dentistry journal

Case Report
Use of a Polyetheretherketone Clasp Retainer for
Removable Partial Denture: A Case Report
Tetsuo Ichikawa * , Kosuke Kurahashi, Lipei Liu, Takashi Matsuda and Yuichi Ishida
Department of Prosthodontics & Oral rehabilitation, Tokushima University, Graduate School of Biomedical
Sciences, 3-18-15 Kuramoto, Tokushima 770-8504, Japan; c301551014@tokushima-u.ac.jp (K.K.);
c301751017@tokushima-u.ac.jp (L.L.); matsuda.takashi.1@tokushima-u.ac.jp (T.M.);
junchan@tokushima-u.ac.jp (Y.I.)
* Correspondence: ichi@tokushima-u.ac.jp; Tel.: +81-88-633-7346




Received: 27 November 2018; Accepted: 20 December 2018; Published: 3 January 2019


Abstract: Clasp retainers made of metal alloys may be esthetically unappealing or cause allergic
reactions. To investigate alternative materials, we used the nonfiller polyetheretherketone (PEEK)
to fabricate the clasp retainer of a removable partial denture for the mandibular bilateral distal
free-end abutment of an 84-year-old female. Two years later, few color and texture changes of PEEK
were found macroscopically. The rest part and the clasp arm fitted well without any deformation.
There were no particular occlusal or periodontal problems. Subjective satisfaction was expressed by
both the practitioner and the patient.

Keywords: polyetheretherketone (PEEK); clasp retainer; removable partial denture; nonmetal clasp

1. Introduction
The clasp retainer is one of the requisite components of removable partial dentures (RPDs),
which are currently used for partial edentulism. The clasp is conventionally made of metal alloys,
but most wearers of these dentures show a strong dislike for the metallic color when the clasp is
installed in the esthetic zone. In addition, metal allergies present a clinical problem [1,2]. It is therefore
desirable to investigate the use of nonmetal materials as substitutes for these clasps.
Materials used for nonmetal denture clasps include polyamide, polyester, polycarbonate, acrylic,
and polypropylene, many of which are thermoplastic resins. Physical properties that contribute
to the suitability of clasp material include bending strength, flexural modulus, adhesive strength,
water absorption properties, abrasion resistance, surface hardness, impact resistance, color stability,
compatibility, and ease of processing. However, substitute materials with more esthetic appeal
compared with metals frequently do not meet the necessary physical criteria [3,4]. In particular,
one problem is material degradation with color and texture changes. Another issue is deterioration in
self-cleaning action is another problem for nonmetal denture clasps, which cover the cervical part of
the abutment tooth in many cases [5].
Polyetheretherketone (PEEK) is a ketone-based semicrystalline thermoplastic that has been widely
used for medical and industrial applications because of its excellent mechanical and chemical resistance
properties. In the dental field, its use for crowns, implant superstructures, fixed partial dentures,
and RPD frameworks is being investigated [6–9].
In this case report, we used PEEK to fabricate a clasp retainer for RPDs for the mandibular bilateral
distal free-end abutment, although RPD components, such as denture base, retainer, and connector are
generally composed of just a thermoplastic resin in the nonmetal clasp denture. After two years of use,
we clinically assessed the attributes of this clasp including color and color changes, bacterial adhesion,
and compatibility.

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2. Case Presentation
2. Case Presentation
2. An
Case84-year-old
Presentation female patient presented to Tokushima University Hospital with only three
An 84-year-old female patient presented to Tokushima University Hospital with only three
anteriorAn residual
84-year-oldroots in thepatient
maxilla and anterior teeth with a bilateral free endwithsaddle in the
anterior residual roots in female
the maxilla and presented
anteriorto Tokushima
teeth University
with a bilateral freeHospital
end saddle inonly
the three
mandible.
mandible.
anterior Although
residual roots the crowns in the lower
in the maxilla jaw had
and anterior poorwith
teeth esthetics, the patient
a bilateral free endwas unwilling
saddle in the to
Although
receive athe crowns
revised in the
prosthesis. lower jaw had
A treatment poorwas
plan esthetics, thethat patient was unwilling a to receive a
mandible. Although the crowns in the lower jaw haddevised
poor esthetics, involved
the patient fitting
was of complete
unwilling to
revised prosthesis.
overdenture A treatment
to the prosthesis.
maxilla and plan was devised that involved fitting of a complete overdenture to
receive a revised A atreatment
RPD to planthe mandible.
was devised Silicone impressions
that involved fitting(Exadenture,
of a completeGC
theCorporation,
maxilla and
overdentureTokyo,
a RPD to
to the Japan)
the mandible.
maxilla using
Silicone
and a individual
RPD to thetrays
impressions
and the
mandible.
(Exadenture,
interocclusal
Silicone impressions
GC Corporation,
record were obtained
(Exadenture,
Tokyo,
GC
Japan) using
according individual
to conventional trays and
methods. the interocclusal
After trial record
application were
of
Corporation, Tokyo, Japan) using individual trays and the interocclusal record were a obtained
wax according
denture, the finaltodenture
conventional
obtained was
methods.
made After
(Figureto1).
according trial application
The clasp retainer
conventional of a
methods.was wax
Afterdenture,
made
trialof the final denture
nonfiller type
application of a waxPEEK was made
as follows.
denture, (Figure
First,
the final 1). The
wasclasp
we scanned
denture
retainer
themade was
working made
(Figure
model of
1). Thenonfiller
withclasp type
retainer
a dental PEEK
was made
scanner; as follows.
then,ofwe First,
nonfiller
designed we
typethe scanned
PEEKclasp the
asretainer working
follows. with
First,CAD model
we scanned with a
software
dentalthescanner;
working
(Geomagic modelwe
then,
Freeform, with a dental South
3Ddesigned
Systems, scanner;
the clasp then, weUSA)
retainer
Carolina, designed
withandCADthe clasp
used retainer
software
a milling with CAD
(Geomagic
machine software
Freeform,
(RXP500 DSC,3D
(Geomagic
Roeders
Systems, BmbH,
South Freeform,
Soltau,3D
Carolina, Systems,
Germany)
USA) and South
to
used Carolina,
shape
a milling USA)
the clasp and used
from
machine a(RXP500
PEEKa milling
disk
DSC,machine
(JUVORA
Roeders(RXP500
Dental
BmbH, DSC,
Discs,
Soltau,
Roeders
Lancashire, BmbH,
UK) Soltau,
(Figure Germany)
2). Details to
of shape
form the
were clasp from
modified a
using
Germany) to shape the clasp from a PEEK disk (JUVORA Dental Discs, Lancashire, UK) (Figure PEEK disk
technical (JUVORA
bars, and Dental
polishingDiscs,
was 2).
Lancashire,
performed withUK) (Figure
silicone 2).
pointsDetails
(Shofu, of form
Kyoto,were modified
Japan) using technical bars, and polishing was
Details of form were modified using technical bars, andand a Robinson
polishing bristle brush
was performed withwith polishing
silicone points
performed with silicone points (Shofu, Kyoto, Japan) and a Robinson bristle brush with polishing
paste.
(Shofu, Kyoto, Japan) and a Robinson bristle brush with polishing paste.
paste.

Figure 1. Complete upper denture and removable partial denture with nonfiller polyetheretherketone
Figure Complete
1. 1.
Figure Completeupper
upperdenture
dentureand
and removable partial
partialdenture
denturewith
withnonfiller
nonfiller polyetheretherketone
polyetheretherketone
(PEEK) clasps, at delivery.
(PEEK)
(PEEK)clasps, atat
clasps, delivery.
delivery.

Figure 2. PEEK clasp components milled in the PEEK disk.

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Figure 2. PEEK clasp components milled in the PEEK disk.

Figure 2. PEEK clasp components milled in the PEEK disk.
The adhered surface of PEEK embedded in a resin base was treated using sand blasting with
The adhered surface of PEEK embedded in a resin base was treated using sand blasting with
Al2 O3 50-µmThe adhered
particlessurface of PEEK
(HiBlaster embedded
Ovaljet, Shofu,inKyoto,
a resin Japan).
base wasThe treated usingwas
denture sand blasting
then molded withusing
Al2O3 50-μm particles (HiBlaster Ovaljet, Shofu, Kyoto, Japan). The denture was then molded using
Al 2O3 50-μm particles (HiBlaster Ovaljet, Shofu, Kyoto, Japan). The denture was then molded using
a heat-curing acrylic resin (Acron, GC, Tokyo, Japan) with aa conventional
conventionalflask flaskinvestment
investment method
a heat-curing
a heat-curing
acrylic
acrylic
resin
resin
(Acron,
(Acron,
GC, Tokyo,
GC, primarily
Japan) with
Tokyo, Japan)
with a conventional flaskofinvestment
method
method
(Figure
(Figure3). Although
3).3).
Although the clasp apex was positioned in the far zone the abutment teeth at
(Figure Althoughthe theclasp
claspapex
apexwas
wasprimarily
primarily positioned
positioned in inthe
thefar
farzone
zoneofofthe
theabutment
abutment teeth
teeth at at
thethe
fabrication,
fabrication,it was prepared slightly beyond the central line of the abutment at the denture delivery
the fabrication,it itwas
wasprepared
preparedslightly
slightly beyond
beyond the central line
the central line ofofthe
theabutment
abutmentatatthethe denture
denture
because of the aesthetic problem.
delivery because of the aesthetic problem.
delivery because of the aesthetic problem.

FigureFigure 3. PEEK
3. PEEK clasp
clasp installed
installed ininthe
thedenture
denture base.
base. The
Thecurly
curlybracket
bracketregion waswas
region treated withwith
treated sand sand
Figure 3. PEEK
blasting beforeclasp installed in the denture base. The curly bracket region was treated with sand
flasking.
blasting before flasking.
blasting before flasking.
Figures 4–6 show the PEEK clasps two years after delivery. The patient reported that denture
Figures 4–6 show the PEEK clasps two years after delivery. The patient reported that denture had
Figures
had 4–6 show
been rinsed underthe PEEKwater
running claspsafter
twoevery
yearsmeal
afterand
delivery.
immersed Theinto
patient reported
a denture thatfor
cleanser denture
the
been rinsed under running water after every meal and immersed into a denture cleanser for the night
hadnight
beenatrinsed
bedtime. Fewrunning
under color and texture
water afterchanges were and
every meal found macroscopically,
immersed and denture
into a denture plaque
cleanser for the
at bedtime. Fewaround
adherence
color and texture
thecolor
claspand
changesminimal.
appeared
were found macroscopically, and denture plaque adherence
night at bedtime. Few texture changesHowever,
were found staining with a plaque-disclosing
macroscopically, and dentureagent
plaque
around the clasp
revealed around appeared
clear denture minimal.
plaque However,
on both the staining
inside and with a plaque-disclosing
outsidestaining
of the clasps. agent revealed clear
adherence the clasp appeared minimal. However, with a plaque-disclosing agent
denture plaque
revealed clear on both the
denture inside
plaque and outside
on both of and
the inside the clasps.
outside of the clasps.

(a) (b)

(a) (b)

(c)

(c)

Figure 4. Fit of the PEEK clasps to abutments. (a) just after delivery, (b) Labial view (two years later),
and (c): Occlusal view (two years later).
 The rest part and the clasp arm still fitted well without any deformation, and the participant
The no
reported restparticular
part andproblem
the claspwith
armocclusal
still fitted well without any deformation, and the participant
contact.
reported no particular
No specific problem
mobility of the with occlusal
abutment contact.
teeth, and no specific inflammation of the gingiva around
No specific mobility of the abutment teeth,
the abutment teeth were found. The subjective operational and no specific
opinioninflammation of the gingiva
of the practitioner around
about wearing
the abutment
Dent.
and detachingteeth
J. 2019, 7, 4 of thewere found.
denture wasThe subjective
also reportedoperational
as good. opinion of the practitioner about wearing4 of 6
and detaching of the denture was also reported as good.

(a) (b)
(a) (b)

(c) (d)
(c) (d)
Figure 5. Bacterial adherence on PEEK clasps two years later. (a), (c): before staining and (b), (d): after
Figure 5.
Figure 5. Bacterial
staining. Bacterialadherence
adherenceon
onPEEK
PEEKclasps
clasps two
two years
years later.
later. (a),before
(a,c) (c): before staining
staining andafter
and (b,d) (b), (d): after
staining.
staining.

(a) (b)
(a) (b)
Figure
Figure6.6.Surface
Surfacechange
changeon
onthe
thePEEK
PEEKclasp.
clasp.(a):
(a) just after delivery and (b): two years
(b) two yearslater.
later.
Figure 6. Surface change on the PEEK clasp. (a): just after delivery and (b): two years later.
The rest part and the clasp arm still fitted well without any deformation, and the participant
3. Discussion
3. Discussion
reported no particular problem with occlusal contact.
This case report on the PEEK clasp involved a follow-up of short duration (two years), but both
No
Thisspecific
case mobility
report of PEEK
on were
the the abutment
clasp teeth, and
involved no specific
of inflammation of(two
the gingiva around
patient and practitioner almost satisfied withathe
follow-up
outcome. shortcolor
Few duration
and texture years), but
changes both
were
the abutment
patient and teeth were
practitioner found.
were The
almost subjective
satisfied operational
with the opinion
outcome. Fewof the
colorpractitioner
and texture about wearing
changes were
observed, reconfirming the chemical stability and biocompatibility of PEEK, although it has been
and detaching
observed, of the denture
reconfirming was also stability
theinchemical reported and
as good.
biocompatibility of PEEK,found
although it has been
reported that such changes other nonmetal clasp materials are occasionally several months
reported
after that such changes in other nonmetal clasp materials are occasionally found several months
delivery.
3. Discussion
after delivery.
This case report on the PEEK clasp involved a follow-up of short duration (two years), but both
patient and practitioner were almost satisfied with the outcome. Few color and texture changes were
observed, reconfirming the chemical stability and biocompatibility of PEEK, although it has been
reported that such changes in other nonmetal clasp materials are occasionally found several months
after delivery.
Biofilm formation on the surface of PEEK has been reported to be equal to or lower than that on
the surface of conventionally applied abutment materials, such as zirconia and titanium [10]. However,
bacterial adherence is easily overlooked, because the colors of denture plaque and PEEK material
Dent. J. 2019, 7, 4 5 of 6

are similar. Clinical examination revealed no periodontitis or gingivitis in relation to the abutment
teeth. The clasp design of PEEK may be similar to that of nonmetal denture clasps considering the
mechanical property of PEEK, while the PEEK clasp permits reduction of the coverage/proximity of
the cervical part of abutment teeth. Therefore, the gingiva around the PEEK clasp should be monitored
with regular check-ups.
Clinical complications around the interface between the metal frame and denture base resin, such
as fracture of the denture base and invasion of foreign objects into the gap, often occur in conventional
RPDs [11]. In our case study, such complications were not found after two years. The difference in
elastic modulus between PEEK and acrylic resin is smaller than that between metal and resin, reducing
the likelihood of these interface problems, although there is no chemical adhesion between PEEK and
acrylic resin [12].
Esthetically, the color of conventional nonmetal clasp materials is viewed as that of gingiva, while
the color of PEEK is that of teeth. The slightly grayish, nontransparent white color of PEEK was more
acceptable than the silver color of a metal clasp. Nonetheless, it did not match the tooth or crown color
sufficiently. If the PEEK clasp is placed in the esthetic zone, the clasp apex had not better located in
the far zone of the abutment teeth, but rather positioned slightly beyond the central line of the crown
as we did in our case. Future development of PEEK that matches the tooth color more closely and is
slightly more transparent will improve its esthetics.
The elastic coefficient of PEEK is approximately 4 GPa [13], which is considerably less than that
of gold alloy (100 GPa) and Co–Cr alloy (200 GPa) [14]. Appropriate retention force and bracing will
need to be attained by increasing the thickness and width of the clasp arms in PEEK relative to those
of conventional metal clasp. Clasp retentive force is directly proportional to these attributes, and also
to elastic modulus and the degree of undercut, and is inversely proportional to the length of the clasp
arm [15,16]. Therefore, the shortened and wide clasp arm, with the clasp apex slightly overlapping
the center, contributed to improved aesthetics and to increased retentive force. In contrast, the lower
flexural modulus than that of metal may be beneficial, because it reduces the risk of excessive force on
the abutment tooth [17]. To date, it has not been reported that the PEEK clasp occlusal force distribution
was unsatisfactory in this case. Clasp design without coverage of the cervical area, in contrast with
conventional thermoplastic resins, is advantageous for periodontal disease and root caries.
A PEEK clasp has the same disadvantages as other nonmetal clasp materials: difficulty of polishing
and adjusting retention capacity. The appropriate polishing procedure of PEEK is under consideration;
it is expected to have the same smoothness as that of acrylic resin. It is impossible to adjust the
retention capacity due to clasp bending at delivery; therefore, preoperative designing is necessary for
a PEEK clasp.
In conclusion, we have presented a satisfactory outcome of an RPD case utilizing a PEEK clasp
retainer over a short observation period. Standardizations of clasp design and laboratory and clinical
work will be required in the near future.

Author Contributions: All dental treatment procedures: T.I., and K.K.; Writing—Preparation of Original Draft,
T.I., Y.I., L.L., and T.M.; Writing—Review and Editing, T.I. and L.L.
Funding: This work was partially supported by JSPS KAKENHI Grant Number JP16K11597. The subject gave her
informed consent for inclusion before she participated in the study. The study was conducted in accordance with
the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Tokushima University
Hospital (No. 2413).
Acknowledgments: We would like to express our gratitude to Shizuo Higuchi (Wada Precision Dental Laboratories,
Osaka, Japan) for the fabrication of the PEEK clasps.
Conflicts of Interest: PEEK material was kindly provided by InvibioTM Biomaterial Solutions. The authors
declare no conflicts of interest.
Dent. J. 2019, 7, 4 6 of 6

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