Monolithic zirconia has become widely used for single crowns, with the advantages of minimal tooth reduction and good esthetics. However, clinical studies evaluating the performance of and patient satisfaction with posterior monolithic zirconia crowns are sparse. The purpose of this clinical study was to evaluate the clinical performance of and patient satisfaction with posterior monolithic zirconia crowns. Within a prospective cohort study design, participants were recruited from a university dental clinic if they required 1 posterior monolithic zirconia crown. The clinical performance was evaluated at follow-up appointments 1, 2, and 3 years after insertion. Bleeding on probing and pocket probing depths for the crowned teeth were recorded. Overall patient satisfaction was measured by using a visual analog scale (VAS), and quality of life was measured by using the validated German version of the Oral Health Impact Profile 14 (OHIP-G14). Descriptive statistical methods were applied. Mean values were calculated and compared by using the paired t test (α=.05). Thirty participants received a monolithic zirconia crown (14 premolars, 16 molars). One biologic complication (vertical root fracture) was identified at the 1-year follow-up. Three years after insertion, 22 participants could be examined, and the crowns were still in function. The gingival and the periodontal status of the crowned teeth had not changed significantly over the 3 years. After insertion, a significant improvement in patient satisfaction was measured up to 3 years CONCLUSIONS: Posterior monolithic zirconia crowns led to enhanced patient satisfaction up to 3 years after insertion. They provided good middle-term success and offered a promising alternative to conventional metal-ceramic crowns.