Received: 18 January 2022 Revised: 2 April 2022 Accepted: 12 April 2022

DOI: 10.1111/cid.13094

ORIGINAL ARTICLE

A comparative evaluation of neurophysiological activity, active

tactile sensibility and stereognostic ability of complete denture
prosthesis, and implant-supported prosthesis wearer—A
pilot study

Bappaditya Bhattacharjee BDS1 | Ritu Saneja MDS1 | Atul Bhatnagar MDS1 |

Ashish Verma PhD, DNB2 | Romesh Soni MDS1 | Ankita Singh MDS1 |
Pavan Dubey MDS1

1
Department of Prosthodontics, Faculty of
Dental Sciences, Banaras Hindu University,
Varanasi, Uttar Pradesh, India
2
Department of Radiodiagnosis and Imaging,
Institute of Medical Sciences, Banaras Hindu
University, Varanasi, Uttar Pradesh, India
Correspondence
Atul Bhatnagar, Department of
Prosthodontics, Faculty of Dental Sciences,
Banaras Hindu University, Varanasi 221005,
Uttar Pradesh, India.
Email: atuldent@hotmail.com
Funding information
Indian Council of Medical Research
Abstract
Aim: The study aimed to evaluate the effect of implant-supported prosthesis in
completely edentulous participants in terms of osseoperception ability, neural activ-
ity, and stereognostic ability in comparison to removable prosthetic options.
Materials and Methods: A total sample of 18 patients, irrespective of gender and age
were allocated into three groups according to the three-treatment protocol (upper
and lower complete denture, upper complete denture opposing lower implant-
retained overdenture, implant-supported fixed prosthesis in both arches). Four weeks
after completion of the treatment procedure active tactile sensibility (ATS) was
checked by using varying thicknesses (12, 40, 80, 100, 200 μ) of articulating foils and
papers. Functional magnetic resonance imaging (fMRI) was performed to record neu-
rophysiological activity in cerebral cortex in all the participants. Various forms of test
pieces (heat cure acrylic resin) were used to evaluate stereognostic ability. Data
regarding the neurophysiological activity were analyzed by using Krushkal–Wallis
test and p ≤ 0.05 was considered to be statistically significant. Data from
stereognostic ability test procedure and ATS were compared by using chi-squared
test and p ≤ 0.05 was considered to be statistically significant.
Results: Statistically significant difference was found in between the articulating foils
in terms of true negative responses as the foil thickness increased in participants
wearing complete denture in both the arches (p = 0.004) and implant-supported
fixed prosthesis in both the arches (p = 0.010). Participants in implant-supported
fixed prosthesis group showed significantly more activation in primary motor cortex
(right side), somatosensory cortex (left side), angular gyrus (both sides), temporal lobe
(left) compared to other groups. No significant difference found in thalamus and
premotor cortex region in between the participants of different groups. No statisti-
cally significant difference found in between the groups in terms of true responses
identifying correct shapes. Mean number of correct responses in stereognostic ability
test were 4.16 (83.33%), 3.5 (70%), 3.83 (76.66%) for participants of complete

Clin Implant Dent Relat Res. 2022;1–12. wileyonlinelibrary.com/journal/cid © 2022 Wiley Periodicals LLC. 1
2 BHATTACHARJEE ET AL.

denture group, upper complete denture opposing lower implant retained overdenture
group, and implant-supported fixed prosthesis group, respectively.
Conclusion: Primary motor cortex, somatosensory cortex, and other regions of brain
were diffusely activated in participants wearing implant-supported fixed prosthesis in
both the arches. Less number of false responses were recorded in participants of
implant-supported fixed prosthesis group and upper complete denture opposing
lower implant-retained overdenture group in ATS test compared to participants
wearing complete denture in both the arches.

KEYWORDS
edentulous mandible, fixed implant prosthesis, overdenture

Summary Box

What is known
• Progressive recovery of osseoperception occurs around implant-supported prosthesis.
• Recent studies have showed implant-supported prosthesis used to activate different regions
of cerebral cortex.
• Little is known on the stereognostic ability of different combination of prosthesis.

What this study adds

This comparative study evaluated active tactile sensibility, neurophysiological activity and
stereognostic ability in different types of prosthesis wearer and aimed to generate scientific evi-
dence on this topic.

1 | I N T RO DU CT I O N prosthesis undergoes integration with the stomatognathic system similar

Oral function and quality of life are dependent on number and condition
of functional tooth units which influence the functioning of masticatory
apparatus of an individual.1,2 Various implant-supported prosthetic
options (implant-retained overdentures, implant-supported fixed pros-
thesis, and all-on-four prosthesis) have become available in recent times
to rehabilitate edentulous ridges. Sensory perception of implant-
supported prosthetic options may play a role in its longevity and choice
of loading protocol.3 The presence of mechanoreception observed after
4
loading of the implant is termed as osseoperception. Patient's percep-
tion level in response to mechanical stimuli may reduce complications
for and around dental implants. Complications may further be reduced
through optimal occlusal contact and appropriate loading protocols.3,5
The oral perception sensibility of dental implants can be tested
either by having the test persons bite on thin test bodies (active tactile
sensibility [ATS]) or by passively applying pressure on the occlusal sur-
face of the implant (passive tactile sensibility).6,7 How the sensory signals
reach the cerebral cortex and how it remodels after extraction of teeth is
a common research question of oral neuroscience in recent times.
Batista and colleagues evaluated mean threshold of sensory perception
of different combination of prosthesis in a comparative study. Study
showed threshold of sensory perception of implant-supported prosthesis
was quite high (10–14 μ) compared to complete denture wearers
(92 μ).8 Various studies have also reported that implant-supported
to natural dentition. Perception level of implant-supported prosthesis is
quite similar to natural antagonists.9,10,11 It is quite evident that cerebral
cortex and sensory homunculus in the brain undergoes some structural
and functional changes to adapt with altered sensory perception in rela-
tion to any part of human body.12 This phenomenon of structural and
functional adaptation of human brain has been termed as “Neuro-
plasticity.”13 Various factors like critical developmental periods of brain,
neuromodulatory inhibitors, and other factors like age, sex, and diseases
affecting brain can modify neuroplasticity phenomenon of human
brain.13 Extraction of teeth and rehabilitation of edentulous space with
dental implant show changes in cerebral cortex of brain.14
Evaluation of activated regions in the brain can be done through
various imaging systems. Positron emission tomography (PET) was
widely used in past to evaluate the activated regions. However, due
to its low temporal and spatial resolution and invasive nature of the
procedure newer imaging systems have evolved. Functional magnetic
resonance imaging (fMRI) techniques make it possible to explore, non-
invasively, the neuroplasticity in humans using BOLD (blood oxygen
level dependent) method that measures blood flow changes in the
brain, and uses these changes to determine brain areas activity during
a specific task.15 Oral stereognosis (OS) is the neurosensorial ability of
the oral mucous membrane to recognize and discriminate the forms of
objects in the oral cavity. Temporal lobe of the cerebral cortex is the
higher center for discriminating size, shapes, and stereognostic
BHATTACHARJEE ET AL. 3

ability.16 Proper masticatory function generally improves when the
texture and shape of the particles can be adequately felt by an individ-
ual. These sensory signals are transmitted to the second and third
order neurons which relay in the cerebral cortex to generate the
chewing force and modulate three-dimensional movement of
mandible.17
There is sizable evidence of progressive osseoperceptive recovery
after dental implant placement. However, there appears to be meager
number of studies exploring neuroplastic and stereognostic changes
occurring in brain and oral cavity in response to altered oral environ-
ment. There seems to be a lack of clarity on relationship of
osseoperception and neurosensory feedback pathways with neuro-
plasticity. It is aimed with this pilot study to evaluate the correlation
between the neurophysiological activity through fMRI images, ATS,
and stereognostic ability of participants wearing implant-supported
fixed prosthesis, implant-retained overdenture opposing complete
denture, and complete denture opposing complete denture.
• Participants rehabilitated with implant-supported fixed prosthesis
were allocated in Group 3.
2.3 | Clinical procedures
Complete dentures were fabricated using conventional technique and
by following selective pressure impression technique. Teeth setting
were done in semi-adjustable articulator and bilateral-balanced occlu-
sion was used as an occlusal scheme. In participants of second group
two bone level-tapered implants (Touareg-S, Adin Dental Implant Sys-
tem Ltd., Afula, Israel) with alumina oxide blasted/acid etched surface
were placed in mandibular canine region (Figure 1). Standard surgical
protocol and strict asepsis was maintained during the implant
placement.
TABLE 1 Inclusion and exclusion criteria

Inclusion criteria Exclusion criteria

2 | MATERIALS AND METHODS
1. Healthy patients with good 1. Patients with uncontrolled
oral hygiene systemic disorders
2.1 | Clinical data 2. Patients without any history 2. Patients with smoking habit
of temporomandibular joint and history of alcoholism
Completely edentulous patients were selected from departmental disorders, psychiatric 3. Patients with claustrophobia
disorders or on 4. Patients with implanted device
OPD by convenience sampling method due to COVID-19 pandemic
neurophysiology modifying (cardiac pacemakers, MRI
from February 2020 to July 2021. The edentulous participants who medication incompatible prosthetic heart
were willing to undergo with removable complete denture or fixed 3. Completely edentulous valves) that can affect the
implant-supported prosthesis or implant-supported overdenture were patients who were willing fMRI findings
included in this study. The study adopted parallel arm study design. for rehabilitation with 5. Patients with parafunctional
removable prosthesis disorders like clenching,
The study aimed to evaluate the effect of implant-supported pros-
4. Completely edentulous bruxism, tongue thrusting, etc.
thesis in completely edentulous participants in terms of osseoperception patients with bilateral severe 6. Patients with recent history of
ability, neural activity, and stereognostic ability in comparison to remov- pneumatization of maxillary undergoing radiotherapy
able prosthetic options. Participants were appraised in detail on study sinuses 7. Indifferent and poorly
5. Completely edentulous motivated patients
procedures, bi-lingual consent was obtained from all the participants.
patients with less vertical 8. Patients who were not willing
Ethical clearance was obtained from Banaras Hindu University bone height available in to appear in the follow-up visit
(Dean/2020/EC/1919) dated January 21, 2020. Trial was registered maxillary and mandibular due to other reasons.
in Clinical Trial Registry of India with reference number posterior region

CTRI/2020/11/029169. Abbreviation: fMRI, functional magnetic resonance imaging.

2.2 | Sample size and allocation

A total sample of 18 patients, irrespective of gender and age were

selected for study in accordance to the inclusion and exclusion criteria
(Table 1). Participants were allocated into three groups with each
group containing six participants. Individual groups were created
according to the treatment protocol.

• Edentulous participants rehabilitated with complete denture were

allocated in Group 1.
• Edentulous participants rehabilitated with maxillary complete den-
ture and two-implant-retained overdenture in mandibular arch F I G U R E 1 Postoperative radiographic view after placement of
were allocated in Group 2. implants in participants of Group 2
4 BHATTACHARJEE ET AL.

F I G U R E 2 Postoperative radiographic view

after placement of implants in participants of
Group 3

Lignocaine hydrochloride 2% with adrenaline (1:100 000) was

used through infiltration during surgery. Complete denture of the par-
ticipants was duplicated and used as a custom-made surgical guide.
Osteotomy was done under copious irrigation after elevating full-
thickness muco-periosteal flap by giving a midcrestal incision. After
completion of healing phase of 3 months, a second stage surgery was
performed and healing abutments were placed. After a healing period
of 2 weeks, ball abutments were placed. Acrylic resin was removed
from the intaglio surface of the mandibular denture and a space was
created for metal housing. Metal housing along with plastic sleeve was
placed on the ball abutment and self-cure acrylic resin was filled in the
previously made gap in the intaglio surface of the denture. Direct pick
up was taken. Proper seating of denture was then evaluated. Occlusal
evaluation and interferences were checked and corrected. FIGURE 3 Articulating foils and papers used in the study
In implant-supported fixed prosthesis group some participants
were rehabilitated with all-on-four treatment protocol as proposed by Patients of fixed implant-supported prosthesis group were reha-
Malo and colleagues18 and some participants were rehabilitated with bilitated with either screw-retained hybrid prosthesis/metal-ceramic
conventional implant-supported fixed prosthesis. In case of all-on-four prosthesis after evaluating the crown-height space. Participants reha-
treatment protocol in maxilla, initial osteotomy was started posteriorly bilitated with implant-supported metal-ceramic prosthesis were not

from second premolar/first molar region with pilot drill in a 30–45 included in this study due to chance of procedural complications dur-
angulation parallel to anterior wall of maxillary sinus. In the anterior ing functional MRI.
region, osteotomy were done in a parallel manner upto a sufficient
length to engage the nasal cortex. Subsequently osteotomy was
enlarged with drills of specific diameter and final implant placement 2.4 | Evaluation of data
(Touareg-S, Adin Dental Implant System Ltd.) were done.
In mandible initial, osteotomy was done in a tilted manner so that 2.4.1 | Active tactile sensibility
the apex of osteotomy remained a safe distance from mental foram-
ina. Posterior implants were inserted at tilted angulation (30–45 ). In the psychophysical approach, ATS of participants were checked
Anteriorly two implants were placed in axial manner with appropriate 4 weeks after the completion of treatment procedure. Varying thick-
length and diameter (Figure 2). nesses (12, 40, 80, 100, 200 μ) of articulating foils and papers were
In case of fixed implant-supported prosthesis, implant number introduced in between the occluding surfaces (maximum intercuspal
was decided depending on the available bone, arch form, and mastica- position) for five times (Figure 3).
tory dynamics of the patient. Key implant position (Canine and molar Each foil was tested between the occluding teeth, following a ran-
region) and other rules of implant placement for fixed prosthesis were dom order of true and false insertions. Soon after participants
followed. Implant diameter was selected depending on the available occluded in maximum intercuspation of teeth, the subject responses
bucco-lingual width of bone and length was determined depending on (yes or no) concerning sensation of presence of foil was recorded. If
height of bone available maintaining a safe distance from anatomical response was “yes” then the subject was asked to show thumb up
structures. and if response was no then the subject was asked to show thumb
BHATTACHARJEE ET AL.
down. True positive and false negative responses were recorded and
score was given according to the maximum number of responses. Sim-
ilarly, five times false placement of artifoils and papers was done and
true negative and false positive responses were recorded.
2.5 | Neurophysiological activity
fMRI was performed to record neural activity in cerebral cortex
4 weeks after the completion of rehabilitation procedure.
Subjects were instructed to lie comfortably with their eye closed
in a supine position. Head of the participants was immobilized with
vacuum-pads, ear-plugs were inserted to reduce the foreign noise and
they were advised to practice clenching.
In a single session, 25 contiguous axial slice comprising the entire
brain (each slice 3 mm thick, with no gap) were acquired using a single
shot echo planner image T2-sensitive sequence with repetition time
(TR) = 3560 ms and echo time (TE) = 50 ms, and 176 slide per slab
and field of view 192 mm. For display purpose, a high-resolution
T1-weighted structural MRI was acquired for each subject using
three-dimensional FLASH SEQUENCE (1 mm thick, no gap, TR/TE/
Fractional Anisotropy (FA) = 1900 ms/3.37 ms/256 mm).
The task paradigm was an alteration between 25 s of clenching
(on) and 25 s of rest (off). This procedure was repeated four times in
each scanner run. Before each functional scan, an 8 mm whole brain
three-dimensional anatomic image scanning procedure was
performed.
Activation of different regions of brain was examined by obtaining
functional MRI images by instructing the participants to perform inter-
cuspal clenching task in a blindfolded position. Six different regions of
brain (primary motor cortex, somatosensory cortex, premotor cortex,
angular gyrus, thalamus, temporal lobe) were mainly compared in
between the groups. These regions have been shown to be activated
during clenching and action of masticatory muscles according to the
previous literature. Apart from this, other activated regions of brain
were also evaluated. Group 1 was considered as complete denture
treatment protocol, Group 2 was considered to be implant-retained
overdenture, Group 3 was considered to be implant-supported fixed
prosthesis treatment protocol. Codings used in this section to indicate
activity in a regional part of brain were: (0) means no activity in a partic-
ular region of brain. (1) means slight activity in a particular region of
brain (light yellow color in a particular region in image). (2) means mod-
erate activity in a particular region of brain (reddish yellow color in a
particular region in image).
2.6 | Stereognostic ability
The various forms used to evaluate stereognostic ability were square,
rectangle, triangle, circle, and oval. These test forms were chosen in
accordance with the guidelines provided by the National Institute of
Dental Research which developed a range of 20 shapes to assess
OS. The test forms used were of 5 mm in thickness and 10 mm in
5
FIGURE 4 Stereognostic test pieces used in the study
diameter. Five forms were used to prevent fatigue. Heat cure acrylic
resin was used to fabricate the test pieces (Figure 4). After each use
test pieces were autoclaved. Participants were blindfolded and test
pieces were placed in the participant's mouth. Participants were
shown a chart containing drawing of all the test pieces to identify the
correct form.
Test was performed 4 weeks after the completion of treatment
procedure in a calm quite environment after instructing them to com-
fortably lying in a dental chair. Test pieces were placed in mid-dorsum
of tongue in a blindfolded position and participants were asked to
manipulate the test forms inside the oral cavity. A chart corresponding
to all the test pieces was shown to the participants to identify the cor-
rect shape.
A two-point scale (0, 1) was used for recording the oral
stereognostic analysis score. The scale used was as follows: 0—for not
identifying the test sample, 1—for correct identification of the test
sample, if all answers were correct, a full five points was scored. Thus,
the higher the score, the better is an individual's stereognostic ability.
Five different shapes (circle, oval, rectangle, square, and triangle)
were used.
2.7 | Statistical analysis used
Data from the results were compared in between the groups by apply-
ing chi-squared test and p ≤ 0.05 was considered to be statistically sig-
nificant. Intra-group comparison of ATS of different articulating papers
was done through Cochran's-Q test and p ≤ 0.05 was considered to be
statistically significant. Data regarding the neurophysiological activity
were analyzed by using Krushkal–Wallis test and p ≤ 0.05 was consid-
ered to be statistically significant. Data from stereognostic ability test
procedure were compared by using chi-squared test and p ≤ 0.05 was
considered to be statistically significant.
3 | RE SU LT S
Demographic characteristics of all the 18 participants have been men-
tioned in Table 2. True positive and true negative responses were
6 BHATTACHARJEE ET AL.

TABLE 2 Demographic characteristics of the participants T A B L E 3 Intra-group comparison of active tactile sensibility in
relation to different articulating papers in Group 1
Overall
Age and sex of demographic Absence of articulating foil False positive True negative
Group the participants characteristics
12 μ 2 4
Group 1 (complete 55 female Mean age—61 years
40 μ 3 3
denture) 63 male Female 4
59 female Male 2 80 μ 3 3
65 female 100 μ 0 6
67 male
200 μ 1 5
57 female
Cochran Q = 5.231; p = 0.264 (Not significant)
Group 2 (implant- 63 male Mean age—
retained 58 male 59.83 years Presence of articulating foil False negative True negative
overdenture) 65 male Male 4 12 μ 6 0
58 male Female 2
40 μ 5 1
61 female
54 female 80 μ 3 3

Group 3 (implant- 63 male Mean age— 100 μ 1 5

supported fixed 64 female 61.33 years 200 μ 0 6
prosthesis group) 55 female Male 4
Cochran Q = 15.294; p = 0.004 (Significant)
59 male Female 2
62 male
65 male
T A B L E 4 Intra-group comparison of active tactile sensibility in
relation to different articulating papers in group 2

Absence of articulating foil False positive True negative

12 μ 1 5
40 μ 2 4
80 μ 2 4
100 μ 1 5
200 μ 1 5
Cochran Q = 1.091; p = 0.896 (Not significant)
Presence of articulating foil False negative True negative
12 μ 5 1
40 μ 4 2
F I G U R E 5 Bar chart showing comparison of active tactile
sensibility between different groups on absence of different 80 μ 2 4
thicknesses of articulating foils 100 μ 1 5
200 μ 1 5
Cochran Q = 9.429; p = 0.051 (Not significant)

supported fixed prosthesis with 40 and 80 μ articulating papers

F I G U R E 6 Bar chart showing comparison of active tactile
sensibility between different groups on presence of different
thicknesses of articulating foils
more with correct identification of artifoils in case of implant-
supported fixed prosthesis compared to other two treatment options.
Number of false responses were comparatively low in implant-
(Figures 5 and 6). No statistically significant difference was found in
between the groups due to limited number of sample size and low
study duration period owing to COVD-19 pandemic. Statistically sig-
nificant difference was found in between the articulating foils in terms
of true negative responses as the foil thickness increased in partici-
pants of Group 1 (p = 0.004) and Group 3 (p = 0.010) (Tables 3–5).
Participants in implant-supported fixed prosthesis showed signifi-
cantly more activation in primary motor cortex (right side), somatosen-
sory cortex (left side), angular gyrus (both sides), temporal lobe (left)
compared to other groups (Tables 6 and 7) (Figures 7–9). No signifi-
cant difference found in thalamus and premotor cortex region in
between the participants of different groups. Participants in all the
groups showed activation pattern in other regions also which are
mentioned in Table 8.
BHATTACHARJEE ET AL. 7

T A B L E 5 Intra-group comparison of active tactile sensibility in No statistically significant difference found in between the
relation to different articulating papers in group 3 groups in terms of true responses identifying correct shapes. Mean
Absence of articulating foil False positive True negative number of correct responses were 4.16 (83.33%), 3.5 (70%), 3.83

12 μ 0 6 (76.66%) for participants of Groups 3, 2, and 1, respectively.

Highest correct responses were recorded in identifying triangle and
40 μ 2 4
lowest correct responses were recorded in identifying rectangle
80 μ 1 5
and oval after evaluation of the data from all the participants
100 μ 2 4
(Table 9) (Figure 10).
200 μ 1 5
Cochran Q = 3.111; p = 0.539 (Not significant)
Presence of articulating foil False negative True negative 4 | DI SCU SSION
12 μ 4 2
40 μ 1 5 Sensory homunculus or the topographic representation of body sur-
80 μ 0 6 faces in somatosensory cortex is closely linked with the neuroplastic
100 μ 0 6 changes in brain. Studies have shown that chewing activates various
200 μ 0 6 region in human brain-like sensorimotor cortex, supplementary motor

Cochran Q = 13.333; p = 0.010 (Significant) area, thalamus, and cerebellum.19,20

TABLE 6 Inter group comparison of activity in primary motor cortex, somatosensory cortex and prefrontal cortex region

Primary motor Primary motor Somatosensory Somatosensory Premotor cortex Premotor

Group Score cortex (right) cortex (left) cortex (right) cortex (left) (right) cortex (left)
Group 1 0 4 2 3 3 3 3
1 2 4 3 3 3 3
2
Group 2 0 2 1 1 2 1
1 5 4 5 4 4 5
2 1 1
Group 3 0 1 1 1
1 4 2 4 4 5 3
2 2 3 2 2 2
p = 0.013 p = 0.171 (Not p = 0.046 p = 0.074 (Not p = 0.492 (Not p = 0.194 (Not
(Significant) significant) (Significant) significant) significant) significant)

TABLE 7 Inter group comparison of activity in angular gyrus, thalamus, and temporal lobe region

Group Score Angular gyrus (right) Angular gyrus (left) Thalamus Temporal lobe (right) Temporal lobe (left)
Group 0 3 3 4 3 5
1
1 3 2 3 1
2 1 2
Group 0 2 4 3 2 2
2
1 4 2 1 3 4
2 2 1
Group 0 1 1
3
1 3 4 3 4 2
2 3 2 2 2 3
p = 0.026 p = 0.049 p = 0.567 (Not p = 0.098 (Not p = 0.031
(Significant) (Significant) significant) significant) (Significant)
8 BHATTACHARJEE ET AL.

TABLE 8 Other activated regions in different groups

Group 1 Group 2 Group 3

Midbrain— Insular cortex—three Insular cortex—more
moderate out of six activation in four
activation two participants participants out of
participants Midbrain—three out six
among six of six participants Midbrain—more
(Substantia nigra, Supramarginal activation
crus cerebri in gyrus—four out of amygdala,
one, red nucleus, six participants hippocampal body,
subthalamic Lateral occipito and
nucleus in one) temporal gyrus— parahippocampal
Cerebellum— four out of six gyrus region
F I G U R E 7 Neurophysiological activity in a participant of Group (moderate in participants Cerebellum—Bilateral
1 (complete denture) two, greater in Hippocampal body— activation in five
one) three two out of six participants out of
participants participants six participants
among six Cerebellum—three Supramarginal gyrus
Orbital gyrus— out of six and lateral
Bilateral in one, participants occipitofrontal
left in one gyrus showed
Occipital gyrus— more activation
three than other groups
participants
Lateral occipital
temporal gyrus—
three
participants

F I G U R E 8 Neurophysiological activity in a participant of Group
2 (maxillary complete denture opposing mandibular implant retained
overdenture)
F I G U R E 9 Neurophysiological activity in a participant of Group
3 (implant-supported fixed prosthesis in both the arches)
Previously, one study explored the functional neural networks
during teeth tapping in old dentulous and edentulous patients through
functional MRI-based study. Psychophysiological interaction analysis
in between edentulous patients wearing dentures and nondenture
wearers showed that subcortical and cortical structures, such as pri-
mary motor cortex, sensory cortex, supplementary motor cortex,
insula cortex, basal ganglia, and cerebellum are likely to be functional
center and form an inteconnected network.19 Studies based on PET
imaging showed that cerebral blood flow increases during mastication.
Mastication can increase blood flow in the primary sensorimotor areas
by 25%–28% in the supplementary motor areas and insulae by 9%–
17%, and in the cerebellum and striatum by 8%–11% according to a
study.20
Kimoto and colleagues studied the changes in brain activities in
completely edentulous individuals by transforming their complete
denture to implant-retained overdentures. Results showed that
implant overdenture suppressed chewing induced brain activity in
prefrontal cortex, sensorimotor cortex, and cerebellum. Group com-
parison did not show any change in activity in supplementary motor
area, thalamus, and insula in between the groups.21
In an animal study, it has been clearly shown that sensory cortex
can reorganize itself after extraction of tooth in naked mole-rats.22
Another functional MRI-based study showed that osseointegrated
thumb prosthesis-improved activation in primary motor cortex and
bilateral activation in sensory cortex in a patient compared to preop-
erative situation.23
Yan and colleagues24 also suggested that implant-supported pros-
thesis play a role in restoring sensory and motor feedback to the cen-
tral nervous system. Blood oxygen level-dependent signals were
elevated in the primary sensorimotor cortex in patients with implant-
supported fixed prosthesis in this study. Prefrontal cortex, Brocas
area, premotor cortex, supplementary motor area, superior temporal
gyrus, insular, basal ganglion, and hippocampus were also activated.
Then, activation signals in primary sensorimotor cortex signified the
BHATTACHARJEE ET AL. 9

TABLE 9 Inter-group comparison of stereognostic ability

Circle Oval Square Rectangle Triangle

False True False True False True False True False True
Group response response response response response response response response response response
Group 1 1 (16.7%) 5 (83.3%) 3 (50%) 3 (50%) 1 (16.7%) 5 (83.3%) 2 (33.3%) 4 (66.7%) 0 (0%) 6 (100%)
Group 2 1 (16.7%) 5 (83.3%) 2 (33.3%) 4 (66.7%) 2 (33.3%) 4 (66.7%) 4 (66.7%) 2 (33.3%) 1 (16.7%) 5 (83.3%)
Group 3 0 (0%) 6 (100%) 2 (33.3%) 4 (66.7%) 0 (0%) 6 (100%) 1 (16.7%) 5 (83.3%) 0 (0%) 6 (100%)
p = 0.570 (Not p = 0.792 (Not p = 0.301 (Not p = 0.195 (Not p = 0.347 (Not
significant) significant) significant) significant) significant)

group and implant-supported fixed prosthesis group. In case of

100 and 200 μ articulating papers, all the participants in each group
showed maximum number of true positive and true negative
responses. Overall, the result of this study added scientific evidence
that osseoperceptive ability of implant-supported fixed prosthesis is
much greater than any removable prosthesis and mean threshold of
detecting articulating foils is also lower than removable options. Bet-
ter tactile perception can improve the survival rate of dental implants
by preventing undue overload and rhythmic neuromuscular coordina-
tion during functional activities.

F I G U R E 1 0 Bar-chart showing comparison of stereognostic In terms of neurophysiological activity, implant-supported fixed

ability in between different groups
correlation of the improved tactile, stereognostic ability, mastication
functions, and underlying mechanism of osseoperception.24
In the current study, response of the participants were checked
both in presence and absence of foils to crosscheck the perceptive
ability. Blindfolding of the participants and application of white noise
were done to reduce the bias of the confounding factors during the
study. Each participant was checked 4 weeks after the completion of
treatment to provide sufficient time to adapt with prosthesis. None of
the patients had monoplane teeth in the prosthesis, cusped, sem-
ianatomic teeth were used in complete denture and implant over-
denture group. Implant-supported fixed prosthesis showed greater
number of true positive and true negative responses during applica-
tion and nonapplication of articulating paper, respectively. There were
no statistically significant differences found in between the groups
due to limited sample size and shorter study duration period. Progres-
sive recovery of osseoperception could not be observed due to lesser
number of patient appointments and shortened follow-up periods due
to COVID-19. In complete denture and in implant-supported fixed
prosthesis group, there was statistically significant difference found in
detecting the presence of articulating papers as the thickness
increased. Denture base movement and reduced mechanoreceptor
density around prosthesis may contribute toward more false
responses in complete denture group, apart from this patient satisfac-
tion, psychological integration might also play a role. There was an
increased number of correct responses in identifying 40 and 80 μ
articulating papers showed by participants in implant overdenture
prosthesis showed statistically significant more activation in primary
motor cortex and somatosensory cortex on right side compared to
implant overdenture and complete denture. On the left side no sta-
tistically significant differences were found although number of
moderate activations in these regions were more in case of implant-
supported treatment modalities. Studies have shown that somato-
sensory cortex and motor cortex play a role in jaw movement and
orofacial functions in natural dentition.25,26 Moderate activations of
primary motor cortex (right), somatosensory cortex (both side) were
present in two patients in implant-supported group, whereas moder-
ate activation was not seen in any of patients with complete den-
ture. Only one patient in implant overdenture group showed
moderate activation in somatosensory cortex (left side) and primary
motor cortex (right side). Premotor cortex which is an important
region for cognitive learning did not show significant changes in
terms of activation between the groups. Most of the patients in all
the groups showed slight or no activation in premotor region. Mod-
erate activation found in only two patients with implant-supported
fixed prosthesis. Somatosensory, motor, premotor, and supplemen-
tary cortex forms a circuit through which planning and execution of
movements occur. Increased activation in implant-supported treat-
ment option may be due to adaptability of cerebral cortex and its
association with increased density of the mechanoreceptors in peri-
implant region that transmit the sensory inputs to central nervous
systems.
Angular gyrus was bilaterally activated in most of the patients in
group 3 (three patients in implant-supported fixed prosthesis) and sta-
tistically significant difference found compared to other group of
patients. Thalamus showed moderate activation in two patients in all
10
the groups and no significant difference was present in between the
groups. Temporal lobe which has a distinct role in long-term memory
and declarative memory showed significantly more activation in left
side in implant-supported group.
Other regions of brain like cerebellum which controls the fine
rhythmic movements showed moderate activation in five out of six
patients in implant-supported group. Hippocampus and para-
hippocampal region showed activation in two patients in both implant
overdenture and implant-supported fixed prosthesis group. Hippo-
campal region is mainly associated with learning and memory which is
very much needed for fine tuning of movements in oro-mandibular
region. Insular cortex and supramarginal gyrus were the other promi-
nent regions that got activated implant-supported treatment modality.
In complete denture, Group 2 patients showed moderate activation in
midbrain (substantia nigra) and Group 3 patients showed activation in
lateral occipito-temporal gyrus.
Somatic sensory system has two pathways in human being, one
for detection of mechanical stimuli (light touch, vibration, pressure,
and cutaneous tension) and another for detection of pain and temper-
ature. A question arises, how is this information from external sur-
faces or oral cavity processed in the thalamus and cortex in order to
identify objects, and how is this information used in guiding and for-
mulating motor control? There are various mechanorecptors like
pacinian corpuscles, ruffini nerve endings; merkel cells are present in
the soft tissue regions of mouth and in external surfaces also. Peri-
odontal ligaments of teeth, dental pulp also contain mechanorecep-
tors. These receptors are responsible for conducting touch and other
tactile perceptions in the higher centers of brain.16,17,27 OS is con-
trolled by various mechanoreceptors in the oral cavity but predomi-
nant role is played by receptors present in tongue, palate, and
16
periodontium.
Only one study has been found till now in literature regarding
stereognostic ability in implant-supported prosthesis. Ikbal and col-
leagues28 conducted a study in which three group of participants
were compared in terms of stereognostic ability. Group 1 comprised
of dentate individuals, Group 2 consisted of complete denture
patients and in Group 3 patients were rehabilitated with implant-
supported fixed prosthesis in upper arch. Statistically significant dif-
ference was found in perception of stereognostic patterns in between
participants of control group and other groups (p < 0.001). The partici-
pants wearing implant-supported dentures (Group 3) perceived pyra-
mid and drop shapes (round shapes tested: circle, pyramid, window,
drop, and cone) statistically significantly earlier in comparison to
Group 2 (p < 0.001). Participants of Group 3 perceived the shapes sta-
tistically significantly earlier (except for circles and drops) than Group
2 without dentures.
In current study, patients with implant-supported fixed prosthesis
showed highest number of correct responses and implant retained
overdenture group of patients scored lowest mean score in
stereognostic ability test. There was no statistically significant differ-
ence in between the groups in terms of correct response. Identifica-
tion ability of triangular test piece was highest due to distinct shape,
BHATTACHARJEE ET AL.
oval and rectangular test pieces were the difficult ones to identify.
Inter-participant variability and coordination of receptors present in
tongue, palate, and periodontium generally modulate the result of
stereognostic ability. Decreased prosthesis movement and psycholog-
ical benefit were believed to be the most important reasons for better
stereognostic ability score in implant-supported fixed prosthesis. Pre-
vious study on stereognostic ability of maxillary implant-supported
overdenture compared to complete denture also did not find any
significant changes similar to the current study.28 All the partici-
pants in Group 2 had complete dentures in upper arch so no major
variability was found in terms of movement of tongue around the
palate which was covered by acrylic (both in Groups 1 and 2).
Slightly less overall number of score in participants of Group 2 may
be found due to inter-participant variability and neuromuscular
coordination. Retentive mechanism of implant retained over-
dentures had no significant relation with this finding. Omission of
palatal part of prosthesis in implant-supported fixed group may had
contributed to report more number of correct responses in case of
Group 3.
Current study was conducted in a parallel arm design with differ-
ent participants in all the study groups, in future edentulous partici-
pants previously rehabilitated with complete denture can be
transitioned into implant-supported fixed prosthesis to evaluate all
the test procedures to form a more conclusive evidence. Three differ-
ent test procedures were applied in the study to get a correlation of
various perspectives of neuromuscular control. As per author's knowl-
edge, previously no studies have been done on three different treat-
ment modalities evaluating three different test procedures in this
topic. ATS was given importance in this study instead of passive tac-
tile sensibility because ATS show direct activation of receptors around
peri-implant region compared to passive tactile sensibility tests. Limi-
tations of the study were low sample size and less number of follow-
up periods owing to pandemic situation. Inter-patient variables and
occlusal contacts may have also influence in the result despite of
checking occlusal contacts with specific thickness of articulating
papers for different prosthesis. Concurrent evaluation of electroen-
cephalogram (EEG) and real time functional MRI can also be done to
generate dynamic activity of cerebral cortex with better temporal and
spatial resolution in future which can help us to get a clearer picture
about the feedback pathway during oral functions with these
prosthesis.
There is appreciable scope present in future to conduct further
study on this topic to overcome the limitations of this study. Sam-
ple size can be increased to evaluate the effect in larger population.
Equilibration of occlusal contacts can be done in a more systematic
manner by the use of digital technologies like T-scan occlusal
device so that correlation can be drawn intensity of occlusal con-
tacts and brain activity. Treatment modality variation can be done
in a single patient to reduce the effect of confounding factors. Spa-
tial and temporal resolution of the images can be improved by
applying concurrent electroencephalogram recordings and Func-
tional MRI reading.
BHATTACHARJEE ET AL.
5 | C O N CL U S I O N
Increased number of true responses was found in using specific
dimension of foils in case of implant-supported fixed prosthesis indi-
cated that density of mechanoreceptors around implant-supported
prosthesis may be more compared to removable prosthesis. Number
of false responses were recorded less in participants of implant-
supported fixed prosthesis group and upper complete denture
opposing lower implant-retained overdenture group in ATS test
compared to participants wearing complete denture in both the
arches. Primary motor cortex, somatosensory cortex, and other
regions of brain were diffusely activated in participants of Group
3 signifying the restoration of peripheral feedback pathway. Side to
side variation in both the cerebral hemispheres could not be justified
in this study. Intensity of occlusal contacts and dominance of unilat-
eral cerebral hemisphere may have played a causative role in activat-
ing different regions of brain in both the sides. No significant
differences were found in other two treatment modalities in
stereognostic ability test procedure.
ACKNOWLEDGMENTS
Indian Council of Medical Research (ICMR).
CONF LICT OF IN TE RE ST
No conflict of interest.
AUTHOR CONTRIBUTIONS
Concept/design—Bappaditya Bhattacharjee, Ritu Saneja, Atul Bhatnagar.
Data analysis/interpretation—Bappaditya Bhattacharjee, Atul Bhatnagar,
Ashish Verma. Drafting article—Bappaditya Bhattacharjee, Ritu
Saneja. Critical revision of article—Romesh Soni, Ankita Singh,
Pavan Dubey. Approval of article—Atul Bhatnagar. Statistics—
Ashish Verma, Bappaditya Bhattacharjee. Data collection—
Bappaditya Bhattacharjee, Ritu Saneja.
ORCID
Bappaditya Bhattacharjee https://orcid.org/0000-0001-6823-1188
Atul Bhatnagar https://orcid.org/0000-0001-7091-5132
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BHATTACHARJEE ET AL.
How to cite this article: Bhattacharjee B, Saneja R,
Bhatnagar A, et al. A comparative evaluation of
neurophysiological activity, active tactile sensibility and
stereognostic ability of complete denture prosthesis, and
implant-supported prosthesis wearer—A pilot study. Clin
Implant Dent Relat Res. 2022;1‐12. doi:10.1111/cid.13094