Review Article

From osseoperception to implant-mediated sensory-motor

interactions and related clinical implications*
R. JACOBS & D. VAN STEENBERGHE
1
Laboratory of Oral Physiology, Department of Periodontology, Faculty of
Medicine, Catholic University of Leuven, Leuven, Belgium
SUMMARY Osseointegration of implants in the jaw
bone has been studied thoroughly, dealing with
various aspects such as bone apposition, bone qual-
ity, microbiology, biomechanics, aesthetics, etc. A
key issue that has received much less attention is
the physiologic integration of the implant(s) and the
associated prosthesis in the body. The latter aspect is
however very important to obtain new insights in
oral functioning with implant-supported pros-
theses. Amputated patients rehabilitated with a
lower limb prosthesis anchored to the bone by
means of an osseointegrated implant, have reported
that they could recognize the type of soil they were
walking on. Clinical observations on patients with
oral implants, have conrmed a special sensory
perception skill. The underlying mechanism of this
so-called osseoperception phenomenon remains a
matter of debate, because extraction of teeth
involves elimination of the extremely sensitive
periodontal ligaments while functional reinnerva-
tion around implants is still uncertain. Histological,
neurophysiological and psychophysical evidence of
osseoperception have been collected, making the
assumption more likely that a proper peripheral
feedback pathway can be restored when using
osseointegrated implants. This implant-mediated
sensory-motor control may have important clinical
implications, because a more natural functioning
with implant-supported prostheses can be attemp-
ted. It may open doors for global integration in the
human body.
KEYWORDS: osseoperception, dental implant, jaw,
trigeminal nerve, tactile function, physiology
Accepted for publication 1 January 2006
Introduction
Sensory feedback plays an essential role in ne tuning
of limb motor control. Thus, it is clear that amputation
of a limb will not only involve destruction of an
important part of the peripheral feedback pathways, but
also hamper ne motor control. Conventional socket
prostheses do not carry enough sensory information to
restore the necessary natural feedback pathways for
motor function (1). Comparable observations can be
made after extraction of teeth. The periodontal liga-
ment harbours a very rich innervation, carrying rened
mechanoreceptive properties by an intimate contact
between collagen bres and Rufni-like endings (2).
The role of periodontal neural feedback is well-known
(3, 4). After extraction of teeth however, this feedback
pathway may be damaged as periodontal ligament
receptors are eliminated. Thus, the impact of tooth
extraction on the sensory feedback pathway seems
considerable (36). Dentures can be compared with
socket prostheses and are not able to fully compensate
for normal tooth loading and force transfer. The
peripheral feedback mechanisms are more limited as
the mucosal mechanoreceptor function is less efcient
than the periodontal ligament function. Consequently,
oral function remains impaired (4).
*Based on the Journal of Oral Rehabilitation Summer School 2005 in
Bavagna, Italy. Kindly sponsored by Blackwell Munksgaard and Nobel
Biocare.
1
Holder of the P-I Bra nemark Chair in Osseointegration
2006 The Authors. Journal compilation 2006 Blackwell Publishing Ltd doi: 10.1111/j.1365-2842.2006.01621.x
Journal of Oral Rehabilitation 2006 33; 282292
It has been assumed that by anchoring prosthetic
limbs directly to the bone via osseointegrated implants,
partial sensory substitution can be realized (1, 5, 6). If
the feedback pathway can be restored, such concept of
bone-anchored limb prostheses would signify an
important step towards global integration of a pros-
thesis in the body. Amputated as well as edentulous
patients, rehabilitated with a bone-anchored prosthesis,
report a specic feeling around endosseous implants.
Psychophysical threshold determination studies con-
rmed that patients may perceive mechanical stimuli
exerted on osseointegrated implants in the bone
(1, 5, 6). This phenomenon has raised questions. Would
this special feeling result from a changed impact force
through the rigid implantbone interface, in contrast to
the cushioning effect of the skin or mucosa under the
socket prosthesis? Or would intra-osseous or periosteal
neural endings be involved?
The latter observations brings along the discussions of
which receptor groups are responsible for this so-called
osseoperception phenomenon. New insights and more
objective non-invasive approaches may help clarifying
this question. First, Somatosensory Evoked Potentials
(SEPs), which are routinely used to screen for neuro-
logical disorders, could assist localizing the origin of
sensory phenomena observed upon implant stimula-
tion. For trigeminal SEPs, thorough signal analyses are
needed rather than visual inspection, to obtain reliable
data on the SEP signals and enable further interpret-
ation on the receptors activated upon implant stimula-
tion (7, 8). A most promising approach is the use of
functional Magnetic Resonance Imaging (fMRI), which
has the advantage of being a static and/or dynamic
imaging technique, without the drawback of exposure
to ionizing radiation (9). This fMRI might help visual-
izing activity centres on the pathway from the stimu-
lation site to the cortex. Both non-invasive approaches
offer new perspectives for osseoperception research and
may try linking the anatomical and histological back-
ground to the clinical observations. If such link is
present, osseoperception might help in physiologic and
functional integration of implants in the body.
The present review attempts to provide arguments
and scientic evidence to support this hypothesis.
Neurovascularization of the jaw bones
The jaws are richly supplied by neurovascular struc-
tures. This needs to be carefully considered when
performing surgical procedures in the jaw, such as
inserting implants. Pre-surgical localization of neuro-
vascular structures is essential to guarantee an
uneventful outcome (10). On the other hand, the rich
jaw bone innervation may help to sense mechanical
deformation during loading of oral implant and thus
contribute to restore peripheral feedback after tooth
extraction and implant placement. Even in the anterior
jaw bone, where the presence and functional signi-
cance of neurovascularization was somewhat neglected
in the past, recent studies on a variety of human
cadaver material have conrmed a rich innervation
with clear sensory nerve characteristics (1012)
(Fig. 1). The neurovascular content of a well-dened
mandibular incisive and lingual canal and a maxillary
nasopalatine canal structure may explain a number of
altered sensations after anterior implant placement
(Fig. 2).
Histological background
Tooth extraction results in damage of a large number of
sensory nerve bres and corresponds to an amputation,
where the target organ and peripheral nervous struc-
tures have been destroyed (13). After extraction of
teeth, the myelinated bre content of the inferior
alveolar nerve is reduced by 20% (14). This nding
indicates that bres originally innervating the tooth and
periodontal ligament are still present in the inferior
alveolar nerve. Linden and Scott (15) succeeded to
stimulate nerves of periodontal origin in healed extrac-
tions sockets, which implies that some nerve endings
remain functional. Nevertheless, most of the surviving
mechanoreceptive neurons represented in the mesen-
cephalic nucleus may lose some functionality (15).
These experiments have been the basis for a further and
long-lasting debate on the presence and potential
function of sensory nerves bres in the bone and
peri-implant environment. Histological evidence indi-
cates that there may be some reinnervation around
osseointegrated implants (16, 17). Indeed, it has been
shown that endosseous implants may lead to degener-
ation of environing neural bres by surgical trauma.
Soon however, sprouting of new bres is observed and
the number of free nerve endings close to the bone-to-
implant interface gradually increases during the rst
weeks of healing (18). Amore recent study inthe dog has
succeeded to partially regenerate the periodontal liga-
ment on an implant surface (19). Whether such regen-
OS S E OP E R C E P T I ON AND S E NS OR Y - MOT OR I NT E R AC T I ONS 283
2006 The Authors. Journal compilation 2006 Blackwell Publishing Ltd
eration might also induce restoration of the peripheral
feedback pathway has however not been studied.
On the other hand, existing mechanoreceptors in the
periosteum may also play a role in tactile function upon
implant stimulation. It is evident that oral implants
offer another type of loading and force transfer than
teeth, considering an intimate bone-to-implant contact
with elastic bone properties instead of the characteristic
viscoelasticity of the periodontal ligament. Thus, forces
applied to osseointegrated implants are directly trans-
ferred to the bone and bone deformation may lead to
receptor activation in the peri-implant bone and the
neighbouring periosteum (20).
Cortical plasticity after tooth extraction
The cortex of the brain reveals a somatotopically ordered
representational map for movements that resembles a
distorted cartoon of the body (21). After limb amputa-
tion, the regions of the cortex deprived of a target acquire
new targets. Remodelling takes place at a cortical or
subcortical level (22). The potential cortical adaptation
and/or plasticity that might occur after tooth extraction
and implant placement has not yet been fully explored.
A very interesting study was recently carried out on
mole-rats (23). Henry et al. (23) extracted the lower right
incisor in mole-rats. Five to 8 months afterwards, the
oro-facial representation in S1 was considerably reor-
ganized. Neurons in the cortical lower tooth representa-
tion were responsive to tactile inputs from surrounding
oro-facial structures. This studymayindicate that cortical
representation of teeth may signicantly restructure
after tooth loss. These data parallel ndings after deaf-
ferentation in the somatosensory hand area of primates
where tactile inputs from the chin and upper arm may
activate the hand cortical area.
Unfortunately, until now, similar evidence in
humans has not yet been produced. Future research
should therefore try to visualize cortical plasticity after
Fig. 2. Placement of implants in the anterior mandible may
present some risk for neurovascular damage. In the present cross-
sectional image of a cone beam CT of the anterior mandible, the
intimate contact between a canine osseointegrated implant and
the incisive nerve becomes obvious.
(a)
(b)
Fig. 1. Histological section (a) and high resolution MRI image (b)
show one bony canal branching into two canals. Figure (a)
visualizes two branches (arrow) of the canal on a histological
section. Figure (b) is an horizontal MRI section showing one bony
canal (grey arrow) branching into two canals (black arrows).
[Reprinted from Dentomaxillofacial Radiology, vol.34, Liang X,
Jacobs R, Lambrichts I, Vandewalle G, van Oostveldt D, Schepers
E, Adriaensens P, Gelan J. Microanatomical and histological
assessment of the content of superior genial spinal foramen and its
bony canal, pp 362368, Copyright 2005, with permission from
the British Institute of Radiology].
R. J AC OBS & D. VAN S T E E NB E R GHE 284
2006 The Authors. Journal compilation 2006 Blackwell Publishing Ltd
tooth extraction and further functional rehabilitation
with implants. It should be considered that an imme-
diate extraction and implant rehabilitation protocol
might induce a different cortical remodelling than a
traditional two-stage implant rehabilitation protocol.
An interesting phenomenon with respect to sensory-
motor integration of osseointegrated implants, may be
the so-called phantom tooth (after extraction) or
phantom limb (after amputation), allowing perception
of lost body parts (24). In fact, it could be assumed that
such a phantom feeling of the lost limb may overlap
with or enforce the feeling of a bone-anchored pros-
thetic limb (1, 5). In this way, phantom sensations
might contribute to physiological integration of a bone-
anchored prosthesis in the human body (5).
Neurophysiological versus psychophysical
data
Information on oral tactile function can be examined by
neurophysiological as well as psychophysical methods.
Neurophysiological investigations on the sensory func-
tion of the trigeminal system in man are scarce.
Afferent nerve recordings of the human trigeminal
nerve require skilful performance and only few studies
have been reported so far (2527). [see also review by
Trulsson (28)].
Evidence can also be found by non-invasive approa-
ches for evaluation of oral tactile function. The rst
approach is the recording of the so-called trigeminal
somatosensory evoked potentials (TSEP) after stimula-
tion of receptors in the oral cavity (7, 8). This set-up has
the advantage of obtaining information on the cortical
response of the trigeminal afferent system upon non-
invasive stimulation of oral receptors. Another non-
invasive method to assess sensory function is the
visualization of brain activities by fMRI (9). It is a very
promising technique, which has so far received hardly
any attention in relation to tactile function of teeth and
implants.
Conversely, psychophysical studies on the oral sen-
sory function are numerous (4). A major advantage of
this type of studies is that these are simple non-invasive
techniques that may be performed in a clinical
environment. Psychophysics includes a series of well-
dened methodologies to help determining the thresh-
old level of sensory receptors in man. Psychophysical
methods allow connecting the psychological response
of the patient to the physiological functions of the
receptors involved. When performed meticulously and
under standardized conditions, these studies may reveal
nearly as precise information as neurophysiological set-
ups (3, 4, 29).
Regardless of the tests used, one must keep in mind
that many variables contribute to the subjective nature
of psychophysical sensory testing. Some variables are
manageable, others are more difcult to deal with. The
inuencing factors are found in the different compo-
nents of the experimental set-up (environmental inu-
ence, psychophysical approach, patient-related factors,
etc.) (3, 4, 29).
Environmental factors should be well-controlled as
background noise is distracting to patient and examiner.
To minimize the effect of noise, testing should be done in
a quiet room with stable background illumination (29).
Different psychophysical procedures have been des-
cribed in order to reliably assess tactile function (30).
Adaptive methods are generally recommended for
threshold level determination, as these seem very
effective and consistent. Such approaches are called
adaptive as the subsequent stimulus value depends on
the subjects response in the preceding trials. In the
staircase method, the stimulus value is changed by a
constant amount. When the answer shifts from one
answer toanother, the stimulus directionis changed. The
threshold is then determined by averaging the peaks and
valleys throughout all runs. Some patients may imagine
a stimulus when there is none. Others admit feeling a
sensation only if they are absolutely positive that it was
felt. The inclusion of false alarms (implying that no
stimulus is presented in the specied time interval) may
exclude response bias and a guessing strategy of the
subject. A thorough and standardized instruction to all
subjects is important in this perspective.
Other patient-related factors that should be consid-
ered are of physical origin and include age, gender,
dental status, and dexterity. Age is an important
variable with respect to implant physiology, consider-
ing the fact that edentulous patients are usually found
amongst the elderly. In general, motor changes occur
with age leading to impairment of balance and
unsteadiness of motion. Besides, a deterioration of
most sensory modalities in the distal extremities occurs
(31). A decline in oral sensory function is also
established. After the age of 80, the ability to differ-
entiate tactile and vibratory stimuli on the lip decrea-
ses and two-point discrimination deteriorates on the
upper lip, on the cheeks and on the lower lip, but not
OS S E OP E R C E P T I ON AND S E NS OR Y - MOT OR I NT E R AC T I ONS 285
2006 The Authors. Journal compilation 2006 Blackwell Publishing Ltd
on the tongue and the palate (32). The stereognostic
ability also declines with age (33, 34). It is clear that
this age-effect should be considered in experimental
studies.
In contrast to age, the existence of some gender effect
remains a matter of debate. Taking into account the
important inter-individual variability, clear-cut gender
differences are not easily discerned with regard to oral
sensory function. There is no marked gender effect on
stereognostic ability or vibrotactile function (35, 36).
The tactile sensory systems of men and women seem to
operate similarly at both threshold and suprathreshold
levels of stimulation (37, 38). However, females seem to
have greater ability to discern subtle changes in lip,
cheek and chin position than males (38). Dexterity is
another patient-related variable. Although there is
some relation between masticatory performance and
dexterity (39), this is the case for neither tactile
function nor stereognosis (29, 40).
Tactile function of oral implants
Periodontal neural receptors play an essential role in
oral tactile function (3). Most receptors can be found in
the periodontal ligament, which is evidently lacking
around permucosal oral implants. In that case, remain-
ing receptors in gingiva, alveolar mucosa and periost-
eum may take over part of the normal exteroceptive
function.
It seems attractive to explain the observed tactile
sensitivity of endosseous implants, coined osseopercep-
tion, by the surrounding endosseous and periosteal
neural endings. To prove it, part of the evidence is
provided by a series of psychophysical and neurophys-
iological experiments in man (4, 5). Neurophysiological
evidence can be found in some experiments evoking
TSEPs upon implant stimulation. By triggering sweeps
in the electroencephalogram by means of an implant
stimulation device and by cumulating and advanced
analysis of the sweeps, one can nally note signicant
waves. The experiments indicate that it is indeed
endosseous and/or periosteal receptors around the
implants, which convey the sensation (8, 41).
Psychophyscial testing has been performed by active
and passive (vibro)tactile detection and discrimination
tasks as well as by oral stereognosis (4, 29). During
active threshold determination, subjects are asked
detecting foils placed in between the teeth. During
passive threshold level assessment, the concentrated
patient is undergoing an external force applied to the
implant (Fig. 3). As soon as the subject detects the foil
or the force, he has to signal it (29). From several
studies, it has been established that the oral tactile
function is inuenced by tooth position and dental
status (3, 4, 6, 29). The tactile function of teeth is
primarily determined by the presence of periodontal
ligament receptors. Vital or non-vital teeth show a
comparable tactile function (4) (Table 1). However,
when periodontal ligament receptors are reduced in
numbers or eliminated (e.g. periodontitis, chewing,
extraction, anaesthesia, etc.), tactile function is
impaired (4). This clinically implies that the patients
ability to detect occlusal inaccuracies is decreased in
these situations. Indeed, exteroceptors inform the
nervous system on the characteristics of the stimulus,
which then allows modulation of the motoneuron pool
to avoid overloading. Elimination of these exterocep-
tors by tooth extraction may reduce the tactile function
to an important extent (4, 6, 42, 43). Even after
rehabilitation with a prosthesis, the tactile function
remains impaired. The inappropriate exteroceptive
feedback may thus present a risk for overloading the
Fig. 3. Set-up of passive threshold determination of a maxillary
front tooth by applying axial pushing forces against the tooth.
Table 1. Factors inuencing the tactile function of teeth (6, 28,
41, 42)
Dental status
Active detection
threshold (lm)
Passive detection
threshold (g)
Vital tooth 20 2
Non-vital tooth 20 2
Removable prosthesis 150 150
Implant-supported
prosthesis
50 100
R. J AC OBS & D. VAN S T E E NB E R GHE 286
2006 The Authors. Journal compilation 2006 Blackwell Publishing Ltd
prosthesis (1, 5). In comparison with the tactile func-
tion of natural dentitions, the active threshold is seven
to eight times higher for dentures but only three to ve
times higher for implants (42) (see Table 1). For the
passive detection of forces applied to upper teeth,
thresholds for dentures are 75 times increased and for
implants 50 times (43) (see Table 1). The large discrep-
ancies between active and passive thresholds can be
explained by the fact that several receptor groups may
respond to active testing, while the passive method
selectively activates periodontal ligament receptors. The
latter are eliminated after extraction, which may
explain the reduced tactile function in edentulous
patients. After rehabilitation with a bone-anchored
prosthesis however, edentulous patients seem to func-
tion quite well. These patients perceive mechanical
stimuli exerted on osseointegrated implants in the jaw
bone (43). If subjects are followed up after implant
placement, there is a noticeable improvement in tactile
function with oral implants following a 3-months
healing period (44). Some people rehabilitated with
osseointegrated implants even note a special sensory
awareness with the bone-anchored prosthesis, coined
osseoperception (1, 5). The existence of this phenom-
enon could imply that the feedback pathway to the
sensory cortex is partly restored with an hypothetical
representation of the prosthesis in the sensory cortex
allowing a more appropriate modulation of the moto-
neuron pool leading to a more natural functioning and
avoiding overload.
Oral mechanoreceptors activated during
oral tactile function
When performing psychophysical testing, various types
of oral mechanoreceptors may be activated. Mecha-
noreceptors in the oral region may be located in
the periodontal ligament, oral mucosa, gingiva, bone,
periosteum, and tongue. Mechanoreceptors in the
periodontal ligament contribute to the very high
sensitivity of teeth to mechanical stimuli (3, 4). The
periodontal ligament is richly supplied with mecha-
noreceptors, with the majority being identied histo-
logically as Rufni-like endings (2). During passive
threshold determination, these receptors will be acti-
vated. The assessment of the active tactile threshold
level however is not solely based on activation of
periodontal mechanoreceptors. Temporomandibular
joint (TMJ) receptors are found to play only a minor
role but muscular receptors are important in the
discriminatory ability for mouth openings of 5 mm
and more (45). In the oral mucosa, different types of
mechanoreceptors can be identied including Meiss-
ners corpuscules, glomerular endings, Merkel cells,
Rufni-like endings, and free nerve endings. The
number of nerve bres per unit area is greater in
the anterior areas of the oral cavity, making this region
the most sensitive part of the oral mucosa (46).
The gingiva contains round and oval lamellar cor-
puscles (2). These receptors respond to mechanical
stimuli and are involved in the co-ordination of lip and
buccal muscles during mastication (25, 26). Cutaneous
mechanoreceptors in the facial skin are activated by
skin stretching or contraction of facial muscles and may
operate as proprioceptors involved in facial kinaesthesia
and motor control (47).
The periosteum contains free nerve endings, complex
unencapsulated and encapsulated endings. The free
nerve endings are activated by pressure or stretching of
the periosteum through the action of masticatory
muscles and the skin (20). When applying forces to
osseointegrated implants in the jaw bone, it might be
assumed that the pressure build-up in the bone is
sometimes large enough to allow deformation of the
bone and its surrounding periosteum (43). The involve-
ment of bone innervation in mechanoreception
remains however a matter of debate (48).
Oral stereognosis and osseointegration
Another functional test is the so-called stereognosis.
The stereognostic ability is dened as the ability to
recognize and discriminate different forms presented as
a stimulus (49). While touch may obtain information
on the mechanoreceptors activated by simple detection
or discrimination of mechanical stimuli, stereognosis is
a more complex process. It is a function of both
peripheral receptors (touch and kinaesthetic) and cen-
tral integrating processes (49). It may give an idea on
daily functioning and may be applied to measure
sensory impairment because of the presence of general
or local pathology (speech pathology, blindness, deaf-
ness, cleft lip and palate, temporary sensory ablations,
etc.).
A change in the oral cavity by means of partial or
complete loss of the dentition certainly creates certain
changes to the oral sensory function. In dentate
subjects, the role of periodontal neural receptors
OS S E OP E R C E P T I ON AND S E NS OR Y - MOT OR I NT E R AC T I ONS 287
2006 The Authors. Journal compilation 2006 Blackwell Publishing Ltd
and of the tongue seems essential. After a bilateral
mandibular block, the stereognostic ability decreases
with about 20% (50). When comparing teeth with full
dentures, a far better stereognostic ability is noted for
natural teeth when freely manipulating the test pieces
(49, 50). When removing the denture(s) in complete
denture wearers, a considerable reduction in stereo-
gnostic ability is noted (50). An interesting observation
is that edentulous subjects showing a lot of problems
and a low satisfaction level after insertion of their new
denture demonstrate higher levels of oral stereognostic
ability than those subjects having few or no problems
(51), but this could not be conrmed by Mu ller et al.
(34).
Lundqvist (52) demonstrated an improvement of
the stereognostic ability after rehabilitation with oral
implants. Jacobs et al. (53) compared different pros-
thetic superstructures and noted no signicantly
different stereognostic ability with implant-supported
xed or removable prostheses, even when elimin-
ating the involvement of tongue- and lip receptors
(Fig. 4).
Oral mechanoreceptors activated during
oral stereognosis
To assess the stereognostic ability, test pieces are
inserted in the oral cavity and in most experimental
set-ups free manipulation of the test pieces is allowed.
The latter implies activation of a large number of
receptor groups (periodontal, mucosal, muscular, arti-
cular, etc.]. As the tip of the tongue is one of the most
densely innervated areas of the human body, it plays an
important role in stereognosis of objects inserted in the
mouth (49). Based on studies involving anaesthesia of
the tongue, the palate or the absence of teeth, it could
be stated that oral stereognostic ability is determined
mostly by receptors in the tongue mucosa, the palate
and to a lesser extent the periodontal ligament (49).
A major modication to the experimental set-up is the
insertion of a toothpick in each test piece to eliminate
the involvement of lip and tongue receptors, to allow
easy handling and standardized placement in between
two antagonistic teeth (53) (Fig. 5).
The role of the TMJ receptors is less clear. In fact, in
studies on tactile function, an interocclusal thickness of
5 mm and more seems able to activate receptors in the
TMJ and the jaw muscles (4, 45). In the stereognostic
ability tests, pieces are mostly manipulated inside the
mouth and seldom kept between two antagonistic
teeth, which excludes very often the need for a mouth
opening of 5 mm or even more.
Stereognostic ability testing is not designed to detect
specic receptor groups, it rather reects an overall
sensory ability. A good result in a stereognosis test
should indicate that the subject receives full and
accurate information about what is going on in the
mouth. Even if manipulation is allowed to identify the
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Fig. 4. Average of correct identica-
tions out of 10 for all the groups in
the oral test. [Reprinted from Clinical
Oral lnvestigations, vol. 1, Stereo-
gnosis with teeth and implants: a
comparison between natural
dentition, implant-supported xed
prostheses and overdentures on
implants, pp 8994, Copyright 1997:
with kind permission of Springer
Science and Business Media].
R. J AC OBS & D. VAN S T E E NB E R GHE 288
2006 The Authors. Journal compilation 2006 Blackwell Publishing Ltd
test piece, identication itself is a sensory rather than a
motor accomplishment (49). It is an indicator of
functional sensibility including synthesis of numerous
sensory inputs in higher brain centres (49).
From osseoperception to implant-
mediated sensory motor interactions
During the last few decades, millions of patients have
already been rehabilitated by means of osseointegrated
implants. Although part of the peripheral feedback
mechanism is lost after tooth extraction, edentulous
patients seem to function quite well, especially when
rehabilitated with a prosthesis retained by or anchored
to osseointegrated implants (5). These ndings corres-
pond well to the observation in amputees rehabilitated
with a bone-anchored prosthesis rather than a socket
prosthesis. During skeletal reconstruction, psychophys-
ical testing reveals an improved tactile and vibrotactile
capacity with an osseointegrated implant and the bone-
anchored prosthetic limb (Fig. 6). Furthermore, both
edentulous patients and amputees seem to report an
improved awareness and special feeling with the
implant-supported prosthesis, allowing a partial restor-
ation of the peripheral feedback pathway with a
hypothesized potential representation of the articial
limb feeling in the sensory cortex. If that could be
conrmed, osseointegrated implants in the jaw or
other skeletal bones might contribute to an implant-
mediated sensory-motor control allowing physiological
Fig. 5. The stereognostic ability is dened as the ability to
recognize and discriminate different forms presented as a stimulus.
(a) To eliminate the involvement of lip and tongue receptors, as
well as to allow easy handling and standardized placement in
between two antagonistic teeth, a toothpick is inserted in each test
piece. (b) As soon as the subject has identied the form of the test
piece, he has to indicate it on a chart visualizing the various forms
presented in the mouth.
(a)
(b)
Fig. 6. Vibrotactile testing of a lower arm (a) and a lower leg (b)
prosthesis yields superior functioning with such bone-anchored
prosthetic limbs as compared with conventional socket prostheses.
[Reprinted from Prosthetics and Orthotics International, vol. 24,
Jacobs R, Bra nemarkR, Olmarker K, RydevikB, vanSteenbergheD,
Bra nemark P-I. Evaluation of the psycho-physical detection
threshold level for vibrotactile and pressure stimulation of prosthe-
tic limbs using bone anchorage or soft tissue support, pp 133142,
Copyright 2000, with permission from Taylor and Francis].
OS S E OP E R C E P T I ON AND S E NS OR Y - MOT OR I NT E R AC T I ONS 289
2006 The Authors. Journal compilation 2006 Blackwell Publishing Ltd
integration of the implant in the human body. The
phenomenon of the so-called osseoperception might
contribute to physiological integration and more nat-
ural functioning. Originally, osseoperception has been
dened as the conscious perception of external stimuli
transmitted via a bone-anchored prosthesis by activa-
tion of neural endings and/or receptors in the peri-
implant environment such as the bone and more likely
the periosteum (5). To put stress on the incorporation
of the tactile function in a series of sensory-motor
interactions, a recent consensus statement on osseo-
perception added the aforementioned sensory-motor
interactions to the denition, yielding: (i) the sensation
arising from mechanical stimulation of a bone-
anchored prosthesis, transduced by mechanoreceptors
that may include those located in muscle, joint,
mucosal and periosteal tissues; together with (ii) a
change in central neural processing in maintaining
sensorimotor function (54). The present review sug-
gests keeping the original denition of osseoperception,
but consider this phenomenon as part of an overall
sensory-motor integration of the endosseous implants
in the human body.
Clinical implications of implant-mediated
sensory-motor interaction
Psychophysical testing on various bone-anchored pros-
theses conrm an improved tactile function leading to a
better physiological integration of the limb. If percep-
tion upon implant stimulation is working well, periph-
eral feedback mechanism may be restored and help
tuning ne motor control. This implant-mediated
sensory-motor interaction may thus help to achieve a
more natural function with the bone-anchored pros-
thesis (1, 5). Osseointegrated thumb prostheses even
allow patients to perform the activities of daily life
without any problem (55).
Considering the increased tactile threshold level for
oral implant stimulation, one should however consider
a few clinical implications. During rehabilitation by
means of implant-supported prostheses, dentist should
not rely on the patients perception of occlusion. In this
respect, one should also be aware of gradually increas-
ing tactile function during the healing period after
implant placement. This may be of particular import-
ance when dealing with immediate loading protocols.
To avoid any overloading related to suboptimal feed-
back mechanisms, patients should be encouraged to
limit chewing forces by soft food intake during the
healing period. Furthermore, parafunctional habits
such as grinding or clenching, might have a negative
impact during the implant healing phase. Bruxism has
therefore been dened as a relative contra-indication
for immediate loading protocols (56). [see also Review
by Lobbezoo (57)].
Conclusions
Endosseous implants are routinely used to rehabilitate
amputations of limbs or teeth. In order to reach
satisfactory clinical function with such bone-anchored
prostheses, physiological as well as psychological integ-
ration of the implant(s) should take place. Clinical
observations on patients with oral implants indicate the
presence of sensory perception after some time. The
underlying mechanism of this so-called osseopercep-
tion phenomenon remains a matter of debate. In any
case, scientic evidence allows to state that implant-
mediated sensory-motor interactions may offer poten-
tials for physiological integration of the implant in the
human body. The latter might help restoring the
peripheral feedback pathways and attempt a more
natural functioning. It could even be assumed that
such physiological integration might lead to better
acceptance and improved psychological integration.
This is a step forward towards total implantbody
integration. However, further research is required to
make practical use of osseoperception in the design of
novel bone-anchored prosthetic appliances and bionic
limbs.
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Correspondence: Reinhilde Jacobs, Laboratory of Oral Physiology,
Department of Periodontology, Faculty of Medicine, Catholic Univer-
sity of Leuven, Kapucijnenvoer 7, 3000 Leuven, Belgium.
E-mail: reinhilde.jacobs@med.kuleuven.be
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2006 The Authors. Journal compilation 2006 Blackwell Publishing Ltd