journal of dentistry 42 (2014) 48–52

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Shade matching quality among dental students

using visual and instrumental methods

Salma A. Bahannan *
Oral and Maxillofacial Rehabilitation Department, Faculty of Dentistry, King Abdulaziz University, Saudi Arabia

article info abstract

Article history: Objectives: Study aims were to compare shade matching quality between visual and
Received 15 March 2013 machine-aided shade selection among dental students and to evaluate the effect of
Received in revised form experience and gender.
21 August 2013 Methods: A total of 204 undergraduates and interns participated. They were briefed about
Accepted 10 November 2013 colour matching using a visual method with a Vita-3D Master system and a spectropho-
tometer. Participants with colour vision deficiency were excluded. Six maxillary anterior
teeth of a maxillary blue stone cast were replaced with six maxillary artificial teeth.
Keywords: Participants selected the best shade match using each method. A daylight illuminator with
Colour the GTI mini-matcher colour viewing system was used during the test. The results were
Shade statistically analysed with SPSS version 19 with 95% confidence intervals. Frequencies and
Matching Chi-square tests were used to analyse the data, at a = 0.05 and with P < 0.05 indicating
Visual significance.
Students Results: Among the participants, 36.3% visually selected the correct shade, and 80.4% did so
Gender using the Easy Shade Compact machine. Experience (P = 0.177) and gender (P = 0.560) did not
affect visual shade selection; in addition, with the Easy Shade Compact device, males and
females equally mastered its use (P = 1.0), and experience did not influence outcomes
(P = 0.552).
Conclusions: The shade matching device was significantly better than the conventional
visual method. With both techniques, neither experience nor gender influenced shade
matching quality.
Clinical significance: Visual tooth colour matching is unreliable and inconsistent because of
various subjective and objective factors, and the use of a colour measuring device might
improve the quality of shade matching among dental students.
# 2013 Elsevier Ltd. All rights reserved.

background.1–7 Previous studies have noted differences

1. Introduction
The success of aesthetic restorations depends primarily on the
proper shade selection, and matching the correct tooth shade
for anterior teeth is one of the most critical procedures. Many
factors that contribute to the quality of shade matching have
been mentioned in the literature and include receivers, tooth
texture and contour, light source, the surroundings, and
among dentists concerning shade matching for the same
teeth over days and among practitioners.8,9 Researchers have
claimed that many variables such as colour deficiency, gender,
experience, and eye fatigue can lead to inconsistencies and
affect ability to select the proper shade.3,10–14
To eliminate the variability of conventional visual shade
selection, electronic shade matching devices have been
marketed. The devices are generally one of three types:

* Correspondence to: P.O. Box 10390, Jeddah 21433, Saudi Arabia. Tel.: +966 504 695 411; fax: +966 2 6952847.
E-mail addresses: sbahannan@kau.edu.sa, sbahannan@gmail.com.
0300-5712/$ – see front matter # 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jdent.2013.11.001
 journal of dentistry 42 (2014) 48–52
spectrophotometer, digital colour analyser, or colorimeter.1–15
These devices basically consist of a detector and signal
conditioner and software that processes the signal to make
the data usable in the clinic or laboratory.15 The selection of
such an instrument depends on its reliability, accuracy,
working life, and cost. A number of these electronic devices
have been tested by evaluating their accuracy and precision or
comparing results to visual observation.3–5,9,13,15–18 Yet, the
subject remains controversial among researchers. Although
one group concluded that the visual method (human
examiners) was significantly better than that of the three
digital devices tested,19 other groups have found that shade
matching devices or digital cameras are more reliable and
accurate.8,17,18
The purposes of this study were to compare the shade
matching quality of visual matching and a shade selection
device among dental students, and to evaluate the effect of the
experience and gender on shade matching quality. The null
hypothesis was that there would be no difference between
methods and that gender and experience would have no effect
on selecting the correct tooth shade.
2. Materials and methods
2.1. Subjects
A total of 204 volunteer students, all undergraduates and
interns, participated in this study (102 men). The age range
was 20–30 years with different levels of dental education
(Table 1). The study was performed at the Faculty of Dentistry,
King Abdulaziz University (KAU), in Jeddah, Saudi Arabia. It
was approved by the Research Ethics Committee of the Faculty
of Dentistry (REC-FD #019-11). All participants provided
written consent before the study commenced. Two examiners
did all procedures, helping each other.
Participants were divided into two groups based on
experience and education level. The first group consisted of
third, fourth and fifth-year students who had little or no
knowledge or experience regarding tooth shade matching. The
second group had the knowledge and clinical experience with
matching the tooth shade using the Vita- 3D Master Shade
Guide System (Vita Zahnfabrik, Bad Sackingen, Germany). All
participants underwent a Colour Vision Deficiency (CVD) test
using Ishihara charts, which is a test for Colour-Blindness
(Ishihara’s. Tokyo, Kanehara). CVD test was performed to each
participant separately. Ishihara chart was held 75 cm from the
participant and tilted so that the plane of the paper was
perpendicular to the line of the vision. The participant read the
Ishihara chart and the examiner compared it with the
checklist provided with the booklet of the chart. A daylight
Table 1 – Student class listing by frequency.
Education level
3rd 4th 5th 6th Intern Total
Year Year Year Year
Frequency 43 35 45 41 40 204
Valid Percent 21.1 17.2 22.1 20.1 19.6
49
Fig. 1 – Maxillary cast with six maxillary artificial teeth.
illuminator with a GTI mini-matcher colour viewing system
(GTI Graphic Technology, NY, USA) was used during the test.
Participants with CVD were excluded.
2.2. Shade matching
A maxillary blue stone cast (Whip Mix, Germany) was
fabricated. The six maxillary stone anterior teeth were
replaced with six maxillary artificial teeth (Vita Lumin
Vacuum, Vita Zahnfabrik, Germany) (Fig. 1). The participants
were given a presentation about how to do tooth shade
matching using two techniques. The first one was a visual
technique with the Vita-3D Master system (Vita Zahnfabrik,
Germany), and the other one was the Easy Shade Compact
device (Vita Zahnfabrik, Germany). The participants were
asked to match one shade that of the maxillary right central
incisor to avoid eye fatigue. Each participant selected the best
shade match following the manufacturer’s instructions by
selecting the value, chroma, and hue. The shade matching
with the Vita-3D Master shade guide was done under the
daylight illuminator (GTI Graphic Technology, NY, USA). The
study was double blinded so that neither the examiners nor
the participants knew the shade of the artificial teeth; only the
principal investigator knew the correct shade. The Easy Shade
Compact device was used according to the manufacturer’s
instructions. It was calibrated after each participant’s usage.
Since there is no contamination, the shield was not placed on
the probe. The probe was touching the middle third of the
tooth, and the shade tab mode was used for quality control.
2.3. Statistical analysis
The results were analysed with SPSS version 19 and 95%
confidence intervals. Frequencies and Chi-square tests were
used to analyse the data, with a = 0.05 and significance set at
P < 0.05.
3. Results
The overall ability for all students was low (36.3%) with the
visual method (Table 2). There was not a statistical difference
for experience in terms of ability to select the correct shade
(P = 0.177). Table 3 also shows the lack of a significant gender
difference in ability to visually select the correct matching
shade (P = 0.560).
50 journal of dentistry 42 (2014) 48–52

Table 2 – Test correct by students class. P = 0.452.

Types of shade matching Groups Total P value

Group 1 (3rd, 4th, 5th year) Group 2 (6th Year, Intern)

Visual correct count (%) 41 (33.3%) 33 (40.7%) 74 (36.3%) 0.0177%
Easy shade correct count (%) 99 (80.5%) 65 (80.2%) 164 (80.4% 0.552%

Table 3 – Test correct by gender.

Types of shade matching Gender Total P value

Male Female
Visual correct count (%) 35 (34.3%) 39 (38.2%) 74 (36.3%) 0.56
Easy shade correct count (%) 82 (80.4%) 82 (80.4%) 164 (80.4%) 1.00

comparable age ranges and were divided into two groups

Table 4 – Easy shade correct vs. test correct P = .098. based on education level. The Vita-3D Master Shade Guide
Types of shade Visual test correct Total System was chosen because it has resulted in higher colour
matching match in studies comparing it with the Vitapan classical shade
Yes No guide.11,20–22 It has been reported that Vita Classic shade guide
tabs are not systematically distributed in the colour space
Easy shade? 64 (39.0%) 100 (61.0%) 164 (100.0%)
Yes count (%)
relevant to human teeth, and that there is even overlap.23
No count (%) 10 (25.0%) 30 (75.0%) 40 (100.0%) Human visual colour assessments are a summation of
Total count (%) 74 (36.3%) 130 (63.7%) 204 (100.0%) physiological and psychological responses to a colour stimu-
lus. The perception of colour by an observer is subjective,
resulting in varied and unpredictable differences in colour
In contrast, 80.4% of participants (n = 164) gauged the correct evaluation and matching among clinicians.23,24 Researches
shade using the Easy Shade Compact machine. Student reported that various factors such as the type and intensity of
experience had no significant influence (P < 0.552) (Table 2), light source, angle of incidence, tooth texture and contour will
and neither did gender (Table 3), as males and females equally complicate the shade taking procedure.
mastered the use of the Easy Shade Compact device (P = 1.0). However, participants with CVD were excluded here by use
When the visual and Easy Shade methods were compared, of the Ishihara test, one of the most commonly used screening
61.0% of those who could not match shades visually could do tools for CVDs.11 This decision also took into account the
so with the Easy Shade (Table 4). Odds ratio (OR) analysis results of Davison and Myslinski, who reported that colour-
(Table 5) comparing the visual and Easy Shade methods defective dental personnel make significantly greater errors in
revealed that students were 1.92 times less likely to match hue and chroma selection than normal-vision dental person-
correctly using the visual method than to do so using the Easy nel.10
Shade machine (OR = 1.92, 95% confidence interval, 0.879 to In this study, the shade matching for an artificial tooth with
4.194, P = 0.098). the conventional visual method differed significantly in
percentage of correct matches (36.3%) compared with results
for the Easy Shade Compact device (80.4%). With the visual
4. Discussion technique, those 36.3% of participants chose the correct shade
(value, chroma, and hue), but 22% had only the correct value
About 30% of undergraduate students and interns at the and chroma. The participants found that this spectrophotom-
Faculty of Dentistry at KAU participated in this study. All had eter was much easier to use than the conventional visual
method. In addition, they did not have to worry about the light
source, environment, or background.
Our results are in agreement with others who have
Table 5 – Odds ratio and relative risk. Easy shade correct reported better results with spectrophotometer colour match-
vs. test correct.
ing compared to visual shade assessment.17,25–28 Paul et al.
Value 95% confidence suggested that spectrophotometric shade analysis is more
interval accurate and more reproducible compared with human shade
Lower Upper assessment.29 It has been mentioned that this approach can
serve as a reliable addition in colour matching and enhances
Odds ratio for visual correct 1.920 0.879 4.194
(correct/incorrect)
the level of shade analysis, communication, interpretation,
For cohort easy shade 1.124 0.987 1.281 and fabrication of dental restorations.30 Witkowski et al.
correct = correct reported that the accuracy and reproducibility of dental shade
For cohort easy shade 0.586 0.304 1.129 selection using a digital spectrophotometer with respect to
correct = incorrect examiner and illumination conditions reflected the reliability
No. of valid cases 204
of the device.31
 journal of dentistry 42 (2014) 48–52
In this study, the two groups organized by education level
did not differ in their shade matching results. This finding is in
agreement with those of previous groups13,27,28 that reported
no effect on results of experience in shade matching. In
contrast, however, Della Bona and colleagues reported that
previous training in shade matching and clinical experience
in dentistry played important roles in shade matching
accuracy.32
In terms of gender, the traditional belief has been that
women are more capable of matching colours than men,13 and
other researchers have evaluated whether a difference exists
between men and women in terms of shade matching
ability.14,33–38 Haddad et al. found that females achieved
significantly better shade matching results than males.13
Surprisingly, Miranda reported that men were more success-
ful in discriminating shades.33 However, investigators in other
studies have been unable to identify a significant influence of
sex on shade matching ability.14,16,31,34,35 In agreement, our
results showed that sex is not an important factor in shade
matching and that male and female participants did not differ
using either technique.
Comparing the visual and Easy Shade methods, 61.0% of
those who could not match shades visually for an artificial
tooth could do so with Easy Shade. In addition, students were
1.92 times less likely to match correctly with the visual
approach than to do so using the Easy Shade machine.
The limitations of this study are that one shade was
selected, but we were concerned about eye fatigue. To
compensate for that limitation, the number of participants
was increased. However artificial tooth was used to mimic the
clinical situation.
5. Conclusion
Within the limitations of this study, the shade matching device
(Easy Shade Compact) was significantly better than the
conventional visual method in yielding accurate results. Males
and females did not differ significantly in outcomes with either
technique, and experience had no significant influence on shade
matching quality when selecting shade for artificial tooth.
Conflict of interest statement
No conflict of interest is declared for this work.
Acknowledgments
This Project was funded by Deanship of Scientific Research
(DSR), King Abdulaziz University, Jeddah, under grant no.
1433/165/500. The author, therefore, acknowledge with
thanks the technical and financial support. The author
would like to express her sincere thanks to Professor Garnett
Henley, Howard University College of Dentistry, USA, and Dr.
Hanan Kadi in King abdulaziz University for their assistance
in the statistical analysis. However she appreciates the help
of Dr. Ghada Essa and Dr. Ghadi Muamenah in collecting the
clinical data.
51
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