Objectives <p>To evaluate the clinical outcomes of zirconia dental implants over five years, considering the growing demand for metal-free alternatives to titanium due to aesthetic concerns and potential hypersensitivity reactions to metals.</p> Materials and methods <p>This retrospective study analyzed 80 zirconia implants from an initial cohort of 95, with 15 excluded due to loss to follow-up or not meeting inclusion criteria. Both one-piece and two-piece designs were included, and some cases involved Guided Bone Regeneration (GBR). The primary outcome was implant survival.</p> Results <p>The overall survival rate was 83.8% (67/80) after a mean follow-up of 29.0 ± 16.6 months (maximum 62 months). Kaplan–Meier analysis estimated mean survival at 52.6 ± 2.38 months, with the median not reached due to censoring. Survival was significantly lower with immediate placement (<i>p</i> = 0.016). GBR was linked to higher survival, with all GBR implants surviving and failures only in non-GBR cases (<i>p</i> &lt; 0.001). No significant differences appeared in implant design, loading protocol, diameter, jaw location, prosthesis, surface, zirconia brand, or patient sex.</p> Conclusions <p>Zirconia implants showed 83.8% survival at five years, supporting their clinical applicability as metal-free implant systems<i>.</i> Immediate placement had significantly lower survival, favoring late placement. No significant differences were found between one-piece and two-piece implants, or between implants placed with and without GBR. Larger prospective studies with standardized clinical and radiographic assessments are needed to confirm these findings and refine zirconia implant protocols.</p> Clinical Relevance <p>Zirconia implants show good mid-term survival and can be an alternative to titanium. However, immediate placement should be approached cautiously due to potential impacts on success.</p>