Abstract
Purpose
To evaluate the influence of prosthetic material type on the survival of tooth-supported fixed dental prostheses by comparing metal-ceramic, all-ceramic, and zirconia restorations, as well as the associated technical and biological complications.
Materials and Methods
A systematic review of the literature was conducted using PubMed, ScienceDirect, and Wiley Online Library databases for the period 2015–2026. The search strategy was based on keywords related to fixed dental prostheses. Seventeen studies were included after applying inclusion and exclusion criteria. Qualitative analysis of the data was performed owing to the methodological heterogeneity of the included studies.
Results
Seventeen studies were included in this systematic review. Metal-ceramic restorations showed high survival rates, reaching 100% at 5 and 10 years in some studies. All-ceramic restorations demonstrated survival rates ranging from 88% to 100%, with excellent esthetic performance but mechanical variability depending on the material. Zirconia restorations showed variable survival rates, ranging from 71% to over 100%, depending on the study and follow-up duration, with a higher frequency of technical complications, particularly chipping of the veneering ceramic in layered restorations.
Conclusion
Metal-ceramic restorations are a benchmark for clinical reliability. All-ceramic and zirconia restorations are effective alternatives, particularly when high esthetic demands are involved. Material selection should be individualized and based on biomechanical constraints, esthetic requirements, and patient-specific characteristics to optimize the long-term clinical outcomes.
Keywords: fixed dental prosthesis, clinical survival, metal-ceramic, all-ceramic, zirconia, prosthetic complications
Introduction
Fixed prosthetic restorations are a commonly used therapeutic option for restoring severely damaged teeth and replacing missing teeth. Their clinical success depends not only on biological and mechanical conditions, but also on the type of material used.1
Metal-ceramic restorations have long been considered a benchmark in fixed prosthodontics owing to their clinical reliability and high long-term survival rates.2,3
However, the development of all-ceramic and zirconia-based restorations has modified therapeutic approaches owing to their esthetic advantages and favorable biomechanical properties.3
Literature indicates that metal-ceramic, all-ceramic, and zirconia restorations generally show high survival rates. Nevertheless, reported technical and biological complications differ according to the material, type of restoration, and clinical conditions.2,3
Although several systematic reviews have evaluated the clinical performance of metal-ceramic, all-ceramic, or zirconia restorations, most have focused on a single material category, specific restoration designs, or limited follow-up periods. Moreover, recent systematic reviews have not comprehensively compared the survival outcomes and complications associated with the principal prosthetic material types used for tooth-supported fixed dental prostheses. Therefore, an updated systematic review is warranted to provide clinicians with a comprehensive synthesis of the current evidence and to facilitate evidence-based material selection in clinical practice.
The choice of prosthetic material plays a crucial role in the long-term success of tooth-supported fixed dental prostheses, influencing not only survival but also biological and technical complications, esthetic outcomes, and maintenance requirements. Therefore, providing clinicians with an updated evidence-based comparison of the available prosthetic materials is essential to support informed treatment planning and optimize patient care.
In this context, it is necessary to comparatively analyze the influence of the material on the survival of tooth-supported fixed dental prostheses.
Materials and Methods
Study Type
The present work consisted of a systematic review of the literature aimed at evaluating the impact of prosthetic material type on the survival of tooth-supported fixed dental prostheses.
Literature Search Strategy
A literature search was conducted using the PubMed, ScienceDirect, and Wiley Online Library databases. Publications published between 2015 and 2026 are also included.
The search strategy was developed using keywords combined with the Boolean operators AND and OR.
The keywords used included fixed dental prosthesis, fixed prosthesis, dental crown, dental bridge, survival rate, longevity, clinical performance, metal-ceramic, porcelain fused to metal, all-ceramic, and zirconia.
No additional manual searches, citation tracking, or other supplementary search methods were performed beyond the electronic database search.
The PRISMA 2020 checklist4 is provided in Supplementary Table 1, and the complete search strategies for all databases are provided in Supplementary Table 2.
Inclusion and Exclusion Criteria
Studies involving adult patients rehabilitated with tooth-supported fixed dental prostheses and those evaluating the clinical survival and/or complications of metal-ceramic, all-ceramic, or zirconia restorations were included. Articles were available in the full text and were published in English and/or French.
Studies were eligible if they reported a minimum clinical follow-up of 1 year. This minimum follow-up period was selected to ensure that the included studies provided clinically meaningful data regarding the survival and complications of tooth-supported fixed dental prostheses while allowing the inclusion of an adequate number of relevant studies.
In vitro studies, isolated clinical case reports, narrative reviews, editorials, letters, and studies focusing on implant-supported restorations were also excluded.
Study Selection
The selection process included the identification of references, removal of duplicates, screening of titles and abstracts, assessment of full-text articles, and final study inclusion according to the predefined eligibility criteria. Following the full-text assessment, 17 studies met the eligibility criteria and were included in the qualitative synthesis.
Study selection was performed independently by two reviewers. Any disagreements regarding study eligibility were resolved through discussion until a consensus was reached.
Data Extraction
A standardized data extraction form was developed a priori to ensure the systematic and consistent collection of relevant information from all eligible studies. Data extraction was performed independently by two reviewers using a predefined extraction form. Any discrepancies between the reviewers were resolved through discussion until consensus was reached.
The extracted variables included the first author’s name, study design, sample size, type of tooth-supported fixed dental prosthesis, prosthetic material evaluated, restoration design, follow-up duration, survival and success rates, reported biological and technical complications. In addition, the methodological quality and risk of bias of each included study were assessed using the appropriate assessment tool according to the study design (RoB 2 for randomized controlled trials, Newcastle–Ottawa Scale for observational studies, and AMSTAR-2 for systematic reviews and meta-analyses).
Following extraction, all data were cross-checked for accuracy and completeness before being entered into the evidence synthesis table. Because of the substantial methodological and clinical heterogeneity among the included studies, the extracted data were synthesized qualitatively rather than quantitatively.
Risk of Bias Assessment
The methodological quality of the included studies was assessed according to the study design. Randomized controlled trials were evaluated using the Cochrane Risk of Bias 2 (RoB 2) tool. Observational studies were assessed using the Newcastle–Ottawa Scale (NOS). Systematic reviews and meta-analyses were evaluated using the AMSTAR-2 tool. The overall risk of bias for each included study is summarized in Table 1.
Table 1.
Risk of Bias Assessment of the Included Studies
| Study Design | Assessment Tool | Proposed Risk of Bias | Main Justification | |
|---|---|---|---|---|
| Rinke and al5 | Prospective comparative non-randomized study | Newcastle–Ottawa Scale (NOS) | Moderate | Lack of randomization and relatively small sample size. |
| Suárez and al6 | Randomized controlled trial | Cochrane RoB 2 | Low | Adequate randomization with an overall low risk of bias. |
| Sailer and al7 | Randomized controlled trial | Cochrane RoB 2 | Low | High-quality randomized clinical trial with 10-year follow-up. |
| Limones and al8 | Systematic review and meta-analysis | AMSTAR-2 | Low | Well-conducted systematic review with rigorous methodology. |
| Rinke and al9 | Prospective clinical study | Newcastle–Ottawa Scale (NOS) | Moderate | Single-center design without randomized control group. |
| Stefanescu and al10 | Systematic review | AMSTAR-2 | Moderate | Considerable heterogeneity and absence of quantitative synthesis. |
| Matta and al11 | Prospective clinical study | Newcastle–Ottawa Scale (NOS) | Moderate | Small sample size and considerable loss to follow-up. |
| Grguraš Lestan and al12 | Prospective clinical study | Newcastle–Ottawa Scale (NOS) | Moderate | Limited sample size (20 patients). |
| Takaesu and al13 | Retrospective cohort study | Newcastle–Ottawa Scale (NOS) | Moderate | Retrospective cohort with potential selection bias. |
| Hjerppe and al14 | Randomized controlled trial | Cochrane RoB 2 | Low | Multicenter randomized controlled trial with robust methodology. |
| Sulaiman and al15 | Retrospective clinical study | Newcastle–Ottawa Scale (NOS) | Moderate | Large sample size, but retrospective design. |
| Saravi and al16 | Systematic review and meta-analysis | AMSTAR-2 | Low to Moderate | Significant heterogeneity among the included studies. |
| Mazza and al17 | Systematic review and meta-analysis | AMSTAR-2 | Low | High methodological quality with comprehensive analysis. |
| Pott and al18 | Retrospective clinical study | Newcastle–Ottawa Scale (NOS) | High | Retrospective design, no control group, and heterogeneous follow-up duration. |
| Homa and al19 | Multicenter longitudinal clinical study | Newcastle–Ottawa Scale (NOS) | Moderate | Small sample size despite the multicenter design. |
| Ling, Huang20 | Systematic review and meta-analysis | AMSTAR-2 | Moderate | Substantial heterogeneity reported by the authors. |
| Romandini and al21 | Systematic review and meta-analysis | AMSTAR-2 | Low | Recent, comprehensive systematic review and meta-analysis with robust methodology. |
Data Analysis
Due to the substantial clinical and methodological heterogeneity among the included studies, a quantitative meta-analysis was not performed. The studies differed considerably in terms of study design (randomized clinical trials, prospective studies, retrospective studies, and systematic reviews), prosthetic materials, restoration types, follow-up duration, sample size, and reported clinical outcomes. Furthermore, variations in outcome definitions and reporting methods precluded meaningful statistical pooling of the data. Therefore, a qualitative narrative synthesis was considered the most appropriate approach to summarize the available evidence.
Results
The study selection process is summarized in the PRISMA flow diagram (Figure 1), illustrating the different stages of literature identification, screening, eligibility assessment, and final inclusion. Following the application of the predefined eligibility criteria, 17 studies were included in the qualitative synthesis.
Figure 1.
PRISMA flow diagram illustrating the study selection process for inclusion in the systematic review.
The 17 included studies comprised prospective clinical studies, retrospective clinical studies, randomized controlled trials, systematic reviews, and meta-analyses. Follow-up durations ranged from 1 to 15 years. Sample sizes varied considerably, ranging from 20 patients to 21340 restorations, reflecting the substantial methodological and clinical heterogeneity of the included evidence.
The main characteristics of the included studies are summarized in Table 2.
Table 2.
Main Characteristics of the Included Studies Evaluating Survival and Complications of Tooth-Supported Fixed Prosthetic Restorations
| Author(s) | Study Type | Objective | Sample Size | Type of Restoration | Follow-Up | Survival Rate | Reported Complications |
|---|---|---|---|---|---|---|---|
| Rinke and al5 | Prospective comparative non-randomized clinical study | To evaluate and compare over a five-year period the survival, overall success, and esthetic ceramic success of metal-ceramic and zirconia molar crowns, taking into account the influence of their position. | 45 patients; 91 crowns (41 metal-ceramic, 50 zirconia) | Tooth-supported single molar crowns: metal-ceramic and layered zirconia | 5 years |
|
Complete failures: secondary caries, periapical granuloma, major ceramic fracture, loss of retention. Other complications: chipping No framework fracture reported |
| Suárez and al6 | Randomized controlled clinical trial | To compare survival, success, failure rates, and biological and technical complications of posterior three-unit zirconia versus metal-ceramic bridges. | 40 patients; 40 bridges (20 metal-ceramic, 20 zirconia) | Posterior three-unit bridges: metal-ceramic vs zirconia | 5 years |
|
Biological complications: secondary caries, loss of vitality. Technical complications: ceramic chipping No framework fracture reported |
| Sailer and al7 | Randomized clinical trial | To follow posterior zirconia and metal-ceramic fixed dental prostheses in terms of survival and technical and biological complications. | 58 patients, 76 bridges (40 zirconia, 36 metal-ceramic) | Posterior fixed dental prostheses (3 to 5 units): zirconia and metal-ceramic | 10 years | -Zirconia: 91.3% - MC: 100% |
Technical complications:
|
| Limones and al8 | Systematic review and meta-analysis of randomized clinical trials | To evaluate and compare survival rates and biological and technical complications of posterior multi-unit zirconia and metal-ceramic fixed dental prostheses. | 330 prostheses (177 zirconia and 173 metal-ceramic) | Posterior multi-unit fixed dental prostheses (3–5 units): layered zirconia, metal-ceramic | 3 to 5 years; one study with 10-year follow-up | -Zirconia: 95.4% - MC: 96.9% |
Biological complications:
|
| Rinke and al9 | Prospective clinical study | To evaluate the long-term survival and success rates of posterior zirconia fixed dental prostheses fabricated with first-generation CAD/CAM technologies | 75 patients/99 prostheses (81 three-unit bridges, 18 four-unit bridges) | Posterior tooth-supported zirconia fixed dental prostheses with zirconia frameworks and veneering ceramic | 10 years | Overall survival 75% Technical survival 84% overall success 40% technical success 57% |
Technical complications: framework fractures, veneering ceramic fractures, loss of retention. Biological complications: secondary caries, periodontal lesions, root fractures. Frequent events: ceramic chipping (most frequent), debonding. |
| Stefanescu and al10 | Systematic review | To evaluate the survival and success rates of zirconia-based multi-unit fixed dental prostheses, as well as associated biological and technical complications, with a minimum clinical follow-up of 5 years | 368 patients/430 zirconia prostheses | Multi-unit zirconia bridges (mostly three-unit) | 5 to 10 years | 89.43% ± 10.01% | Technical complications:
|
| Matta and al11 | Prospective clinical study | To evaluate the long-term clinical performance of posterior zirconia bridges (3 and 4 units). | 25 patients (including 8 lost to follow-up) | Posterior zirconia bridges layered with feldspathic ceramic | 10 years | Approximately 88.2% |
|
| Grguraš Lestan and al12 | Prospective clinical study | To evaluate the clinical performance of posterior multi-unit monolithic zirconia fixed dental prostheses. | 20 patients/33 monolithic zirconia prostheses | Posterior multi-unit monolithic zirconia fixed dental prostheses (CAD/CAM) | 39.8 ± 16.7 months | 93.9% | Biological complications: gingivitis (1 patient), increased probing depth (15.1%), 1 biological failure (periodontal inflammation). Technical complications: connector fracture (1 case). |
| Takaesu and al13 | Retrospective cohort study | To compare long-term survival and success rates of monolithic zirconia versus veneered zirconia crowns in posterior teeth. | 235 patients/255 zirconia crowns | Posterior crowns: monolithic zirconia vs veneered zirconia | Up to 10 years | − 86% for monolithic zirconia; - 71% for veneered zirconia |
Higher risk of complications depending on site (maxillary molars associated with more complications). |
| Hjerppe and al14 | Randomized clinical trial | To compare survival rates, technical complications, and clinical outcomes between posterior three-unit monolithic zirconia bridges and partially or fully veneered zirconia bridges in patients with single posterior edentulous spaces during a one-year follow-up. | 64 patients | Posterior three-unit zirconia bridges divided into three groups:
|
1 year | None of the restorations were lost after one year in any of the three groups | Technical complications:
Biological/periodontal complications/secondary caries no notable periodontal problems or other major biological complications explicitly mentioned in the available overview. |
| Sulaiman and al15 | Retrospective clinical study | To evaluate the failure rate of lithium disilicate restorations. | 21340 restorations (15802 monolithic; 5538 layered) | Lithium disilicate restorations: single crowns, bridges, veneers, inlays/onlays | 45 months | Not reported | Failures defined as material fractures requiring replacement of the restoration. |
| Saravi and al16 | Systematic review and meta-analysis | To analyze the survival rates and complications of CAD/CAM all-ceramic restorations. | 34 included studies | Single crowns and all-ceramic fixed dental prostheses | 1 to 10 years (depending on the studies) | 88–100% depending on the type of restoration and follow-up duration |
|
| Mazza and al17 | Systematic review and meta-analysis | To evaluate survival rates as well as biological and technical complications of monolithic ceramic restorations (single crowns and bridges). | For single crowns several studies included. For bridges 4 studies included. Total: 104 prostheses analyzed |
|
12 to 167 months | Monolithic crowns
|
Biological complications: for crowns approximately 1%; for bridges approximately 5% (endodontic problems, secondary caries, periodontal disease). Technical complications: for crowns approximately 2%; for bridges approximately 5% (fracture, framework fracture, debonding, chipping, proximal contact loss, antagonist crack). |
| Pott and al18 | Retrospective clinical study | To evaluate the success rate of all-ceramic fixed dental prostheses according to the period of restoration (2011–2023). | 342 all-ceramic prostheses | All-ceramic restorations (crowns, bridges, veneers) | Up to approximately 11.8 years |
|
|
| Homa and al19 | Multicenter clinical study with longitudinal follow-up | To evaluate the long-term clinical performance of anterior and premolar lithium disilicate bridges fabricated by CAD/CAM. | 32 patients/32 three-unit lithium disilicate bridges | Three-unit monolithic lithium disilicate fixed dental prostheses (CAD/CAM) | Mean 10 years, max 15 years |
84.4% at 10 years |
|
| Ling, Huang20 | Systematic review and meta-analysis | To evaluate the survival rates of CAD/CAM all-ceramic restorations and analyze certain associated clinical parameters. | 25 included studies: 13 randomized controlled trials and 12 cohort studies | CAD/CAM all-ceramic restorations | Variable depending on the included studies |
|
|
| Romandini and al21 | Systematic review and meta-analysis | To evaluate 5-year survival, failures, and biological and technical complications of multi-unit fixed dental prostheses made of metal-ceramic, layered ceramic, and monolithic ceramic. | 41 included studies; 600 metal-ceramic prostheses and 1532 all-ceramic prostheses | Multi-unit fixed dental prostheses: metal-ceramic, layered densely sintered zirconia, monolithic zirconia, glass-infiltrated alumina, lithium disilicate glass-ceramic | 5 years | Layered zirconia 92.9% metal-ceramic 91.3% monolithic zirconia 87.9%; glass-infiltrated alumina 88.4%; lithium disilicate 82.5% |
|
Figure 2 illustrates the proportional distribution of the study designs included in the systematic review.
Figure 2.
Proportional distribution of study types included in the systematic review.
Discussion
This systematic review aimed to evaluate the influence of prosthetic material type on the survival of tooth-supported fixed dental prostheses by comparing metal-ceramic, all-ceramic, and zirconia restorations, as well as the technical and biological complications associated with them. Overall, the included studies showed generally high survival rates for the different materials, but they also highlighted notable differences depending on the nature of the material, prosthetic design, extent of restoration, and duration of follow-up. More than survival alone the complication profile and long-term clinical stability distinguish the materials.
Metal-ceramic restorations appear to be the most consistent in terms of clinically reliable. In a prospective comparative study by Rinke et al,5 metal-ceramic molar crowns showed a survival rate of 97.6% at 5 years compared with 94.0% for layered zirconia crowns. The reported failures included secondary caries, periapical granuloma, major ceramic fractures, and loss of retention, with no framework fractures observed. These results suggest good clinical stability for both materials while confirming a slight advantage for metal-ceramic restorations.
This trend is reinforced by the findings of Suárez et al,6 who compared three-unit posterior metal-ceramic and zirconia bridges. The authors reported a 100% survival rate for both metal-ceramic and zirconia restorations after five years. The biological complications were mainly secondary caries and loss of vitality, whereas ceramic chipping was the main technical complication in the zirconia group. This shows that even when survival rates remain high, the nature of complications differs according to the material.
The results of Sailer et al7 further confirmed the long-term clinical superiority of metal-ceramic restorations in posterior regions. At 10 years, the survival rate of posterior fixed dental prostheses was 100% for metal-ceramic restorations versus 91.3% for zirconia prostheses. In the zirconia group, the technical complications included minor chipping of the veneering ceramic, occlusal wear, framework fractures, debonding, major ceramic fractures, and marginal adaptation defects. In contrast, the biological parameters were comparable between the two groups. These data support the view that metal-ceramic restorations retain their status as a benchmark, particularly in areas subjected to high occlusal loads.
The systematic review and meta-analysis by Limones et al8 point in the same direction. The authors reported comparable survival rates for posterior multi-unit layered zirconia prostheses (95.4%) and metal-ceramic prostheses (96.9%) but with a higher frequency of technical complications in the zirconia group, particularly chipping of the veneering ceramic. Therefore, similar survival rates do not necessarily imply complete clinical equivalence, as maintenance needs and the nature of prosthetic incidents differ.
Regarding zirconia restorations, the results are more heterogeneous and appear to depend strongly on the prosthetic design, particularly whether the restoration is layered or monolithic. Layered zirconia restorations demonstrate acceptable performance, but remain marked by a substantial frequency of technical complications, especially those related to the veneering layer. In a 10-year prospective study of first-generation posterior zirconia fixed dental prostheses, Rinke et al9 reported an overall survival rate of 75%, technical survival rate of 84%, overall success rate of 40%, and technical success rate of 57%. The main technical complications were framework fractures, veneering ceramic fractures, and loss of retention, whereas the biological complications included secondary caries, periodontal lesions, and root fractures. Ceramic chipping was the most frequent event.
The data from the systematic review by Stefanescu et al10 are consistent with this finding, with an average survival of 89.43% ± 10.01% for multi-unit zirconia framework bridges over 5 to 10 years of follow-up. The most frequently reported complications included chipping, core fracture, loss of retention, and marginal fit defects, whereas biological complications were more common. These results indicate that zirconia has good clinical potential, but the main weakness of layered restorations is the behavior of the veneering ceramic.
This interpretation is also supported by a prospective study by Matta et al11, in which posterior layered zirconia bridges showed a survival rate of approximately 88.2% at 10 years. Once again, chipping of the veneering ceramic is the most frequent complication. This indicates that, in many cases, the principal clinical problem is not the resistance of the zirconia framework itself, but rather the vulnerability of the veneering material.
Conversely, monolithic zirconia restorations offer improved mechanical stability. A prospective clinical study by Grguraš Lestan et al12 showed a survival rate of 93.9% for posterior multi-unit monolithic zirconia fixed dental prostheses after a mean follow-up of 39.8 ± 16.7 months. Biological complications were limited, and only one connector fracture was observed. These results suggest that eliminating the veneering layer significantly reduced chipping-related complications.
The comparison between monolithic zirconia and veneered zirconia was further illustrated by Takaesu et al,13 who reported a survival rate of 86% for posterior monolithic zirconia crowns and 71% for veneered zirconia crowns. The authors also emphasized that the risk of complications was higher in maxillary molars, showing that prognosis depends not only on the material but also on the clinical site and local functional constraints.
Similarly, a randomized clinical trial by Hjerppe et al14 showed that no prosthesis was lost at 1 year, regardless of whether the posterior three-unit zirconia bridges were monolithic, partially veneered, or fully veneered. However, technical complications differed markedly depending on the design no fractures or chipping were observed in the monolithic group, compared with approximately 9.5% in the partially veneered group and 22.7% in the fully veneered group. Although follow-up remains limited, these results further support the clinical value of monolithic restorations.
All-ceramic restorations also demonstrated globally satisfactory performance, although with variability depending on the material used and type of restoration. The retrospective study by Sulaiman et al,15 which included a very large sample of lithium disilicate restorations, did not report a direct survival rate; however, failures were mainly defined as material fractures requiring replacement of the restoration. This suggests a favorable performance of lithium disilicate, while also indicating that fracture remains a key failure mode for this type of material.
The findings of Saravi et al16 confirm the good clinical performance of CAD/CAM all-ceramic restorations, with survival rates ranging from 88% to 100%, depending on the type of restoration and follow-up duration. The most frequent complications were chipping, fractures, and loss of retention; biological complications included secondary caries and gingival inflammation. These data indicate that all-ceramic restorations constitute a credible alternative, although they remain sensitive to biomechanical constraints and clinical indications.
The benefits of monolithic designs were particularly highlighted by Mazza et al,17 who reported a survival rate of approximately 99% for monolithic single crowns and 97% for monolithic bridges. Biological and technical complication rates remained low, whether they were related to fractures, debonding, chipping, proximal contact loss, or antagonist cracks. These results suggest that the monolithic approach provides a favorable compromise between mechanical resistance and clinical integration.
The data reported by Pott et al18 also support the reliability of all-ceramic restorations, with a survival rate of 94.3% and overall success rate of 91.1% over a follow-up period of approximately 11.8 years. The main complications observed were fractures, debonding, chipping, and marginal complications, particularly secondary caries. Nevertheless, these findings indicate that the favorable performance of all-ceramic restorations requires careful selection of cases.
Particular caution is necessary for multi-unit lithium disilicate restorations. Homa et al19 reported a survival rate of 84.4% at 10 years for CAD/CAM-fabricated three-unit monolithic lithium disilicate bridges. Complications include connector fracture, repeated loss of retention, persistent pain, and loss of an abutment tooth. These results show that despite their esthetic qualities and good performance in some indications, multi-unit lithium disilicate restorations may be more vulnerable when mechanical demands are high.
Recent studies have further confirmed that all-ceramic restorations should not be considered a homogeneous group. Ling and Huang,20 in their meta-analysis, reported overall high survival rates of approximately 96% for CAD/CAM all-ceramic restorations, with favorable results regarding color stability, marginal integrity, and the absence of secondary caries, despite substantial heterogeneity among studies. Romandini et al21 reported 5-year survival rates of 92.9%, 91.3%, 87.9%, 88.4%, and 82.5% for layered zirconia, metal-ceramic, monolithic zirconia, glass-infiltrated alumina, and lithium disilicate, respectively. The authors also observed higher rates of marginal caries and loss of retention in all-ceramic prostheses than in metal-ceramic prostheses, whereas framework fractures were more frequent with lithium disilicate and glass-infiltrated alumina. Chipping remained frequent but wasless common with monolithic zirconia.
Overall, the analyzed data clearly showed that material selection should not rely solely on survival rate. It must also take into account the type of expected complication, restoration site, number of units, monolithic or layered design, esthetic requirements, and occlusal constraints. Metal-ceramic restorations retain their most consistent long-term profile. Zirconia restorations constitute an effective alternative, particularly in monolithic forms, whereas layered restorations remain more exposed to chipping of the veneering ceramic. All-ceramic restorations show satisfactory clinical performance, especially in single-unit indications; however, certain forms, such as lithium disilicate bridges, should be indicated with caution when biomechanical demands are high.
However, this study has several limitations. First, the included studies were heterogeneous in terms of design, sample size, follow-up duration, restoration type, and criteria for success or failure. Second, some studies grouped together biomechanically different restorations within the same category without sufficiently distinguishing monolithic from layered designs. Finally, direct comparisons between materials remain limited owing to the lack of methodological standardization. Furthermore, this review focused exclusively on metal-ceramic, all-ceramic, and zirconia tooth-supported fixed dental prostheses, as these represent the most widely investigated materials in clinical practice. Future systematic reviews may broaden the scope by including additional restorative materials and emerging prosthetic technologies as more long-term clinical evidence becomes available. These factors require careful interpretation of the results and highlight the need for long-term standardized prospective clinical studies.
Ultimately, this review confirms that the type of material influences not only the survival of tooth-supported fixed dental prostheses but also their mode of failure, mechanical stability, and long-term clinical behavior. Although metal-ceramic restorations retain a benchmark role because of their durability, zirconia and all-ceramic restorations represent effective alternatives provided that their indication is adapted to the biomechanical, functional, and esthetic requirements specific to each clinical situation.
Clinical Recommendations
The findings of this systematic review suggest that prosthetic material selection should be individualized according to each patient’s clinical situation and treatment objectives. Metal-ceramic restorations remain a reliable option because of their consistently high long-term survival. All-ceramic restorations provide excellent esthetic outcomes while maintaining favorable survival rates in appropriately selected cases. Zirconia restorations also demonstrate good clinical performance; however, clinicians should consider the higher incidence of technical complications, particularly veneering ceramic chipping in layered restorations. Therefore, material selection should be based on esthetic requirements, functional demands, occlusal conditions, and the patient’s long-term prognosis.
Overall, the findings of this systematic review support evidence-based clinical decision-making by highlighting the strengths and limitations of the principal prosthetic materials. Material selection should be guided by a comprehensive evaluation of the patient’s esthetic expectations, functional requirements, occlusal conditions, risk factors, and long-term prognosis, rather than by a single clinical criterion.
Economic Considerations
In addition to clinical performance, economic considerations may also influence the selection of prosthetic materials. Although metal-ceramic restorations have demonstrated excellent long-term survival and remain a cost-effective treatment option, all-ceramic and zirconia restorations generally involve higher laboratory and material costs because of advanced manufacturing techniques and superior esthetic properties. Therefore, treatment decisions should consider not only the expected clinical outcomes but also the patient’s financial situation and individual treatment priorities.
Limitations
The limitation of the present systematic review is the absence of a quantitative meta-analysis. However, this decision was justified by the substantial clinical and methodological heterogeneity among the included studies. Considerable differences were observed regarding study design, prosthetic materials, restoration types, follow-up duration, outcome definitions, and reported clinical endpoints, making statistical pooling inappropriate and potentially misleading. Consequently, a qualitative narrative synthesis was considered the most suitable method for summarizing the available evidence.
Another limitation of the present systematic review is that the certainty of evidence was not formally assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Although GRADE is a valuable tool for evaluating the certainty of evidence, its application was considered inappropriate in the present review because of the substantial clinical and methodological heterogeneity among the included studies. Differences in study designs, prosthetic materials, follow-up durations, outcome measures, and reporting methods precluded a reliable assessment of the overall certainty of evidence. Furthermore, as no quantitative meta-analysis was performed, the use of GRADE would not have provided a meaningful evaluation of the available evidence. Future systematic reviews including more homogeneous studies and quantitative syntheses should incorporate the GRADE methodology to strengthen the certainty of evidence and facilitate evidence-based clinical recommendations.
Future Research
Future well-designed prospective studies with standardized methodologies and longer follow-up periods are needed to provide more robust comparisons between prosthetic materials. Further research should also evaluate the performance of newer restorative materials and emerging prosthetic technologies, while considering patient-reported outcomes, cost-effectiveness, and long-term biological and technical complications. In addition, future systematic reviews including quantitative meta-analyses, when appropriate, would provide stronger evidence to support clinical decision-making.
Conclusion
The type of prosthetic material significantly influences the clinical performance of tooth-supported fixed dental prostheses, not only in terms of survival but also in terms of mechanical behavior, complication profile, and esthetic outcomes.
Metal-ceramic restorations remain the most consistent and reliable long-term solution, particularly in posterior regions that are subjected to major occlusal loads. Zirconia restorations represent an effective alternative, with particular interest in monolithic designs that appear to reduce the risk of chipping observed with layered restorations. All-ceramic restorations, especially those based on lithium disilicate, provide satisfactory clinical outcomes and major esthetic benefits; however, their indications should be made with caution in multi-unit restorations when biomechanical demands are high.
Therefore, prosthetic material selection should be individualized according to the available scientific evidence, the location and extent of the restoration, esthetic requirements, functional demands, and patient-specific characteristics. From a clinical perspective, metal-ceramic restorations remain a reliable option for long-term rehabilitation, particularly in posterior regions subjected to high occlusal loads, whereas all-ceramic restorations are especially appropriate when esthetic outcomes are a priority. Monolithic zirconia restorations also represent a predictable treatment option, provided that their indications are carefully considered. Overall, optimal prosthetic survival depends on careful treatment planning and evidence-based material selection tailored to each patient’s clinical needs.
Disclosure
The authors report no conflicts of interest.
References
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