“A comparative study of tooth shade selection via conventional and digital

methods- An in-vivo study.”

INTRODUCTION
Color is of critical importance to the final outcome of dental restorations and
their acceptance by the patients. Increased patient awareness has led to an
increase in the demand for esthetic restorations. An unmatched restoration
looks more prosthetic than natural. Improper shade selection is said to be the
second most common reason for remake of a ceramic restoration, the tooth
preparation and impression being the first1.
Shade matching is as much an art as a science. Many factors influence our
ability to achieve accurate shade including shade-matching tools, subjectivity,
experience, materials, methods and conditions2. It is also suggested that the
hue of artificial teeth should harmonize with the patient’s complexion
(Boucher et al, 1975; Winkler, 1979).
Color measurement in clinical dentistry can be grouped into two categories:
visual and instrumental3-5. The visual method involves the comparison of
patient’s tooth shade with a color reference i.e., shade guide. Though it’s the
most commonly used method, it’s highly subjective and the results can be
inconsistent due to light source, shade guides and physiological (e.g. saturation
of visual perception) and psychological conditions6. The range of available
colors in the shade guides is inadequate and the color samples are not logically
distributed7. It is not possible to translate the results obtained from shade
guides into the “Commission Internationale del’Enclairage” colour
specifications8.
This brings in an alternative, the instrumental method which was introduced
in the late 1990s to overcome imperfections and inconsistencies of traditional
shade matching. The most common devices are colorimeters and
spectrophotometers, which calculate tooth color by measuring the amount
and spectral composition of reflected light on the surface of the tooth.
The advantages of these techniques are that the readings are objective, can be
quantified, and are more rapidly obtained9. Spectrophotometers are amongst
the most accurate, useful and flexible instruments for overall color matching
and color matching in dentistry10. Compared with observations by the human
eye, or conventional techniques, it was found that spectrophotometers offered
a 33% increase in accuracy and a more objective match in 93.3% of cases 11.
Spectrophotometers are however used less in clinical practice due to their high
cost. Incorrect color reading from the loss of a fraction of light entering the
tooth, the so called “edge-loss error”, is a frequent shortcoming of contact-
type devices12.
Digital photography is a powerful medium of expression and communication.
Photographic images make it possible to evaluate several points on a tooth,
which can aid in determining the true shade. By virtue of advances in
photography and computer technology, the use of a digital camera is now
widespread for color imaging. Images produced with a digital camera may be
analyzed using appropriate imaging software. The advantages include
objectivity, lower cost, convenience, ability of evaluate several points on a
tooth and easier patient record maintenance, efficient communication with
dental laboratory. The images can be easily transferred by electronic mails for
consultation and are easy to store.
Various studies have been conducted to establish a relation between skin color
of individuals with tooth shade values. Contrasting results have been
reported13-14. Specifically, it is suggested the value of the teeth must
correspond to darkness or lightness of the facial skin color 15.
Esan et al.,16 found no significant relationship between facial skin color and
tooth shade. This study, however, did not agree with the findings of Jahangiri
et al.,17 who found a significant inverse relationship between tooth shade value
and skin color.
Hence, this study has been planned to compare the tooth shade selection
methods in dentate patients via conventional and digital methods and to
evaluate the shade variations based on skin color.
 LITERATURE REVIEW
 Miyajiwala JS, Kheur MG et al., (2017) compared three different
methods used for shade selection, i.e., visual method,
spectrophotometer, and digital photography method and concluded
that the digital photography method is a reliable method for shade
selection in a clinical setup.

 Parameswaran V, Anilkumar S et al., (2016) compared the accuracies of

intraoral spectrophotometer and conventional method for shade
selection and demonstrated that visual method has better accuracy than
the spectrophotometer.

 Nalbant D, Babaç YG et al., (2016) examined the natural tooth color

distribution using visual and instrumental shade selection methods and
demonstrated that darker value levels were obtained with instrumental
measurement. The distribution of hue was more reddish in instrumental
examination than visual examination.

 Rekha S.B, Padmasree S et al., (2016) in a computerized cross-sectional

study evaluated the shade differences between natural anterior teeth in
patients of different age groups, skin tone, and gender. Significant tooth
shade differences were discovered among the subjects with skin colors.
Persons with medium to dark skin tones were more likely to have teeth
with higher values (lighter), whereas with lighter skin tones have lower
values (darker).

 Veeraganta S.K, Savadi R.C et al., (2014) evaluated the differences in

tooth shade value according to age, gender and skin color and
demonstrated that younger subjects have lighter tooth shade values.
Gender and skin color did not appear to have a significant relation to
tooth shade value.

 Llena C, Lozano E et al., (2011) evaluated the reliability of two color

selection devices in matching and measuring tooth color and
demonstrated that both EasyShade (ES) and SpectroShade Micro (SSM)
show excellent repeatability so they can be used in office to evaluate
tooth color or to assess color changes after treatment.
Aim of the study:
To evaluate and compare the efficacy of conventional, photographic and digital
shade selection methods in dentate patients and to evaluate the variations of
tooth shade based on skin color.
Objectives:
 To compare the efficacy of conventional methods of shade selection
with digital spectrophotometer.
 To compare the efficacy of photographic method of shade selection with
digital spectrophotometer.
 To evaluate the variations of tooth shade based on skin colour.
Materials and methods:
This study will be conducted in the Department of Prosthodontics Crown &
Bridge and Implantology, Career Post Graduate Institute of Dental Sciences and
Hospital, Lucknow. The present study will be carried out to evaluate and
compare the efficacy of conventional, photographic and digital methods of
shade selection in dentate patients.
Armamentarium used in the study:
 VITA classical shade guide.
 VITA 3D master shade guide.
 Canon 200D SLR camera
 Tokina 100mm 2.8F macro lens with Yongnuo YN24EX Macro flash
 18% gray card.
 VITA Easyshade V digital spectrophotometer.
 Mac foundation shade reference card
 Halogen light source
Selection of participants:
Subjects will be selected according to the following inclusion and exclusion
criteria. A total of fifty subjects will be included in this study.
Inclusion criteria:
1. Subjects having an intact maxillary left central incisor with no history of
restorative or endodontic procedures.
2. Age range: 18-45 years
Exclusion criteria:
Patients to be excluded if the concerned tooth had:
1. A history of trauma
2. Presence of discolorations,
3. White spots,
4. Composite fillings,
5. Veneers or crowns.
6. Endodontic treatment

Method:
1. Conventional shade selection method-
 Visual shade selection is done using VITA classical shade guide first.
 The middle one-third of the left maxillary central incisor is selected.
 The teeth are moistened by asking the subject to rinse with water and
are kept at the examiner’s eye level.
 The shade is recorded by panning the shade guide along the teeth and
selecting the hue first followed by chroma.
 Next the shade selection is done using the Vita 3D master for the same
tooth by the examiner and noted.
 VITA TOOTHGUIDE 3D MASTER is based on CIELAB system and is divided
into six tabs 0,1,2,3,4,5 according to value. Each lightness group includes
a central sample tooth M2 having teeth around it. The chroma increases
from top to bottom and the hue changes from yellowish to reddish from
left to right.
 We start shade selection by selecting the value first.
 This is followed by determining the chroma and then the hue.
The judgement is made quickly and after each measurement a neutral color is
viewed to overcome eye fatigue. Halogen light source is used for accurate
readings18.
2. Digital shade selection method-
 The shade was taken using VITA Easyshade V with ‘tooth single program’
selected.
  The central region of the labial surfaces of maxillary left central incisors
were measured with the device probe set at right angles.
 The manufacturer’s instructions were followed for the calibration of the
device and for shade recordings.
3. Photographic shade selection method-
 Digital photographs were taken with Tokina 100mm 2.8F macro lens
with Yongnuo macro flash mounted on Canon 200D SLR camera, at a
constant distance by maintaining a fixed magnification ration of 1:3.
 An 18% grey card is kept within the confines of the tooth so that color
correction/ standardization can be done in a software. Here we chose
Adobe photoshop for the same.
The image was saved as JPEG, imported in Adobe photoshop and processed
as per the protocol described by Bengel19:
1. In the Adobe Photoshop software, the JPEG image is opened by clicking
“CTRL+O”
2. To eliminate an overall color cast, we open the Levels dialogue by
pressing CTRL + L (or Image, then Adjust, then Levels). A histogram and
three eye-dropper tools will appear. It has three dropper tools.
3. When the middle dropper tool is moved over the gray card in the picture,
the red, blue, and green values (RGB) are obtained. The color space has to
be changed from RGB to L* a* b* to compare it with the results of
spectrophotometer.
4. To do this, the “image” is clicked in the main toolbar, followed by “mode”
and then L* a* b* color. The L* a* b* values of the gray card are thus
obtained.
5. By clicking Image, then Adjust, then Brightness, the brightness level is
adjusted to an L* value of 54. This sets the brightness of the whole image to
a fixed value, which then can be compared with the brightness of other
images. The photograph is thus standardized using the gray card.
6. The maxillary left central incisor is selected by using the magnetic lasso.
The “Magic Wand” tool next to it is used to exclude the reflection on the
tooth surface.
 7. This tooth is now ready for determination of its L* a* b* values which is
depicted in the photoshop histogram.
8. The software derived L* a* b* values thus obtained are converted to the
L* a* b* values as given by the CIEL* a* b* system using the following
formula:
• L* = L1 × 100/255
• a* = (a1 − 128) × 240/255
• b* = (b1 − 128) × 240/255
From the above formula, L* a* b* values are thus recorded for each
subject.
The ΔE (difference in the shade) between the spectrophotometer derived
L* a* b* values, and the values obtained by the digital photography
technique is calculated using the following formula:
ΔE = [(L1 − L2)² + (a1 − a2)² + (b1 − b2)²]1/2
L1, a1, and b1 are the values determined by the spectrophotometric
measurement.
L2, a2, and b2 are the values obtained by the digital photography
technique.
A score of “agreement” or “not in agreement” is given for delta E <2 and
more than 2, respectively. This is done because the color difference
between two objects (delta E) of <2 is not discernible to the human eye as
suggested by Della Bona et al20.

Scope of the study: The statistical data will be analyzed to compare the visual,
spectrophotometer, and photographic shade selection methods to evaluate
the efficacy of the visual and photographic method. The shade differences
based on skin color will also be analyzed.
Note – If deemed necessary suitable changes will be made in the best
interest of the study.
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