The challenge of volumetric augmentation: Titanium vs PEEK

Implant success relies on sufficient residual bone volume, a constant challenge in the face of horizontal maxillary resorptions. While guided bone regeneration (GBR) with non-absorbable materials is a proven technique, traditional titanium meshes present known clinical limitations, notably the need for intraoperative manual adjustments and an increased risk of soft tissue complications. In response, custom PEEK (polyetheretherketone) meshes machined by CAD/CAM offer a promising alternative thanks to their precision of fit, although their influence on vascularization and graft stability needs to be quantified.

This randomized clinical study was conducted on 14 patients (28 sites) to compare two distinct ridge augmentation protocols. The primary objective was to evaluate the horizontal bone gain achieved by a custom-made PEEK mesh (combined with a 70:30 mixture of autogenous bone and xenograft) versus a preformed titanium mesh (60:40 mixture). The authors tested the hypothesis of the clinical efficacy of these devices through a 3D volumetric analysis by CBCT, measuring vertical bone gain, total regenerated volume, and the graft resorption rate after 6 months of healing.

Methodology: a comparative randomized clinical trial

This randomized clinical trial, registered under identifier NCT07040124, included 14 patients with a total of 28 maxillary bone deficiency sites, primarily horizontal with minor vertical components. The objective was to compare two guided bone regeneration (GBR) protocols using distinct grafting materials and compositions.

The sites were divided into two experimental groups:

• Control Group (n = 7): use of a pre-bent titanium mesh, combined with a graft mixture composed of 60% autogenous bone and 40% xenograft.
• Study Group (n = 7): use of a custom-made, CAD/CAM milled PEEK (polyetheretherketone) mesh, combined with a mixture of 70% autogenous bone and 30% xenograft.

The analysis protocol was based on a three-dimensional volumetric evaluation using CBCT imaging performed at three key time points: preoperatively, immediately after surgery, and at 6 months of follow-up (before implant placement). The primary endpoint was horizontal bone gain, while secondary endpoints included vertical gain, total bone volume gained, and the graft resorption rate.

Comparative analysis of bone gains: linear vs volumetric

The results of this randomized study show that both protocols allow for effective maxillary ridge augmentation. On a linear level (primary endpoint), no statistically significant difference was noted between the titanium group and the PEEK group, for both horizontal and vertical gain.

Focus on volumetry and resorption

Three-dimensional CBCT analysis reveals important nuances regarding secondary criteria:

• Bone volume: The PEEK group showed a significantly higher volume gain (499.47 mm³ versus 370.82 mm³ for titanium; p = 0.004). However, the authors point out that this group benefited from a graft mixture richer in autogenous bone (70:30 versus 60:40 for the titanium group).
• Graft resorption: Bone loss volume was also higher in the PEEK group (174.83 mm³ vs. 127.73 mm³; p = 0.040), which could be correlated with the higher proportion of autogenous bone, naturally more prone to remodeling.

Clinical observations and complications

Qualitatively, CBCT imaging confirmed the stability of the reconstructions at 6 months. Regarding clinical safety, complications were considered minimal in both groups. Cases of mesh exposure, although present, were successfully managed without compromising the final augmentation result. For the practitioner, these data suggest that the choice between preformed titanium and custom-made PEEK relies more on surgical ergonomics and cost than on a difference in intrinsic biological performance.

Clinical analysis: functional equivalence despite volumetric disparities

The results of this randomized clinical trial confirm that both customized PEEK and preformed titanium allow for effective horizontal and vertical bone reconstruction. On a linear level, no statistically significant difference was observed: horizontal gain reached 3.02 ± 0.68 mm for titanium versus 2.42 ± 0.38 mm for PEEK (p = 0.065). This proximity suggests that the choice of mesh material alone does not dictate the clinical success of ridge gain.

However, CBCT volumetric analysis reveals an interesting dynamic. The PEEK group generated a higher bone volume (499.47 mm³ vs 370.82 mm³), but also underwent greater graft resorption (174.83 mm³ vs 127.73 mm³). This divergence is likely explained by the differentiated grafting protocol: the PEEK group used an autogenous bone/xenograft ratio of 70:30, compared to 60:40 for the titanium group. The higher the autogenous contribution, the greater the initial volume, but the more marked the early resorption.

The limitations of this study lie primarily in the small sample size (14 patients) and the nesting of variables (grid material and graft composition). This makes it difficult to isolate the pure benefit of PEEK compared to the bone mixture used. Nevertheless, the study validates PEEK as a serious alternative, as its biocompatibility and low tissue irritation allowed for minimal and effective management of complications (grid exposures).

Summary of results

This study demonstrates the clinical equivalence between preformed titanium meshes and CAD/CAM PEEK meshes for horizontal augmentation (gains of ~2.4 to 3 mm). While the PEEK protocol, combined with 70% autogenous bone, maximizes the bone volume gained (499.47 mm³ versus 370.82 mm³ for titanium), it also induces significantly higher volumetric resorption (174.83 mm³, p=0.040).

In concrete terms, for the practitioner:

• Surgical ergonomics: The use of CAD/CAM PEEK eliminates tedious manual adjustment steps and offers radiolucency facilitating postoperative control.
• Graft material management: A high ratio of autogenous bone (70%) boosts the initial regeneration volume, but requires anticipating greater resorption (~35% of the grafted volume) compared to a 60/40 mix.
• Clinical reliability: Both protocols guarantee horizontal and vertical bone gains (~1.1 mm) sufficient for secure implant placement, with minimal and comparable complication rates.

Technical lexicon of the study

PEEK (Poly-ether-ether-ketone): High-performance thermoplastic polymer used here for the manufacturing of GBR meshes by CAD/CAM. Its properties include favorable mechanical rigidity, total radiolucency, and low soft tissue irritation.

Prebent titanium mesh: Non-absorbable rigid device used as a reference (control group) for space maintenance. Unlike customized PEEK, it requires intraoperative adaptation to match the anatomy of the site.

CAD/CAM: Computer-aided design and manufacturing technology (milling) used in this study to produce custom-made PEEK grids, aiming to improve surgical precision and clinical handling.

CBCT volumetric analysis: Three-dimensional evaluation allowing for the precise quantification of bone gain and graft volume loss in cubic millimetres (mm³), beyond simple horizontal or vertical linear measurements.

Composite graft (Autograft/Xenograft): Mixture of autogenous bone and bone substitute used in the study according to two distinct ratios: 60:40 for the titanium group and 70:30 for the PEEK group, potentially influencing the regeneration results.

Graft resorption: Loss of volume of the filling material observed between the immediate postoperative period and the 6-month follow-up, measured here significantly in the PEEK group (174.83 ± 40.78 mm³).

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