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Revised

The effect of surface treatments on the bond strength of polyetheretherketone posts: a systematic review protocol

[version 2; peer review: 2 approved with reservations, 1 not approved]
PUBLISHED 06 Feb 2025
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Abstract

Abstract

Background

Polyetheretherketone (PEEK) is widely used in the biomedical field due to its outstanding biological and mechanical properties. Originally employed as a temporary abutment in implantology, recent research has expanded its indications for more definitive applications, such as frameworks and dental post and core. This shift requires a thorough assessment of PEEK’s adhesion and mechanical characteristics. However, PEEK’s inert properties and intricate chemistry create difficulties in surface treatment, resulting in reduced surface energy and inadequate adhesion. Various physical and chemical modification techniques, including acid etching (e.g., 98% sulfuric acid), sandblasting with alumina oxide (Al₂O₃), plasma treatment, laser irradiation, silanization, and air abrasion with silica-coated particles, have been proposed to enhance PEEK’s bonding performance. Despite its numerous clinical trials, standardized protocols remain lacking. This systematic review aims to assess the impact of surface treatments on the bonding performance of PEEK posts.

Methods

A detailed search of the literature will be conducted across several databases including PubMed, Scopus and clinical trial registries. Additional databases such as Cochrane Central, EMBASE, Web of Science and EBSCO will also be included. The search strategy will target controlled randomized studies and non-randomized clinical trials evaluating the impact of surface treatments on PEEK post adhesion strength. The Newcastle-Ottawa Scale (NOS) will be used to assess bias in non-randomized studies, while the Cochrane Risk of Bias (ROB II) tool will be employed for evaluating randomized controlled trials. Data extraction will focus on study design, treatment methods, outcomes and results.

This systematic review protocol will adhere to the guidelines for systematic reviews outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

Discussion

The discussion will explore the implications of findings on clinical practice, highlighting the importance of enhancing PEEK’s bioactivity and surface energy to improve bonding efficacy in dental procedures. Moreover, it will suggest areas for future research to advance dental materials science, aiming to optimize the utilization of PEEK in dental applications

Systematic review registration

PROSPERO: CRD42024529783 (Registered on 08/04/2024).

Keywords

Polyetheretherketone (PEEK), Posts, Surface treatments, Bond strength, Systematic review

Revised Amendments from Version 1

This revised version of the article includes several key updates to enhance clarity, depth, and relevance to current research. First, the introduction has been restructured to prioritize the discussion of PEEK’s chemical composition, properties, and applications before addressing its role in post-and-core restorations. This revision aligns the introduction more closely with the study’s main objective. Additionally, a more detailed overview of surface treatment techniques, including plasma treatment, acid etching, sandblasting, laser modification, silanization, and air abrasion, has been incorporated to provide a clearer context for the systematic review.
Furthermore, this version expands on the comparative analysis of PEEK posts versus conventional post materials, such as metal, zirconia, and fiber-reinforced composite posts, to emphasize their clinical relevance. Additional references have been integrated to support these discussions, strengthening the evidence base. The conclusion has also been refined to better highlight the implications for clinical practice, digital dentistry, and future research directions.
These modifications aim to enhance the article’s coherence, scientific rigor, and applicability for dental professionals exploring the potential of PEEK in restorative dentistry.

See the authors' detailed response to the review by Noha Taymour
See the authors' detailed response to the review by Marwa Emam

Introduction

Polyetheretherketone (PEEK) is a high-performance thermoplastic polymer that has gained attention in dentistry due to its unique properties. Introduced in the late 20th century for biomedical applications, PEEK is a semicrystalline polymer composed of aromatic rings linked by ketone and ether functional groups. This chemical structure imparts high thermal stability, excellent biocompatibility, and resistance to chemical degradation. One of its most notable advantages in dentistry is its low Young’s modulus (3-4 GPa), which is closer to that of dentin compared to conventional restorative materials like metals and ceramics. These characteristics make PEEK a viable option for multiple dental applications, including implant abutments, removable prostheses, and post-and-core systems.1,2

The use of PEEK in post-and-core restorations has gained interest due to its mechanical properties and aesthetic benefits. Endodontically treated teeth (ETT) with significant coronal structure loss require reinforcement to withstand functional forces, making post placement a necessity in many cases. Traditionally, metal and fiber posts have been employed to enhance retention and stability. However, metal posts, despite their superior strength, have aesthetic limitations and may induce stress concentration, leading to root fractures. Fiber posts, on the other hand, offer improved aesthetics and better stress distribution but exhibit mechanical weaknesses such as resin matrix cracking, fiber fracture, and interfacial debonding. Given these limitations, PEEK posts, available in both prefabricated and custom-made forms, present an alternative that balances mechanical performance with aesthetic considerations.36

Despite its promising properties, PEEK’s clinical application as a post material is hindered by its inherent hydrophobicity and low surface energy, which reduce adhesion to resin-based materials. Unlike conventional post materials such as metal, zirconia, and fiber-reinforced composite posts, PEEK requires surface treatments to improve bonding. Various chemical and micromechanical surface modification techniques, including plasma treatment, acid etching, sandblasting, and silanization, have been proposed to enhance its adhesive properties. These modifications aim to improve the integration of PEEK posts with resin cements and core buildup materials, ensuring the long-term success of restorations.714

The goal of this systematic review is to evaluate the efficacy of different surface treatments in optimizing the adhesion of PEEK posts. Understanding the bonding mechanisms of PEEK and its adhesion performance compared to conventional post materials is crucial for dental professionals seeking reliable restorative solutions. By assessing available evidence, this study aims to provide valuable insights into developing clinically effective bonding protocols for PEEK post-and-core restorations.

Protocol

Methods

This protocol outlines the process for conducting a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.15,16 The methodology from the F1000 journal will be followed to ensure accuracy and consistency at every step. The review protocol is registered in PROSPERO (CRD42024531175) since April 8, 2024.

Objectives

Primary objective: To evaluate the effectiveness of various surface treatments in the improvement of bonding strength for Polyetheretherketone (PEEK) posts.

Secondary objectives:

  • - To provide evidence-based recommendations for clinicians in the choice of surface treatments for PEEK posts during bonding procedures.

  • - To identify gaps in the literature and to propose possible suggestions for further research.

Inclusion criteria

The inclusion criteria are structured according to the PICOS model. This model is designed to specify the key components of the research question.

The research question for this systematic review is: What is the effect of various surface treatments on retention and bond strength of polyetheretherketone (PEEK) posts used in dental restoration compared to untreated PEEK posts?

  • Types of participants: This systematic review will focus on patients requiring dental restoration with polyetheretherketone (PEEK) posts. Eligible participants must be free from medical conditions affecting bone healing, avoid parafunctional habits such as bruxism and have no occlusal problems.

  • Intervention types: This systematic review will explore the use of Polyetheretherketone (PEEK) in dental posts, focusing on various surface treatments aimed at improving adhesion to resin-based materials. The interventions will include both chemical and micromechanical modifications. Chemical treatments will involve etching with 98% sulfuric acid, silanization, and plasma treatment to enhance surface reactivity. Micromechanical techniques such as sandblasting with 50 μm alumina oxide (Al2O3), laser surface modification, and air abrasion with silica-coated particles will also be assessed. The effectiveness of these treatments in promoting bonding between PEEK posts and resin-based cements will be systematically analyzed.

  • Types of outcomes: This systematic review will focus on evaluating PEEK posts in dental restorations with different surface treatments before bonding. Key outcomes will include:

    • Bond strength: Assessed through shear bond strength and push-out bond strength tests to evaluate the adhesive performance between PEEK posts and resin-based materials.

    • Retention rate: Measured by analyzing the longevity of bonded posts in clinical and in vitro studies.

    • Fracture resistance: Compared to traditional post materials such as metal, fiber, and zirconia, using mechanical stress tests.

    • Marginal adaptation quality: Evaluated using scanning electron microscopy (SEM) and microleakage tests to assess the integrity of the restoration interface.

    • Post-operative sensitivity: Reported through clinical studies assessing patient comfort after post placement.

    • Restoration longevity and clinical success rate: Determined by survival analysis and failure modes in long-term studies.

  • Measures of effect: This systematic review will measure effects using quantitative and qualitative assessments. Quantitative measures include statistical analysis of retention rates, fracture resistance, bond strength and restoration longevity.

    Qualitative measures involve evaluating marginal adaptation quality, post-operative sensitivity and clinical success rates through observational data and patient-reported outcomes. Meta-analytical techniques may be used to synthesize findings across studies for comparison.

  • Study types: Included articles will mainly include randomized controlled trials and prospective or retrospective cohort studies. These studies specifically investigate the use of polyetheretherketone (PEEK) posts in dental restorations, focusing on surface treatments. They are chosen for their substantial data and rigorous methodology to meet the research objectives effectively.

    Excluded articles will cover case reports, case series, abstracts, discussions, interviews, editorials, and opinion pieces, along with research that does not center on PEEK posts or surface treatments. Additionally, studies lacking adequate data or methodology will be omitted to ensure the review’s reliability and relevance.

Search strategy

A combination of keywords and precise subject headings relevant to the topic will be employed in the refined search strategy, ensuring a comprehensive exploration of pertinent literature. In addition to MEDLINE, databases such as Web of Science, EBSCO, Scopus, Cochrane Central and EMBASE will be meticulously searched to reduce the likelihood of missing relevant studies.

To achieve comprehensiveness, attempts will be made to locate grey literature and active clinical trials through sources such as dissertations, conference proceedings and clinical trial registries. The expert panel will offer guidance in identifying grey literature sources and evaluating their pertinence to the review.17

Furthermore, reference lists of included studies will be systematically examined as part of the search strategy to identify supplementary articles not retrieved solely through electronic databases.

This approach aims to reduce publication bias and ensure a thorough review of the available evidence.

Study selection

For this systematic review, the study selection process will involve a comprehensive search across all identified databases. Two independent reviewers will screen titles and abstracts to exclude irrelevant studies. Full-text articles of potentially eligible studies will be assessed using predefined inclusion criteria. These criteria will focus on studies that evaluate surface treatments of PEEK in dental post applications.

Reviewers will check article reference lists for additional relevant studies. Articles meeting inclusion criteria will proceed to data extraction.

During screening, any discrepancies among reviewers will be resolved through discussion. If needed, an additional reviewer (HH) will be consulted to ensure accuracy and consensus.

Evaluation of methodological quality and risk of bias

To ensure the reliability of the findings, the methodological quality and risk of bias of the included studies will be evaluated using standardized tools.

For randomized controlled trials (RCTs), the Cochrane Risk of Bias (ROB II) tool will be used to assess key methodological domains, including randomization procedures, adherence to intended interventions, completeness of outcome data, outcome measurement, and accuracy in reporting results. Each domain will be classified as having a low, high, or unclear risk of bias. Studies categorized as having an unclear or high risk of bias will be further analyzed through sensitivity analysis to determine their impact on the overall findings.18,19

For non-randomized studies, the Newcastle-Ottawa Scale (NOS) will be employed to assess quality based on three main criteria: selection of study participants, group comparability, and outcome ascertainment. Each study will be scored based on these criteria, with higher scores indicating better methodological quality.20

Two independent reviewers will conduct the assessments to minimize bias and enhance reliability. Any discrepancies in the evaluations will be resolved through discussion or by consulting an additional reviewer (HH) to reach a consensus. These measures will ensure that the conclusions of the systematic review are based on high-quality evidence.

Meta-Analysis and Handling of Heterogeneity If the included studies present comparable methodologies and outcome measures, a meta-analysis will be conducted. Heterogeneity among studies will be evaluated using the I2 statistic and Cochran’s Q test. If substantial heterogeneity (I2 > 50%) is detected, subgroup analyses will be performed based on factors such as surface treatment type, study design (in vitro vs. in vivo), and testing methodology. Random-effects models will be applied if heterogeneity is high, while fixed-effects models will be used for homogeneous data. If meta-analysis is not feasible, a qualitative synthesis will be provided to summarize the findings. These approaches will ensure a comprehensive and statistically sound evaluation of the effectiveness of surface treatments for PEEK posts.20

Extraction of data

Data items: The following details will be extracted from the selected studies: participant demographics, specifics of the interventions, outcome measures, study characteristics (publication year, author, study design …) and results pertaining to bond strength and surface characteristics.

Extraction method: A standardized data extraction form will be created in a Microsoft Excel sheet to systematically capture relevant data from each included study.

Data extraction will be conducted by two reviewers working autonomously to ensure consistent and precise handling of the information.

Discussion will be initiated to resolve any discrepancies, and if needed, input will be sought from a third reviewer (HH).

This structured approach will guarantee thorough and dependable data extraction for subsequent analysis.

Analysis and synthesis of data

The extracted data will be rigorously analyzed and synthesized to assess the effectiveness of surface treatments for PEEK in dental post materials. Initial descriptive analysis will summarize study details, participant characteristics, intervention particulars and outcome measures such as bond strength and surface characteristics. Quantitative synthesis, including meta-analysis where feasible, will calculate effect sizes with 95% confidence intervals and assess heterogeneity across studies using statistical tests such as Tau-squared, Cochran’s Q test and I-squared, systematically categorized to understand the range of variability.

Subgroup analyses will explore variations in treatment methods and material types. Sensitivity analyses will test result robustness, and qualitative synthesis will offer a narrative summary where quantitative synthesis is not possible. Findings will be interpreted in the context of clinical relevance, discussing methodological strengths and limitations while proposing directions for future research in optimizing PEEK’s performance in dental applications. Forest plot will be used to depict the results, providing a concise visualization of aggregated study effects.21

Discussion

The outcomes of this systematic review will be highly relevant for practitioners focused on aesthetic and digital dentistry, especially in the management of damaged teeth. By evaluating the efficacy of surface treatments for polyetheretherketone (PEEK) in dental post materials, this review aims to provide evidence-based guidance on enhancing bond strength and surface characteristics critical for durable dental restorations. The findings are anticipated to inform clinical decision-making, facilitating the selection of optimal surface treatment strategies to improve the longevity and aesthetic outcomes of PEEK-based restorations. Moreover, this review will identify areas where current research is lacking and propose avenues for future investigation, aiming to advance the field of dental materials science and enhance patient care in aesthetic and functional dental rehabilitation.

Ethics and dissemination

No ethical approval is needed for this systematic survey. The authors intend to present the findings at target conferences and publish the research findings in a peer-reviewed journal adopting open science practices.

Study status

This systematic review is currently in the data analysis process. The protocol of this systematic review was submitted to PROSPERO registry on 8th April, 2024 (CRD42024529783).

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Version 3
VERSION 3 PUBLISHED 22 Aug 2024
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Boukhris H, Ben Hadj Khalifa A, Hajjami H and Boudegga Ben Youssef S. The effect of surface treatments on the bond strength of polyetheretherketone posts: a systematic review protocol [version 2; peer review: 2 approved with reservations, 1 not approved]. F1000Research 2025, 13:951 (https://doi.org/10.12688/f1000research.154750.2)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Open Peer Review

Current Reviewer Status: ?
Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 2
VERSION 2
PUBLISHED 06 Feb 2025
Revised
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Reviewer Report 22 Mar 2025
Retno Ardhani, Universitas Gadjah Mada, Jalan, Indonesia 
Not Approved
VIEWS 5
The study protocol is confirmed to be registered in the PROSPERO database. The aims of the study are clearly stated and supported by a proper study design. However, the lack of clarity to ensure study replicability is found. Please consider ... Continue reading
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CITE
HOW TO CITE THIS REPORT
Ardhani R. Reviewer Report For: The effect of surface treatments on the bond strength of polyetheretherketone posts: a systematic review protocol [version 2; peer review: 2 approved with reservations, 1 not approved]. F1000Research 2025, 13:951 (https://doi.org/10.5256/f1000research.177690.r371773)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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11
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Reviewer Report 24 Feb 2025
Noha Taymour, Department of Substitutive Dental Sciences, College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia 
Approved with Reservations
VIEWS 11
I would like to thank the authors for their meticulous effort in developing this comprehensive protocol. This systematic review is particularly important as it aims to establish evidence on surface treatment techniques, offering insights that could lead to standardized protocols ... Continue reading
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CITE
HOW TO CITE THIS REPORT
Taymour N. Reviewer Report For: The effect of surface treatments on the bond strength of polyetheretherketone posts: a systematic review protocol [version 2; peer review: 2 approved with reservations, 1 not approved]. F1000Research 2025, 13:951 (https://doi.org/10.5256/f1000research.177690.r366864)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 03 Apr 2025
    Hanen Boukhris, Department of prosthodontics, LR12SP10, University of Monastir, Faculty of Dental Medicine, Monastir, Tunisia
    03 Apr 2025
    Author Response
    We sincerely appreciate the reviewers' thorough and insightful evaluation of our work. Their constructive feedback has been invaluable in refining the study and strengthening its overall quality.

    In response, ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 03 Apr 2025
    Hanen Boukhris, Department of prosthodontics, LR12SP10, University of Monastir, Faculty of Dental Medicine, Monastir, Tunisia
    03 Apr 2025
    Author Response
    We sincerely appreciate the reviewers' thorough and insightful evaluation of our work. Their constructive feedback has been invaluable in refining the study and strengthening its overall quality.

    In response, ... Continue reading
Version 1
VERSION 1
PUBLISHED 22 Aug 2024
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Reviewer Report 18 Sep 2024
Marwa Emam, Ain Shams University,, , Cairo, Egypt 
Approved with Reservations
VIEWS 12
Review report for the submitted manuscript “The effect of surface treatments on the bond strength of polyetheretherketone posts: a systematic review protocol”

I would like to thank the authors for submitting their protocol for review. The use ... Continue reading
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HOW TO CITE THIS REPORT
Emam M. Reviewer Report For: The effect of surface treatments on the bond strength of polyetheretherketone posts: a systematic review protocol [version 2; peer review: 2 approved with reservations, 1 not approved]. F1000Research 2025, 13:951 (https://doi.org/10.5256/f1000research.169814.r316835)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 06 Feb 2025
    Hanen Boukhris, Department of prosthodontics, LR12SP10, University of Monastir, Faculty of Dental Medicine, Monastir, Tunisia
    06 Feb 2025
    Author Response
    We appreciate the reviewers’ valuable feedback, which has helped improve the clarity, depth, and rigor of our manuscript. Below, we provide detailed responses to each comment and indicate the revisions ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 06 Feb 2025
    Hanen Boukhris, Department of prosthodontics, LR12SP10, University of Monastir, Faculty of Dental Medicine, Monastir, Tunisia
    06 Feb 2025
    Author Response
    We appreciate the reviewers’ valuable feedback, which has helped improve the clarity, depth, and rigor of our manuscript. Below, we provide detailed responses to each comment and indicate the revisions ... Continue reading

Comments on this article Comments (0)

Version 3
VERSION 3 PUBLISHED 22 Aug 2024
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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