J Prosthodont Res.

2021; **(**): ****–****

Review
Journal of Prosthodontic Research article

Clinical performance of monolithic CAD/CAM tooth-supported

zirconia restorations: systematic review and meta-analysis
Celina Inês Miranda Brito Leitãoa, Gustavo Vicentis de Oliveira Fernandesb,*, Luís Pedro
Pereira Azevedoc, Filipe Miguel Araújob, Helena Donatod, André Ricardo Maia Correiab
a Faculty of Dental Medicine, Universidade Católica Portuguesa, Viseu, Portugal
b Faculty of Dental Medicine, Universidade Católica Portuguesa, Center for Interdisciplinary Research in Health, Viseu, Portugal
c Faculty of Dentistry, Complutense University of Madrid, Madrid, Spain

d Coimbra Hospital and University Centre, Documentation Department, Coimbra, Portugal

Abstract
Purpose: The purpose of this systematic review was to evaluate the survival rate, biological complications, technical
complications, and clinical behavior of single crowns supported by teeth made up in monolithic zirconia with CAD/CAM
technology.
Study selection: An extensive electronic search was conducted through Medline/PubMed, Embase, and Cochrane Library
databases. Additional manual search was performed on the references of included articles to identify relevant publica-
tions. Two reviewers independently performed the selection and electronic and manual search.
Results: From nine articles included, there was a total of 594 participants and 1657 single-tooth restorations with a mean
exposure time of 1.07 years, and follow-up period between 0.3 and 2.1 years. All studies showed a moderate level of qual-
ity, with a consequent moderate possibility of associated bias, using the Newcastle-Ottawa Scale (NOS), with survival rate
(SR) ranging between 91% to 100%. Bleeding on probing (BOP) were reported with an average value of 29.12%. Marginal
integrity showed high success rate values for the observation periods, except for one that included patients with bruxism
which obtained a SR of 31.60%. Failures and/or fractures, mostly total and requiring replacement, were observed in three
studies. Linear regression showed that there was no statistical correlation between survival rate and type of cementation
and the average years of follow-up (p=0.730 e p=0.454). There was high heterogeneity between studies (I2 = 93.74% and
Q = 79.672).
Conclusions: Within the limitation of this study, monolithic zirconia might be considered as a possible option for restoring
single crowns, especially in the posterior zone.
Keywords: Computer-aided design, Zirconium oxide, Yttria-stabilized tetragonal zirconia, Tooth crown, Fixed partial
denture.

Received 3 April 2021, Accepted 25 July 2021, Available online 6 October 2021

1. Introduction material with the highest strength, it can be used as monolithic ma-
terial, presenting notable advantages mainly related to the non-oc-
In the last two decades, zirconia-based restorations have been in- currence of chipping off a veneering ceramic and its numerous indi-
creasingly used in Dentistry. Patients tend to choose metal-free res- cations of use in single, partial, and full-mouth rehabilitation. Also, it
torations, preferring materials with similar properties to the natural presents high biocompatibility, less wear of the antagonist, easiness
teeth and similar characteristics of light scattering, achieving good to polish, high hardness, low thermal conductivity, and chemical sta-
esthetic results[1]. Polycrystalline ceramics, in which zirconia stands bility[4].
out, are ceramics that do not have glassy components, with a dense
and cohesive structure that are very difficult to break and fracture[2]. The emergence of these new materials like monolithic zirconia (MZ)
Given those characteristics, Garvie et al. (1975)[3] entitled zirconia as combined with digital technology allows increasingly biomimetic
“ceramic steel”. Then, considering that zirconia is the dental ceramic results. In vitro studies showed superior performance and results re-
garding mechanical strength of MZ[5,6], allowing its use mainly for
cases with unfavorable occlusion, parafunctional habits, previous
DOI: https://doi.org/10.2186/jpr.JPR_D_21_00081 fractures, and limited space for restorative materials[7].
*Corresponding author: Gustavo Vicentis de Oliveira Fernandes, Faculty of Dental
Medicine, Universidade Católica Portuguesa, Center for Interdisciplinary Research in
Health, Circunvalacao Road, S/N – Viseu 3506-505, Viseu, Portugal. E-mail address: However, clinical evidence of the existing literature on clinical perfor-
gustfernandes@gmail.com mance and durability of this type of restorations is still scarce. There
Copyright: © 2021 Japan Prosthodontic Society. All rights reserved. is a lack of clinical studies with a follow-up longer than five years,
2 C. Leitão, et al. / J Prosthodont Res. 2021; **(**): ****–****

clinical randomized trials, and the absence of success rate studies of 2.2.  Data extraction and method of analysis
these crowns in the medium and long-term.
Data extraction for descriptive and quantitative synthesis was per-
Thereby, it is essential that professionals can be able to access scien- formed using a standardized form and recorded in an Excel table
tific evidence to make critical and rigorous decisions on oral rehabili- (v.15.17 - Microsoft, Redmond, USA). The information extracted in-
tation treatment. Hence, the purpose of this systematic review and cluded: study (Authors/Year of publication), type of study, country,
meta-analysis was to assess the survival rate, biological complica- age, restorations (n), drop-outs (n), CAD/CAM system, monolithic zir-
tions, technical complications, and clinical behavior of single teeth- conia type/brand, glaze/stain (yes or no), dental preparation, impres-
supported monolithic zirconia crowns, developed with the CAD/ sion (digital/conventional), CAD/CAM system, cement/cementation
CAM system, to help clinicians in the decision process. process, follow-up period (years), evaluation system, location (an-
terior/posterior), dental group, whether in the maxilla or mandible,
2.  Materials and Methods occlusal adjustments (yes or no), wear antagonist, absence or pres-
ence of plaque, surface treatment, marginal integrity, bleeding on
This systematic review and meta-analysis was conducted following probing (BOP), color stability (yes or no), dental vitality (n), number
the PRISMA guidelines (Preferred Reporting Items for Systematic of failure (considered only facture in which the material cannot be
Reviews and Meta-analysis)[8,9] and the research question was de- replaced or adjusted), and survival rate. In situations where the de-
fined through the PICOT format (population, intervention, compari- sired information about survival and/or failure rates was not present,
son, outcomes, and time)[10]. The protocol was registered in PROS- it was excluded from the selection.
PERO (International Prospective Register of Systematic Reviews),
CRD42020166112, organized by the Center for Reviews and Dissemi- 2.3.  Statistical analysis method
nation (University of York, National Institute for Health Research,
United Kingdom). This meta-analysis compared data obtained on success/survival rates
after a minimum of three months in function. All analyzes were per-
The focused question was: “In an adult population, does monolithic formed using Excel software (Microsoft, Redmond, USA), where the
zirconia restorations on natural teeth, in comparison when available random effect model at a 5% significance level was used. To assess
with other type of material for crown rehabilitation, have superior the quality of the cohort studies, the Newcastle-Ottawa Scale (NOS)
survival rate and clinical results in a minimum 3 months follow-up?” for Quality Assessment was used. Heterogeneity among the studies
was quantified using the Cochran test (Test Q) and the inconsistency
2.1.  Information sources and search strategy test (I2 ≥ 50%). Values above 75% (in both tests) were considered an
indication of substantial heterogeneity, not allowing a fixed-effect
This electronic survey was initiated on 5 February 2020 and con- analysis method to be applied (i.e., the effect of interest is not the
ducted until 10 May 2020 in three different databases, applying the same in all studies and therefore it is not possible to consider that
English-language limitation: Medline/PubMed (National Library of the studies are homogeneous and derived from the same popula-
Medicine), Embase, and Cochrane Library. At Medline/PubMed and tion)[11].
Cochrane Library, different MeSH (medical subject headings) terms
were combined by using Boolean operators AND, OR, and NOT (Sup- Since the confidence interval (CI) was not provided, the standard
plementary Tables 1-3). A search was also carried out in the form of deviation (SD) value was used to calculate it. Linear regression (the
free text, using the search terms: “Monolithic zirconia”; “Monolithic relationship between survival rate, cementation, and average follow-
dental crown”; “Zirconia dental crown” (Supplementary Table 3). up period) was also performed. Associated with this, a Q-Q graph
(scatter diagram) was developed to compare two probability distri-
In the Embase database, a natural language search was performed butions. This means that, if the two sets of quantiles come from the
also with Boolean operators AND and OR (Supplementary Table 4). same distribution, we must observe the points in the graph. If this
Controlled language research was also carried out, combining the line is approximately straight, we would be facing a normal distribu-
different Emtree terms (Embase subject headings), accompanied tion.
by the Booleans operators AND and OR, and using the same search
terms. Combining research in controlled English-language at Em- 3. Results
base, a total of 565 articles was obtained. For the selection of the
studies, inclusion, and exclusion criteria were defined (Supplemen- 3.1.  Study Selection
tary Table 5), such as only abstracts published in congress, e-posters,
content non-published, gray literature, and letter to editor. Through the search strategy, 1298 references were initially identi-
fied (360 from Medline/PubMed, 373 from the Cochrane Library, and
After eliminating duplicates, the titles and abstracts of all identified 565 from Embase). Of these, 224 duplicate articles were removed,
articles were systematically evaluated by two researchers (C.L. and resulting in a total of 1074 articles. Subsequently, through the selec-
L.A.). In situations where the relevance of a study was unclear, it was tion by the inclusion and exclusion criteria (reading the title), 930
included for full-text reading and it was evaluated. Subsequently, the articles were eliminated, leaving a total of 144 articles. Of these, 13
articles were read in full and the reasons for their exclusion were re- articles were selected by abstract and four articles were eliminated
corded. Any disagreement and/or discrepancy about the eligibility after full read (Supplementary Table 6). The research flowchart and
of the studies for this purpose was resolved with the presence of a the identification process are schematically shown in Figure 1 and
third reviewer (A.C). Cohen’s kappa value was calculated to measure Supplementary Table 6. Through a complete reading of the nine final
inter-rate agreement in the study selection process. articles, quantitative synthesis of them was carried out. Present infor-
mation from the selected studies, such as study design, study objec-
 C. Leitão, et al. / J Prosthodont Res. 2021; **(**): ****–**** 3

Fig. 1.  Article selection strategy according to the PRISMA Flowchart (Preferred Reporting Items for Systematic Re-
views and Meta-Analyzes).

tive, sample size, evaluation methodology, and follow-up period are dition, three studies[12,17,18] reported drop-outs of patients during
shown in Table 1. the follow-up period, but only one article reported the associated
causes[17]. The average number of patients who, for various reasons,
3.2.  Study characteristics could not be followed up was relatively low (9.7%, n=28). Of these, six
patients were lost for the following reasons: one death, three housing
Descriptive analysis with total data, about follow-up time, type of changes, and two refusals to participate due to another disease[17].
study, tooth position, and patient characteristics are shown in Sup-
plementary Table 7. In this quantitative analysis, 1657 monolithic zir- 3.5.  Tooth preparation
conia unitary restorations were included. Most studies reported pos-
terior mandibular restorations (premolars and molars), the majority Most of the dental preparations were made with the monolithic ce-
of which (n=423) were maxillary restorations (n=380). The evaluated ramic crowns’ standard reductions (i.e., a minimum wall thickness of
studies had an observation period between 0.3 and 2.1 years, with 1mm, occlusal reduction of 1.5 to 2.0mm, axial reduction of 1.0 to
an average follow-up of 1.07 years. Thus, nine articles (1 random- 1.5mm)[21].
ized controlled trial[12]; 3 prospective cohort clinical trial[13–15]; 1
prospective observational case-series[16]; 2 retrospectives clinical 3.6.  Crown cementation
trial[17,18]; 1 retrospective observational clinical trial[19]; 1 retrospec-
tive observational case-series[20]) published between 2014 and 2019 Konstantidinis et al.[13] refer to a pre-cementation treatment of the
were included in this systematic review (Table 1). crown with an aluminum oxide blast (50 microns). Gunge et al.[18]
refer to the application of a low pressure (0.6MPa) blasting of alumi-
3.3.  Inter-rater agreement na and a 10-MDP primer (Clearfil® Ceramic Primer, Kuraray Noritake
Dental Inc.) in the monolithic crown prior to its cementation.
Cohen’s kappa value was calculated to measure the inter-rater agree-
ment in the study selection process. The standard deviation calcu- In 6 of the 9 studies, the authors refer to the use of resin cement for
lation was 0.98 (±0.14) for the first selection stage and 0.78 (±0.23) the cementation of crowns[13–15,17–19]. One study reported the
for the second stage, which represents an excellent and good agree- use of glass-ionomer cement and another one refers to the use of
ment, respectively, between the two independent researchers (C.L. resin-modified glass ionomer cement[16]. The information about
and L.A.). All disagreements were resolved by a third independent the cementation material was not available in 1 of the 9 studies in-
researcher (A.C.) cluded[20].

3.4.  Patient characteristics 3.7.  Clinical evaluation of the restorations

In this systematic review, a total of 594 individuals were reported, The quality assessment of the restorations was done with two dif-
with an estimated average age of 49.1 years. These studies included ferent classifications. Thus, three articles[14–16] used the modified
238 male patients and 316 female patients, with data about the pa- criteria of the California Dental Association (CDA) and four arti-
tient’s gender not being reported in three studies[12,13,20]. In ad- cles[12,13,18,20] used the modified criteria of the United States Public
4 C. Leitão, et al. / J Prosthodont Res. 2021; **(**): ****–****

Table 1.  Data extraction table and descriptive analysis of the included articles.
Article (Authors/Year of Study Country Age Individuals (n) Zirconia Drop-outs (n) Type/Brand of
publication) type Restorations (n) Zircónia Monolítica
Konstantinidis et al. 2018 Pro GR 49.52 65 65 s/d Zenostar (Wieland, Canada)
Batson et al. 2014 Pro US s/d 22 10 13 (total) Zenostar (Wieland, Canada)
Tang et al. 2019 Pro CN 41.3 46 49 s/d Zenostar (Wieland, Canada)
Kitaoka et al. 2018 Pro JP 54 18 26 s/d Aadva (GC Europe)
Gunge et al. 2018 Retro JP > 20 years 101 148 6 Cercon ht (Dentsply Sirona K.K.)
Zou et al. 2018 Retro CN 37 289 321 s/d YZ HT 40/19 (Vita Zahn-fabrik, Germany)
Hansen et al. 2018 Pro NO 56.3 13 84 s/d BruxZir (Glidewell Laboratories, USA)
Worni et al. 2017 Retro SZ 59.1 40 238 6 Ceramill Zolid (Amann Girrbach)
Belli et al. 2015 Retro GM s/d s/d 716 s/d Zenostar (Ivoclar Vivadent, Liechtestein)
Pro= Prospective; Retro= Retrospective | s/d= No data | SA= No alterations | GR=Greece | GM= Germany | US= United States | CN = Canada | JP = Japan |
NO=Norway | SZ= Switzerland.

Table 1 (cont.).  Data extraction table and descriptive analysis of the included articles.
Article (Authors/Year of Dental Impressions CAD/CAM Cement/Cementing Average Follow-up
publication) preparation (digital/ conventional) system Process time (years)
Zenotec CAM (Wieland Resin cement
Konstantinidis et al. 2018 Standard Conventional 0.8
Dental)
Mini-mill (Wieland Glass Ionomer cement
Batson et al. 2014 Standard Digital 0.3
Dental)
Tang et al. 2019 Standard Conventional 3Shape (Denmark) Resin cement 0.8
Aadva Mill LD-1 (GC Resin cement
Kitaoka et al. 2018 Standard Conventional 0.9
Europe)
Cercon brain (Dentsply Resin cement
Gunge et al. 2018 Minimum Conventional 2.1
Sirona K.K.)
Zou et al. 2018 Endocrown Digital Cerec (Dentsply Sirona) Resin cement 1.6
Resin modified Glass
Hansen et al. 2018 s/d s/d s/d 1.7
ionomer cement
Ceramill Motion 2 Resin cement
Worni et al. 2017 Standard Conventional 2.0
(Amann Girrbach)
Belli et al. 2015 s/d Digital Multiple Systems s/d 0.3
s/d= No data.

Table 1 (cont.).  Data extraction table and descriptive analysis of the included articles.
Article (Authors/Year of Evaluation Glaze/Stain Location (anterior / Dental Group Site Site Occlusal Antagonist/Wear
publication) system (yes or no) posterior) (maxilla) (mandible) adjustments
(yes or no)
Konstantinidis et al. 2018 USPHS Yes Posterior PM/M 29 36 Yes s/d
Batson et al. 2014 USPHS Yes Posterior s/d s/d s/d No (in 80%) s/d
Tang et al. 2019 CDA No Posterior M 24 25 Yes No
Yes (Crack in two
Kitaoka et al. 2018 CDA No Posterior PM/M 13 13 s/d
antagonist teeth)
Gunge et al. 2018 s/d Yes Posterior PM/M 71 77 Yes No
Zou et al. 2018 USPHS No Posterior M 157 165 Yes s/d
Hansen et al. 2018 CDA No Anterior Incisive/canine/PM 20 64 No s/d
Worni et al. 2017 USPHS Yes Posterior/Anterior Incisive/canine/PM/M 66 43 s/d s/d
Belli et al. 2015 s/d s/d Posterior PM/M s/d s/d s/d s/d
s/d= No data.
 C. Leitão, et al. / J Prosthodont Res. 2021; **(**): ****–**** 5

Table 1 (cont.).  Data extraction table and descriptive analysis of the included articles.
Article (Authors/Year of Presence/Absence Surface Marginal Bleeding on Color stability Dental Failures Survival
publication) of Plaque treatment integrity Probing (BOP) (yes or no) Vitality (n) (n) rate
Konstantinidis et al. 2018 Absence s/d 93.80% 1.80% No 19 0 100%
Batson et al. 2014 s/d Final polishing 90% SA No s/d 0 100%
Tang et al. 2019 Presence Final polishing 100% 4.08% Yes s/d 1 93%
Kitaoka et al. 2018 Presence Final polishing 88.46% SA No 3 0 100%
Gunge et al. 2018 s/d Final polishing s/d s/d s/d 0 1 91%
Zou et al. 2018 s/d Final polishing 98.80% s/d Yes 0 0 100%
Hansen et al. 2018 Presence Final polishing 31.60% 100% Yes s/d 1 98.81%
Worni et al. 2017 Presence Final polishing 100% 10.60% No 0 0 100%
Belli et al. 2015 s/d Final polishing s/d s/d s/d s/d 0 100%
s/d= No data | SA= No alterations.

Health Service (USPHS). In two articles[17,19] the rating system was In the Zou et al.[19] study, the restorations were assessed using the
not mentioned. United States Public Health Service (USPHS) criteria at 6 months,
then 1, 2, and 3 years after treatment. The ratings for anatomic form,
Tang et al.[14], using the modified criteria of the California Dental marginal adaptation, color match, marginal discoloration, surface
Association (CDA), concluded that the survival parameters such as roughness, and caries of the endocrowns proved to be practically
marginal adaptation, anatomic form, crown margin integrity, color unchanged compared with the high quality that was initially estab-
match, and gross fracture did not show significant differences com- lished. There were no significant differences in the repeated assess-
pared with the different time points (P=.999). Surface texture at dif- ments for up to 3 years (P>0.05).
ferent times did not change significantly (P=.807). Kitaoka et al.[15],
according to the CDA quality evaluation, rated most crowns as “ex- The records obtained by the USPHS by Worni et al.[17] revealed good
cellent” for marginal integrity and surface and “excellent” or “accept- clinical outcomes. While the scores for “color match” (P<.001) and
able” for color and anatomical form. Only one crown was evaluated “anatomical form” (P=.005) were different between the two exam-
as a “correction” for color after placement. iners, no difference was found for marginal adaptation (P=.71). No
secondary caries or loss of vitality of abutment teeth were recorded
Hansen et al.[16] evaluated the surfaces (using CDA criteria) and al- during the follow-up period.
most all crowns (90,5%) had excellent surfaces, the rest were evaluat-
ed as satisfactory. Besides that, the color was rated as satisfactory on 3.8.  Biological complications
all crowns. Most of the crowns (75.3%) had excellent shape whereas
the remaining were evaluated as having a satisfactory shape. The The analysis of biological complications was performed using the
crown margins were excellent on most of the crowns (66.8%) and following parameters: presence/absence of bacterial plaque, bleed-
satisfactory on the rest. Overall, all crowns were evaluated as 100% ing on probing, and dental vitality. When evaluating the studies, it
satisfactory and not in need of repair or remake regarding any of the can be seen that the presence of plaque was mentioned in four of
CDA variables. them[14–17], with only one study reporting that the bacterial plaque
was absent[13]. Bleeding on probing was reported in four stud-
Using USPHS criteria, Konstantinidis et al.[13] concluded that at the ies[13,14,16,17] with an average value of 29.12%.
6- and 12-month examination all restorations (regarding the quality
assessment) were rated either with Alpha or Bravo, except for one Regarding tooth vitality, it should be noted that a total of 22 pre-
restoration which rated with Charlie for marginal discoloration. For pared teeth were vital[13,15] and that in three studies[17–19], all teeth
the criteria “secondary caries” and “gross fracture” all crowns ob- used had a root canal treatment. In a retrospective study by Gunge et
tained an Alpha score. al.[18], some biological complications were reported, although with
a low prevalence (pulp complications: 2.03%; one fracture of the
This resulted in a success rate of 98.5%. The percentages of resto- abutment tooth: 0.68%; and presence of secondary caries).
rations with a B rating for marginal discoloration increased from
4.6% at the baseline to 16.88 at the 6- and 12-month examination. In the prospective study by Hansen et al.[16], visible plaque was
Regarding the “surface texture”, the B rating changed from 1.5% to found in two patients, and bleeding on probing was present in one
6.2% at the 6-month examination, and then remained at the same or more teeth in all patients. According to Tang et al.[14], there was
percentage at the 12-month examination. From the 6-month to the no incidence of secondary caries. However, at the end of the total
12-month examination, most of the percentages of A and B rates did follow-up period (96 weeks), 45 crowns had no plaque, three crowns
not change. had visible plaque and only one crown had a moderate plaque index
at the level of the gingival margin.
Batson et al.[12] within each USPHS criterion presented that Zr
crowns were statistically significantly different from lithium disilicate 3.9.  Technical complications
(LD) and metal ceramic (MC) crowns for occlusion (P<.001). Eighty
percent of Zr crowns had an “excellent” rating and needed no oc- The technical complications examined were: occlusal wear of the
clusal adjustment. antagonist tooth, surface treatment, marginal integrity, failures/frac-
6 C. Leitão, et al. / J Prosthodont Res. 2021; **(**): ****–****

Table 2.  Quality assessment of studies included at risk of bias using the Newcastle-Ottawa Scale.
Authors/Year Konstantinidis Batson Tang Kitaoka Gunge Zou Hansen Worni Belli
et al. 2018 et al. 2014 et al. 2019 et al. 2018 et al. 2017 et al. 2018 et al. 2018 et al. 2017 et al. 2015
Selection (up to 4*) **** ** ** ** ** ** ** ** **
Comparability (up to 2*) ** **
Outcome/Exposure (up to 3*) ** ** *** ** ** ** ** *** **
TOTAL 6/9 4/9 5/9 4/9 6/9 4/9 6/9 5/9 4/9
INTERPRETATION Moderate Moderate Moderate Moderate Moderate Moderate Moderate Moderate Moderate
1 to 3 – Low quality; 4 to 6 – Moderate quality; 7 to 9 – High quality of assessment.

tures, occlusal adjustments, and presence/absence of glaze/stain.

Only Kitaoka et al.[15] reported two cracks in the antagonistic teeth.
Regarding the surface treatment, most crowns were subjected to fi-
nal polishing. Marginal integrity, in most studies, showed high suc-
cess rate values for the observation periods. However, in the study by
Hansen et al.[16], in which was included patients with bruxism, this
value was relatively low (31.60%).

Failures/fractures, mostly total and requiring replacement, were

observed in three out of nine studies[14,16,18]. In the retrospective
study by Gunge et al.[18], with a survival rate of 91.5% after 3.5 years
in clinical function, six monolithic zirconia crowns for natural teeth
were lost, such as by hyperesthesia (1), root fracture of an abutment
tooth (1), restoration fracture (1), pulpitis (2), and one restoration
was removed because the tooth was used as an abutment tooth for
Fig. 2.  Forest plot graph of survival rate in relation to the study analysis pe-
a fixed partial denture after root fracture of an adjacent tooth, with riod.
other technical problems related to marginal discoloration, loss of
retention and compromised esthetics being occasionally reported.
Then, only 1 failure was really considered in this study[18] due to a
Initially, an analysis of the SR was carried out, according to the obser-
direct failure/fracture of the restauration.
vation period of the studies (Figure 2). Heterogeneity of 92.49% (I2)
and 81.518 (Q) was found. Through the analysis of the graphic, it was
In the prospective study by Hansen et al.[16], only one complete
observed in two studies a lower survival rate[14,18], due to Gunge
fracture (1.19%) occurred after 16 months and was replaced by a new
et al.[18] study, since it was the only work with the longest follow-
monolithic zirconia crown. This fracture was caused by a defect in
up period and one of the largest crown samples (n=148). However,
the mesial margin of the crown. This author registered other techni-
Tang et al.[14], with a relatively short period of analysis (0.8 years),
cal findings/complications (e.g. marginal gap, overcountured, wear
presented a 93% survival rate.
facet) but none caused the loss of the crown.
Linear regression was performed, correlating SR with the type of ce-
According to Tang et al.[14], the evaluated survival parameters (mar-
mentation, and also with the average years of follow-up. The results
ginal adaptation, anatomical shape, marginal integrity, color stabil-
showed that there was no statistical significance for these correla-
ity, and surface texture) did not show significant changes between
tions (respectively, p=0.730 and p=0.454) (Supplementary Table 8).
the different follow-up periods observed (p=0.999). Final occlusal
With these data, a Q-Q plot graph was developed, in which some
adjustments were made to monolithic zirconia crowns in five studies,
points are represented alongside a line (with slight variations). How-
making a total of 593 crowns[12–14,18,19]. Glaze/stain was present in
ever, they follow a distribution pattern considered normal (Supple-
461 restorations, being mentioned in four studies[12,13,17,18].
mentary Figure 1).
3.10.  Survival rate (SR)
A forest plot graph was developed to analyze the SR concern-
ing bleeding on probing, where there was high heterogeneity
In order to assess the survival rate and clinical performance, and clini-
(I2=93.74% and Q=79.672). The studies included were suggested to
cal behavior of monolithic zirconia single crowns supported by teeth
be within acceptable bleeding on probing (BOP) pattern which did
made with CAD/CAM technology, this was defined as their perma-
not influence the survival rate of prosthetic rehabilitation. Only one
nence in situ (with or without modifications). The results obtained for
study[13] showed an altered correlation due to high BOP (Figure 3).
the survival rate are shown in the results of the meta-analysis.
The forest plot graphic analysis of the relationship between marginal
3.11.  Quality of assessment and Statistical analysis
integrity and SR (Figure 4) was done. It was found once again that
only the article by Hansen et al.[16] presented marginal integrity as a
The Newcastle-Ottawa Scale (NOS) was used to assess the quality of
risk factor that interfered with the SR of the restorations. This article
studies (Table 2). All studies showed a moderate level of quality, with
was the same verified in the previous graph, which suggested this
the consequent moderate possibility of associated bias.
study is the main factor of heterogeneity.
 C. Leitão, et al. / J Prosthodont Res. 2021; **(**): ****–**** 7

Fig. 4.  Forest plot graph of the relationship between marginal integrity and
survival rate.
Fig. 3.  Forest plot graph of the relationship between bleeding on probing
and survival rate.

After statistical analysis, it was also found that there was high het-
Linear regression was performed to verify statistically whether there erogeneity, for survival rate (I2=92.49% and Q=81.518) and the rela-
was a significant difference between survival rate with BOP and mar- tionship between survival rate and BOP (I2=93,74% and Q=79.672).
ginal integrity. After data analysis, the correlation had a significative Although BOP is mentioned in all articles, only one study was statis-
statistical difference, respectively, for BOP (p=0.441) and marginal tically significant (Hansen et al.[16]), showing interference between
integrity (p=0.418) (Supplementary Table 9). BOP and survival rate of monolithic zirconia crowns. In this study, it
was verified that BOP was present in all patients, in more than one
Furthermore, it was performed the SR, according to the period of tooth.
analysis, comparing the crowns produced with monolithic zirconia
and other materials. However, only 2 out of 9 included studies[12,20] MZ restoration usually has a polished surface, which facilitates clean-
analyzed other materials, and one[20] out of 2 those articles, did not ing by the patient avoiding the accumulation of biofilm, contribut-
describe adequately the SR obtained for other materials, hamper- ing to the maintenance of the health of the periodontal tissues[14].
ing the development of the statistical analysis. On the other hand, In addition, it was reported in two articles[14,16] that patients were
both confectioned the crowns digitally, for posterior teeth, and had a followed up by providing oral hygiene care during the observation
follow-up period of 3 months; one was a prospective[12] and another period.
retrospective study[20]. From the baseline data found in the Batson
et al.’s study[12], excluding the dropout due to this study did not in- 4.2.  Technical aspects and complications
form the values after the occurrence of that, the monolithic zirconia
crown had a SR of 90% (10% were unacceptable or rejected), 75% for Regarding the reported technical complications, significant differ-
metal-ceramic (MC), and 80% for lithium disilicate (LD). ences occurred in three studies[14,16,18], all with the occurrence of
one fracture of MZ restoration - a total of three failures (0.18%). The
lowest SR, according to statistical analysis, was found in two of these
4. Discussion studies[14,18]. However, when analyzed Gunge et al.’s study[18], it
was noticeable that, in addition to being the only work with an ob-
Systematic reviews and meta-analysis are usually assessed as high-
servation period greater than two years, it is also one of the studies
quality scientific evidence, systematically identifying the relevant
with the largest number of samples (n=148). This may be a justifica-
published information[10]. The introduction of new technologies,
tion for the lowest survival found (91.5%).
manufacturing processes, and materials in dental clinical practice
should ideally be supported by scientific evidence. However, there is
Tang et al.[14] reported that, in one of the failures, the patient devel-
a lack of evidence on the clinical performance of monolithic ceramic
oped greater activity and masticatory strength on the rehabilitated
(zirconia) crowns, which becomes necessary for more scientific stud-
side during the first four months, having reported contralateral tooth
ies with longer follow-up periods[22].
pain, a consequence of chronic pulpitis. Still, as an aggravating fac-
tor, this patient reported having preferably consumed harder foods.
4.1.  Biological complications
It was also mentioned that occlusal adjustments were made in all
crowns, which can be a differentiating factor in the monitoring of
The main biological complications reported were increased BOP in
rehabilitation and results in quality.
the abutment teeth, secondary caries, bacterial plaque, loss of vital-
ity, and fracture of the abutment tooth. However, it is worthy of note
Currently and associated with CAD/CAM technology, it is possible
that the evidence is scarce in this regard since not all studies pro-
to manufacture a wide variety of metal-free materials. Thus, the
vided information and/or used different evaluation systems (USPHS
strength and stability of MZ have been tested in several in vitro in-
or CDA).
vestigations[23,24], which have shown restorations with overlay ce-
ramics are more susceptible to wear when compared to polycrystal-
line ceramics[25–28].
8 C. Leitão, et al. / J Prosthodont Res. 2021; **(**): ****–****

Fractures associated with the material under analysis were observed mentation. In particular, Konstantidinis et al.[13] referred to the use of
in the study by Hansen et al.[16], which was predictable and ex- an aluminum oxide blast (50 microns). Still, in Gunge et al.’s study[18],
pected by the authors, since the patients included in the study were they applied a 10-MDP primer (Clearfil Ceramic Primer, Kuraray Nori-
grinding patients, presenting severe tooth wear (prior to restorative take Dental Inc.) and low-pressure alumina blasting (0.6MPa) in the
treatment), which may be a justification for the high heterogeneity monolithic crown.
found. Typically, these types of patients are excluded from studies
that evaluate survival and/or failure rates. Thus, a higher failure rate 4.4.  Occlusion and Marginal adaptation
would be previously expected in these patients, which is a limitation
of the study. Final occlusal adjustments were made to the MZ crowns in five stud-
ies, making a total of 593 monolithic crowns[12–14,18,19]. If minimal
Extreme tightening or defects in the crown margins may be possi- occlusal adjustments are necessary to optimize occlusal contact, the
bly associated causes of fractures[29,30]. The manufacturing process external surfaces of the MZ must be carefully polished to reduce any
may introduce defects in pre-cementation restoration, reducing abrasive effects[44]. This is necessary because by making occlusal
the crown’s resistance[29,30]. Also, the phenomenon of low-tem- adjustments to the ceramic surface, microfractures can be created
perature degradation may be associated with this type of failure which can later develop into a total fracture[44]. Occlusal adjust-
(since it spreads into the material)[29,30]. According to Nakamura et ments were required in two of the fractured restorations, which may
al.[31], this phenomenon, when associated with wear, can influence have contributed to this event[14,18].
the quality of the surface, leading to an increase in the roughness.
However, the clinical relevance of this phenomenon is still uncertain. Regarding marginal adaptation, Hamza et al.[45] observed that dif-
Masticatory forces can also induce this phase transformation around ferent CAD/CAM systems have differences associated with marginal
surface microcracks; however, this is not likely to be the associated discrepancy and Kale et al.[46] showed that the marginal adaptation
cause since, in most cases, time in function was relatively low[31]. of monolithic crowns can be affected by the cementation process.
In the analyzed articles, different CAD/CAM systems were used, with
4.3.  Zirconia crown and tooth preparation heterogeneity in the types of cement used, which can interfere with
the marginal adaptation of the crowns. Despite the average preser-
In the study by Zou et al.[19], in which they evaluated MZ molars vation value of marginal integrity observed being high (86.09%), in
endocrowns manufactured with CAD/CAM technology, the clinical the study by Hansen et al.[16], it decreased (31.6%). It is important
success observed was 100% after three years in function. This con- to note that the protocol of this study did not consider the evalu-
trasts with the results obtained in the systematic review[32], where ation of the polymerization contraction of various types of cement
endocrowns presented a high failure rate (2.56% per 100 restora- under different polymerization conditions, as well as the compliance
tion years). The concept of endocrown is related to microretention with the manufacturer’s guidelines, regarding the selection and/or
(through adhesion to dentin), gaining macro-retention and stability use mode, was not evaluated different types of cement. In the meta-
using available space within the pulp chamber[19]. The deeper the analysis prepared in this study, a linear regression correlating the sur-
pulp cavity and its intracoronary extension, the greater the surface vival rate with the type of cementation, and with the average years of
area that can be used for the retention and transmission of mastica- follow-up was performed. Through this, it was possible to conclude
tory forces[33,34]. This could be the reason for the low survival rate of that there was no statistical significance between these correlations
premolars endocrowns when compared to molars endocrowns, over (p=0.730 and p=0.454, respectively).
a 12-year observation period[35].
In a systematic review elaborated by Boitelle et al.[47], they reported
Monolithic crowns have a high fracture resistance, allowing prepara- a lower adaptation value of the prosthetic structure when used CAD/
tion without excessive tooth reduction, which is one of the reasons CAM technology compared to conventional systems (gap less than
by which have become a treatment alternative to metal-ceramic or 80µm between tooth and restoration surface). In addition, the full
ceramic crowns[13]. Previous studies have shown that the design of zirconia crown has high biocompatibility and CAD/CAM technology
the preparation influences significantly and is associated with frac- contributes to the design and manufacture of the crown providing
ture resistance of metal-ceramic crowns[6,34,36–38]. However, ac- excellent marginal adaptation[14].
cording to manufacturers’ instructions, MZ crowns can be placed
with a minimum thickness of 0.5mm[18]. Thus, many previous stud- 4.5.  Material surface
ies have evaluated zirconia strength with a thickness greater than
0.5mm, which allows its use in the molar teeth region, in terms of Regarding the antagonist wear, only in the Kitaoka et al.’s study[15],
fracture resistance[34,36,38]. Previous studies have shown that two cracks were observed in the antagonist teeth and, in the major-
monolithic zirconia crowns with a thickness greater than 1.0mm ity, the crowns were subjected to final polishing. According to Tang
showed a high fracture resistance, being the same as that presented et al.[14], after the final polishing of monolithic zirconia ceramics, the
by metal-ceramic crowns[34]. average surface roughness reaches 0.17±0.07 µm, this value being
less than that presented by glazed zirconia (0.69±4.10µm). Thus, the
Retention loss is significantly greater in zirconia-based restorations application of staining and glazing seems to increase the abrasive-
when compared to other types of restoration[39]. However, some ness of this type of restoration[14].
studies report that crown retention depends on the mechanical
roughness of the internal surface and chemical treatments with the The roughness of a surface is an essential factor for surface wear. A
adhesive monomer in zirconia primers[35,40]. An excellent reported clinical study by Mundhe et al.[48] demonstrated that, during the
option is related to the application of primers or adhesives containing one-year follow-up period, the attrition caused by the monolithic
monomers after blasting, allowing good adhesion to zirconia[41–43]. crown over the antagonistic natural tooth was 42.10±4.30µm for
Only two studies mentioned a pre-treatment of the crown before ce- premolars and 127.00±8.09µm for molars (p<0.001). In addition, it
 C. Leitão, et al. / J Prosthodont Res. 2021; **(**): ****–**** 9

has been shown by other studies that the attrition between mono- (related to color and respective antagonists), long-term chemical sta-
lithic crowns and natural teeth is similar to the wear between op- bility, or associated clinical wear[60].
posing enamel to metal-ceramic and enamel antagonists[49–51].
Still, another study has shown that, after two years of follow-up, the 4.8.  Survival rate compared to different materials
occlusal-cervical dimension of the antagonist tooth, MZ crown, and
contralateral natural tooth decreased by 46µm, 14µm, and 19-26µm In the retrospective study carried out by Belli et al.[20], evaluating
on average, respectively[52]. the SRs of 35,000 posterior ceramic restorations, they concluded that
after 3.5 years, the fracture rate was 1.4%. Also, it was shown that
The results of the aforementioned studies showed that a polished MZ restorations showed a clinical performance without any type of
monolithic zirconia crown causes less enamel attrition when com- failure, in the first 8.5 months of placement. For different types of
pared to other ceramics[52]. Therefore, in light of these findings, a ceramics, a systematic review by Carvalho et al.[32] showed a lower
highly polished zirconia restoration is more desirable than glazed zir- failure rate, with statistical significance, for ceramics made with glass
conia, causing less wear on the antagonist tooth[23,53–55]. matrix when compared with polycrystalline ceramic restorations (p
<0.001; 1.18% versus 3.22%).
4.6.  Esthetic involvement
A meta-analysis study[60] revealed similar results, with a SR of 95.4%
The esthetic aspect of MZ is still a challenge. According to Worni et for fixed partial prostheses in zirconia-ceramic and 96.9% for metal-
al.[17] evaluating the MZ color is a process hampered by numerous ceramic crowns, with no significant differences between the materi-
conditions. Among them, we can mention the place luminous condi- als (p=0.364). However, according to the literature, the SR of fixed
tions, colors of adjacent reconstructions, and/or natural teeth. Since partial prostheses in zirconia-ceramic after 5 years is significantly
MZ is usually a monochromatic structure with an opaquer appear- lower, compared to metal-ceramics (92.1% and 94.7%, respectively)
ance, the lack of translucency and shiny opacity can prevent a natu- [39]. Although the SRs of most all-ceramic restorations are similar to
ral and neutral integration between healthy and unrestored teeth, those reported by metal-ceramic restorations, alumina, and leucite
despite the individual glaze and stain[17]. By comparison, in a study (or lithium disilicate) reported a 96% survival rate and 96.6%, respec-
by Haff et al.[56], 45% of acceptable color was reported in monolithic tively, being higher than zirconia and metal-ceramic. This is aligned
crowns, explained by the color difference between the restoration with the findings of another systematic review[54] that demonstrat-
and adjacent tooth. Nowadays, the dental market presents polychro- ed a high survival rate for single lithium disilicate crowns (97.8%) af-
matic zirconia discs/blocs that may promote better esthetic results, ter 5 years in function. Feldspathic ceramics, despite their excellent
but there is a need for clinical research on this issue. esthetic properties, were those that had a lower survival rate (90.7%),
limiting their application to the posterior sector[39].
4.7.  Analysis of the quality and limitations of included studies
In another study developed in 2014[61], concluded that MZ crowns
This systematic review had numerous limitations and/or associated exhibited greater fracture resistance when compared to lithium dis-
implications. The main limitations are related to the methodology ilicate monolithic crowns, zirconia crowns with ceramic coating, and
heterogeneity, different commercial brands of CAD/CAM and zirco- metal-ceramic crowns. Still, in this same study, it was concluded that
nia systems, and follow-up period. There was no established protocol MZ crowns with a thickness of 1.0mm, can present clinical results
concerning the esthetic and functional analysis of monolithic crowns similar to metal-ceramic crowns. For this study, the observed aver-
and, therefore, this is one of the reasons for the high heterogeneity age SR was 98.15%, with an average follow-up period of 1.07 years. It
found in the included studies. is a promising result, although with a short average follow-up period.

Newcastle-Ottawa Scale (NOS) showed that all studies included in this Considering the inherent limitations to this work, mostly related to
systematic review had a moderate quality of assessment, suggesting the lack of well-standardized and reduced number of studies and
a moderate risk of bias. The limited number of patients involved (not controlled protocols, high heterogeneity, the reduced follow-up
representative of a general population) and crowns examined are period, and the overall survival rate of zirconia monolithic restora-
limitations present in the studies included in this meta-analysis. Still, tions manufactured with CAD/CAM technology, this material might
it is important to mention the workflow limitation, since not all stud- be a feasible option for restoration of single crowns, particularly in
ies refer to the impression conditions. In general, the impressions the posterior sector, however, must be observed the great number
used were conventional, as mentioned in four[13–15,18] of the nine of limitations found. However, additional researches, preferably
studies analyzed. Only one article did not mention the impression long-term randomized controlled studies, are required, using a larg-
conditions[16]. Studies have shown that intraoral scanners appear to er sample of patients, to properly document the possible benefits
indicate greater and improved accuracy, whether in natural teeth or of monolithic zirconia and assert its superiority when compared to
implants when compared to conventional impressions[57,58]. other treatment alternatives.

According to Miyazaki et al.[59], although the range of available ce- Conflicts of Interest
ramics has considerably improved its characteristics, zirconia is argu-
ably the best all-ceramic material. Thus, due to the quick develop- All authors declare no conflict of interest associated to this article.
ment of materials and processing technologies, the application of
zirconia is promising. However, further studies and clinical evalua-
tions are needed[59]. This is also an affirmation of a systematic re-
view[60], implying zirconia as a clinical material of choice for molar
zones (zone of increased occlusal forces). However, some concerns
are still raised (requiring clinical evaluation), such as esthetic aspects
10 C. Leitão, et al. / J Prosthodont Res. 2021; **(**): ****–****

References [22] Pjetursson BE, Lang NP. Prosthetic treatment planning on the basis of
scientific evidence. J Oral Rehabil. 2008;35(suppl 1):72–9. https://doi.
org/10.1111/j.1365-2842.2007.01824.x, PMID:18181936
[1] Denry I, Kelly J. State of the art of zirconia for dental applications. Dent [23] Stawarczyk B, Özcan M, Schmutz F, Trottmann A, Roos M, Hämmerle CHF.
Mater. 2008;24:299–307. https://doi.org/10.1016/j.dental.2007.05.007, Two-body wear of monolithic, veneered and glazed zirconia and their
PMID:17659331 corresponding enamel antagonists. Acta Odontol Scand. 2013;71:102–12.
[2] Zhang Y, Kelly JR. Dental Ceramics for Restoration and Metal Veneer- https://doi.org/10.3109/00016357.2011.654248, PMID:22364372
ing. Dent Clin North Am. 2017;61:797–819. https://doi.org/10.1016/j. [24] Rosentritt M, Preis V, Behr M, Hahnel S, Handel G, Kolbeck C. Two-body
cden.2017.06.005, PMID:28886769 wear of dental porcelain and substructure oxide ceramics. Clin Oral
[3] Garvie RC, Hannink RH, Pascoe RT. Ceramic steel? Nature. 1975;258:703–4. Investig. 2012;16:935–43. https://doi.org/10.1007/s00784-011-0589-9,
https://doi.org/10.1038/258703a0 PMID:21739199
[4] Stawarczyk B, Keul C, Eichberger M, Figge D, Edelhoff D, Lümkemann N. [25] Borba M, de Araújo MD, Fukushima KA, Yoshimura HN, Cesar PF, Griggs
Three generations of zirconia: from veneered to monolithic. Part I. Quintes- JA, et al. Effect of the microstructure on the lifetime of dental ceramics.
sence Int. 2017;48:369–80. PMID:28396886 Dent Mater. 2011;27:710–21. https://doi.org/10.1016/j.dental.2011.04.003,
[5] Ramos G, Monteiro E, Bottino M, Zhang Y, Marques de Melo R. Failure PMID:21536324
Probability of Three Designs of Zirconia Crowns. The International Jour- [26] Gonzaga CC, Cesar PF, Miranda WG Jr, Yoshimura HN. Slow crack growth
nal of Periodontics & Restorative Dentistry. 2015;35:843–9. https://doi. and reliability of dental ceramics. Dent Mater. 2011;27:394–406. https://doi.
org/10.11607/prd.2448, PMID:26509988 org/10.1016/j.dental.2010.10.025, PMID:21185074
[6] Sorrentino R, Triulzio C, Tricarico MG, Bonadeo G, Gherlone EF, Ferrari M. [27] Lohbauer U, Petschelt A, Greil P. Lifetime prediction of CAD/CAM dental
In vitro analysis of the fracture resistance of CAD–CAM monolithic zirconia ceramics. J Biomed Mater Res. 2002;63:780–5. https://doi.org/10.1002/
molar crowns with different occlusal thickness. J Mech Behav Biomed jbm.10468, PMID:12418024
Mater. 2016;61:328–33. https://doi.org/10.1016/j.jmbbm.2016.04.014, [28] Taskonak B, Griggs JA, Mecholsky JJ Jr, Yan JH. Analysis of subcritical crack
PMID:27104931 growth in dental ceramics using fracture mechanics and fractography.
[7] Kontonasaki E, Rigos AE, Ilia C, Istantsos T. Monolithic Zirconia: An Update Dent Mater. 2008;24:700–7. https://doi.org/10.1016/j.dental.2007.08.001,
to Current Knowledge. Optical Properties, Wear, and Clinical Performance. PMID:17845817
Dent J. 2019;7:90. https://doi.org/10.3390/dj7030090, PMID:31480688 [29] Cattani-Lorente M, Scherrer SS, Ammann P, Jobin M, Wiskott HWA. Low tem-
[8] Zorzela L, Loke YK, Ioannidis JP, Golder S, Santaguida P, Altman DG, et al.; perature degradation of a Y-TZP dental ceramic. Acta Biomater. 2011;7:858–
PRISMAHarms Group. PRISMA harms checklist: improving harms reporting 65. https://doi.org/10.1016/j.actbio.2010.09.020, PMID:20854937
in systematic reviews. BMJ. 2016;352:i157. https://doi.org/10.1136/bmj.i157, [30] Chevalier J, Loh J, Gremillard L, Meille S, Adolfson E. Low-temperature deg-
PMID:26830668 radation in zirconia with a porous surface. Acta Biomater. 2011;7:2986–93.
[9] Wright RW, Brand RA, Dunn W, Spindler KP. How to write a system- https://doi.org/10.1016/j.actbio.2011.03.006, PMID:21414426
atic review. Clin Orthop Relat Res. 2007;455:23–9. https://doi.org/10.1097/ [31] Nakamura K, Harada A, Kanno T, Inagaki R, Niwano Y, Milleding P, et al. The
BLO.0b013e31802c9098, PMID:17279036 influence of low-temperature degradation and cyclic loading on the frac-
[10] Donato H, Donato M. [Stages for Undertaking a Systematic Review]. ture resistance of monolithic zirconia molar crowns. J Mech Behav Biomed
Acta Med Port. 2019;32:227–35. https://doi.org/10.20344/amp.11923, Mater. 2015;47:49–56. https://doi.org/10.1016/j.jmbbm.2015.03.007,
PMID:30946795 PMID:25841216
[11] Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta-analysis. [32] Alves de Carvalho I, Marques T, Araújo F, Azevedo L, Donato H, Cor-
Stat Med. 2002;21:1539–58. https://doi.org/10.1002/sim.1186, PMID:12111919 reia A. Clinical Performance of CAD/CAM Tooth-Supported Ceramic Res-
[12] Batson ER, Cooper LF, Duqum I, Mendonça G. Clinical outcomes of torations: A Systematic Review. The International Journal of Periodontics
three different crown systems with CAD/CAM technology. J Prosthet & Restorative Dentistry. 2018;38:e68–78. https://doi.org/10.11607/prd.3519,
Dent. 2014;112:770–7. https://doi.org/10.1016/j.prosdent.2014.05.002, PMID:29889916
PMID:24980739 [33] Mörmann WH, Bindl A, Lüthy H, Rathke A. Effects of preparation and lut-
[13] Konstantinidis I, Trikka D, Gasparatos S, Mitsias M. Clinical Outcomes of ing system on all-ceramic computer-generated crowns. Int J Prosthodont.
Monolithic Zirconia Crowns with CAD/CAM Technology. A 1-Year Follow- 1998;11:333–9. PMID:9758997
Up Prospective Clinical Study of 65 Patients. Int J Environ Res Public Health. [34] Sun T, Zhou S, Lai R, Liu R, Ma S, Zhou Z, et al. Load-bearing capacity and
2018;15:2523. https://doi.org/10.3390/ijerph15112523, PMID:30424474 the recommended thickness of dental monolithic zirconia single crowns.
[14] Tang Z, Zhao X, Wang H, Liu B. Clinical evaluation of monolithic zir- J Mech Behav Biomed Mater. 2014;35:93–101. https://doi.org/10.1016/j.
conia crowns for posterior teeth restorations. Medicine (Baltimore). jmbbm.2014.03.014, PMID:24762856
2019;98:e17385. https://doi.org/10.1097/MD.0000000000017385, [35] Inokoshi M, Poitevin A, De Munck J, Minakuchi S, Van Meerbeek B. Bond-
PMID:31577743 ing effectiveness to different chemically pre-treated dental zirconia. Clin
[15] Kitaoka A, Akatsuka R, Kato H, Yoda N, Sasaki K. Clinical Evaluation of Oral Investig. 2014;18:1803–12. https://doi.org/10.1007/s00784-013-1152-7,
Monolithic Zirconia Crowns: A Short-Term Pilot Report. Int J Prosthodont. PMID:24281895
2018;31:124–6. https://doi.org/10.11607/ijp.5444, PMID:29518806 [36] Nakamura K, Harada A, Inagaki R, Kanno T, Niwano Y, Milleding P, et al. Frac-
[16] Hansen TL, Schriwer C, Øilo M, Gjengedal H. Monolithic zirconia crowns ture resistance of monolithic zirconia molar crowns with reduced thickness.
in the aesthetic zone in heavy grinders with severe tooth wear – An Acta Odontol Scand. 2015;73:602–8. https://doi.org/10.3109/00016357.2015
observational case-series. J Dent. 2018;72:14–20. https://doi.org/10.1016/j. .1007479, PMID:25635734
jdent.2018.01.013, PMID:29452242 [37] Nordahl N, Vult von Steyern P, Larsson C. Fracture strength of ceramic
[17] Worni A, Katsoulis J, Kolgeci L, Worni M, Mericske-Stern R. Monolithic zirco- monolithic crown systems of different thickness. J Oral Sci. 2015;57:255–61.
nia reconstructions supported by teeth and implants: 1- to 3-year results of https://doi.org/10.2334/josnusd.57.255, PMID:26369491
a case series. Quintessence Int. 2017;48:459–67. PMID:28462405 [38] Mitov G, Anastassova-Yoshida Y, Nothdurft FP, von See C, Pospiech P.
[18] Gunge H, Ogino Y, Kihara M, Tsukiyama Y, Koyano K. Retrospective clinical Influence of the preparation design and artificial aging on the fracture
evaluation of posterior monolithic zirconia restorations after 1 to 3.5 years resistance of monolithic zirconia crowns. J Adv Prosthodont. 2016;8:30–6.
of clinical service. J Oral Sci. 2018;60:154–8. https://doi.org/10.2334/jos- https://doi.org/10.4047/jap.2016.8.1.30, PMID:26949485
nusd.17-0176, PMID:29311501 [39] Sailer I, Makarov NA, Thoma DS, Zwahlen M, Pjetursson BE. All-ceramic or
[19] Zou Y, Bai J, Xiang J. Clinical performance of CAD/CAM-fabricated mono- metal-ceramic tooth-supported fixed dental prostheses (FDPs)? A system-
lithic zirconia endocrowns on molars with extensive coronal loss of sub- atic review of the survival and complication rates. Part I: single crowns (SCs).
stance. Int J Comput Dent. 2018;21:225–32. PMID:30264051 Dent Mater. 2015;31:603–23. https://doi.org/10.1016/j.dental.2015.02.011,
[20] Belli R, Petschelt A, Hofner B, Hajtó J, Scherrer SS, Lohbauer U. Fracture Rates PMID:25842099
and Lifetime Estimations of CAD/CAM All-ceramic Restorations. J Dent Res. [40] Xie H, Li Q, Zhang F, Lu Y, Tay FR, Qian M, et al. Comparison of resin bonding
2016;95:67–73. https://doi.org/10.1177/0022034515608187, PMID:26428908 improvements to zirconia between one-bottle universal adhesives and
[21] Herbert T. Shillingburg DASJ, Edwin L. Wilson Jr., Joseph R. Cain, Donald tribochemical silica coating, which is better? Dent Mater. 2016;32:403–11.
L. Mitchell, Luis J. Blanco, James C. Kessler. Fundamentals of fixed prosth- https://doi.org/10.1016/j.dental.2015.12.014, PMID:26754430
odontics. 4th ed: Quintessence Pub Co; 2012. 574 p.
 C. Leitão, et al. / J Prosthodont Res. 2021; **(**): ****–**** 11

[41] Chen L, Suh BI, Brown D, Chen X. Bonding of primed zirconia ceramics: [52] Stober T, Bermejo JL, Schwindling FS, Schmitter M. Clinical assessment
evidence of chemical bonding and improved bond strengths. Am J Dent. of enamel wear caused by monolithic zirconia crowns. J Oral Rehabil.
2012;25:103–8. PMID:22779284 2016;43:621–9. https://doi.org/10.1111/joor.12409, PMID:27198539
[42] Amaral M, Belli R, Cesar PF, Valandro LF, Petschelt A, Lohbauer U. The po- [53] Janyavula S, Lawson N, Cakir D, Beck P, Ramp LC, Burgess JO. The wear of
tential of novel primers and universal adhesives to bond to zirconia. J Dent. polished and glazed zirconia against enamel. J Prosthet Dent. 2013;109:22–
2014;42:90–8. https://doi.org/10.1016/j.jdent.2013.11.004, PMID:24246687 9. https://doi.org/10.1016/S0022-3913(13)60005-0, PMID:23328193
[43] Inokoshi M, De Munck J, Minakuchi S, Van Meerbeek B. Meta-analysis of [54] Kontos L, Schille C, Schweizer E, Geis-Gerstorfer J. Influence of surface
bonding effectiveness to zirconia ceramics. J Dent Res. 2014;93:329–34. treatment on the wear of solid zirconia. Acta Odontol Scand. 2013;71:482–
https://doi.org/10.1177/0022034514524228, PMID:24563487 7. https://doi.org/10.3109/00016357.2012.696690, PMID:23638857
[44] Beuer F, Stimmelmayr M, Gueth JF, Edelhoff D, Naumann M. In vitro perfor- [55] Park JH, Park S, Lee K, Yun KD, Lim HP. Antagonist wear of three CAD/CAM
mance of full-contour zirconia single crowns. Dent Mater. 2012;28:449–56. anatomic contour zirconia ceramics. J Prosthet Dent. 2014;111:20–9. https://
https://doi.org/10.1016/j.dental.2011.11.024, PMID:22196898 doi.org/10.1016/j.prosdent.2013.06.002, PMID:24199603
[45] Hamza TA, Sherif RM. In vitro evaluation of marginal discrepancy of [56]Håff A, Löf H, Gunne J, Sjögren G. A retrospective evaluation of zirconia-fixed
monolithic zirconia restorations fabricated with different CAD-CAM partial dentures in general practices: an up to 13-year study. Dental materi-
systems. J Prosthet Dent. 2017;117:762–6. https://doi.org/10.1016/j.pros- als: official publication of the Acad Dent Mat 2015;31(2):162-70.
dent.2016.09.011, PMID:27836145 [57] Nedelcu R, Olsson P, Nyström I, Thor A. Finish line distinctness and accuracy
[46] Kale E, Yilmaz B, Seker E, Özcelik TB. Effect of fabrication stages and cemen- in 7 intraoral scanners versus conventional impression: an in vitro descrip-
tation on the marginal fit of CAD-CAM monolithic zirconia crowns. J Pros- tive comparison. BMC Oral Health. 2018;18:27. https://doi.org/10.1186/
thet Dent. 2017;118:736–41. https://doi.org/10.1016/j.prosdent.2017.01.004, s12903-018-0489-3, PMID:29471825
PMID:28434679 [58] Mangano F, Veronesi G. Digital versus Analog Procedures for the
[47] Boitelle P, Mawussi B, Tapie L, Fromentin O. A systematic review of CAD/ Prosthetic Restoration of Single Implants: A Randomized Controlled
CAM fit restoration evaluations. J Oral Rehabil. 2014;41:853–74. https://doi. Trial with 1 Year of Follow-Up. BioMed Res Int. 2018;2018:1–20. https://doi.
org/10.1111/joor.12205, PMID:24952991 org/10.1155/2018/5325032, PMID:30112398
[48] Mundhe K, Jain V, Pruthi G, Shah N. Clinical study to evaluate the wear of [59] Miyazaki T, Nakamura T, Matsumura H, Ban S, Kobayashi T. Current status
natural enamel antagonist to zirconia and metal ceramic crowns. J Prosthet of zirconia restoration. J Prosthodont Res. 2013;57:236–61. https://doi.
Dent. 2015;114:358–63. https://doi.org/10.1016/j.prosdent.2015.03.001, org/10.1016/j.jpor.2013.09.001, PMID:24140561
PMID:25985742 [60] Limones A, Molinero-Mourelle P, Azevedo L, Romeo-Rubio M, Correia A,
[49] Esquivel-Upshaw JF, Kim MJ, Hsu SM, Abdulhameed N, Jenkins R, Neal Gómez-Polo M. Zirconia-ceramic versus metal-ceramic posterior multiunit
D, et al. Randomized clinical study of wear of enamel antagonists against tooth-supported fixed dental prostheses: A systematic review and meta-
polished monolithic zirconia crowns. J Dent. 2018;68:19–27. https://doi. analysis of randomized controlled trials. J Am Dent Assoc. 2020;151:230–
org/10.1016/j.jdent.2017.10.005, PMID:29042241 238.e7. https://doi.org/10.1016/j.adaj.2019.12.013, PMID:32222175
[50] Yang SW, Kim JE, Shin Y, Shim JS, Kim JH. Enamel wear and aging of translu- [61] Otto T, Mörmann WH. Clinical performance of chairside CAD/CAM feld-
cent zirconias: in vitro and clinical studies. J Prosthet Dent. 2019;121:417–25. spathic ceramic posterior shoulder crowns and endocrowns up to 12 years.
https://doi.org/10.1016/j.prosdent.2018.04.016, PMID:30391060 Int J Comput Dent. 2015;18:147–61. PMID:26110927
[51] Pathan MS, Kheur MG, Patankar AH, Kheur SM. Assessment of Antago-
nist Enamel Wear and Clinical Performance of Full-Contour Monolithic
Zirconia Crowns: One-Year Results of a Prospective Study. J Prosthodont.
2019;28:e411–6. https://doi.org/10.1111/jopr.12960, PMID:30256495

This is an open-access article distributed under the terms of Creative Commons Attribution-NonCommercial License 4.0 (CC BY-
NC 4.0), which allows users to distribute and copy the material in any format as long as credit is given to the Japan Prosthodontic
Society. It should be noted however, that the material cannot be used for commercial purposes.
12 C. Leitão, et al. / J Prosthodont Res. 2021; **(**): ****–****

Supplementary Table 1. Search equation used in Medline/PubMed and Cochrane Library.

Processing technology Restauration material’s properties Type of Indirect Dental Restoration
“zirconium oxide” [Supplementary Concept] “Crowns”[Mesh] OR “Tooth Crown”[Mesh] OR
OR “yttria stabilized tetragonal zirconia” “Denture, Partial, Fixed”[Mesh] NOT
“Computer-Aided Design”[Mesh] AND AND
[Supplementary Concept] OR “In-Ceram Zirco- “Dental Implants”[Mesh] OR “Dental Im-
nia” [Supplementary Concept] plants, Single-Tooth”[Mesh]
((((“Computer-Aided Design”[Mesh]) AND (“zirconium oxide” [Supplementary Concept] OR “yttria stabilized tetragonal zirconia” [Supplementary Con-
cept] OR “In-Ceram Zirconia” [Supplementary Concept])) AND (“Crowns”[Mesh] OR “Tooth Crown”[Mesh])) OR “Denture, Partial, Fixed”[Mesh]) NOT (“Dental
Implants”[Mesh] OR “Dental Implants, Single-Tooth”[Mesh])

Supplementary Table 2. The research methodology used in Medline/PubMed.

Medline/PubMed®
#1 “Computer-Aided Design”[Mesh]
“zirconium oxide” [Supplementary Concept] OR “yttria stabilized tetragonal zirconia” [Supplementary Concept] OR “In-Ceram
#2
Zirconia” [Supplementary Concept]
#3 “Crowns”[Mesh] OR “Tooth Crown”[Mesh]
#4 “Denture, Partial, Fixed”[Mesh]
#5 “Dental Implants”[Mesh] OR “Dental Implants, Single-Tooth”[Mesh]
Search combination #1 AND #2 AND (#3 OR #4) NOT #5
English, Humans, Adult: 19+years
Applied filters Types of studies: observational study; multicenter study; randomized controlled trial; evaluation studies: controlled clinical trials;
comparative studies; clinical trial.
259 articles
Total articles
(Results available on May 10 2020)

Supplementary Table 3. The research methodology used at Medline/PubMed.

Medline/PubMed®
#1 Monolithic Zirconia
#2 Monolithic dental crown
#3 Zirconia dental crown
Search combination #1 OR #2 OR #3
English, Humans, Adult: 19+years.
Applied filters Observational Study; Multicenter Study; Randomized Controlled Trial; Evaluation Studies; Controlled Clinical Trial;
Comparative Study; Clinical Trial.
Total articles 101 articles (Results available on May 10, 2020)

Supplementary Table 4. The Research equation used at Embase.

Embase®
#1 zirconium OR zirconia OR zirconium oxide
‘computer aided design/computer aided manufacturing’ OR
#2
‘cad/cam software’ OR cad cam OR ‘computer aided design’
#3 crown OR ‘tooth crown’ OR ‘fixed partial denture’
Research merging #1 AND #2 AND #3
Total of articles 565 articles (Results available in 10 May 2020)
(zirconium OR zirconia OR zirconium oxide) AND (‘computer aided design/computer aided manufacturing’ OR ‘cad/cam software’ OR cad cam OR ‘com-
puter aided design’) AND (crown OR ‘tooth crown’ OR ‘fixed partial denture’)

Supplementary Table 5. Inclusion and Exclusion Criteria.

Inclusion Criteria Exclusion Criteria
Published Articles in “Humans” (filter Species / Humans) “Humans”
Rehabilitated patients with partial crowns
(filter Species/Humans)
Single monolithic ceramic crowns other than monolithic zirconia (e.g. feldspar
Adult patients (“19+years”)
ceramic or lithium disilicate)
Rehabilitated patients with monolithic zirconia CAD/CAM single crowns Implant supported crown
Articles with data on survival and/or failure rates Studies based on questionnaires, interviews, case reports and in vitro studies
Minimum three-month follow-up
 C. Leitão, et al. / J Prosthodont Res. 2021; **(**): ****–**** 13

Supplementary Table 6. Studies excluded after full reading and the reason for their exclusion.
Authors, Year Excluded studies and reason for exclusions
Esquivel Upshaw et al. 2018(70) Lack of data on survival rates
Donly et al. 2018(71) Child population (between 3 and 7 years old)
Groten et al. 2010(72) Not specific for monolithic zirconia
Sagirkaya et al. 2012(73) Not specific for monolithic zirconia

Supplementary Table 7. Descriptive analysis: follow-up time, type of study, dental location, and patient characteristics.
Average age
Restorations (n) Individuals (n) Follow-up (TT) Follow-up (TM) Study Location Failure (n)
(μ)
Total
Pro: 55,6% Anterior: 22,2%;
1657 49,1 594 10,5 years 1,07 years 3
Retro: 44,4% Posterior: 88,9%

Supplementary Table 8. Linear regression of the correlation between survival rate and type of cementation and the average years of follow-up.
Model Coefficients – Survival Rate
Predictors Estimate SE t p Stand. Estimate
Cementation
     glass-ionomer - resin -0.0315 0.0830 -0.379 0.730 -0.896
     mean follow-up (y) -0.1027 0.1198 -0.857 0.454 -1.926

Supplementary Table 9. Linear regression evaluating the survival rate with BOP (%) and marginal integrity.
Model Fit Measures
Overall Model Test
Model R R2 F df1 df2 p
1 0.476 0.227 0.440 2 3 0.680

Model Coefficients - Survival rate (%)

Predictor Estimate SE t p
Intercept 116.343 19.074 6.100 0.009
Bleeding on probing (BOP) -0.115 0.130 -0.887 0.441
Marginal integrity -0.185 0.198 -0.937 0.418

Supplementary Figure 1  . Q-Q plot graph.