polymers
Article
Micro-CT Marginal and Internal Fit Evaluation of CAD/CAM
High-Performance Polymer Onlay Restorations
Flavia Roxana Toma 1 , Lavinia Cristina Moleriu 2 and Liliana Porojan 1, *
Citation: Toma, F.R.; Moleriu, L.C.;
Porojan, L. Micro-CT Marginal and
Internal Fit Evaluation of CAD/CAM
High-Performance Polymer Onlay
Restorations. Polymers 2023, 15, 1715.
https://doi.org/10.3390/
polym15071715
Academic Editors: Márk Fráter,
Edina Lempel and Daniel Palkovics
Received: 1 March 2023
Revised: 20 March 2023
Accepted: 27 March 2023
Published: 30 March 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Polymers 2023, 15, 1715. https://doi.org/10.3390/polym15071715
1 Department of Dental Prostheses Technology (Dental Technology), Center for Advanced Technologies in
Dental Prosthodontics, Faculty of Dental Medicine, “Victor Babes, ” University of Medicine and Pharmacy
Timis, oara, Eftimie Murgu Sq. No. 2, 300041 Timisoara, Romania
2 Department of Functional Science, “Victor Babes, ” University of Medicine and Pharmacy Timis, oara, Eftimie
Murgu Sq. No. 2, 300041 Timisoara, Romania
* Correspondence: sliliana@umft.ro
Abstract: (1) Background: The use of high-performance polymers for fixed restorations requires
additional studies regarding their adaptability and processing with CAD/CAM technology. This
in vitro study aims to assess the marginal and internal fit of PEEK and PEKK materials using
microcomputed tomography. (2) Methods: Twenty-four (n = 8) MOD onlays made of PEKK (Pekkton
ivory), unmodified PEEK (Juvora medical), and modified PEEK (BioHPP) were investigated. A
typodont mandibular left first molar was scanned to achieve 24 resin, 3D printed abutment teeth.
The onlays were fabricated with a five-axis milling machine, and after cementation of the specimens,
the marginal (MG) and internal gaps (IG) were evaluated at twelve points in the mesio-distal section
and thirteen points in the bucco-lingual section using microcomputed tomography. For statistical
data analysis, Wilcoxon signed-rank/paired Student t-Test, Mann–Whitney/unpaired Student t-Test,
and one-way ANOVA test were applied. (3) Results: Significant differences (p < 0.05; α = 0.05)
were reported between the MG and IG for each material for all three polymers and also among
two materials in terms of the MG and IG (except Juvora-BioHPP). The highest IG values were
recorded in angular areas (axio-gingival line angle) in the mesio-distal section for all the polymers.
(4) Conclusions: For all the materials, MG < IG. The type of polymer influenced the adaptability; the
lowest marginal and internal gap mean values were recorded for BioHPP. The analyzed polymer
used for onlays are clinically acceptable in terms of adaptability.
Keywords: PAEK; CAD/CAM; marginal and internal fitness; onlay; micro-CT evaluation
1. Introduction
Adaptability is a relevant factor that can influence the quality, fracture resistance,
and longevity of prosthetic restorations; it depends on the frequency and size of gaps
determined by morphological disproportion between the restoration and the dental hard
tissues [1,2]. The marginal gap (MG) is defined as the discrepancy between the edge of
the restoration and the preparation line; the internal gap (IG) is the discrepancy between
the inner part of the onlay and the dental structure [3,4]. Larger marginal gaps cause wear
or dissolution of the cement due to chemical corrosion and physical fatigue, leading to
bacterial infiltration, hypersensitivity, secondary caries, and periodontal disease [5,6]. Poor
inner fitness induces a greater thickness of the cement layer and lower support and retention
of the restoration, increasing the risk of fracture [7,8]. The fit accuracy can be influenced
by the precision of the milling machine, the size and wear of the rotary instruments, the
geometry of the restoration, the type of the material, the evaluation method, and the
number of measuring locations [9–11]; it also depends on the characteristics of the cement
and the adhesion established with the polymer and how resistant it is to mechanical and
thermal stress; self-etch resin cements are the most used cements, ensuring a durable and
effective bond, which can be proven using the chewing fatigue test. It was reported that
https://www.mdpi.com/journal/polymers
Polymers 2023, 15, 1715 2 of 13

the material compensates for accumulated stress exerted on the margins [12,13]. However,
other studies have shown less marginal adaptation; this situation could be induced by
various curing methods, thereby determining the shrinkage of the material and affecting
the quality of the marginal seal [14,15].
With the introduction of the first CAD/CAM system for clinical applications, the
choice of the best material (polymer or ceramic) for obtaining inlay/onlays from prefabri-
cated blocks was intensely debated [16–18]. PMMA-based materials and composite blocks
are used as an alternative to silicate ceramics [19,20]. Several studies reported that compos-
ite onlays and crowns for molars, fabricated using CAD/CAM technology, demonstrated
high fracture resistance, being indicated for long-term restorations [21,22]; PMMA-based
materials showed poorer mechanical properties than those of composites [23]. However, it
should be taken into account that the thermal and elastic expansion qualities of these are
different from those of ceramics and dental hard tissues [24]. The low clinical failure rate,
aesthetic appearance, and stabilization of the tooth substance mean that ceramic was rec-
ommended as the standard material for CAD/CAM inlays/onlays restorations [25,26]. The
excellent properties of thermoplastic high-performance polymers offer new perspectives
for restorative and prosthetic applications; they demonstrated ultra-high mechanical and
chemical performances and can be substitutes for ceramics and metallic alloys for achieving
various fixed and removable restorations [27,28]. These materials are stiff, strong, resistant
to hydrolysis at variable temperatures, have no pores or free monomers, and can withstand
extreme loads.
The PAEK (polyaryletherketone) family includes high-performance polymers such
as PEEK (polyetheretherketone), PEKK (polyetherketoneketone), and AKP (aryl ketone
polymer).
Due to their particular characteristics, PEKK materials are placed at the top of the poly-
mer pyramid; Pekkton ivory (PEKK) has a semi-crystalline structure, high flexibility, and
very good mechanical properties [29]. Regarding PEEK, many studies reported qualities
such as high biocompatibility, temperature resistance, polishing potential, bond strength
with luting cements, radiolucency, low plaque affinity, persistence in many different aging
environments, and compared to those of glass-ceramics, zirconia, or metallic-alloys, the
modulus of elasticity (3–4 GPa) is similar to that of human bone, which make is effective at
absorbing shocks and functional stress [30–33]. To improve their mechanical properties,
ceramic-reinforced PEEK with 20% ceramic fillers (Bio HPP) have been developed [34,35].
Reinforced agents contribute to increasing resistance to occlusal loads in order to prevent
plastic deformation, cracks, or fractures [36,37].
These materials can be processed and milled from prefabricated blocks using dental
CAD/CAM technology systems. An image-capture unit collects data from the prosthetic
field and converts them into virtual measurements, resulting in a digital impression [38].
The scanning process can be performed directly and intraorally by the clinician, with the
data being acquired from the prepared teeth being used to create a virtual model, or indi-
rectly by scanning the conventional impressions or casts in dental laboratories [39,40]. The
properties of computer-aided impressions can be influenced by the scanning method and
principles, color displays, or use of anti-reflection powder. The continued development of
the CAD/CAM system and software updates in general have led to a decrease in marginal
disharmonies [41,42]. The use of high-performance polymers to obtain inlays/onlays is not
very widespread, but the exceptional properties of the materials also mean that they are
recommended for fixed prosthetics; the fit accuracy has been poorly documented; therefore,
additional studies are needed.
Usually, two non-invasive methods are used to assess marginal and internal gaps: the
replica technique and micro-computed tomography [43]. The replica method is accepted
as a less expensive, reliable, and easy technique; however, some disadvantages have been
observed, such as difficult identification of the margins, possible errors resulting from
cutting the silicone, a limited number of points that can be measured, and the accuracy is
affected by the type of impression material and measurement procedure [44–47]. Micro-CT,
Polymers 2023, 15, 1715 3 of 13

a 3D imaging technique, performs the analysis after cementing the specimens without
having to cut them; the samples can be rotated and viewed as virtual slices, which allows
the measurement of any parameters and their comparison in different phases of the experi-
ment [48]. The accuracy of the adaptation is usually evaluated at different points located
on marginal ridges and axial and occlusal walls of the prepared teeth [49].
The purpose of this in vitro study was to analyze and compare the adaptability
(marginal and internal fit) of onlays, both individually for an experimental material and
between groups of monolithic high-performance polymers. The null hypotheses were:
(1) there are no differences according to the reference point between MG and IG for each
polymer; (2) the type of material does not influence the adaptability of the restorations
(there is no difference in terms of MG or IG among the groups).

2. Materials and Methods

2.1. Onlay Preparation Design
A typodont (Standard Model AG-3, Frasaco) mandibular left first molar was prepared
for the (mesio-occlusal-distal) onlay using a high-speed device and diamond rotary burs
(Preparation Set 4180.314 VPE1, Komet Dental, Lemgo, Germany) by a single clinician,
as follows: First, the mesio-occlusal-distal box cavity with a depth of 2 mm and isthmus
width = 2 mm was prepared, and then, the proximal box was also prepared: mesio-distal
width = 1 mm, bucco-oral width = 3 mm, and occlusal-gingival depth = 3 mm; the conver-
gence angle of axial walls was 6◦ ; 1 mm of the occlusal surface was uniformly reduced,
and a 1 mm heavy chamfer on support buccal cusps and a 0.5 mm contra bevel on the
oral cusps were created. The typodont preparation was multiplied to achieve the printed
resin abutment teeth using a 3D printer; the procedure reduces additional errors that may
occur using non-additive methods for multiplication, and the chosen material simulates the
mechanical properties of the natural tooth. Subsequently, twenty-four MOD onlays were
obtained from three different monolithic high-performance polymers (Pekkton ivory—P;
Juvora Natural Dental—J; BioHPP—B) (Table 1). The samples were fabricated according to
the manufacturer’s protocol and divided in three groups (n = 8).

Table 1. The PAEK materials selected for study (n = 8).

Material Manufacturer Composition

Cendrez + Metaux, polyetherketoneketone
Pekkton ivory (P)
Biel/Bienne, Switzerland (PEKK)
Juvora Ltd. Global Technology 100% polyetheretherketone
Juvora Natural Dental (J)
Center, Lancashire, UK (PEEK)
20% ceramic reinforced
Bredent group GmbH & (0.3–0.5 µm grain size)
BioHPP shade 2 (B)
Co.KG, Senden, Germany partially crystalline
polyetheretherketone (PEEK)

2.2. CAD/CAM
The typodont preparation was scanned (Smart Optics Vinyl HR scanner—Smart Optics
Sensortechnik, Bochum, Germany) and designed (Exocad Dental CAD software—Align
Technology, Darmstadt, Germany) to achieve twenty-four 3D printed resin abutment teeth
(Asiga DentaMODEL Asiga, Sydney, Australia) using a 3D printer (Asiga Max 385 UV,
Asiga, Sydney, Australia); the marginal fit was programmed to be 0 µm, and the simulated
cement spacer was set at 0.03 mm (30 µm) starting at 1 mm above the margin. The onlays
were fabricated with a 5-axis milling machine (Imes Icore 350 iPRO+, Imes Icore, Dental &
Medical Solutions, Las Vegas, NV, USA) using water-cooled rotary instruments with sizes
of 1 and 2.5 mm.
Each group of restorations was milled from a single disk corresponding to each type of
material, and eight samples were obtained. Minor adjustments were performed on occlusal
 instruments
Polymers 2023, 15, x FOR PEER REVIEW with sizes of 1 and 2.5 mm. 4 of 13
Each group of restorations was milled from a single disk corresponding to each
type of material, and eight samples were obtained. Minor adjustments were performed
on occlusal or axial
Imes Icore, surfaces
Dental using
& Medical water-cooled
Solutions, fineNV,
Las Vegas, diamond burs water-cooled
USA) using (Preparationrotary
Set
Polymers 2023, 15, 1715 4180.314 VPE1, Komet Dental, Lemgo, Germany)
instruments with sizes of 1 and 2.5 mm. (Figure 1a). 4 of 13
Each group of restorations was milled from a single disk corresponding to each
type of material, and eight samples were obtained. Minor adjustments were performed
on
or occlusal or axial
axial surfaces surfaces
using using fine
water-cooled water-cooled fine (Preparation
diamond burs diamond burs Set(Preparation Set
4180.314 VPE1,
4180.314 VPE1, Komet Dental, Lemgo, Germany)
Komet Dental, Lemgo, Germany) (Figure 1a). (Figure 1a).

(a) (b)
Figure 1. Three-dimensional printed abutments (a) and milled polymer onlays (b) with cemented
onlays.
(a) (b)
2.3. Cementation
Figure
Figure1. 1. Technique
Three-dimensional printed
Three-dimensional abutments
printed (a) and(a)
abutments milled
and polymer onlays (b)onlays
milled polymer with cemented
(b) with
onlays.
All cemented onlays.
the restorations were cemented to the resin abutment teeth using a dual-cure,
self-adhesive resin
2.3.Cementation cement
CementationTechnique (RelyX U200, 3M Espe, Seefeld, Germany) with the same
Technique
2.3.
procedure according
Allthe to the manufacturer’s
the restorations
restorations were instructions. The teeth
auto-mixed cement was
spread evenly All on the inner werecemented
surface cemented
of the
totothethe
onlay,
resin
which
abutment
resin abutment
was then
using
teeth a dual-cure,
using
carefully
self-
a dual-cure,
placed and
adhesive resin cement (RelyX U200, 3M Espe, Seefeld, Germany) with the same procedure
self-adhesive resin cement (RelyX U200, 3M Espe, Seefeld, Germany) with the same
pressed according
on the master preparation with
to the manufacturer’s a standardized
instructions. force ofcement
The auto-mixed 10 N forwas10spread
s, andevenly
then
procedure according to the manufacturer’s instructions. The auto-mixed cement was
light cured
on theforinner
2 s on the of
surface buccal and oral
the onlay, whichsides.
was thenExcess cement
carefully was and
placed removed
pressedusing
on thea
spread evenly on the inner surface of the onlay, which was then carefully placed and
master
scalpel and preparation
light cured again withfor
a standardized
20 s each from force of 10
four N for 10 s,Finally,
directions. and thenthelight cured for
samples 2s
were
pressed
on
on
the buccal
the master
and a
oral
preparation
sides. Excess
with a standardized
cement was
force of 10 N for 10 s, and then
slightlylight
polished
cured using
for low-speed
2 s from
on the buccalhand-piece,
and oral a removed
polishing
sides. Excess
using
cement
a scalpel
brush, was
and light
andremoved
paste cured
(Renfert
using
again
Polish,scalpel
Renfert,for 20 s each
Hilzingen, four
Germany) directions.
(Figure Finally, the samples were slightly polished using a
and light cured again for 20 s each1b).
from four directions. Finally, the samples were
a low-speed hand-piece, a polishing brush, and paste (Renfert Polish, Renfert, Hilzingen,
slightly
Germany) polished
(Figureusing
1b). a low-speed hand-piece, a polishing brush, and paste (Renfert
2.4. Micro-CT AnalysisHilzingen, Germany) (Figure 1b).
Polish, Renfert,
The2.4. Micro-CT
accuracy Analysis
was evaluated using a high-resolution scanner (Nikon XT V 160, Min-
2.4. Micro-CT
ato, Tokyo, Japan), Analysis
and the
The accuracy wasgenerated
evaluated data
usingwere investigatedscanner
a high-resolution (MyVGL software
(Nikon XT V Volume
160, Mi-
nato,
Graphics, Tokyo,
The
Heidelberg,Japan),
accuracy and
was the generated
evaluated
Germany). Theusing data werewas
investigated
a high-resolution
restoration (MyVGL
scanner
scanned, and (Nikonsoftware
image Volume
XTcorrections
V 160, Min-
Graphics,
ato, Tokyo, Heidelberg,
Japan), and Germany).
the The
generated restoration
data were was scanned,
investigated and image
(MyVGL
were made to achieve the best contrast; for each sample, a resolution of 4 µm per pixel corrections
software were
Volume
made to achieve
Graphics, the best contrast; for each sample, awas
resolution of 4and per pixel
µm image was set,
was set, and thenHeidelberg,
each scannedGermany).
sample The
was restoration
reconstructed scanned,
separately with corrections
a resolution of
and
were then
made each
to scanned
achieve sample
the best was reconstructed
contrast; for each separately
sample, a with a
resolutionresolution
of 4 µm of 10 pixel
per µm
10 µm per voxel. The microcomputed tomography included sagittal (mesio-distal) and
perset,
voxel.
andThe microcomputed tomography included sagittal (mesio-distal)
with a and coronalof
coronalwas then
(bucco-lingual)
(bucco-lingual)
each scanned
sections
sections forfor
each
sample
each was reconstructed
material
material (Figure
(Figure 2a–c).
separately
2a–c). resolution
10 µm per voxel. The microcomputed tomography included sagittal (mesio-distal) and
coronal (bucco-lingual) sections for each material (Figure 2a–c).

(a)
Figure 2. Cont.
(a)
ymers 2023,15,
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ymers 2023,Polymers
FOR PEER
2023,
PEER
REVIEW
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1715 5 of 13
55 of 13
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(b)
(b)

(c)
(c)
Figure 2. Micro-CT images with sagittal and coronal sections for: (a) Pekkton; (b) Juvora; (c) Bio-
HPP.
Figure 2.Figure 2. Micro-CT
Micro-CT imagesimages
with with sagittal
sagittal andand coronalsections
coronal sections for:
for: (a)
(a) Pekkton;
Pekkton;(b)(b)
Juvora; (c) BioHPP.
Juvora; (c) Bio-
HPP.
Discrepancy measurements were obtained at twelve locations for each sagittal (me-
Discrepancy measurements were obtained at twelve locations for each sagittal (mesio-
sio-distal) section and thirteen locations for each coronal (bucco-lingual) section. To as-
distal) section and thirteen locations for each coronal (bucco-lingual) section. To assess the
sess theDiscrepancy
thickness of themeasurements
cement, a totalwere obtained measurements
of twenty-five at twelve locations for each
were taken sagittal (me-
of one
thickness of the cement, a total of twenty-five measurements were taken of one preparation,
sio-distal)
preparation, and
section
and
twotwo and thirteen
hundred
hundred
locations
measurements
measurements
for
werewere
each
takentaken
coronal
of eachof each (bucco-lingual)
material.
material. Marginal
Marginal
section.
fit wasfit
To as-
estimated as
was estimated
sess thethe as the
thickness mean
of the of the resulting
cement, a values
total of at locations
twenty-five a, m, and
measurementsn (in both
were sec-
taken
mean of the resulting values at locations a, m, and n (in both sections), and the internal of one
tions), and the
preparation, internal
fit wasand fit was
two hundred
estimated estimated
as the mean as the
measurements mean
from locationswerefrom locations
b to ftaken b to f (in
(in theofmesio-distal
each material.the me-
Marginal
sections) and j tofit
l
sio-distal sections)
was estimated and
as j
theto l (in
mean theofbucco-lingual
the resulting
(in the bucco-lingual sections) (Figure 3a,b). sections)
values (Figure
at 3a,b).
locations a, m, and n (in both sec-
tions), and the internal fit was estimated as the mean from locations b to f (in the me-
sio-distal sections) and j to l (in the bucco-lingual sections) (Figure 3a,b).

(a) (b)
Figure 3. Schematic
Figure 3.presentation of measurement
Schematic presentation location (a) in
of measurement mesio-distal
location section and (b)
(a) in mesio-distal bucco-
section and (b) bucco-
lingual section; marginal points = a, m, and n; internal points = b, c, d, e, f, g, h, i, j, k, and l.
lingual section; marginal points = a, m, and n; internal points = b, c, d, e, f, g, h, i, j, k, and l.
(a) (b)
2.5.Analysis
2.5. Statistical Statistical Analysis
Figure 3. Schematic presentation of measurement location (a) in mesio-distal section and (b) bucco-
lingual first In
In thesection; theusing
part, first descriptive
marginal
part, using statistics,
points = a, m,
descriptive thestatistics,
and n; internal central the central
tendency
points = b, c, d,and tendency and
e, f,dispersion
g, h, i, j, k,pa-
dispersion
and l.
rameters wereparameters
calculated.were Bycalculated.
applying the By Shapiro–Wilk
applying the Shapiro–Wilk test, it was
test, it was established thatestablished
the that
data were the data were
distributed; in distributed;
some cases, in some
the data cases,
were the datadistributed
normally were normally (p > distributed
0.05), and in (p > 0.05),
2.5. Statistical Analysis
others, theyand werein not
others, they were
normally not normally
distributed (p > 0.05);distributed
therefore,(p > 0.05);
both typestherefore,
of tests (par-both types of
In the first part, using descriptive statistics, the central tendency
ametrical and non-parametrical) were performed: unpaired Student t-Test (for normal t-Test (for
tests (parametrical and non-parametrical) were performed: unpaired and dispersion
Student pa-
rameters normal
were distributions)/Mann–Whitney
calculated. By applying the (for not
Shapiro–Wilk normal
distributions)/Mann–Whitney (for not normal distributions) were used for two different distributions)
test, it was were
established used for
that two
the
data (to
groups different
werecompare groups
distributed; (to compare
in some
the marginal and the
cases, marginal
the fits
internal data and
ofwere internal
the two normally fits of the two
distributed
materials); materials);
one-way (p one-way
> 0.05), and in
ANO-
VAothers,
(normal ANOVA (normal distributions)/Kruskal–Wallis (not-normal
they were not normally distributed (p > 0.05); therefore, both types the
distributions)/Kruskal–Wallis (not-normal distributions) distributions)
were used for were used
of tests for
(par-
analysis of the
ametrical
analysis of several
several
and dependent
dependent
groups
non-parametrical)
groups
(marginal (marginal
or internal
were performed:
oramong
fit internal
unpaired allfitthree
among
Student
all three materials);
materials);
t-Test (for normal
two-way two-way ANOVA (normal
ANOVA (normal distributions)/Friedman distributions)/Friedman
(not-normal (not-normal
distributions) distributions)
test test were
distributions)/Mann–Whitney
used to compare more than
(fortwo
not normal
different time
distributions)
points to obtain
were the
used forwere
interaction
two different
effect among
used to compare
groups (to more than
compare the two different
marginal and time points
internal fitstoofobtain
the twothe materials);
interaction one-way
effect ANO-
the material and measurement points (Mg and IG),
among the material and measurement points (Mg and IG), and Tukey post hoc test was and Tukey post hoc test was used
VA (normal distributions)/Kruskal–Wallis
for multiple comparison of the means.(not-normal For statistical distributions) were University
tests, JASP (v.16.2, used for the of
used for multiple comparison of the means. For statistical tests, JASP (v.16.2, University
analysisAmsterdam,
of several dependent
Holland) and groups
the IBM (marginal or internal
SPSS Statistics softwarefit among
(IBM, New all three
York,materials);
NY, USA)
of Amsterdam, Holland) and the IBM SPSS Statistics software (IBM, New York, NY,
two-way
USA) ANOVA
were
were used.
used. A(normal distributions)/Friedman
significance
A significance level
level of α = 0.05 was set.(not-normal distributions) test were
of α =0.05 was set.
used to compare more than two different time points to obtain the interaction effect
among the material and measurement points (Mg and IG), and Tukey post hoc test was
used for multiple comparison of the means. For statistical tests, JASP (v.16.2, University
of Amsterdam, Holland) and the IBM SPSS Statistics software (IBM, New York, NY,
USA) were used. A significance level of α =0.05 was set.
Polymers 2023,
Polymers 15, 15,
2023, 1715x FOR PEER REVIEW 6 of 613
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3.3.Results
Results
For
Foreach
eachspecimen,
specimen, the
the linear space
space between
betweenthe
thedental
dentalpreparation
preparation and
and thethe internal
internal
surfaceofofthe
surface theonlay
onlaywas
wasassessed
assessedatatthe
theestablished
establishedmeasurement
measurement points.
points. The mean val-
values
ofues
theofmarginal
the marginalandand internal
internal gaps
gaps (µm)were
(µm) wereobtained
obtained at each
eachreference
referencepoint forfor
point thethe
mesio-distaland
mesio-distal andbucco-lingual
bucco-lingual sections
sections of
of each
eachmaterial
material(Table
(Table2).2).

Table2.2.Average
Table Average of
of linear
linear measurements
measurementswith
withstandard deviation
standard (SD)
deviation at reference
(SD) points
at reference (a↔n);
points (a↔n);
CI = confidence interval (lower–upper bound) (n = 8).
CI = confidence interval (lower–upper bound) (n = 8).
Pekkton (P) Juvora (J) BioHPP (B)
Point Mean ± SD Pekkton (P)95% CI Mean ± SD Juvora (J)95% CI Mean ± SDBioHPP 95% (B) CI
Point
a Mean
43.75 ± SD
± 5.99 95% CI
31.77–55.73 Mean±±12.23
64.38 SD 95% CI
39.92–88.84 Mean
61.88 ± SD
± 10.73 95% CI
40.42–83.34
ba 19543.75
± 26.93
± 5.99 141,14–248.86
31.77–55.73 197.5 ±
64.38 ± 20.16
12.23 157.18–237.81
39.92–88.84 165 ± 25.73
61.88 ± 10.73 113.54–216.46
40.42–83.34
cb 197.5 195 ± 26.93
± 22.78 151.95–243.06
141.14–248.86 190 ±±25.74
197.5 20.16 138.52–241.48
157.18–237.81 165 ±
183,13 ± 26.63
25.73 129.67–236.39
113.54–216.46
dc 93.12197.5 ± 22.78
± 19.60 151.95–243.06
53.92–132.32 160 ±
190 25.74
± 20.62 138.52–241.48
118.76–201.24 183.13± ±
101.25 26.63 54.3–147.55
23.15 129.67–236.39
ed 93.12
150 ± 19.60
± 28.06 53.92–132.32
93.88–206.12 160 ±±20.62
177.5 24.11 118.76–201.24
129.28–225.72 101.25± ±
145.63 23.15 88.63–202.63
28.50 54.3–147.55
e 150 ± 28.06 93.88–206.12 177.5 ± 24.11 129.28–225.72 145.63 ± 28.50 88.63–202.63
f 195 ± 22.36 150.28–239.72 196.25 ± 16.54 163.17–229.08 168.13 ± 26.98 114.17–222.09
f 195 ± 22.36 150.28–239.72 196.25 ± 16.54 163.17–229.08 168.13 ± 26.98 114.17–222.09
gg 134.38
134.38± 24.99
± 24.99 84.01–83.98
84.01–83.98 158.75±
158.75 ± 23.95
23.95 110–206.65
110–206.65 90.63
90.63± ±
1616 58.63–122.63
58.63–122.63
hh 58.75 ± 12.18
58.75 ± 12.18 34.39–83.11
34.39–83.11 120.63 ±
120.63 ± 21.06 78.51–162.75
78.51–162.75 89.38
89.38± ±
14.78
14.78 59.82–118.94
59.82–118.94
ii 73.13
73.13 ± 13.56
± 13.56 46.01–100.25
46.01–100.25 135 ±
135 ± 22.64 89.72–180.28
89.72–180.28 123.13± ±
123.13 25.67 71.79–174.47
25.67 71.79–174.47
jj 170170 ± 17.68
± 17.68 134.64–205.36
134.64–205.36 170 ±
170 26.09
± 26.09 117.82–222.18
117.82–222.18 173.75± ±
173.75 28.70 116.35–231.15
28.70 116.35–231.15
kk 50 ±
50 ± 11.1811.18 27.64–72.36
27.64–72.36 80 ±
80 13.23
± 13.23 53.54–106.46
53.54–106.46 33.13± ±
33.13 8.45
8.45 16.23–65.59
16.23–65.59
l 67.50 ± 10.90 45.7–89.3 91.25 ± 11.11 69.03–113.47 30 ± 8.66 12.68–47.32
lm 67.50 ± 10.90
76.25 ± 11.66
45.7–89.3
52.93–59.57
91.25 ± 11.11
63.13 ± 12.10
69.03–113.47
34.93–87.33
3035± ±
8.66
7.91
12.68–47.32
19.18–45.82
mn 76.25 ± 11.66
116.25 ± 22.88 52.93–59.57
70.49–162.01 63.13
87.5 ±± 16.39
12.10 34.93–87.33
54.72–120.28 35 ± 7.91
101.25 ± 19 19.18–45.82
63.25–139.25
n 116.25 ± 22.88 70,49–162,01 87.5 ± 16.39 54.72–120.28 101.25 ± 19 63.25–139.25

For
ForP,P, the lowestvalues
the lowest valueswere were reported
reported at points
at points a (43.75
a (43.75 ± 5.99),± k5.99), k (50 ±
(50 ± 11.18), and 11.18),
h
and h (58.75
(58.75 ± 12.18),± 12.18),
and theand the values
highest highestwere values were at
reported reported
points bat points
(195 b (195
± 26.93), ± 26.93),
c (197.5 ±
(197.5 ±
c 22.78), and22.78),
f (195and f (195
± 22.36); for±J, 22.36);
the lowest for values
J, the lowest values at
were reported were reported
points a (64.38at points a
± 12.23)
(64.38
and m ±(63.13
12.23)±and 12.10), and the±highest
m (63.13 12.10),values
and the werehighest
reportedvalues were b
at points reported
(197.5 ± at points
20.16), c b
(190 ±±25.74),
(197.5 20.16),andc (190 ± 25.74),
f (196.25 and ffor
± 16.54); B, the±lowest
(196.25 16.54);values
for B, were
the lowest values
reported were lreported
at points (30 ±
at8.66),
points l (30 ±±8.66),
k (33.13 (35 ± ±
8.45), km(33.13 8.45),
7.91), and ma(35 ± 7.91),
(61.88 andand
± 10.73), a (61.88 ± 10.73),
the highest and the
values werehighest
re-
values
portedwere reported
at points at points
c (183,13 c (183.13
± 26.63) ± 26.63)
and j (173.75 and j (173.75 ± 28.70).
± 28.70).
ItItwas
wasobserved
observed that that for all three
three materials,
materials,the thelowest
lowestvaluesvalues were
wererecorded
recorded at points
at points
a a(P(P<<J J==B),
B),kk(B(B<< PP < J), and
and m m (B(B <<JJ<<P),
P),followed
followedbybyl (B l (B< <
P <P J), and
< J), thethe
and highest
highestvalues
values
wererecorded
were recordedatatpoints
pointsc c(B(B<<JJ<< P),
P), bb (B
(B < P=
P =J),J),and
andf f(B(B< <P P= J), followed
= J), followed byby
j (Pj (P
= J == JB).
= B).
Thetotal
The totalmean
meanvalues
valuesof of the
the evaluation
evaluation points
pointsfor forall
allmaterials
materialsare areshown
shown inin
Figure
Figure 4. 4.

Mean disrepancy for all groups

250.00
Discrepacy values (µm)

200.00

150.00

100.00

50.00

0.00 Pekkton
Juvora
a b c d e f g h i j k l m n
BioHPP
Location of measurement

Figure 4. Average values obtained at the reference points of the both sections.
Polymers 2023, 15, x FOR PEER REVIEW 7 of 13
Polymers 2023, 15, x FOR PEER REVIEW 7 of 13

Polymers 2023, 15, 1715 7 of 13

Figure 4. Average values obtained at the reference points of the both sections.
Figure 4. Average values obtained at the reference points of the both sections.
Regarding
Regarding MG, MG,thethe
lowest
lowestvalue
valuereported
reported forfor
P was
PPwaspoint a (43.75
point aa(43.75± 5.99), thethe
±± 5.99), lowest
lowest
value Regarding
reported for JMG,
was the lowest
point a = mvalue
(63.13reported
± 12.10),forthe was
lowestpoint
value (43.75
reported 5.99),
for the lowest
B was
value
value reported
reported for
for J
J was
was point
point aa == mm (63.13
(63.13 ± ± 12.10),
12.10), the the lowest
lowest valuevalue reported
reported for forwas
B B
point
was mpoint
(35 ± m
7.91),
(35 and
± the highest
7.91), and thevalues
highest were at point
values were nat
forpoint
all the
n materials;
for all the the lowest
materials; the
point m
IG lowest
values (35 recorded
were ± 7.91), and the highest values were at point andntheforhighest
all the materials; therec-
lowest
IG values were at point
recorded katfor all
point the materials,
k for all the materials, and the values
highestwerevalues were
IG
orded values
at points were recorded
c for Pc(197.5 at point
± 22.78) k for all the materials, and the highest values were rec-
recorded at points for P (197.5 ± and
22.78)B (183,13 ± 26.63)±and
and B (183.13 b for
26.63) and J (197.5
b for J±(197.5
20.16).±The20.16).
orded
total mean at points(µm)
c forfor
P (197.5 ± 22.78) and B (183,13 ± 26.63) and b for J (197.5 ± 20.16).
andThe
The totalvalues
mean values MG for
(µm) and MGIG for
andall IGthree polymers
for all are
three polymers displayed in Table
are displayed in3 Table 3
total mean
represented values
graphically (µm)in for MG
Figure 5.and IG for all three polymers are displayed in Table 3 and
and represented graphically in Figure 5.
represented graphically in Figure 5.
Table 3. Average
Table values
3. Average with
values standard
with deviation
standard for for
deviation MGMGandand
IG (n
IG=(n8).= 8).
Table 3. Average values with standard deviation for MG and IG (n = 8).
Mean
Mean
Pekkton (P)
Pekkton
Juvora (J) BioHPP (B)
Mean Pekkton(P) (P) Juvora
Juvora(J) (J) BioHPP
BioHPP(B) (B)
MG 78.75 ± 9.92 71.67 ± 8.74 66.04 ± 7.57
MG 78.75 ± 9.92 71.67 ± 8.74 66.04 ± 7.57
IG MG 78.75
129.17 ± 9.92
± 8.23 71.67
154.27 ± 8.74
± 6.98 66.04
120.99 ± 7.57
± 9.65
IG
IG 129.17±±8.23
129.17
8.23 154.27±±6.98
154.27
6.98 120.99±±9.65
120.99
9.65

Marginal and internal adaptability

200
Marginal and internal adaptability
200
150
150
100
100
50
50 MG
0 MG
0 IG
Pekkton Juvora BioHPP IG
Pekkton Juvora BioHPP
Figure 5. The marginal and internal discrepancy mean values for all three materials.
Figure5.5.The
Figure Themarginal
marginaland
andinternal
internaldiscrepancy
discrepancymean
meanvalues
valuesfor
forall
allthree
threematerials.
materials.
The two-way ANOVA/Friedman test (α = 0.05) reported significant differences (p <
The two-way ANOVA/Friedmantest test(α(α= 0.05)
= 0.05) reported significant differences
0.001) forThe all two-way
three materialsANOVA/Friedman
when the statistical analysisreported significant
was performed differences
to compare the(p <
(p <
0.001)0.001) for
for all atall three
three materials when the statistical analysis was performed to compare the
values recorded the materials
reference whenpointsthe (MG statistical
and IG)analysis
for eachwas performed
material. Following compare
multi- the
values recorded at the reference points (MG and IG) for each material. Following multiple
ple values
pairwise recorded
comparison at the ofreference points (post
the averages (MG and hoc IG)
test),forthere
eachwere
material. Following
significant multi-
differ-
pairwise
ple pairwisecomparison
comparison of theofaverages
the (post hoc
averages (posttest),
hoc there
test),were significant
there were differences
significant in
differ-
ences in terms of MG (points a–m–n), except for J at points a–m, and for IG (from points
terms of MG (points a–m–n), except for except
J at points Ja–m, and for IG and
(from forpoints b to points
j), the
b toences
j), theindataterms
areof MG
ordered (points
in thea–m–n),
sequence B > Pfor at points
> J, with a–m,
the note that points IGb,(from
c, and f
data
b to are
j), ordered
the data in the
are sequence
ordered in B>
the P > J, with
sequence B >the
P >note
J, thatthe
with points
note b, c, and
that f present
points b, c, thef
and
present the most significant differences in relation to the other internal points (l, k, g, h,
most significant differences in relation to the other internal points (l, k, g, h, and (l, k, g,all
i) for
andpresent
i) for all thethe
most significant polymers.
experimental differencesThere in relation
was atosignificant
the other discrepancy
internal points between h,
the
and experimental
i) for all the polymers.
experimental There was
polymers. a significant
There was discrepancy
a between
significant MG
discrepancy and IG in
between
MG and IG in each group (a more evident one for J) (Figure 6a–c).
each
MG and group IG(ainmore
each evident
group (aone morefor evident
J) (Figure 6a–c).
one for J) (Figure 6a–c).

(a) (b) (c)

(a) (b) (c)
Figure 6. Descriptive
Figure plots
6. Descriptive MG—IG.
plots (a) Pekkton;
MG—IG. (b) Juvora;
(a) Pekkton; (c) BioHPP.
(b) Juvora; (c) BioHPP.
Figure 6. Descriptive plots MG—IG. (a) Pekkton; (b) Juvora; (c) BioHPP.
When
When thethe statistical
statistical tests
tests wereapplied
were applied(Table
(Table4)4)to
to compare
compare the MG MG andandIGIGamong
amongtwo
When
two(Figure
(Figure7a–c)the statistical
7a–c)ororthree tests
threematerials were
materials(Figureapplied
(Figure8a,b),(Table
it it
8a,b), 4)
revealed to
revealed compare
significantthe
significant MG and
differences
differencesIG among
(p (p
< 0.05)
<
two
0.05) (Figure
between
between P–J, 7a–c)
P–B,
P–J, P–B,or
and three
and J–BJ–Bmaterials
(except
(exceptMG,(Figure
MG, 8a,b),
p >p 0.05).
> 0,05). it
The
The revealed
MGMG and
and significant
IGIGforfor differences
B were
B were signifi-(p <
significantly
0.05) between
smaller P–J,of
than those P–B,
J andandP, J–B
and(except MG,
the IG of p > significantly
J was 0,05). The MG and than
larger IG for B were
that of B andsignifi-
P.
 Polymers 2023, 15, 1715 8 of 13

Polymers 2023, 15, x FOR PEER REVIEW Table 4. p values regarding MG and IG among polymer groups (n = 8). 8 of 13
mers 2023, 15, x FOR PEER REVIEW 8 of 13

MG IG
P-J p = 0.047 p < 0.001
cantly smaller than those of J and P, and the IG of J was significantly larger than that of B
cantly smaller than those P-B
of J and P, and the IG of J was
p < significantly
0.001 larger than that
p =of B
0.013
and P. J-B p = 0.11 p < 0.001
and P.

(a)
(a)

(b)
(b)

(c)
(c)
Figure 7. Descriptive plots for MG and MG between materials: (a) Juvora-Pekkton; (b) BioHPP-
Figure 7. Descriptive
Figure 7.plots for MG plots
Descriptive and MG between
for MG materials:
and MG between (a) materials:
Juvora-Pekkton; (b) BioHPP- (b) BioHPP-
(a) Juvora-Pekkton;
Pekkton; (c) BioHPP-Juvora.
Pekkton; (c) BioHPP-Juvora.
Pekkton; (c) BioHPP-Juvora.

(a) (b)
(a) (b)
Figure 8.Figure
Descriptive plots of (a)
8. Descriptive MGofand
plots (b) IG
(a) MG for(b)
and allIG
materials.
for all materials.
Figure 8. Descriptive plots of (a) MG and (b) IG for all materials.

Table 4. p4.values
Discussion
regarding MG and IG among polymer groups (n = 8).
Table 4. p values regarding MG and IG among polymer groups (n = 8).
The aim of this study was to evaluate the marginal and internal fits of MOD onlays
fabricated by the milling of three MG IG using CAD/CAM
MGdifferent high-performanceIG polymers
P-J
technology and visualized with p3D= 0.047
radiographic micro-CT; < 0.001
passessment
P-J p = 0.047 p <the
0.001 of adaptability
was P-B
carried out by measuring < 0.001
pthe thickness of the cement p = 0.013
layer at different locations
P-B p < 0.001 p = 0.013
J-B
(marginal and internal points) p = 0.11 p < 0.001
J-B p =and
0.11statistical analysis of thep mean
< 0.001values determined in the
two (sagittal and coronal) sections both for the polymer and among the materials to present
4. Discussion
4. Discussion
The aim of this study was to evaluate the marginal and internal fits of MOD onlays
The aim of this study was to evaluate the marginal and internal fits of MOD onlays
fabricated by the milling of three different high-performance polymers using CAD/CAM
fabricated by the milling of three different high-performance polymers using CAD/CAM
Polymers 2023, 15, 1715 9 of 13

a complete picture of the restoration procedure for master preparation. To obtain clinically
relevant information, Groten [50] recommends a number of 50 measurement points, but for
a more extensive analysis, we exceeded this number.
In the current study, significant discrepancies between MG and IG for each experimen-
tal material were reported; the results showed that the internal gaps are significantly greater
than the marginal gaps are for each material (more evident with Juvora), and additionally,
after multiple pairwise comparisons of the average values measured at the reference points,
there were significant differences between the marginal gap points (a, m, and n), except
for Juvora (a–m with almost equal values) and among the internal gap points (from b to
j); the values at points b, c, and f are significant greater than those at points l, k, g, h, and
i for all materials; therefore, the first null hypothesis is rejected. A potential explanation
for this aspect may be the largest gaps at locations b and c due to the preparations in
these areas being geometrically complex with angles, and these were not adapted during
fitting. This situation can be attributed to the reduced scanning accuracy, resulting in
rounded edges [51,52], or to the milling processing [53]; the diameter of the smallest rotary
instruments was 1 mm, which in narrow areas, such as the proximal cavity, can lead to
unwanted removal of the material. It is also possible that the accuracy of resin abutment
is adversely affected with deformed or sloping surfaces, causing larger internal gaps. It
seems that a consequence of this state is the reduction of adaptability and the increase in
the size of the cement layer in other locations such as f and j, where higher values were
recorded for all the polymers. The measuring points are located on relatively flat surfaces,
allowing the good flow and placement of the cement, and the layer should be minimal if
the onlay is optimally adapted to the preparation. Lower values were recorded on the axial
walls of the preparations at locations h and l for Pekkton, l for BioHPP, and k for all the
materials-as a result of the hydraulic pressure applied on the convergent axial walls, which
forced the cement towards the occlusal or marginal areas, allowing flow and evacuation
until the minimum potential thickness was obtained [54].
The results support the opinion that the type of material, the manufacturing technol-
ogy, and the cementing technique can influence the fit of the restoration. Perfect adaptability
reduces percolation and cement dissolution and helps to maintain gingival health [55–57].
CAD/CAM restorations can be affected by the scanning systems; great adaptability de-
pends on the accuracy of scanning [58,59] and the fabricating technique and the milling
equipment (size and wear of the rotary instruments) [60,61]; however, no statistical dif-
ferences were reported when the discrepancies between three samples obtained with a
five-axis milling machine were analyzed [62]. Every innovative stage of development in
the CAD/CAM system, from its design to mechanical processing, had a positive impact on
the marginal and internal fit of the restorations [63,64].
Among the materials, in terms of the MG and IG, significance differences (p < 0.05)
were reported (except for MG: J–B); BioHPP showed significantly better marginal and
internal accuracy than the other two groups did; Pekkton had the largest marginal gaps,
and Juvora had the largest internal gaps. J and B belong to the PEEK group—J is a
100% polyetheretherketone and B is a ceramic-reinforced PEEK with 20% ceramic fillers,
which improve its mechanical properties; P is a PEKK (polyetherketoneketone) and
presents excellent mechanical properties. The compression/flexural strength values for
Pekkton = 246 MPa, for filled PEEK > 150 MPa, and for non-filled PEEK = 111 MPa [29]. In
this study, it was observed that BioHPP showed the best adaptability, better machinability,
and less susceptibility to fracture; it seems that of the three polymers, it can be more easily
processed to obtain inlays/onlays from prefabricated blocks. Juvora had a lower flexural
strength and hardness than the other two polymers did, and a greater quantity of material
was removed from intaglio surface by the rotary instruments during milling. In the cur-
rent study, it was revealed that the type of material influences the quality of adaptability;
therefore, the second null hypothesis is rejected.
The preparation and configuration of the finish line are essential factors that can
influence the marginal discrepancy; heavy chamfer preparation for support buccal (func-
Polymers 2023, 15, 1715 10 of 13

tional) cusps and a contra bevel margin for the lingual (non-functional) cusp were used
according to investigations that assessed the impact of various marginal lines [65,66]; in
other studies, insignificance differences between the chamfer and shoulder preparation
were found [67,68]. No significant differences were found when we were comparing the
points a–m for Juvora and MG between Juvora and BioHPP. PEEK materials exhibit good
marginal machinability, regardless of finish line design; however, at the point n (contra
bevel), the highest values among the marginal points were recorded for all the polymers.
Several studies have assessed that a marginal gap less of than 120 µm and internal
gap ranging from 20 to 200 µm are suitable for the optimal fit of fixed restorations [69,70].
In the present study, the mean values for cement thickness range from 30 to 200 µm for
onlays, which is considered to be clinically acceptable.
The limitation of this study could be that only a few materials were investigated with
a single scanner, and it is possible that other systems with different image capture methods
and light sources may lead to other results; therefore, further studies are needed to evaluate
the adaptability of fixed restorations obtained using CAD/CAM technology.

5. Conclusions
For all the tested specimens related to the investigated reference locations, various
levels of adaption were recorded (less marginal ones for Juvora), and the IG values were
significantly greater than the MG values were for all three materials.
The type (composition, mechanical properties, and machinability) of polymer influ-
enced the accuracy. The best behavior is related to the ceramic-reinforced PEEK material,
followed by unmodified PEKK and PEKK; all the polymers are clinically acceptable in
terms of adaptability.
A poor fit in the angular areas affects adaptability in others areas of the
restoration differently.

Author Contributions: Conceptualization, F.R.T. and L.P.; methodology, F.R.T. and L.P.; software,
F.R.T. and L.C.M.; validation, F.R.T. and L.P.; investigation, F.R.T., L.C.M. and L.P.; writing—F.R.T.;
writing—review and editing, L.P.; supervision, L.P. All authors have read and agreed to the published
version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.

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