Recent advances in engineering methods and characterization have rendered the addition of nanometer scale features on endosteal implant surfaces. Such modifications usually occur hierarchically in tandem with modifications at the micrometer scale level, and its main objective is to support the bone response through enhanced interaction between the immediate and intermediate implant and host after surgical placement. This chapter describes the increasing basic science experimental basis for surface nanotopographical alterations and the limited clinical evidence of nanometer scale surface modifications.