Background: Osteoporosis compromises bone quality, potentially impairing dental implant osseointegration. Titanium (Ti) implants are the clinical gold standard, but zirconia (ZrO₂) implants offer esthetic and biocompatibility advantages. However, their comparative performance in osteoporotic bone remains inadequately characterized. Objective: To compare osseointegration outcomes of Ti and ZrO₂ implants in osteoporotic patients over 12 months. Methods: A randomized controlled trial enrolled 60 osteoporotic patients (30 Ti, 30 ZrO₂). Implant stability quotient (ISQ), bone-implant contact (BIC), and survival rates were assessed at 3, 6, and 12 months. Key Findings: At 12 months, Ti implants exhibited significantly higher ISQ (75.2 ± 3.1 vs. 72.8 ± 4.2; p = 0.012) and BIC (58.3 ± 5.2% vs. 52.1 ± 6.1%; p = 0.003) than ZrO₂. Survival rates were comparable (Ti: 96.7%, ZrO₂: 90.0%; p = 0.308). ISQ increased over time in both groups (p < 0.001). Conclusion: Ti implants demonstrate superior osseointegration in osteoporotic patients, though ZrO₂ implants achieve clinically acceptable stability. Ti remains the preferred material, but ZrO₂ may be suitable for patients with metal hypersensitivity.