Statement of Problem: Data on the clinical performance of monolithic Zirconia screw-retained
crowns on external hexagon implants fabricated from digital scans through a cast-free, fully
digital workflow is lacking and needs to be included. Purpose: This retrospective multicentric
study aimed to evaluate the real-life clinical results of monolithic Zirconia screw-retained crowns
without the interposition of a Ti-base on external hexagon implants fabricated from intraoral
scans and a cast-free approach in private practices. Materials and Methods: Single external hex
implant fixtures were restored with monolithic zirconia crowns without the interposition of a Tibase.
The crowns were directly screwed on external hexagonal implant connections with a castfree,
fully digital workflow. Data were analyzed using descriptive statistics and the Kaplan–
Meier test. Between September 2022 and March 2023, the California Dental Association
modified criteria were adopted for clinical evaluation after recalling all patients. Results: A total
of 304 single tooth restorations in the maxillary and mandibular posterior regions fabricated
between July 2014 and July 2022 in 252 patients (120 males and 132 females, mean age 53.6
years, SD 23.3). Seven crowns were excluded because of patient dropout. The most common
minor technical complications were screw loosening (3 crowns) and loss of the screw-access
hole filling (3 crowns). Four failures included two implant failures with mobility and two
fractured crowns. No screw or implant fractures were recorded. The overall cumulative survival
rate was 98.6% and the average success rate (crowns experiencing no failures or complications)
was 96.0%. The mean overall survival time was 101.3 months (standard error, 0.847; 95%
confidence interval for the mean, 99.67-102.99). The overall survival probability was 87.9% up
to 97 months. Conclusions: With careful case selection and comprehensive periodontal
maintenance program, single crowns directly screwed onto an external hexagon platform have
shown to have excellent survival and success (complication-free) rates, comparable to available
data regarding single crowns with a metal implant- prosthetic interface.