PEEK vs titanium cranioplasty: which is right for your patient?
Both materials give good results in patient-specific cranioplasty. They differ in revision risk, fluid collections, imaging, comfort and cost. Here is what the evidence shows and how to choose.
The short answer
| PEEK | Titanium | |
|---|---|---|
| Revision rate (pooled) | About 5% | About 13% |
| Subgaleal fluid collection | More common | Less common |
| CT / MRI artefacts | Minimal (radiolucent) | Present |
| Strength and form | Solid, bone-like stiffness | Highest strength, thin mesh or plate |
| Feels hot or cold | No, low heat conduction | Can, conducts heat |
| Cost | Higher | Lower |
Choose PEEK when cosmesis, follow-up imaging and a low revision risk matter most. Choose titanium when strength, cost or a very large defect lead the decision. The treating surgeon makes the final call for each patient.
The two materials in brief
PEEK (polyether ether ketone) is a high-performance implantable polymer. A patient-specific PEEK implant is machined as one solid piece to fill the defect exactly. It is radiolucent, light, and has stiffness close to cortical bone.
Titanium (usually Ti-6Al-4V) has been used in cranioplasty for decades. Patient-specific titanium is supplied as a pre-contoured perforated mesh or a 3D-printed plate. It is very strong for its thickness and is the lower-cost option of the two.
What the evidence says about complications
The largest comparison so far is a 2021 systematic review and network meta-analysis in Neurosurgery that included 31 studies of cranioplasty materials. Pooled revision rates were:
- PEEK: 8 of 157 patients (5%)
- Titanium: 84 of 599 patients (13%)
- Prefabricated PMMA: 7 of 59 (9%), hand-moulded PMMA: 61 of 317 (18%)
- Autologous bone: 131 of 684 (19%)
Compared directly, PEEK carried a lower risk of reoperation than titanium (risk ratio 0.39, 95% CI 0.17 to 0.92). The authors concluded that PEEK appears to have the lowest revision risk, while noting that more research is needed. Most included studies were observational, and the PEEK group was smaller than the titanium group.
PEEK has a trade-off. A 2022 single-centre study of 130 cranioplasties after decompressive craniectomy found subgaleal fluid collections in 86% of PEEK cases versus 54% of titanium mesh cases, and midline shift above 5 mm in 20% versus 6%. Most collections settle, but it is worth planning drainage and early follow-up when using PEEK after craniectomy.
A multicentre randomised trial comparing titanium mesh with PEEK (140 patients, 15 centres in China) has been registered. Its results should give a clearer answer on implant failure and cosmetic outcome.
Imaging and follow-up
If the patient will need regular CT or MRI, for example after meningioma or glioma surgery, PEEK has a clear advantage. Titanium causes artefacts that can hide the brain directly under the implant. PEEK is radiolucent and lets you see the operative bed on follow-up scans.
Strength, contour and comfort
- Strength: titanium gives the highest strength in the thinnest form, which helps for very large or complex defects.
- Contour: a solid PEEK implant reproduces the skull's curvature closely, including the temporal region where hollowing is a common cosmetic complaint.
- Temperature: titanium conducts heat, so some patients notice it feeling cold or warm. PEEK conducts little heat.
- Fluid: the perforations in titanium mesh let fluid pass through. A solid PEEK implant does not, which may explain the higher rate of fluid collections.
Cost
PEEK is generally the more expensive of the two, and titanium sits in the middle, with PMMA the most cost-conscious option. In many cases a lower revision risk can offset the higher upfront cost, but budget and insurance cover often decide the material in practice. We provide a quotation for each case after reviewing the CT.
A practical decision guide
PEEK is usually the better fit when
- The defect is in a visible area, such as frontal or fronto-temporal
- Regular follow-up CT or MRI is expected
- The patient is young, active or concerned about appearance
- A previous implant has failed and revision risk must be kept low
Titanium is usually the better fit when
- The defect is very large or needs maximum strength
- Budget is the main constraint
- The surgeon prefers mesh that allows fluid drainage
- Follow-up imaging of the area is not a priority
Where PMMA fits: prefabricated, patient-specific PMMA is a cost-conscious alternative with a lower pooled revision rate (9%) than hand-moulded PMMA (18%). It is radiolucent but less strong than PEEK or titanium.
Why patient-specific design matters for both
Whatever the material, an implant designed from the patient's CT fits the defect without trimming or bending in theatre. That shortens surgery, improves symmetry and reduces the dead space where infection can start. The surgeon reviews and approves the design before it is made.
References
- Complications of cranioplasty in relation to material: systematic review, network meta-analysis and meta-regression. Neurosurgery. 2021;89(3):383–394. doi:10.1093/neuros/nyab180. PubMed
- Ji T, Yao P, Zeng Y, Qian Z, Wang K, Gao L. Subgaleal effusion and brain midline shift after cranioplasty: a retrospective study between polyetheretherketone cranioplasty and titanium cranioplasty after decompressive craniectomy. Front Surg. 2022;9:923987. Frontiers
- Yang J, Sun T, Yuan Y, Li X, Yu H, Guan J. Evaluation of titanium mesh cranioplasty and polyetheretherketone cranioplasty: protocol for a multicentre, assessor-blinded, randomised controlled trial. BMJ Open. 2019;9(12):e033997. PMC
This guide is for healthcare professionals and summarises published evidence. It is not a substitute for clinical judgement. Material selection is the decision of the treating surgeon.