Survival and biological and technical complications of veneered zirconia-ceramic versus metal-ceramic restorations: a systematic review and meta-analysis

Abstract

This systematic review and meta-analysis aimed to critically assess and compare the survival rates and the spectrum of biological and technical complications associated with veneered zirconia-ceramic versus metal-ceramic restorations. By synthesizing evidence from randomized clinical trials, the study provides clinicians with robust, evidence-based guidance for material selection in fixed prosthodontics. A comprehensive literature search was conducted in PubMed/MEDLINE, Scopus, EMBASE, Web of Science, the Cochrane Library, and ClinicalTrials.gov from inception to April 2025. Eligible RCTs comparing veneered zirconia-ceramic and metal-ceramic restorations were included. Statistical analyses were performed using STATA version 18, and risk of bias was assessed using the Cochrane Risk of Bias 2 (RoB 2) tool. The certainty of evidence was evaluated using the GRADE approach. Fourteen randomized clinical trials met the inclusion criteria and were included in the systematic review. Most studies reported survival outcomes and biological or technical complications for both veneered zirconia-ceramic and metal-ceramic restorations, whereas secondary caries data were limited and were synthesized narratively. Quantitative synthesis suggested a marginally higher survival probability for veneered zirconia-ceramic restorations compared with metal-ceramic restorations (RR = 1.03; 95% CI: 1.00–1.09; I² = 73.7%). Veneered zirconia-ceramic restorations were also associated with a lower risk of chipping (RR = 0.59; 95% CI: 0.48–0.72; I² = 58.2%). No statistically significant differences were observed for framework fracture, discoloration, anatomical form, marginal integrity, or occlusal wear. Low-certainty evidence suggested a marginally higher survival probability and a lower risk of chipping with veneered zirconia-ceramic restorations compared with metal-ceramic restorations. However, substantial heterogeneity across several outcomes, evidence of small-study effects, and imprecision in some estimates limit confidence in the available evidence. Therefore, these findings should be interpreted with caution, and restorative material selection should be individualized according to patient-specific biological, functional, and esthetic considerations.