ISSN: 2320-5407 Int. J. Adv. Res.

12(06), 702-712

Journal Homepage: -www.journalijar.com

Article DOI:10.21474/IJAR01/18934
DOI URL: http://dx.doi.org/10.21474/IJAR01/18934

RESEARCH ARTICLE
EVALUATION OF EFFICACY OF COLOUR CORRECTED LIGHT SOURCE IN DETERMINING THE
ACCURACY OF SHADE MATCHING DONE WITH A COMMONLY USED SHADE GUIDE SYSTEM
BY CONVENTIONAL VISUAL METHOD AND AN INTRA ORAL SPECTROPHOTOMETER

Dr. Pinky Vincent1, Dr. Rajesh C2, Dr. S. Anilkumar3 and Dr. Sandhya M. Raghavan4
1. Resident, Department of Prosthodontics, Government Dental College, Kottayam.
2. Associate Professor, Department of Prosthodontics, Government Dental College, Kottayam.
3. Controller of Examinations, Kerala University of Health Sciences.
4. Associate Professor, Department of Prosthodontics, Government Dental College, Kottayam.
……………………………………………………………………………………………………....
Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Aim: The objective of this study was to evaluate the efficiency of
Received: 18 April 2024 colour corrected light source in shade matching and to determine
Final Accepted: 23 May 2024 accuracies and inter-rater agreement of three shade matching methods
Published: June 2024 (conventional visual method, visual method using colour corrected light
source and spectrophotometric method).
Key words:-
Dental Shade Matching, Colour Methodology: In the conventional visual method and the visual
Corrected Light Source, method using colour corrected light source, four examiners with normal
Spectrophotometer, Visual, Accuracy, colour vision matched five target control shade tabs taken from the
Repeatability, Shade Guide
VITAPAN 3D MasterTM shade guide, with other full set of the same
shade guide. Shade matching with the colour corrected light source was
done under “daylight” mode simulating 5500K or natural daylight.
Each tab was matched three times to determine repeatability of visual
examiners. In the spectrophotometric method, two independent
examiners matched the control tabs with three repetitions for each tab.
The data was collected and statistical analysis was performed.
Results: Visual method using colour corrected light source produced
more accurate results (80%) than the conventional visual method
(68.3%) and spectrophotometric method (0%), thus proving the
efficacy of colour corrected light source (p<0.05). All three methods
exhibited poor inter-rater agreement.
Conclusion: The question is whether handheld light correcting devices
and digital assessments are clinically useful or are they unreliable
andunnecessary costly. Even though visual shade matching is
subjective, it is not inferior and should not be underrated. The low
accuracy value obtained for the spectrophotometer may be a
misrepresentation of the machine’s capabilities due to its inability to
measure any reading as“close” to the correct value. If both analyses are
combined, digital determination of the basic shade and visual
determination of the effects, can provide the best possible esthetic
outcome. Although human eye will be the finalarbitrator, success can
best be achieved by combining traditional artistic techniques with
advancements in technology, complemented with innovations in
colour-related research, education, and training of dental professionals.

Corresponding Author:- Dr. Pinky Vincent 702

Address:- Resident, Department of Prosthodontics, Government Dental College,
Kottayam.
ISSN: 2320-5407 Int. J. Adv. Res. 12(06), 702-712

Copy Right, IJAR, 2024,. All rights reserved

……………………………………………………………………………………………………....
Introduction
Shade determination is one of the key factors in creating an esthetically successful restoration.Shade selection is
more of an art than a science. Success in color construction and communication can best be achieved by combining
traditional artistic techniques with the advancements in technology. The advances in technology must be
complemented with innovations in color-related research, education, and training of dental professionals.

The most important factor in shade-matching is the lighting condition.1 The correct light source allows the clinician
to get the shade right the first time and avoid remakes, extra appointments and increase in cost. Since natural light
conditions vary, recommendations for shade-matching include proper colour temperature that come up to 5500k and
a colour-rendering index (CRI)greater than 93 for dental professionals. The CRI measures the equal balance of all
the visible wavelengths,and viewing teeth under diffuse illumination will minimise the distortion of the reflected
light. A low light intensity will make the clinician miss the fine details and complicate hue perception.

The value guide should be used first, preferably with low light levels, even if the operator must squint, since it is the
best for value evaluation.2 There is strong and reliable evidence that supports the use of a light-correcting source
during tooth shade-matching. Shade-matching was also much better under a light-correcting source when compared
to natural or clinical light.3 Even when light conditions are improved by using a low temperature illuminator, there is
a notable improvement in colour vision-deficient individuals.4,5In another Irish study,6 the overall results indicated
that the most beneficial factor for shade-taking was the light-correcting source. The closer the spectral reflectance
curves (optical properties) of the two materials to be matched, the more successful the colour matches will be,
thereby minimising metamerism.7–9

Colour corrected light source (Rite-lite2)

Rite-lite2(Figure 1) is a portable and wireless light-correcting device which has been designed to aid in shade-
matching.Clad in satin-finished aluminium and weighing 184.3g, the round top has an external diameter of 5.3cm
and 12 LEDs. The inner window-hole for viewing patient’s teeth has a diameter of 3cm. The patient side of the
round top section illuminates the dentition from all directions to avoid glare or distortions by direct reflections. The
bottom section is a cylindrical handle that is 9.6cm long with a diameter of 2cm.

Fig. 1:Colour corrected light source (Rite-lite2).

The objectives of the study were:

1. To compare the accuracy of shade matching by conventional visual method undernatural daylight and by using a
colour corrected light source operated under“daylight” mode.

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2. To compare the accuracy of shade matching by conventional visual method using colour corrected light source
and an intra-oral spectrophotometer.
3. To compare the precision (inter-rater agreement) of the visual method, with andwithout using colour corrected
light source, and the spectrophotometric shade matching methods.

Method
Two sets of a commercially available shade guide systemVITAPAN 3D Master TM and a colour corrected light
source (Rite-lite2)were used for conducting this study. An intraoral spectrophotometer (VITA Easyshade TM) was
used to record the spectrophotometric readings.

Four examiners with normal color vision who were trained to use the equipment and the shade guide system and
colour corrected light source participated in the visual shade matching process. All examiners were post graduates in
Prosthodontics. Visual acuity of the participants was tested using the standard Ishihara test for color blindness.

The spectrophotometric shade matching was performed by two independent examiners to determine the inter-rater
agreement of the equipment.

Five shade tabs from the VITAPAN 3D MasterTM were selected as the target control tabs from one set of the shade
guide system. These were then obscured by tape and assigned numbers. (Figure 2). Natural extracted teeth were not
used in this study as they dehydrate over time and result in shade variables which are undesirable, hence the use of
shade guide tabs for standardization.10

Fig. 2:VITAPAN 3D MasterTM Shade Tabs.

Each of the five target control tabs were repeated three times by each of the four examiners in the visual method of
shade matching, first in the conventional manner and then by using a colour corrected light source. Each target
control tab was repeated five times by the two independent examiners in the spectrophotometric method. A total of
150 readings were recorded. (60 readings for visual, 60 readings for visual method using colour corrected light
source and 30 readings for spectrophotometric method)

The study was carried out in a double blinded design in that the identity of target control tabs were concealed from
participants of shade matching and the person who recorded the observations. The tabs were revealed only after all
the observations were recorded.

An explanation was then given to each volunteer on how to use the shade guides, irrespective of whether they had
used them previously. The volunteers were then allowed to look at the control tabs and decide what they thought

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was the best shade match. The volunteers were allowed to pick up the shade tabs, and no time limits were imposed.
Volunteers were given the control tabs one by one in a random manner. Participants were not required to do the test
in any particular order, and were given no help in choosing a shade. Participants were however told that there were
no doubles.

Visual Method –
The examiners were independently required to match all the masked target control tabs of VITAPAN
3DMASTERTM with another complete set of the VITAPAN 3DMASTERTM shade guide.

Visual method with colour corrected light source –

The examiners were independently required to match all the masked target control tabs of VITAPAN
3DMASTERTM with another complete set of the VITAPAN 3DMASTERTM shade guide by viewing through the
inner window hole of the colour corrected light source (Rite-lite2) in the “daylight” mode. The distance at which to
hold the color corrected light source was not specified.

The matching was done under standardized lighting conditions. An A4 sheet of grey card was used to rest the
subject’s eyes betweenshade assessments. The ideal background color is neutral gray as it has no complimentary
color and is restful to the cones. 10 Pink background is also considered an ideal colour reference. 1 Examiners were
asked to look at it for 15 seconds to avoid colour fatigue.

Spectrophotometric method-
Two independent examiners were required to match the control tabs with each tab being matched five times. The
spectrophotometer was used in the “shade tab” mode. The examiners were asked to match the shade tab at its middle
third as previous studies have shown that the basic shade is best represented at the middle third. 44 (Figure 3) The
inter examiner reproducibility and the intra examiner repeatability of the spectrophotometer was thus assessed.

Fig. 3: Shade matching Process- Spectrophotometer.

Once data collection was complete the identity of the control tabs was revealed and noted. Scores were assigned
strictly on a correct or incorrect basis.

The statistical analysis was done using statistical software (SPSS 25 for Windows, Agreestat2013.1, MedCalc
software). The difference in accuracy for the conventional visual method,visual method using colour corrected light
source and the spectrophotometer was analyzed using Chi square tests.

Cohen’s kappa was calculated to estimate interrater agreement with the spectrophotometric method as only two
examiners were involved. For the visual method, however, Fleiss kappa scores were determined based on the criteria
proposed by Fleiss.11 P values < 0.005 were considered significant for all tests.

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Results
A comparison of accuracies between shade matching methods revealed that the visual method using colour corrected
light source was better than the conventional visual method and spectrophotometric method. The difference in
accuracy between the three methods was statistically significant. (Table 1, Figure 4)

Table 1:COMPARISON OF ACCURACY BETWEEN SHADE MATCHING METHODS.

Method Correct (%) Incorrect (%) Total Chi square df p value

Visual 41 19 60
Visual with colour
corrected-light source 48 12 60 56.40 2 00.000⃰

Spectrophotometer 0 30 30
* The difference in proportions was statistically significant (chi square test)

Fig.4: Comparison of accuracy between conventional visual method,visual method using colour corrected light
source and spectrophotometric method.

Unfortunately, the spectrophotometer gave all the responses incorrect when the shade tabs from the VITAPAN 3D
MasterTM shade guide were matched. The accuracy between shade guides evaluated by visual method using colour
corrected light source and the conventional visual method showed varied results with the shade guide. (Figure 5,
Figure 6)

The comparison of inter examiner accuracy among the three methods produced interesting results. The responses
given by the machine were consistent irrespective of the examiners using it. They were the same whether correct or
incorrect. No correct responses were given by the machine for both the examiners. (Table 4)

The conventional visual method of shade matching showed different results for inter-examiner accuracy. The
number of correct and incorrect responses for the shade tabs from the shade guide were different for each of the
examiners who participated in the study. (Table 2, Table 3)

The level of inter-rater agreement wassummarized using the classification proposed by Fleiss. 11 All the three
methods showed poor level of inter-rater agreement. (Table 5)

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Fig.5: Comparison of Accuracy between Shade Tabs from VITAPAN 3D Master TM Shade Guide by Visual Method.

Fig.6:- Comparison Of Accuracy Between Shade Tabs from VITAPAN 3D- MasterTM Shade Guide by Visual
Method Using Colour Corrected Light Source.

Table 2: COMPARISON OF ACCURACY BETWEEN EXAMINERS BYVISUAL METHOD USING VITAPAN

3D-MASTERTM SHADE GUIDE.

Examiner Correct (%) Incorrect (%) Total Chi square df p value

Examiner1 9(22) 6(31.6) 15

Examiner2 10(24.4) 5(26.3) 15

Examiner3 10(24.4) 5(26.3) 15 1.463 3 0.691⃰

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Examiner4 12(29.3) 3(15.8) 15

Total 41(100) 19(100) 60
* The difference in proportions was statistically insignificant

Table 3:COMPARISON OF ACCURACY BETWEEN EXAMINERS BY VISUAL METHOD WITH

COLOURCORRECTED LIGHT SOURCE USING VITAPAN 3D-MASTERTM SHADE GUIDE.

Examiner Correct (%) Incorrect (%) Total Chi square df p value

Examiner1 11(22.9) 4(33.3) 15
Examiner2 11(22.9) 4(33.3) 15
Examiner3 12(25) 3(25) 15
Examiner4 14(29.2) 1(8.3) 15 2.500 3 0.475⃰
Total 48(100) 12(100) 60
* The difference in proportions was statistically insignificant

Table 4:COMPARISON OF ACCURACY BETWEEN EXAMINERS BY SPECTROPHOTOMETRIC

METHOD USINGVITAPAN 3D-MASTER TM SHADE GUIDE.

Examiner Correct (%) Incorrect (%) Total

Examiner 5 0 15(100) 15(100)

Examiner 6 0 15(100) 15(100)

Total 0 15(100) 15(100)

Table 5:COMPARISON OF INTER-RATER AGREEMENT AMONG DIFFERENT METHODS.

Method Shade Guide Statistic Value Strength of Agreement

Visual Vitapan 3D- Fleiss Kappa -0.111 Poor

MasterTM

Visual with colour corrected light Vitapan 3D- Fleiss Kappa -0113 Poor
source MasterTM

Spectrophotometer Vitapan 3D- Fleiss Kappa -0.161 Poor

MasterTM
*as proposed by Fleiss11

Discussion:
The present study evaluated the efficacy of a colour corrected light source in determining the shade and compared
the accuracies of conventional visual method, visual method using colour corrected light source and intraoral
spectrophotometric (VITA EasyshadeTM) method using VITAPAN 3D MasterTMshade guide system. The results
support rejection of the null hypothesis that the colour corrected light source is not efficient in determining the
accuracy of shade matching.

In this study, accuracy refers to the exact reproduction of the masked shade tab using either the spectrophotometric
method or the visual method with and without using colour corrected light source. The study showed the visual
method using colour corrected light source to be more accurate than the conventional visual method and
spectrophotometric method.

One possible explanation for this is that the examiners were focused solely and directly on the shade matching area
observed through a small window of the handheld light. This could have reduced background distraction and
increased focus on the shade-matching exercise. These are clinically favourable results (additionally,having a

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viewing booth in a clinical setting is not practical). The advantages of the evaluated handheld lights compared with
other available shade-matching aids include their portability, user friendliness, and affordability. 12

The correct light source allows the clinician to get the shade right the first time and avoid remakes, extra
appointments and increase in cost.1 In the United Kingdom, clinician scientists combined the use of colour-
correcting and digital recording devices showing an improved ability to match dental shades when compared to the
digital device alone under normal light conditions.Shade-matching was also much better under a light-correcting
source when compared to natural or clinical light. 3 Even when light conditions are improved by using a low
temperature illuminator, there is a notable improvement in colour vision-deficient individuals.4,5

On comparison of the conventional visual method and spectrophotometric method, the spectrophotometer was found
to be less accurate. Previous studies have shown conflicting results. While most of the studies13,14–16 indicate that
shade matching instruments are more accurate, evidence to the contrary is also available. 17–19

In a study by Hugo B et al20, the authors concluded that computer-aided color shade determination of natural teeth
seems to not reflect human perception. Another study conducted in 2011 by Ratzmann A et al21 also showed that
validity was better for visual than for electronic color assessment. Another recent study by Sarafianou A et al 16 in
2012 suggested a particularly low level of agreement for Easyshade and SpectroShade readings performed under any
of the illuminants tested suggesting poor inter device reliability.

These results are similar to those obtained in the present study. It is pertinent to evaluate the reasons for such low
accuracy levels for the spectrophotometric method in the study.

The influence of methodology on the accuracy levels of spectrophotometric method also needs to be considered. The
fact that this study used shade tabs as targets could have led to a reduction in accuracy as only an exact match was
considered accurate. This could partly account for the reduced accuracy of the spectrophotometer. Majority of the
readings obtained were in the same value-range as that of the target shade tabs, but were considered incorrect as
only the exact match was deemed correct.

The third objective of this study was to assess the precision or level of inter-rater agreement for the three shade
matching methods. It is determined by how closely two observations agree, but not whether they are correct. The
study results showed that the conventional visual method, visual method using colour corrected light source and
spectrophotometric method produced poor level of inter-rater agreement.

The results obtained in this study are not in accordance with the literature in that the spectrophotometer provides far
better inter-rater agreement as compared to the conventional visual method. In the systematic review conducted by
Chen H et al22 in 2012, the authors have reviewed eighteen studies that have reported Inter-evaluator/Inter
equipment agreement.

The exceptions were one study23 in which spectrophotometers failed to consistently produce greater agreement than
conventional visual measurement, two studies24,25 in which the precision percentage of a spectrophotometric
measurement was smaller than that of a colorimeter, and another study26 in which the spectrophotometric shade
match was the least reproducible. The relatively lower reproducibility yielded by spectrophotometers in these studies
may have been caused by device-dependent biases 27,28.

Thus, it can be inferred that the poor level of inter- rater agreement of the spectrophotometer is in this study was due
to the device dependent biases and the strict and narrow criteria for choosing the correct response as even the
responses which were very close to or within the same value range as the target tabs were considered incorrect.

Another perspective to reflect upon is the validity of evaluating inter rater agreement as the response given by the
machine is objective and does not depend on the examiner using it, except for the correct placement of the
spectrophotometer on the shade tab.

The poor level of inter-rater agreement of the visual methods, with and without using colour corrected light source
can be attributed to the difference in subjective perception of the examiners, education and training, gender, color
deficiency, and numerous physiological and psychological factors (fatigue, age, nutrition, medications).12

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Strengths and limitations

The study reveals marked differences in accuracies between the visual methods, with and without using colour
corrected light source and instrumental methods of shade matching. As the shade tabs used in the study had definite
predetermined values, the results of matching these control tabs could be certainly assigned as correct and incorrect.
Hence, the study design can be considered as the best predictor for accuracy of shade matching. Moreover, the
responses with relative closeness to the correct shade tab was deemed incorrect which led to the reduced accuracy
level of the spectrophotometer.

To test the accuracy of any electronic device intended for use in the oral environment, an intraoral standard must be
developed. Despite this lack in standardization, the shade guides are the “de-facto standard’’ for color determination
in dentistry,29 hence the advantage of using shade tabs as target controls.

A strength of this study is that the shade guide and the spectrophotometer used in the study are produced by the
same manufacturer. This implies that the spectrophotometer VITA Easyshade TM has the software programmed in it
to detect the shades from the VITAPAN 3D Master TM shade guide.

An added benefit is that it takes into consideration both repeatability and accuracy aspects of both methods of shade
matching. In other words, precision and accuracy both of which are factors on a par to be considered are interpreted.

Theoretically, instrumental readings are objective, can be quantified, and more rapidly obtained18. However, the
VITA EasyshadeTM digital spectrophotometer did not perform as well as expected. The machine was calibrated
between measurements and switched off after testing 10 tabs so as to avoid overheating it. As discussed earlier, the
reasons for such low levels of accuracy obtained for the spectrophotometer might have been because the responses
were graded correct or incorrect with no measure of "closeness" to the correct value.

Another shortcoming is that when spectrophotometer was used, the probe tip was arbitrarily positioned on the
middle third. A positioning device to replicate the same area was not used. 28 However, the study results reveal that
this has not affected the repeatability issues of the spectrophotometer. The hope for the spectrophotometer remains
as it gave consistent results.

Another limitation was that this study was done taking readings from four examiners for visual shade matching and
two independent examiners for spectrophotometer. The participation of four examiners cannot indeed expose nearly
all the limitations of visual method of shade matching.

A shortcoming with the colour corrected light source is that the distance at which it was held from the target control
tabs was arbitrarily decided. And the fact that the target control tabs had to be viewed through the glass made the
shade matching process cumbersome and tiring for the examiners.

Comparison between visual and instrumental findings is a very attractive topic as it reveals the pros and cons of both
methods. The answer whether to use visual or instrumental method for color matching in dentistry is: whenever
possible, use both, as they complement each other and can lead towards a predictable appealing outcome 14,20,30.

Further research might evaluate the influence of different lights and polarizing filters on the shade selection of
natural teeth because the optical properties of enamel and dentin are different from those of the shade tabs. 12 The
superiority of a correcting light is a fact and could also be seen as convenient since it is portable, wireless and
readily available as it is often found in the dental market industry. 1

Conclusion
Within the limitations of this study, the following conclusions were obtained:
1. A comparison of accuracies between shade matching methods revealed that there were significant
differences,proving that the colour corrected light source is more efficient in determining the accuracy of shade
matching.
2. Comparison of conventional visual method and spectrophotometric methods show greater accuracy for the
visual method.
3. Comparison of inter-rater agreement between examiners were poor for all the three methods.

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4. Similar research evaluating the importance of lighting conditions and comparing the visual and instrumental
shade matching methods is warranted in the future to delineate the exact roles for either technique to achieve the
ultimategoal of providing an esthetic clinical outcome.

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