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Critical Appraisal jerd_255 202..

208

COLOR IN DENTISTRY: IMPROVING THE ODDS OF


CORRECT SHADE SELECTION

Author

Rade D. Paravina, DDS, MS, PhD*

Associate Editor
Edward J. Swift Jr., DMD, MS

T his Critical Appraisal focuses on how well dental shade guides correspond to the color range and
distribution of natural teeth. In other words, we will discuss “chances” of shade guides to match
shades of human teeth and demonstrate alternatives.

C O V E R A G E E R R O R O F T H R E E C O N C E P T U A L LY D I F F E R E N T S H A D E G U I D E S Y S T E M S T O V I TA L
UNRESTORED DENTITION

F. Bayindir, S. Kuo, W.M. Johnston, A.G. Wee


Journal of Prosthetic Dentistry 2007 (98:175–85)

ABSTRACT Materials and Methods: The CEs tab (without a backing) were mea-
of the following shade guide sured by using a spectroradiometer
Statement of the Problem: It systems were evaluated to deter- and an external light source at
remains unclear which shade guide mine which shade guide system is wavelengths from 380 to 780 nm
system is most representative most effective in producing the at 2-nm intervals. All spectral
of the shades found in the best visual shade match: (1) Vita reflectance measurements were
human dentition. Lumin (Vita Zahnfabrik, Bad Säck- made by using 0-degree observer
ingen, Germany), (2) Chromascop and 45-degree illumination and
Purpose: The aims of this study (Ivoclar Vivadent, Schaan, Liecht- were converted to Commission
were to determine and to compare enstein), (3) Vitapan 3D-Master Internationale de l’Eclairage,
the coverage errors (CEs) of three (Vita Zahnfabrik), and (4) a com- Vienna, Austria values. The color
different shades in a selected popu- bination of the three shade guide parameters of 359 anterior teeth
lation (five age groups: 18–29, systems. The spectral reflectance were measured with the same pro-
30–39, 40–49, 50–59, and 60–85 values of the central one-ninth tocol. The CEs for each of the 359
years old). (1-mm diameter) of each shade anterior teeth for each shade guide

*Assistant professor, Department of Restorative Dentistry and Biomaterials,


University of Texas Dental Branch at Houston, Houston, TX, USA
Contact for editorial questions: Rade.Paravina@uth.tmc.edu.

© 2009, COPYRIGHT THE AUTHORS


J O U R N A L C O M P I L AT I O N © 2 0 0 9 , W I L E Y P E R I O D I C A L S , I N C .
202 DOI 10.1111/j.1708-8240.2009.00255.x VOLUME 21, NUMBER 3, 2009
PA R AV I N A

system, and with all three shade not differ significantly from the a* values of natural teeth. The
guide systems, were determined CEs when all three shade guide highest a* values in three shade
and averaged. Repeated measures systems were combined. guides were recorded for C4 of
analysis of variance was used to Vita Lumin (2.6), 540 of
evaluate the mean minimum CEs C O M M E N TA RY Chromascop (7.6), and 5M3 of
within-subject (shade guide system) Shade guides are tools for visual Vitapan 3D-Master (7.0). At the
and between-subject (age) differ- color matching in dentistry. Dental same time, extreme green–red coor-
ence as well as the interaction color standards are supposed to be dinate values for natural teeth were
between these variables. Post schematic representations of tooth up to a* ª 12. The maximum color
hoc multiple comparisons were color and consist of a certain difference of DE* ª 27 for each
performed by using the number of shade tabs. Although shade guide was likely influenced
Tukey–Kramer test. several instruments for intraoral by the a* coordinate discrepancy.
color measurement are available, These findings are very interesting
Results: A significant difference visual color matching method by and agree with the clinical observa-
was found between the mean means of shade guides is by far the tion that shade guides lack redder
minimum CEs of the three shade predominant method. The term shades. What is not in accordance
guide systems and their combina- “coverage error” (CE) was intro- with the literature and clinical
tion but not between age groups. duced in 1991 to describe the practice is that the best matches
The interaction of shade guide mean color difference between for almost 50% of natural teeth
systems and age was significant. each evaluated natural tooth and were shades C3, C4, D2, and
The mean minimum CEs for the the best matching tab from a D3, with C3, C4, and D3 being
Vita Lumin (5.39 DE) and particular shade guide. more frequent than any of
Chromascop (5.28 DE) shade guide A-group shades.
systems were not significantly dif- CEs reported in this study (5.4 for
ferent from each other. However, Vita Lumin, 5.3 for Chromascop, SUGGESTED READING

the combination of all three shade and 3.9 for Vitapan 3D-Master) Hall NR, Kafalias MC. Composite colour
guide systems (3.69 DE) and are larger than those reported in matching: the development and evaluation
of a restorative colour matching system.
Vitapan 3D-Master (3.93 DE) was 1991, when the CE was 3.0 for Aust Prosthodont J 1991;5:47–52.
significantly different from the Vita both Vita Lumin and Bioform
(Dentsply Prosthetics, York, PA, O’Brien WJ, Boenke KM, Groh CL. Coverage
Lumin and Chromascop shade errors of two shade guides. Int J Prosth-
guide systems. The rankings of the USA) shade guides. A 2004 study odont 1991;4:45–50.
shade guide systems within each also reported smaller CE values:
Rubino M, Garcia JA, Jiménez del Barco L,
age group were similar between the 3.1, 3.3, and 2.7 for Vita Lumin, Romero J. Colour measurement of human
age groups. Trubyte Bioform, and Vitapan teeth and evaluation of a colour guide.
Col Res Appl 1994;19:19–22.
3D-Master, respectively.
Conclusions: The Vitapan Hasegawa A, Motonomi A, Ikeda I, Kawagu-
3D-Master shade guide system Based on one of the figures in the chi S. Color of natural tooth crown in
Japanese people. Color Res Appl
resulted in lower CEs than the Vita paper presented in this abstract, 2000;25:43–8.
Lumin or Chromascop shade guide the a* values (green–red coordi-
Analoui M, Papkosta E, Cochran M, Matis B.
systems. CEs for the Vitapan nate) of all evaluated shade guides Designing visually optimal shade guides.
3D-Master shade guide system did were lower than the corresponding J Prosthet Dent 2004;92:371–6.

VOLUME 21, NUMBER 3, 2009 203


CRITICAL APPRAISAL

I N V I V O S P E C T R O R A D I O M E T R I C E VA L U AT I O N O F C O L O R M AT C H I N G E R R O R S A M O N G F I V E
SHADE GUIDES

Q. Li, H. Yu, Y.N. Wang


Journal of Oral Rehabilitation 2009 (36:65–70)

ABSTRACT beyond the clinical threshold of 3.3 matching tabs were selected
units. Consensus provided better visually. Therefore, the selected tabs
Purpose: The purpose of this study color matching than the single- were not necessarily the ones with
was to evaluate the color errors decision group for the Vitapan the smallest color difference com-
of visual shade selection by five 3D-Master and Vintage Halo NCC pared with natural teeth. The
different shade guides. (Shofu, Menlo Park, CA, USA) increases in visual CEs (with con-
shade guides. Significant differences sensus) compared with instrumen-
Materials and Methods: The max- were found for DEs by shade guide tally obtained values were 5.7,
illary left central incisors of 60 system and clinical experience. 10.3, 13.4, 22.3, and 24.1% for
subjects were visually evaluated by Vitapan 3D-Master and Vita Lumin
two groups of prosthodontists Conclusions: None of the shade (Vita Zahnfabrik, Bad Sackingen,
having different levels of clinical guide systems achieved clinically Germany), Vintage Halo and
experience. The shade selection compatible shade matching. Vintage Halo NCC (Shofu, Menlo
results were recorded, and the However, the Vitapan 3D-Master Park, CA, USA), and Chromascop,
most frequently selected tab was had the lowest CEs and DEs. Con- respectively. Obviously, a smaller
determined as the resultant shade sensus could be helpful in enhanc- discrepancy between the visual and
for each tooth. If totally different ing the esthetic results by using the instrumental CEs is more favorable
opinions were obtained, consensus Vitapan 3D-Master and Shofu and might originate from the tab
was forced to determine the result- NCC (Shofu, Menlo Park, CA, arrangement, which directly influ-
ant shade among the observers. USA) shade guides. ences the user friendliness of the
The Commission Internationale de shade-matching procedure.
l’Eclairage L*a*b* (CIELAB) coor- C O M M E N TA RY
dinates of each tooth and shade In addition to providing the instru- It appears that the visual CE,
tab were measured by using a spec- mental findings on the CEs of dif- reported for the first time in this
troradiometer. The CEs of each ferent shade guides (as in the first article, deserves full attention
shade guide and color difference paper presented in this Critical because the line between the objec-
(DE) between a tooth and the Appraisal), this study considered tive and the subjective is very thin
selected shade tab were calculated. visual (subjective) CE and the in color science and in psychophys-
Two-way ANOVA and Tukey’s influence of consensus and years ics. Color measurement instru-
post hoc analysis were used to in practice on the quality of ments are considered to be
evaluate the differences of CE and shade matching. objective but only if their readings
DE values between shade guides are in accordance with visual
and level of clinical experience. The visual CEs were calculated by (subjective) findings.
using the same approach as in the
Results: CEs and DEs in all of the instrumental (objective) method. If we put errors in visual shade
five shade guide systems were all The only difference is that the best- matching aside for a second, what

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204 J O U R N A L C O M P I L AT I O N © 2 0 0 9 , W I L E Y P E R I O D I C A L S , I N C .
PA R AV I N A

if the best match instrumentally is lightness, chroma and hue but will Standardization of color-matching
really not the best match visually? not tell us which color difference method and conditions, together
Visual thresholds for lightness (L, from our examples really appears with monitoring color temperature
achromatic, black to white, value), larger visually. One example to and illuminance, would add more
chroma (C, color strength, pale to illustrate that simply following the significance to this otherwise very
strong), and hue (h, color name) numbers can be misleading is a nice contribution.
differences are not the same, comparison of the A1 and B1 Vita
whereas the DE* value per se tells shades. Although A1 actually has a SUGGESTED READING
us nothing about the origin of higher value, the vast majority of Sproull RC. Color matching in dentistry. II.
color difference. In other words, dental professionals consider that Practical applications of the organization
of color. J Prosthet Dent 1973;29:556–66.
the DE* provides information on B1 (which is less chromatic) is the
the magnitude but not the direc- lighter shade and is the first tab of O’Brien WJ, Hemmendinger H, Boenke KM,
tion of color differences. the so-called value orientation of et al. Color distribution of three regions
of extracted human teeth. Dent Mater
the Vita shade guide. 1997;13:179–85.
Therefore, a DE* = 3 that predomi-
Chu SJ, Devigus A, Mieleszko A. Fundamen-
nantly originates from the hue dif- Whereas the decrease in visual CEs tals of color: shade matching and commu-
ference might visually appear more with consensus for some shade nication in esthetic dentistry. Hanover
Park (IL): Quintessence; 2004.
pronounced than the DE* = 4 that guides might be clinically relevant,
predominantly originates from the the number of observers in this Berns RS. Billmayer and Saltzman’s principles
of color technology. 3rd ed. New York:
difference in lightness. The instru- study probably diminishes the Wiley; 2000.
ments do not have awareness of significance of findings on the
Paravina RD, Powers JM. Esthetic color train-
that. They will give us numbers for influence of years in practice ing in dentistry. St. Louis (MO): Elsevier;
color differences and differences in on shade-matching quality. 2004.

O P T I M I Z AT I O N O F T O O T H C O L O R A N D S H A D E G U I D E D E S I G N

R.D. Paravina, G. Majkic, F.H. Imai, J.M. Powers


Journal of Prosthodontics 2007 (16:269–76)

ABSTRACT newly developed shade guide was hierarchical clustering, and nonlin-
DE* < 2, with a corresponding ear constrained optimization. CE
Purpose: One critical prerequisite CIEDE2000 (DE’) value.* was calculated for both CIELAB
for dental shade guides is to match and CIEDE2000 values. Recorded
the color range and distribution of Materials and Methods: A total of values were compared with CE
human teeth. The aims of this study 1064 teeth were evaluated in vivo of the Vitapan Classical (Vita
were to design computer models for by using an intraoral spectropho- Zahnfabrik) shade guide. Wilcoxon
dental shade guides and to compare tometer. Shade guide models were signed-rank test for paired samples
them with an existing shade guide. designed by using different methods and linear regression was used in
A targeted CIELAB (DE*) CE for a for representation of the data set, the statistical analysis.

*CIELAB and CIEDE2000 are color difference formulae of the CIE system.

VOLUME 21, NUMBER 3, 2009 205


CRITICAL APPRAISAL

Results: CE of the Vitapan Classi- representation of tooth color than The 26-tab model, derived from an
cal was 4.1, ranging from 0.5 to an existing dental shade guide. in vitro study of 150 extracted
11.5 DE*. Group A shades had the Optimization outperformed cluster- teeth with the use of hierarchical
best match for human teeth ing and is therefore recommended clustering only, exhibited the same
(43.9%) followed by Groups C as a method of choice for represen- CE as the 24-tab model in this
(24.1%), B (20.4%), and D tation of tooth color and design of study of 1064 teeth in vivo
(11.7%) shades, respectively. dental shade guides. with the use of both clustering
CIELAB CEs of the newly designed and optimization.
24-tab shade guide using clustering
and optimization were 2.05 and C O M M E N TA RY It is interesting that the Vitapan
1.96, respectively. Corresponding The aim of the studies presented in Classical exhibited almost the
CIEDE2000 CE values were 1.43 the previous two abstracts was to identical CE to permanent teeth
and 1.40, respectively. A significant determine CE of various dental (DE*COV = 4.1) and primary teeth
difference between results obtained shade guides. Results were not (DE*COV = 4.2), as recorded in two
by using clustering and optimiza- quite satisfactory for some of the independent studies and data sets.
tion was determined. CIELAB color evaluated products. However, the color difference
differences were greater but highly between mean L*a*b* values for
correlated as compared with The objective of this in vivo study primary and permanent teeth was
their CIEDE2000 counterparts was to compare CEs of an existing 8.2, with the former being lighter,
(DE’ = 0.64 ¥ DE* + 0.13, r > 0.99). shade guide with computer models redder, and less chromatic. Because
This means that DE* values can for dental shade guides. Four sets of the narrower ranges of lightness,
be successfully calculated based of 30 model shade guides (contain- chroma, and hue, the computer
on a known DE’ value and ing 1, 2, 3 . . . , and 30 tabs) were modeling worked even better with
vice versa. designed by using two methods for primary teeth; CIELAB CE of
representation of the data set (clus- Vitapan Classical was matched
Discussion: This study demon- tering and optimization) and two with corresponding two-tab
strated that, compared with exist- color difference formulae (CIELAB optimized model.
ing shade guides, future shade and CIEDE2000) based on color
guides can provide either coordinates of 1064 natural teeth. Several issues should be mentioned
(1) similar coverage of tooth color The CIELAB CE of Vitapan Classi- relative to the computer models of
with fewer tabs, thus simplifying cal to natural teeth (DE*COV = 4.1) dental shade guides:
the shade-matching procedure, or was matched with the correspond-
(2) better coverage of tooth color ing five-tab optimized model. 1. The color differences between
with a similar number of tabs. The 12-tab model matched the natural teeth and best-matching
Either approach could improve the 50:50% acceptability threshold of tabs were obtained from the
chances of satisfactory matches DE* = 2.7, and the 24-tab model measuring device database
and, consequently, could provide had DE*COV < 2.0. Corresponding 2. The models were ideal for given
better esthetics. CIEDE2000 CEs for 5, 12, and data sets, and it would be rea-
24-tab optimized shade guide sonable to expect higher CE
Conclusions: Both clustering models were 2.7, 1.9, when applying them to indepen-
and optimization enabled better and 1.4, respectively. dent data sets. When the models

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from one study of primary manufactured based on com- primary teeth. Eur Arch Paediatr Dent
2008;9:74–8.
teeth were applied to the data puter models could
set from another study, the be challenging.
Ragain JC, Johnston WM. Color acceptance of
CE value increase was 5 direct dental restorative materials by
Computer-designed shade guides human observers. Color Res Appl
to 18%.
could enable a better esthetic 2000;25:278–85.
3. Color formulation and repro-
outcome, and this topic certainly
duction of physical shade tabs
requires additional research. Until Analoui M, Papkosta E, Cochran M, Matis B.
are complicated by the fact that Designing visually optimal shade guides.
they appear on the market, it will J Prosthet Dent 2004;92:371–6.
teeth are small, curved,
be beneficial to learn how to use
polychromatic, translucent,
the existing products to their Paravina RD, O’Keefe KL, Kuljic BL. Color of
and multilayered permanent teeth: a prospective clinical
best advantage.
4. The creation of a shade study. BaSS J 2006;10:93–7.

guide with logical and user- SUGGESTED READING


Kim J, Paravina R, Chen JW. In vivo evalua-
friendly tab arrangement Paravina RD, Majkic G, Stalker JR, et al. tion of color of primary teeth. Pediatr
out of the physical tabs Development of a model shade guide for Dent 2007;29:383–6.

THE BOTTOM LINE

The most critical prerequisite for dental shade guides is to match the color range and distribution of
natural teeth. They also should be logically arranged and user friendly so that dentists and technicians
with limited or no knowledge in color science can successfully match shades. However, additional educa-
tion, including information on appropriate shade-matching method and conditions, and color training are
always a plus and should be a permanent task for dental educators.

Although the absolute numbers reported as coverage errors (CEs) of available shade guides are different,
largely to variety of color measurement instruments and techniques (contact or noncontact type), the
bottom line is fairly clear: Vitapan Classical (Lumin Vacuum) and Trubyte Bioform have the biggest CE,
and Vitapan 3D-Master has the smallest CE (i.e., it matches natural teeth the best). CEs of other shade
guides are in-between these boundaries—Chromascop and Vintage Halo are closer to Classical, whereas
Vintage Halo NCC is closer to the 3D-Master.

CE is a very convenient and simple method for evaluation of how well dental shade guides match the
color of human teeth—the smaller the CE, the better the shade guide and the better the chances of select-
ing an appropriate match. The CE should be interpreted through the comparison with the 50:50% accept-
ability threshold—the color difference that is acceptable for 50% of observers (the remaining 50% of
observers would replace or correct color of the restoration; see the previous Critical Appraisal by
this author).

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CRITICAL APPRAISAL

Generally, a good shade guide would have the CE at or below the 50:50% acceptability threshold.
Getting closer to the 50:50% perceptibility threshold would probably make a shade guide less practical,
as it would need to have a huge number of tabs. The number of tabs in the custom-designed shade guide
models depends on the targeted CE. Fewer tabs and higher CE might be sufficient for direct restorative
materials because of color shifting due to blending effect and physical translucency. Fewer tabs might
also be needed for primary teeth because of their narrow color range. On the other hand, more tabs
and lower CE might be needed to achieve the same esthetic outcome with fixed or removable
prosthodontic restorations.

Current shade guide designs employ two basic conceptions: empiric (Vitapan Classical and shade guides
keyed to it) and scientific (3D-Master), with the latter method being clearly superior. Within the scientific
method, there are two main approaches. The existing one is mechanical, with the shade tabs relatively
uniformly distributed within the tooth color space (as in 3D-Master). The second one is computer gener-
ated, custom-tailored, and based on realistic tooth color distribution (which is not uniform). If the first
approach is the current state of the art, the second one appears to be very promising as a next step in evo-
lution of dental shade guides. The study presented in the third abstract demonstrated that, compared with
existing products, future dental color standards can provide either similar CE with fewer tabs (thus
simplifying shade-matching procedure) or smaller CE with a similar number of tabs. This is a win–win
scenario that might lead to better shade matching results, enhanced esthetics, and, ultimately, improved
patient satisfaction.

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