RestorativeDentistry

270 DentalUpdate June 2009

Brian Stevenson
Current Methods of Shade
Matching in Dentistry: A Review of
the Supporting Literature
Abstract: The difficulties of shade matching in dentistry are discussed and various suggestions are given to improve the process.
Several authors have described shade-taking routines with the aim of improving shade-matching. These are summarized and a method
for choosing the appropriate shade from the previous guidelines is given. The scientific principles and evidence-base behind the new
technique are given. The problems and advantages of instrumental shade-taking devices are reviewed.
Clinical Relevance: Consistent and correct shade selection is fundamental to the placement of aesthetic restorations which are an essential
part of everyday practice.
Dent Update 2009; 36: 270276
One of the main driving forces in dentistry
today is the demand for aesthetic
dentistry. Aesthetics have grown in
importance in restorative dentistry
and the need for the correct shade
of restoration, as well as other factors
such as contour, amount of glaze and
surface texture are essential if the final
restoration is going to meet the patients
and the clinicians expectations. This
review focuses on the literature available
on clinical shade matching, while other
authors provide an excellent overview of
the other factors cited, including reference
to the technical processes.
1
Knowledge of colour is
required to communicate accurately the
shade of restorations. The colour perceived
is dependent on three factors, the light
source, the object being viewed and
the observer. If any of these elements
is changed, the colour perceived and
described will be different. Colour is
described by its three attributes:
Hue: The quality by which we
distinguish one colour family from
another, such as red from yellow, or green
from blue or purple.
Value: The quality by which we
distinguish a light and dark colour.
Chroma: The quality of colour by which
we distinguish a strong colour from a
weak one.
Dentine provides the main
source of colour in a tooth but it is
modified by enamel. In addition, as one
ages and secondary dentine is laid down,
its Value decreases and therefore the
tooth is darker.
2
The shade guide most
commonly used for indirect restorations is
based on the Vita Classical shades. Shade
guides for direct restorations are usually
provided by the manufacturer and are
based on the Vita shades, or they consist
of dentine, enamel and effect colours.
The Vita Classical shade guide
is organized into groups of similar hues
(A to D), with these groups being divided
further via numerical values (1 to 4).
Generally, the Chroma (intensity of colour)
increases and Value (lightness) decreases
as the numbers rise.
Brian Stevenson, BDS MFDS RCS Ed, Clinical
Lecturer in Restorative Dentistry, Dundee
Dental Hospital, University of Dundee, Park
Place, Dundee, DD1 4HN, UK.
The Vita System 3D-Master
is a different type of shade guide which
arranges tabs systematically. The tabs are
divided into five lightness groups (six if
the bleached shades are included). Each
group includes a central tab with tabs
arranged around it for the determination
Figure 1. Vita System 3D-Master, Vita Classical, and
Coltene-Whaledent Miris 2 Shade Guides.
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of differences in chroma and hue. These
tabs are equally spaced from each
other and intermediate shades can
therefore be accurately calculated. The
manufacturers instructions should be
used when selecting a shade with this
shade guide.
Several shade guides are
available for direct restorations. One
example is the Miris 2 system (Coltene-
Whaledent). Its shade guide concept
works using dentine and enamel masses
whose optical properties are comparable
with those of the natural tissues.
The Vita Classical, Vita System
3D-Master and the Coltene-Whaledent
Miris 2 guides are shown in Figure 1.
If the Vita System 3D-Master
is used, it is important to ensure that
the technician has the corresponding
ceramic, as Vita 3D shades can be
converted to Classical shades but
the opposite does not apply. The Vita
3D-Master is currently the only shade
guide to meet the relevant ADA standard.
The problems associated
with shade matching teeth have been
described
3
and are a result of a number
of unique properties of the teeth and
inconsistency in material manufacture.
Teeth exhibit fluorescence, opalescence,
translucency, metamerism, have a non-
uniform surface, are inhomogeneous,
and are of small size and irregular
shape. There are many materials used to
create aesthetic restorations, however,
these do not always exhibit colour
consistency. There are visible colour
differences between batches
4,5
and
brands of ceramic
6,7
and composite
resin.
8
Additionally, shade guides do not
match each other,
9-13
correspond to the
colour of teeth,
9-12
nor do they match the
materials they represent.
4,7,13-15
Custom
shade guides manufactured from the
batch of ceramic and composite resin
to be used have been suggested.
16-18
However, this is often not a practical
alternative.
The method by which the
shade of a restoration should be selected,
using a standard shade guide, has been
discussed by many authors.
10,19-23
These
six guidelines have been collated and
summarized in a flowchart (Figure 2) and
some evidence for using these guidelines
is available via scientific data.
Shade selection at the start of
the appointment
There is no dental literature
which examines the effect of eye fatigue
on shade selection. However, it is known
that tired eyes can occur as a result of
local and systemic factors, as well as
mental fatigue. In addition, after-images
are created when one stares at an object,
for example, during tooth preparation. It is
for these reasons of eye fatigue that shade
selection should occur at the start of the
appointment.
Teeth are not colour stable
and shade selections should therefore
be made before any treatment. Teeth
dehydrate and therefore appear lighter
following impression-making
24
and the
application of rubber dam.
24-26
Saliva will
re-hydrate teeth, but this may take several
hours and, even during photography, it
has been suggested that teeth should be
given time to recover.
1
Surroundings
Blue bibs have been considered
to rest ones eyes between shade matches.
1. Shade selection should be at the start of the appointment.

2. The patient and room surroundings should be of neutral colours, bright colours may
have to be covered or removed.

3. The patient should be at eye level directly in front of the observer.

4. The value (brightness) of the restoration should be selected first.

5. It is suggested to use canines as a guide to the Hue of the teeth.

6. Use appropriate standard lighting and differing lighting conditions and view the
teeth and shade tabs when wet and dry.

7. Closely observe contra-lateral, adjacent and opposing teeth to gain a complete

picture of the shade and texture required for the restoration.

8. Separate the teeth into at least three sections and then record the appropriate shade
for each area.

9. Magnification may be used to examine individual characteristics of a tooth (3.5 to 4.5

times is suggested).
Figure 2. Shade Matching Flowchart
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272 DentalUpdate June 2009
However, there is a risk of after-image
production and selection of a hue
that is too orange.
27
Staring at a blue
bib increases the sensitivity of ones
eyes to yellow/orange colours and,
therefore, may result in the shade
being too yellow/orange. A grey
bib has been recommended as an
alternative to rest ones eyes,
28
as
grey does not have a complementary
colour. There is no evidence in the
dental literature comparing the
accuracy of shade selection using
these two backgrounds.
Brightly coloured walls
or lipstick/clothing may affect the
shade selected. There is currently
no conclusive evidence to state that
these colours adversely affect the
shade chosen.
Eye level
It is known that receptors
in our eyes, rods and cones serve two
different purposes. Their distribution
is not even across our retina, with rods
far outnumbering cones. Cones are
responsible for medium to high light
level vision in full colour, whilst the rods
are responsible for night vision which is
monochromatic. Cones are virtually non-
existent at the periphery of our vision,
although this is rarely noticed as ones
eyes are constantly adjusting to allow the
recognition of colours at the edge of the
visual field. It is sensible to reduce the
amount of strain/re-adjustment required,
and shade selection should therefore take
place at eye level while directly in front of
the patient.
Value first
It is stated in the dental
literature that Value is the most important
component of colour
29
in dental shade
matching as small changes in Value can
more easily be identified than small
changes in other aspects of colour (eg
yellowness). The longer one stares at
a tooth, the lower the Value of shade
selected.
30
Value is usually selected by
arranging the shade guide in long-range
or Value order.
31
Figure 3 shows a Vita
Classical shade guide arranged in this
manner.
32
The shade tabs and teeth should
be edge-to-edge for shade comparisons
(Figure 4) to allow true comparisons of the
shade of the tabs by helping to reduce the
effect of the stains,
11
the metal backing
of the tab, and to eliminate binocular
differences and allow light to strike at the
same angle.
Hue selection
Several authors
33 34
have
investigated the relationship between
the shades of different tooth types. These
authors showed that canines exhibit the
highest Chroma values and can be used as
a useful guide to the Hue of the dentition.
Lighting
Metamerism is defined as the
phenomenon by which objects match
each other under one set of lighting
conditions but mismatch under another.
Daylight, which is variable, depending
on location, time of day and year,
35
photographic flashes and standard light
sources should all be used when selecting
a shade to eliminate metameric effects.
The ideal properties of the lighting
conditions used were discussed in the
early 1970s.
36
Light sources should:
Have a full colour content a light
source lacking a certain colour means that
colour cannot be seen in the object being
observed;
Be of the correct intensity, to prevent
the object from being washed out (losing
its colour saturation) by a strong light
source; and
Be reproducible, to standardize shade
selection conditions over time.
Several authors
37-39
support
the claim that the accuracy of the
colour match is dependent on the light
source used. Visible colour differences
are seen between samples measured
by instruments and humans under
different light sources. Figure 5 shows a
standard light source used in dental shade
matching.
Characterization
The character and surface
anatomy of the tooth (vertical and
Figure 3. Shade Tabs in Value (Long Range) Order, from lightest to darkest.
Figure 4. Matching shade tab to a tooth (Courtesy
of Richard Ibbetson).
Figure 5. Dental Shade Matching D
65
Light
Source.
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274 DentalUpdate June 2009
horizontal tooth form characteristics,
transition lines, emergence profile, lustre,
translucency, opalescence, dentine effects,
etc) and their replication all affect the
clinical acceptability of the restoration.
These must be recorded and copied to
produce a satisfactory restoration. Sending
a photograph to the laboratory can help
remove some of the subjectivity around
the description of tooth character.
Shade mapping
Tooth brightness varies with
location on the tooth
1,33,40
and Dozic et
al
41
illustrated colour differences between
different areas of a tooth. The guidelines
suggest splitting the tooth into at least
three sections (incisal, body and gingival)
or five areas (adding mesial and distal
areas), thereby producing a shade map of
the tooth (Figure 6). Photographs, both
pre-operatively and occasionally with
selected shade tabs in situ, can help with
characterization and shade mapping.
Magnification
Magnification is not supported
in the literature and there is no
evidence available to support the use of
magnification. However, it can give the
clinician a clearer idea of subtle surface
character. The standard light shown in
Figure 5 has a magnifying section in the
centre.
Recording of the shade
The recording and
communication of the shade is subject to
variation owing to differences between
individuals, time constraints in the
recording of a shade and ones preference
for a particular shade or shades.
The day-to-day repeatability
of individual human observers has been
shown to vary.
42-45
These studies showed
intra-observer repeatability levels of
between 20% and 73% when working
with dentally relevant samples both in
vivo and in vitro. Different observers also
show variation in shade selection of the
same shade of material.
42,43,46
The shade
guide used can affect this repeatability.
Shade matching by general practitioners
improved statistically when the Vita
System 3D-Master was used compared to
the original Vita Classical shade guide.
45
It is known that age alters
our cornea and lens. The cornea and
lens yellow and, in addition, the cornea
browns as one ages. It has therefore
been advocated, by some authors, that a
younger member of staff is present during
shade matching. Gender did not affect the
shade-matching abilities of individuals.
47
A colour vision deficiency
(colour-blindness) is a disease that has
a wide range of severities which affects
810% of the male population, with
females being much less commonly
affected (less than 0.5%). The literature is
equivocal on the effect of colour vision
deficiencies on the dental shade-matching
process.
48,49
A review of shade matching
is not complete without discussion of
instrumental shade selection and some
authors have investigated these devices
both in vitro and in vivo.
Instrumental shade taking
systems make use of a colorimeter,
spectrophotometer or digital images
to make measurements at one or a
number of points on a tooths surface.
The recorded values can be available to
Figure 6. Shade Map, dividing the tooth into 3 or 5 sections (Courtesy of Richard Ibbetson).
Figure 7. Examples of Instrumental Shade-Matching Devices that use a spectrophotometer and digital
camera.
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the dentist, patient and technician almost
immediately and numerous systems are
available. Figure 7 shows IdentaColor II
and Ikam that use a spectrophotometer
and digital camera, respectively, to record
the colour of a tooth.
Each system, depending
on the instrument-type used and the
manufacturer, has recommended routines
for the shade selection which are outwith
the scope of this article to mention.
However, most involve the use of a probe,
which is approximated to the tooth to be
used for shade matching. Measurements
are taken and immediately displayed by
the system.
There are problems with some
of these devices, including edge-losses,
instrumental drift, approximation and cost.
However, they are more repeatable than
humans, with more recent studies showing
day-to-day repeatability of 83% to 100%.
However, colour measurements of the
same sample over time have previously
been shown to produce colour difference
values that would be visible.
44
Recently, there have been
research papers that have attempted to
compare the colour-matching abilities
of dental observers to the shades gained
using an instrumental method.
43,46,50-54
Some studies have shown that
instruments may improve the clinical
shade-matching process, while others have
shown little difference. One investigation
53
showed that only 8% to 34% of the
shade tabs selected by human observers
matched those selected by these devices.
Studies
43,51,52
have compared crowns
made after instrumental shade taking
and compared them to human observers.
Okubo et al
43
tested the ability of
humans and instruments to match shade
tabs to a standard shade guide. They
demonstrated little difference in shade
matching, 48% and 50% correct shade
matches for humans and instruments,
respectively. Paul et al
51
demonstrated
larger differences in the match of crowns
made when conventional shade selection
was used in 93% of all cases, although the
size of difference was not always clinically
relevant. In a separate study these
authors
52
used crowns and showed that 9
out of the 10 crowns made were a better
shade match when instrumental shade
selection was used.
The general consensus from
these pieces of research is that the
instruments are consistent. They are able
to produce results that illustrate that the
machines give results that agree over time
and this is an improvement compared to
human observers. The shortcomings and
variability of these instruments occurs in
their dental accuracy, as slight calibration
errors will result in consistent but incorrect
shades. Their use in the oral environment
used to be problematic owing to cross-
infection problems, but this has now
largely been overcome. Unfortunately,
several authors
46,50,54
could not find a
correlation between the magnitude of
the instrumentally measured colour
difference and the clinical ratings given to
restorations by human observers.
Instrumental methods
appear to be a promising area for
further research and are well suited in
long-term observational studies, for
example, assessment of bleaching. They
undoubtedly can aid people who have
problems with colour matching and can
be used to provide a base shade from
which the laboratory prescription can be
formed.
Further research is needed
to assess these devices with regard to
corrections needed in their software to
match human observers and this may
require increased co-operation between
dental materials companies. In addition,
further research is needed to provide an
evidence base for all parts of the shade-
matching process.
Conclusion
In conclusion, using a
repeatable process should improve
the shade-matching procedure.
Photographs or diagrams can show the
individual characteristics of each tooth
to a technician who can then provide an
aesthetic restoration.
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CPD ANSWERS
May 2009
1. A, C, D 6. B, C
2. A, B, D 7. A, B, C
3. A, B, C, D 8. A, B D
4. A, B, D 9. A, B, D
5. A, B, C 10. A, C, D
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