Objective. Osseointegration has been a proven concept in implant dentistry and orthopedics for decades. Substantial efforts for engineering implants for reduced treatment time frames have focused on micrometer and most recently on nanometer length scale alterations with negligible attention devoted to the effect of both macrometer design alterations and surgical instrumentation on osseointegration. This manuscript revisits osseointegration addressing the individual and combined role of alterations on the macrometer, micrometer, and nanometer length scales on the basis of cell culture, preclinical in vivo studies, and clinical evidence. Methods. A critical appraisal of the literature was performed regarding the impact of dental implant designing on osseointegration. Results from studies with different methodological approaches and the commonly observed inconsistencies are discussed. Results. It is a consensus that implant surface topographical and chemical alterations can hasten osseointegration. However, the tailored combination between multiple length scale design parameters that provides maximal host response is yet to be determined. Signcance. In spite of the overabundant literature on osseointegration, a proportional inconsistency in findings hitherto encountered warrants a call for appropriate multivariable study designing to ensure that adequate data collection will enable osseointegration maximization and/or optimization, which will possibly lead to the engineering of endosteal implant designs that can be immediately placed/loaded regardless of patient dependent conditions.