Are monolithic zirconia complete arch implant-supported prostheses reliable? A systematic review and meta-analysis

STATEMENT OF PROBLEM: Despite the increasing use of monolithic zirconia for complete arch implant-supported prostheses, evidence regarding their long-term survival, complication rates, and clinical predictability remains limited and heterogeneous. PURPOSE: The purpose of this systematic review was to evaluate the survival and overall performance of monolithic zirconia complete arch implant-supported prostheses. MATERIAL AND METHODS: An electronic search was conducted in 9 databases following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and registered on PROSPERO (CRD: 42025640173). Meta-analyses were performed using random-effects models (α=.05). Subgroup analyses evaluated the pooled proportion of prosthetic failures, implant longevity, and technical complications. The risk of bias was assessed using the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool, and the certainty of evidence was graded according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. RESULTS: Thirteen studies comprising 2841 prostheses and 3940 implants were included in this systematic review. The pooled proportion rate of monolithic zirconia complete arch prostheses in function at the last follow-up (12 to 62 months) was 99% (95% confidence interval [CI]): 97% to 100%; I²=72%, while implant longevity reached 100% (95% CI: 99% to 100%; I²=75%). The pooled technical complication rate was 14% (95% CI: 4% to 27%; I²=96%). Subgroup analyses revealed higher complication rates in veneered designs (up to 27%) compared with monolithic configurations (1% to 3%). Most studies presented a moderate to serious risk of bias according to ROBINS-I, mainly due to retrospective designs and confounding. The certainty of evidence was rated as low by GRADE, primarily because of methodological limitations and heterogeneity. CONCLUSIONS: Monolithic zirconia complete arch implant-supported prostheses demonstrated high cumulative proportions of prostheses remaining in function and low rates of technical and biological complications within the reported follow-up periods.