The membrane biofilm reactor (MBfR), which is based on the counter diffusion of the electron donors and acceptors into the biofilm, represents a novel technology for wastewater treatment. When process air or oxygen is supplied, the MBfR is known as the membrane aerated biofilm reactor (MABR), which has high oxygen transfer rate and efficiency, promoting microbial growth and activity within the biofilm. Over the past few decades, lab-scale studies have helped researchers and practitioners understand the relevance of influencing factors and biological transformations in MABRs. In recent years, pilot- to full-scale installations are increasing along with process modeling. The resulting accumulated knowledge has greatly improved understanding of the counter-diffusional biological process, with new challenges and opportunities arising. Therefore, it is crucial to provide new insights by conducting this review. This paper reviews wastewater treatment advancements using MABR technology, including design and operational considerations, microbial community ecology, and process modeling. Treatment performance of pilot- to full-scale MABRs for process intensification in existing facilities is assessed. This paper also reviews other emerging applications of MABRs, including sulfur recovery, industrial wastewater, and xenobiotics bioremediation, space-based wastewater treatment, and autotrophic nitrogen removal. In conclusion, commercial applications demonstrate that MABR technology is beneficial for pollutants (COD, N, P, xenobiotics) removal, resource recovery (e.g., sulfur), and N2O mitigation. Further research is needed to increase packing density while retaining efficient external mass transfer, understand the microbial interactions occurring, address existing assumptions to improve process modeling and control, and optimize the operational conditions with site-specific considerations.