Restorative Dentistry Original Article

COMPARISON OF TOOTH SHADE MATCHING USING VISUAL AND

DIGITAL CAMERA METHODS
1
SAQIB NAEEM SIDDIQUE, 2FARHAN RAZA KHAN, 3PALWASHA BABAR
ABSTRACT
Accurate recording of the shade of the tooth, its communication to the dental laboratory and its
reproduction plays a fundamental role in the restorative and prosthetic procedures. Visual shade
selection with a reference shade guide is the most common method for shade matching employed in
routine clinical practice but it is associated with a high degree of subjectivity. Recently digital devices
like colorimeters and spectrometers have been developed to objectively measure the colour. These devices
can read the colour data in terms of luminance (L), chroma (C), and hue (h). Researchers have also
used high end digital cameras in combination with graphical softwares to measure the tooth colour.
A photograph with a digital camera can replicate the true colours and presents this information in
terms of numerical data. The aim of this study is to compare the tooth shade matching using simple
visual method and digital camera assisted method.
In vitro experimental study conducted at the prosthetic laboratory of Aga Khan University Hospital,
Pakistan
All shade tabs from a vita classic shade guide were photographed using a compact digital camera to
acquire three images of each tab at a pre-set object-camera distance generating 144 reference images.
Same was done with six masked tabs to acquire a set of 18 test images. Colour values were obtained
for an area over body of each image and the closest match between test and reference tabs was deter-
mined for digital method. For visual method, participants were asked to match the tooth shade. The
outcome was correct match versus incorrect match.
Data was analyzed using SPSS 19.0. Chi square test was applied to compare the visual and digital
methods and to compare colour matching skills of the dentists and their assistants. P value of <0.05
was taken as significant.
With the visual and digital method, correct shade was selected in 39.4% and 66% cases respectively.
The digital method yielded better shade matching that was statistically significant
Digital colour matching was found to be superior to the visual method. Significantly better shade
selection can be done by using compact digital cameras as compared to the visual method alone. Males
and dental assistants exhibited better colour matching skills than females and the dentists.
Key Words: Dental esthetics, Shade selection, Color matching, Teeth shade

INTRODUCTION anterior crown or bridge restoration. Accurate recording

of shade of the tooth, its communication to the dental
Accurate determination of the tooth shade is a cru-
laboratory and its reproduction in the final restoration
cial factor in restorative and prosthetic procedures1. It
plays a fundamental role in these procedures.
is the key factor that influences the esthetic outcome of
1
Dr Saqib Naeem Siddique, BDS, FCPS, Assistant Professor Oper-
Visual shade selection with a reference shade guide
ative Dentistry Department, University College of Dentistry, The is the most common method for shade matching em-
University of Lahore, Lahore, E-mail: [email protected] Cell: ployed in routine clinical practice2,3 but it is associated
0331-7274267 with high degree of subjectivity.4 The colour perception
2
Dr Farhan Raza Khan, BDS, MCPS, FCPS, MSc, Associate Professor between different individuals is variable and is great-
Operative Dentistry, The Aga Khan University Hospital, Karachi,
Pakistan E-mail: [email protected] Cell: 0305-2225117 ly influenced by the individual’s experience in shade
3
Dr Palwasha Babar, BDS, MDS, Registrar Paediatric Dentistry matching.5 The light source, direction and intensity
Department, University College of Dentistry, The University of also influence the perception of colour.6 Natural teeth
Lahore, Lahore E-mail: [email protected] Mobile no: 0334- show a wide variation in colour that the common shade
8740767
Received for Publication: April 25, 2019
guides cannot encompass. Visual shade matching owing
Revised: May 17, 2019 to its subjectivity is a concern for the dental clinicians
Approved: May 17, 2019

Pakistan Oral & Dental Journal Vol 39, No. 2 (April-June 2019) 184
 Tooth shade matching

so different devices have been introduced to aid the ages at 10cm, 15cm and 30cm. The two set of images
colour selection for achieving optimum aesthetics.7 (reference images and test images) were imported in the
Adobe Photoshop® CS5 software. A small white area
The use of electronic shade-matching devices has in background of all images was selected and its colour
become common in dentistry. Recently digital devices was matched in all the images using the command:
like colorimeters and spectrometers have been devel- Image> Adjustments> Match colour, to standardize
oped to objectively measure the colour.8,9 These devices the white balance of the images and remove any colour
can read the colour data in terms of luminance (L), cast. A small area on the middle third of the body of
chroma (C), and hue (h) which can be stored for later each shade tab was selected and the colour of selected
comparison and calculate the colour difference (E) area was averaged using Filter>blur>Average command
between the two objects using the CIELCh formula. in photoshop. The grid tool in photoshop was used in
Various studies have been conducted to determine order to select the same area on each image. Colour
their accuracy and reliability which have supported parameters (hue, chroma and value) were recorded for
their use for this purpose.10,11  Researchers have also all the images using histogram tool in the photoshop.
used high end digital cameras in combination with In order to select the best match, the colour differences
graphical software to measure the tooth colour12 A between all test tabs and each of the reference tabs at
digital photograph with a good camera can replicate the corresponding distances were calculated using CIE
the true colours and present this information in terms formula: ∆E= √ (∆L2 + ∆C2 + ∆h2). The reference tab
of numerical data. Studies have described different with the least value of colour difference (∆E) from the
settings and object-to-camera distances to acquire the test tab at corresponding distance was labeled as the
images for digital shade matching.9,12,13 correct match determined digitally.
Numerous devices have been developed to aid the For visual method, 11 people related to the dental
shade selection but there is no consensus regarding the profession participated. All the participants in the study
ideal method of shade selection.7 These are expensive had normal colour vision. The protocols followed for each
and may not be readily available in general dental individual were uniform and standardized. During the
practice. Literature strongly recommends the use of shade matching procedure, the participants were made
supplementary tools in routine to enhance esthetic to sit on the chair placed at the same area of the room
outcome.3 The objective of the current study was to at the same time of the day. Six masked test tabs (A1,
compare the visual shade matching versus digital image A2, A3, A3.5, C2 and C3) were presented to each of the
obtained from a commonly available digital camera 11 participants (six males and five females). They were
using graphical software. given a full set of Vita Classic shade guide to visually
MATERIALS AND METHODS match each masked tab to the correct tab from the
shade guide. All the shade matching was carried out
The study was conducted at the dental clinics and under optimal daylight. The evaluators were given up
prosthetic laboratory of Aga Khan University Hospital, to 20 minutes to select the correct match to each test
Pakistan. For the preparation of digital shade guide, tab.
all sixteen shade tabs from Vita Classic shade guide
were individually mounted on a custom setup to record DATA ANALYSIS
the baseline values of all the shades for later compar- Data was analyzed using SPSS 19.0. Descriptive
ison to the test tabs. All the tabs were illuminated in measures such as counts of correctly identified shades
standard 6500 K light using two light sources (Philips® were obtained. Chi square test was applied to compare
Tornado 25W Daylight) which were kept at a 45⁰ angle the visual and digital methods. Spearman rank order
to a perpendicular drawn from center of body of the correlation test was applied to determine correlation
shade tab to avoid unwanted reflection of light which between object to camera distance and shade match-
might influence the colour recording. An ultra-compact ing ability. Chi square test was also used to compare
digital camera (Sony CyberShot, DSC-W380, 14.1 Mega the colour matching skills of the two genders and the
Pixels, Taiwan) was used to generate the images by a dentists and their assistants. A p-value of <0.05 was
single photographer. For all the pictures, the camera taken as statistically significant.
settings were kept constant at ISO: 100, White-balance:
Auto, EV: 0, zoom: 1.9 X. Three images of each tab in RESULTS
the shade guide were taken at a pre-set object-camera
distance of 10cm, 15cm and 30cm. In this way, 144 ref- There were 11 participants in the study, 6 males
erence images were generated. Out of focus or blurred and 5 females. Of the six male participants, two were
images were discarded and new image was taken to dentists and four were dental assistants while the five
replace it.  female participants comprised of four dentists and one
dental assistant. The details are summarized in Table
For establishing test tabs, six tabs from vita classic 1. The six male participants assessed 36 tabs (six each
shade guide (A1, A2, A3, A3.5, C2 and C3) were used participant) and selected correct match for 18, thus
and their identity was masked. The photographer was resulting in 50% correct shade match. The female
blinded to the shade number and the above mentioned participants assessed 30 tabs (six each participant)
procedure was repeated to acquire a set of 18 test im- and selected correct match for 8, resulting in 26.6% of

Pakistan Oral & Dental Journal Vol 39, No. 2 (April-June 2019) 185
 Tooth shade matching

the correct shade match. The p-value was calculated and psychologic factors. It may vary as a result of fatigue,
to be 0.053 which was marginally significant. aging, emotions, lightning conditions, previous eye ex-
posure, object position and metamarism18. Numerous
When comparing dentists and dental assistants, studies have demonstrated an improved selection of
dentists correctly matched 8 out of 36 shades (22.2%) correct shade by digital methods when compared to
while the assistants correctly matched 18 out of 30 the conventional visual method.19,20 In a recent study
shades (60%). The difference between the two groups by Miyajiwala and colleagues14, three methods for
was statistically significant (p-value 0.002). Overall, tooth shade selection were compared i.e. visual, digital
with the visual and digital method, correct shade was photography and spectrophotometer. They concluded
selected in 39.4% and 66% cases respectively. Digital that digital photography is a potential alternative
method yielded better shade matching that was sta- to the use of spectrophotometers for shade selection.
tistically significant with a p-value of 0.03. The results Lars Schropp12  conducted a study using professional
are summarized in Table 2. camera and visual shade matching and found that
When using digital camera, it was found that 50% correct shade match with visual and digital method
(n=3) of the test tabs were correctly identified when was 32% and 67% respectively. He concluded that
images were taken at 10cm and 15cm camera distance. shade matching assisted with digital photographs and
However at 30cm, shades of all the test tabs were cor- computer software is significantly more reliable com-
rectly identified. The results are shown in Table 3. pared to the conventional visual methods. The results
of this study are comparable to his study. In a similar
DISCUSSION study by Jarad and colleagues13, digital imaging and
conventional visual methods were compared. Correct
The restoration and prosthesis indicated in the
match was observed in 43% and 61.1% by conventional
aesthetic zone of the oral cavity warrants accurate
and digital methods respectively. They also found that
shade selection. Shade matching is both an art and
colour parameters determined by the spectrophotometer
science.14 Improper shade selection was found to be
and digital photography methods were in agreement
the second most common reason for re-fabrication of
to each other and therefore digital radiography can be
ceramic restorations.15 Visual shade matching using
used for shade selection clinically. Similar results were
a shade guide is the oldest method of shade selection
obtained by study conducted by Farah.21 The results of
which is prone to errors owing to its subjectivity. Differ-
these studies are also in agreement with our study.
ent commercial shade guides also vary with respect to
hue, value and chroma.16 Shade selection using digital Another interesting finding in the study was the
methods enables the dentist to perform an objective
analysis of the shade which is both more accurate and TABLE 1: DEMOGRAPHIC DETAILS OF THE
easily reproducible.17 Nowadays, spectrophotometers, PARTICIPANTS IN THE VISUAL METHOD
colorimeters and high-end digital cameras are being
used for this purpose.8,9 The results of the study showed Gender Dentist Assistant Total
a significant difference in visual and digital methods Male 2 4 6
of shade selection. 39.4% correct shade matching was
achieved visually by the participants while the results Female 4 1 5
were 66% for digital method. Visual assessment of the Total 6 5 11
colour by an individual depends on various physiologic
TABLE 2: COMPARISON OF CORRECT SHADE MATCHING WITH VISUAL AND DIGITAL METHODS

Settings Shades
A1 A2 A3 A3.5 C2 C3 Total % P-Value
V i s u a l Correct 5/11 5/11 4/11 7/11 2/11 3/11 26/66 39.4 0.03
Method Shade
Digital Correct 2/3 2/3 2/3 2/3 3/3 1/3 12/18 66.0
Method Shade

TABLE 3: CORRECT SHADE MATCH BY DIGITAL METHOD AT DIFFERENT OBJECT-CAMERA DIS-

TANCE

Object-Cam- Correct Shade Match

era Distance A1 A2 A3 A3.5 C2 C3
10 cm   
15cm   
30cm      

Pakistan Oral & Dental Journal Vol 39, No. 2 (April-June 2019) 186
 Tooth shade matching

effect of changing the object to camera distance on involve the dental assistant in shade matching pro-
the correct shade selection using the digital method. cedure. Another reason for these results could be the
Different studies have used different distances for the clinical experience of the participants which was not
shade matching purposes but none have compared considered in the study. Clinical experience is a crucial
its effect on the process of shade matching.11,14 In our factor in shade selection.33 It is important to compare
study, an increase in the distance from 10cm to 30 cm the capability of different individuals based on their
resulted in an excellent match of shade as shown in experience in shade matching.
Table 4. Further studies may be necessary to test this
In the study, male participants correctly matched
phenomenon as it may ease up the process of digital
50% of the shades while females were able to match
shade matching using non-contact based method using
only 26.6%. The results were marginally significant.
hand-held photography which is easier chair-side as
This is in contrast to various studies in the literature
compared to the use of tripod or other fixed approaches
in which females showed better results than male ob-
mentioned in previous studies.
servers.34 It is considered that men and women differ
In the current study, a compact digital camera was in their capacity to distinguish shades35 and women are
used instead of a professional one because it is easily generally better in shade matching than men. Miran-
available and can be used in routine practice. It was da33 found similar results in their study in which men
found that even a compact digital camera can serve showed better results compared to the woman. Same
the purpose by demonstrating better colour matching results were obtained by Donahue and colleagues.36
ability compared to the visual method. The use of digital Bimler35 explained this in his research that men as
cameras for accurate shade matching has the advantage less sensitive to stimuli on green-red axis but are more
owing to its easy availability and cost effectiveness.22 sensitive along the axis of brightness. He proposed that
There are numerous advantages of the digital photog- as value of any shade is the most critical component of
raphy technique compared to the traditional method colour in shade matching, it could possibly account for
of shade selection using shade guides. If this technique better shade matching by men. This is perhaps one of
is carried out in the correct scientific manner, it is an the reasons that explain the results of the current study
objective method and is not dependent on the dentist whereby men selected correct shade more frequently.
and patient factors. It is easy to perform and the exact
colours of different areas of the same tooth can be ob- LIMITATIONS
tained in the similar manner.14 The only disadvantage
The limitations of the study show that only one
of digital methods is the learning curve associated
type of shade guide (Vita Classic) was utilized in this
with the use of computer software and ensuring the
study. Only one digital camera (Sony DSC-W380 cam-
standardization of photographs taken with the camera
era) was used. Convenience sampling was done for the
at a stable distance and constant illumination.23
participants in visual method. The clinical experience
In the current study, dental assistants showed sig- of the participants plays a major role in shade selection
nificantly better colour matching ability for visual shade which was not accounted for in the study.
matching than dentists. The correct shade match was
(8/36) 22.2% among dentists and (18/30) that is 60% for CONCLUSIONS
dental assistants. The results are supported by various The process for shade matching using electronic
studies in which dental technicians and dentists showed devices like spectrophotometers, colorimeters and
comparable results in shade selection.24,25 However digital camera appears to be relatively complex and
some studies showed no significant difference among time consuming. However, when compared to visual
different occupational groups.26,27 Schropp12 found that method, it invariably results in improved colour match-
the dentists were able to determine the correct shade in ing which can save valuable clinical time by avoiding
35% of cases and the assistants were able to match the mismatched restorations. Therefore, the use of hand
shade in 31% of cases. The difference in shade matching held photography is a step forward to facilitate the
could probably be attributed to the phenomenon of “eye process chair-side. Within the limitations of the study,
fatigue”. Constant stimulation of the nerves involved in it can be concluded that:
colour vision results in a decrease in eye’s response.28
It is found that the colour vision capability of the eyes 1. Significantly better shade selection can be done by
decreases when the tooth is viewed for more than 10 using compact digital cameras as compared to the
seconds.29 Alvin30 and Azad et al.31 suggested painting visual method alone.
the operatory walls pale blue (contrast to the colour
2. It is suggested to involve dental assistants in the
of teeth) to improve the accuracy of shade selection.
shade matching procedure.
Focusing on the pale blue colour immediately before
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CONTRIBUTIONS BY AUTHORS
1 Saqib Naeem Siddique: Conducted literature review, collected all the data and compiled the
results, wrote the first draft of this publication.
2 Farhan Raza Khan: Supervised the entire research, helped in the interpretation of the results,
proof reading of the first and final draft for publication.
3 Palwasha Babar: Helped in literature review and publication writing, refined the first
draft written by the first author, wrote the final draft of this publication.

Pakistan Oral & Dental Journal Vol 39, No. 2 (April-June 2019) 188