polymer-on-metal joint replacement materials of enhanced lifespan and biocompatibility via tuning interface nanostructures. STATEMENT OF SIGNIFICANCE: Adverse tissue responses to metal wear and corrosion products from metal base implants remain a challenge to surgeons and patients. We demonstrated that leaching of metal ions and release of metallic debris are well decreased via tuning interface nanostructures of metal-polymer joint bearings by dispersing β-SiC nanoparticles into polyetheretherketone (PEEK). It is identified that the addition of β-SiC greatly improves the tribological performances of the PEEK materials and mitigated corrosion of the steel. Tribo-chemistry reactions of SiC induce the formation of complex structures which provide protection and shielding effects. Nanostructures of the tribofilm were also comprehensively investigated. These novel findings proposed a potential route for designing high performance metal-polymer joint replacement materials.

Multifunctional sulfonated polyetheretherketone coating with beta-defensin-14 for yielding durable and broad-spectrum antibacterial activity and osseointegration

To address periprosthetic joint infection (PJI), a formidable complication after joint arthroplasty, an implant with excellent osseointegration and effective antibacterial activity has being extensively pursued and developed. In this work, the mouse beta-defensin-14 (MBD-14) was immobilized on the polyetheretherketone (PEEK) surface with three-dimensional (3D) porous structure to improve its antibacterial activity and osseointegration. An in vitro antibacterial evaluation showed that the porous PEEK loaded with MBD-14 wages a durable and effective fight against both Staphylococcus aureus (gram-positive) and Pseudomonas aeruginosa (gram-negative). In addition to the superior antibacterial activity, we found that the enhanced proliferation and osteogenic differentiation of bone mesenchymal stem cells were verified through various in vitro analyses. To evaluate the in vivo bactericidal effect and osseointegration of the samples, the rat femoral models with infection and non-infection were established. The enhanced osseointegration of the MBD-14-loaded samples was found in both two in vivo models. And no bacteria survived on the surfaces of samples with a relatively high MBD-14 concentration. Above results indicate that the 3D porous PEEK coating loaded with MBD-14 simultaneously yields excellent osseointegration while exerting durable and broad-spectrum antibacterial activity. And it paves the way for PEEK to be applied clinically to address PJI. STATEMENT OF SIGNIFICANCE: (1). By using the physio-chemical technique including sulfonation and lyophilization etc., a three-dimensional porous network is developed on polyetheretherketone (PEEK) surface, in which mouse beta-defensin-14 (MBD-14, a broad-spectrum antimicrobial peptide) is then loaded. It endows PEEK with antibacterial activity and osseointegration. (2). Two in vivo animal models with infection and non-infection are used to prove the new bone formation around the samples. (3). Supplementary material also proves that MBD-14 promotes the osteogenic differentiation of BMSCs. However, its potential mechanism needs to be further studied in future. (4). The modified PEEK, including excellent osseointegration and a durable and broad-spectrum antibacterial activity, could be applied clinically to address PJI which is a hot potato for surgeons and patients undergoing total joint arthroplasty.

Evaluating the bioactivity of a hydroxyapatite-incorporated polyetheretherketone biocomposite

Background

Polyetheretherketone (PEEK) exhibits stable chemical properties, excellent biocompatibility, and rational mechanical properties that are similar to those of human cortical bone, but the lack of bioactivity impedes its clinical application.

Methods

In this study, hydroxyapatite (HA) was incorporated into PEEK to fabricate HA/PEEK biocomposite using a compounding and injection-molding technique. The tensile properties of the prepared HA/PEEK composites (HA content from 0 to 40 wt%) were tested to choose an optimal HA content. To evaluate the bioactivity of the composite, the cell attachment, proliferation, spreading and alkaline phosphatase (ALP) activity of MC3T3-E1 cells, and apatite formation after immersion in simulated body fluid (SBF), and osseointegration in a rabbit cranial defect model were investigated. The results were compared to those from ultra-high molecular weight polyethylene (UHMWPE) and pure PEEK.

Results

By evaluating the tensile properties and elastic moduli of PEEK composite samples/PEEK composites with different HA contents, the 30 wt% HA/PEEK composite was chosen for use in the subsequent tests. The results of the cell tests demonstrated that PEEK composite samples/PEEK composite exhibited better cell attachment, proliferation, spreading, and higher ALP activity than those of UHMWPE and pure PEEK. Apatite islands formed on the HA/PEEK composite after immersion in SBF for 7 days and grew continuously with longer time periods. Animal tests indicated that bone contact and new bone formation around the HA/PEEK composite were more obvious than those around UHMWPE and pure PEEK.

Conclusions

The HA/PEEK biocomposite created by a compounding and injection-molding technique exhibited enhanced osteogenesis and could be used as a candidate of orthopedic implants.

A Multimaterial Scaffold With Tunable Properties: Toward Bone Tissue Repair

Polyetheretherketone (PEEK)/β-tricalcium phosphate (β-TCP) scaffolds are expected to be able to combine the excellent mechanical strength of PEEK and the good bioactivity and biodegradability of β-TCP. While PEEK acts as a closed membrane in which β-TCP is completely wrapped after the melting/solidifying processing, the PEEK membrane degrades very little, hence the scaffolds cannot display bioactivity and biodegradability. The strategy reported here is to blend a biodegradable polymer with PEEK and β-TCP to fabricate multi-material scaffolds via selective laser sintering (SLS). The biodegradable polymer first degrades and leaves caverns on the closed membrane, and then the wrapped β-TCP is exposed to body fluid. In this study, poly(l-lactide) (PLLA) is adopted as the biodegradable polymer. The results show that large numbers of caverns form on the membrane with the degradation of PLLA, enabling direct contact between β-TCP and body fluid, and allowing for their ion-exchange. As a consequence, the scaffolds display the bioactivity, biodegradability and cytocompatibility. Moreover, bone defect repair studies reveal that new bone tissues grow from the margin towards the center of the scaffolds from the histological analysis. The bone defect region is completely connected to the host bone end after 8 weeks of implantation.

The Utility of Polyether-Ether-Ketone Implants Adjacent to Sinus Cavities After Craniofacial Trauma

PURPOSE

Polyether-ether-ketone (PEEK) implants have become increasingly popular for use in reconstructive procedures. It is imperative to understand the consequences of using this biomaterial in anatomic sites that can pose a risk of infection. Specifically, the use of PEEK in paranasal sinus cavity reconstruction is not well documented. This study examined postoperative complications, namely surgical site infection and implant loss, in patients who underwent paranasal sinus cavity reconstruction using PEEK implants.

MATERIALS AND METHODS

This study is a single-center case series. Patients who underwent craniomaxillofacial reconstruction with a custom-made PEEK implant in intimate contact with a functional paranasal sinus from June 2013 to May 2017 were included. Baseline characteristics and preoperative and postoperative variables were collected by retrospective chart review.

RESULTS

Eight patients were included in this study. Average patient age was 45.75 ± 19.36 years. Average follow-up duration was 300 ± 263 days. Mean operative time for PEEK implantation was 214.13 ± 66.03 minutes. Implant size ranged from 5 to nearly 100 cm². No patients were diagnosed with acute or chronic sinusitis postoperatively. One patient underwent explantation of his PEEK implant secondary to breakdown of overlying skin that separated from the site of the frontal sinus because of coagulase-negative Staphylococcus epidermis infection.

CONCLUSIONS

Literature review indicates that this is the largest case series reported to date documenting the use of PEEK implants in reconstruction of the region of the paranasal sinuses. Specific biologic, or alloplastic, barriers outside the formation of native scar tissue or regional fasciocutaneous tissues at the sites of reconstruction were not used in these reconstructions, although consideration for placement of these barriers can be at the discretion of the operative surgeon. The authors conclude that PEEK implants can be used in complex craniomaxillofacial reconstructive procedures to achieve near anatomic reconstruction not easily attainable through conventional means. Defects that involve the paranasal sinus cavities with a functional ostium or obliterated sinus cavity can be reconstructed with PEEK implants without increasing the risk of infection and need for explantation. Long-term follow-up and continued outcome results of this treatment modality will be necessary to verify its clinical usefulness in the future.

Platelet activation and erythrocyte lysis during brief exposure of blood to pathophysiological shear stress in vitro

BACKGROUND

Interaction of von Willebrand factor (VWF) with circulating platelets is the trigger for thrombosis in a region of arterial stenosis. These events are typically studied in vitro under conditions where platelets adhere to a VWF-coated surface. Our approach assesses platelet responses in the absence of adhesion.

OBJECTIVE

To characterize extent of platelet activation and erythrocyte lysis in an artificial stenosis model.

METHODS

Whole blood is perfused through a length of polyetheretherketone tubing that includes an artificial stenosis, comprising narrow-bore (89-381 μm) tubing. Secretion of [14C] serotonin and hemoglobin release was measured to evaluate platelet activation and hemolysis respectively at various perfusion rates and different stenosis dimensions.

RESULTS

Platelet activation and erythrocyte lysis increased progressively with increasing perfusion rate and decreasing stenosis diameter; the length of the stenosis had negligible influence. Modest platelet activation (5-10% secretion of [14C] serotonin) occurred without significant erythrocyte lysis under a limited range of perfusion conditions (4-6 mL/min flow through a 127 μm stenosis).

CONCLUSIONS

Our experimental approach mimics conditions in severe arterial stenosis or a mechanical heart valve. It could be a valuable aid in the development of novel drugs to treat arterial thrombosis and in the design of heart valves.