Zirconia-based versus metal-framework veneered complete-arch implant-supported fixed dental prostheses: a systematic review of comparative clinical studies with integrated cost-effectiveness analysis

Objectives: To systematically compare the outcomes of zirconia-based versus metal framework veneered implant-supported fixed complete dental prostheses (ISFCDPs). We integrate cost effectiveness analysis comparing monolithic zirconia versus titanium PMMA ISFCDPs to model the 20 year costs and benefits associated with each arm. Data sources: PubMed/MEDLINE, Cochrane CENTRAL, Scopus, ClinicalTrials.gov and WHO ICTRP were searched on March 6 2026 with no date restrictions applied. Study selection: Two arm comparative studies reporting clinical outcomes for both zirconia-based and metal framework veneered ISFCDPs with a minimum of one year follow up after prosthesis delivery. Data extraction and synthesis: Two independent reviewers extracted data and assessed the risk of bias using the Newcastle Ottawa Scale. Narrative synthesis followed SWiM guidelines. A tiered material classification system was employed to handle framework alloy heterogeneity. Meta-analysis was not possible due to heterogeneity in outcomes reported and methodological differences. A Markov cohort model estimated cost-effectiveness from a patient perspective over a 20 year horizon. Deterministic and probabilistic sensitivity analysis (PSA) tested results robustness. Results: Eight retrospective cohort studies (396 patients; 551 prostheses) were included in final analysis. All were classified as Tier 1 due to inconsistent alloy reporting. Prosthesis and implant survival rates were high across both arms but with no statistical difference for any primary outcome. Cost-effectiveness analysis estimated total discounted per-patient costs of {pound}23,295 for titanium-PMMA and {pound}29,170 for monolithic zirconia over 20 years. This results in an ICER of {pound}315,417 per QALY gained. PSA confirmed zirconia as cost-effective in only 0.50% of 10,000 iterations at the {pound}20,000/QALY threshold. Net monetary benefit was consistently negative for zirconia. Conclusions: Both types of ISFCDPs provided high prosthesis and implant survival with no statistically significant difference in primary clinical outcomes, though all evidence was graded at very low certainty. We estimated a per-patient premium of {pound}5,875 for monolithic zirconia over a 20 year horizon with marginal QALY gains (0.019). Adequately powered RCTs with standardised material reporting are needed to strengthen our clinical and economic conclusions. Systematic review registration: OSF: 10.17605/OSFJO/CF796