Clinical outcomes of tooth-supported monolithic zirconia vs. porcelain-veneered zirconia fixed dental prosthesis, with an additional focus on the cement type: a systematic review and meta-analysis

Clinical Oral Investigations https://doi.org/10.1007/s00784-023-05219-4 REVIEW Clinical outcomes of tooth‑supported monolithic zirconia vs. porcelain‑veneered zirconia fixed dental prosthesis, with an additional focus on the cement type: a systematic review and meta‑analysis Shahed Shihabi1 · Bruno Ramos Chrcanovic2 Received: 3 July 2023 / Accepted: 15 August 2023 © The Author(s) 2023 Abstract Purpose To compare the failure rates and the prevalence of technical complications between full-coverage tooth-supported monolithic zirconia (MZ) and porcelain-veneered zirconia (PVZ) fixed dental prosthesis, based on a systematic literature review. Methods An electronic search was performed in three databases, supplemented by hand searching. Several statistical methods were used. Results Seventy-four publications reported 6370 restorations (4264 PVZ; 2106 MZ; 8200 abutment teeth; 3549 patients), followed up until 152 months. A total of 216 prostheses failed, and survival was statistically significant different between groups. PVZ had higher occurrence of complications than MZ; the difference was especially greater for either minor or major chipping. The difference in prevalence of either minor or major chipping was statistically significant for PVZ prostheses between cementation with glass ionomer and adhesive resin cement (higher), adhesive resin and resin-modified glass ionomer cement (RMGIC, higher), and between RMGIC (higher) and glass ionomer cement. For MZ the difference was significant only for minor chipping between RMGIC (higher) and adhesive resin cement. Abutment teeth to PVZ prostheses more often lost vitality. Decementation was not observed with RMGIC. Air abrasion did not seem to clinically decrease the decementation risk. The 5-year difference in the occurrence of minor or major chipping between MZ and PVZ prostheses was statistically significant, but nor for catastrophic fracture. Conclusion Tooth-supported PVZ prostheses present higher failure and complication rates than MZ prosthesis. The difference in complications is striking when it comes to chipping. Clinical relevance Awareness of the outcome differences between different types of zirconia prostheses is important for clinical practice. Keywords Dental prosthesis · Tooth-supported prosthesis · Monolithic zirconia · Porcelain-veneered zirconia · Cement type · Cementation · Failure · Complications · Systematic review Introduction * Bruno Ramos Chrcanovic ; Shahed Shihabi 1 Faculty of Odontology, Malmö University, Malmö, Sweden 2 Department of Prosthodontics, Faculty of Odontology, Malmö University, Carl Gustafs Väg 34, 214 21 Malmö, Sweden The development of yttria-stabilized tetragonal zirconia polycrystalline (Y-TZP) for dental purposes has resulted in a range of different products. The main advantages of Y-TZP include exceptional mechanical properties, biocompatibility, and resistance to corrosion [1, 2]. One of the greatest disadvantages of the Y-TZP, at least when it comes to dental restorations, is the less than desirable translucency of the material. Translucency is important, as a certain degree of translucency of the dental ceramic is needed to let the natural background color shine throughout the translucent 13 Vol.:(0123456789) Clinical Oral Investigations material, so the dental restoration can present a more natural appearance [3]. There are today two main categories of dental prostheses made of Y-TZP: monolithic zirconia (MZ), in which the bulk of the restorations is made of zirconia and external stains are painted in order to better copy the natural colors of teeth, and porcelain-veneered zirconia (PVZ), in which a framework of zirconia is fabricated, upon which veneering porcelain is applied [4]. Prostheses made of MZ are stronger, but present a compromised aesthetic aspect, while PVZ prostheses, with a core of Y-TZP and an outer layer of ceramic (also called as bilayer structure), better resemble natural teeth, although are vulnerable to chipping and delamination [2]. This may predispose PVZ to a higher prevalence of clinical technical complications. Questions have been raised concerning the effect of cement type on the clinical outcomes, although a recent review failed to find evidence of difference in the complication patterns between adhesive and conventional cementation for zirconia and lithium disilicate tooth-supported crowns [5]. Therefore, the purpose of the present systematic review of the literature was to test the null hypothesis of no difference in the failure rates and the prevalence of technical complications between full-coverage tooth-supported MZ and PVZ fixed dental prosthesis (FDP). The review presented an additional focus on the effect of the type of cement used on the occurrence of complications. Materials and methods This study followed the PRISMA Statement guidelines [6]. Registration in PROSPERO was undertaken (registration number CRD42022342097). Objective The focused question was elaborated according to the PICO format (participants, interventions, comparisons, outcomes): In patients being rehabilitated with dental prosthetic restorations, is there a difference in the failure rate and in the prevalence of technical complications between monolithic zirconia and porcelain-veneered zirconia prostheses? Search strategies An electronic search without time restrictions was undertaken in October 2021, with a complementary updated search in June 2023, in the following databases: PubMed/ Medline, Web of Science, and Science Direct. The following terms were used in the search strategies: (tooth OR teeth OR tooth-supported) AND (dental prosthesis OR 13 dental restoration) AND (monolithic zirconia OR porcelain-veneered zirconia OR porcelain fused to zirconia OR pressed on zirconia ceramics). Due to the initial large number of search entries in Science Direct, the options “research articles” and “review articles” were selected in the filter “Article type.” A manual search of all related prosthodontic and specialist dental and oral journals was performed. The reference list of the identified studies and the relevant reviews on the subject were also checked for possible additional studies. Gray literature was not searched. Inclusion and exclusion criteria Eligibility criteria included clinical human studies, either randomized or not, providing information on the clinical outcomes of full-coverage tooth-supported MZ and/or PVZ FDPs. The minimum of follow-up was set to 6 months. Only publications written in English were considered for inclusion. Combined tooth-implant-supported FDP cases were excluded, as well as zirconia copings to be used with removable partial dentures. Inlay-retained FDP cases were excluded, as they do not present the same quality of support as a conventional FDP. Cases of zirconia restorations aimed to be cemented on abutment teeth for partial removable dental prosthesis were excluded, as these are subjected to additional forces on the occ (...truncated)