Shade matching performance of normal

and color vision-deficient dental

professionals with standard daylight
and tungsten illuminants
Hasan Suat Gokce, DDS, PhD,a Bulent Piskin, DDS, PhD,b
Dogan Ceyhan, MD,c Sila Mermut Gokce, DDS, PhD,d
and Volkan Arisan, DDS, PhDe
Gulhane Military Medical Academy, Ankara, Turkey; Van Military
Hospital, Van, Turkey; Faculty of Dentistry, Istanbul University,
Istanbul, Turkey

Statement of problem. The lighting conditions of the environment and visual deficiencies such as red-green color
vision deficiency affect the clinical shade matching performance of dental professionals.
Purpose. The purpose of this study was to evaluate the shade matching performance of normal and color visiondeficient dental professionals with standard daylight and tungsten illuminants.
Material and methods. Two sets of porcelain disc replicas of 16 shade guide tabs (VITA Lumin) were manufactured
to exact L*a*b* values by using a colorimeter. Then these twin porcelain discs (13 mm x 2.4 mm) were mixed up and
placed into a color-matching cabinet that standardized the lighting conditions for the observation tests. Normal and
red-green color vision-deficient dental professionals were asked to match the 32 porcelain discs using standard artificial daylight D65 (high color temperature) and tungsten filament lamp light (T) (low color temperature) illuminants.
The results were analyzed by repeated-measures ANOVA and paired and independent samples t tests for the differences between dental professionals and differences between the illuminants (_=.05).
Results. Regarding the sum of the correct shade match scores of all observations with both illuminants, the difference
between normal vision and red-green color vision-deficient dental professional groups was not statistically significant
(F=4.132; P=.054). However, the correct shade match scores of each group were significantly different for each illuminant (P<.005). The correct shade matching scores of normal color vision dental professionals were significantly higher
with D65 illuminant (t=7.004; P<.001). Color matching scores of red-green color vision-deficient dental professionals
(approximately 5.7 more pairs than with D65) were significantly higher with T illuminant (t=5.977; P<.001).
Conclusions. Within the limitations of this study, the shade matching performance of dental professionals was affected
by color vision deficiency and the color temperature of the illuminant. The color vision-deficient group was notably unsuccessful with the D65 illuminant in shade matching. In contrast, there was a significant increase in the shade matching performance of the color vision-deficient group with T illuminant. The lower color temperature illuminant dramatically decreased the normal color vision groups correct shade matching score. (J Prosthet Dent 2010;103:139-147)

Assistant Professor, Department of Prosthodontics, Dental Sciences Center, Gulhane Military Medical Academy.
Former Resident, Department of Prosthodontics, Dental Sciences Center, Gulhane Military Medical Academy.
c
Chief, Department of Pediatric Ophthalmology, Van Military Hospital.
d
Assistant Professor, Department of Orthodontics, Dental Sciences Center, Gulhane Military Medical Academy.
e
Research Scientist, Department of Oral Implantology, Faculty of Dentistry, Istanbul University.
b

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Volume 103 Issue 3

Clinical Implications
The recommended neutral daylight illuminant for shade determination
is rarely available in clinical practice. Within the specific test
populations of this study, the visual discrimination and matching
abilities of the clinicians with normal color vision decreased with
low color temperature illumination. However, the poor shade
matching performance of red-green color vision-deficient clinicians
with D65 was improved with a low color temperature illuminant.
Certain color vision-deficient clinicians could use T illuminant for
shade matching and be as accurate as clinicians with normal color
vision using D65 illumination.

Successful shade matching of an

intraoral restoration or prosthesis to
the remaining dentition is an essential aspect of restorative and esthetic
dentistry.1,2 Generally, the desired
shade, or combination of shades,
for intraoral restorations is transmitted to dental technicians by using
shades selected from a shade guide.2-7
Although guidelines for ideal shade
selection have long been known,
the use of shade guides remains an
obstacle in attaining acceptable
esthetic results.5 Intraoral shade
matching is dependent upon each
clinicians visual discrimination and
matching abilities.8
Barret et al8 indicated that the
shade matching success of subjects
with normal color vision (NCV) was
about 70%. Hammand3 analyzed the
reproducibility of shade selection by
dental professionals and found that
success rates varied between 35% and
67%. Klemetti et al5 reported that
the shade selection performances of
novice dental professionals varied
between 53% and 71% with different
shade tabs. Okubo et al9 tested recognition of VITA Lumin shade tabs (VITA
Zahnfabrik, Bad Sckingen, Germany)
using another identical shade guide
and found that the visual examiners
were successful in 48% of the situations. Because of these low and varying success percentages for the shade
matching tests, investigators focus on
different approaches for measuring
tooth color, such as spectrophotome-

ters, colorimeters, and computer analysis of photographic images.1,4,5,9-12

However, the color properties of
teeth are nonuniform and involve a
complex layering of tooth structure
and subtle color changes that challenge even the best instruments.4 Instruments are also subject to mechanical problems. Okubo et al9 found that
there was no significant difference between the shade matching accuracy of
the colorimeter and human observers.
Additionally, the high cost and limited
utility of these instruments prevent
their common use in clinical dental
practice.1,4
The understanding of color principles is important for accurate shade
matching. The Commission Internationale de lEclairage CIE L*a*b* system is a useful 3-dimensional color
model with uniform color spacing in
its values. In this system, L* represents
the lightness of color (L* = 0 represents black and L* = 100 indicates
diffuse white; specular white may be
higher), a* represents the color coordinate between red/magenta and
green (negative a* values indicate
green, while positive a* values indicate red/magenta), and b* represents
the color coordinate between yellow
and blue (negative b* values indicate
blue, and positive b* values indicate
yellow).1,13,14 Dental shade guides and
technically based shade matching systems such as colorimeters and spectrophotometers are fabricated based
upon this system.13

The Journal of Prosthetic Dentistry

The color and appearance of natural teeth is a complex phenomenon,

with many factors such as lighting
conditions, translucency, opacity,
light scattering, and gloss, and the
human eye, brain, physiology, and
psychology influencing the overall
perception of tooth color.1 Also, inconsistencies in shade determination
can result from aging, previous eye
exposure/fatigue, and visual deficiencies. Red-green color vision deficiency
(RGCVD) (achromatopsia, Daltonism) is known as deficiency in color
perception and has an important role
in shade selection.13-15 Achromatopsia is an inherited, most commonly
X-linked, nonprogressive, and untreatable disorder, and the incidence is
reported to vary between 2.8% and
9.99%, depending on the population,
age, and gender.1,16-19 This condition is
caused by a deficiency in or absence
of one or more of the 3 types of photosensitive pigments which are able to
detect red, green, and blue. These pigments are contained in the photosensitive cells in the human eye that allow
color perception. These cells are called
cones and are located in the center of
the retina. The effect of color deficiency is that hues that appear different to
most people look the same to those
with color blindness. In other words,
having a color vision deficiency means
that the ability to discriminate hue,
saturation, and lightness is reduced.20
A color vision-deficiency diagnosis
can be established using the Ishihara,

Gokce et al

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March 2010
Nagel anomaloscope, Farnsworth
D15, Richmond HRR, and the Medmont C-100 tests.16,21-23 Color perception is greatly distorted in individuals
with achromatopsia. This may be a
significant handicap for dental professionals.17-19,22-27 Moser et al28 performed a survey of 670 dental professionals, and results showed that 10%
of this group tested positive for some
red-green color deficiency. Barna et
al27 evaluated the influence of light
intensity on the ability to discriminate
color differences and found differences between normal color vision and
color vision-deficient dentists. The
authors suggested that color visiondeficient dentists should obtain assistance when matching tooth shades.27
This highlights the importance of dentists and dental students awareness
of possible color vision deficiency.
The task of judging color under an illuminant represents a significant challenge to the visual system.15,19,21,29-32 Dain et al21 reported
that the color under one illuminant is
not always the same as under another illuminant. Shade matching tests
have been primarily conducted with
daylight (D65) illumination.1,3,4,19,21,25
A neutral illuminant is CIE daylight
D65 (CIE, 1986), and it has a spectrum corresponding to a typical mixture of direct sunlight and scattered
skylight with 6504 K (Kelvin) color
temperature (natural, bluish white,
daylight).19 However, daylight constantly changes with the time of day;
time of year and weather conditions
also affect the color of sunlight. Consequently, standard daylight is rarely
available.4,15,19,31 Therefore, some authors13,21,25,33 investigated the color
matching accuracy under alternative
illuminants with different color temperatures ranging between 2856 K
and 7000 K.
Park et al31 studied the influence
of different illuminants on the color
distribution of 2 shade guides. The
authors indicated that the 3 color parameters of value, chroma, and hue
varied significantly based on the illuminant. Also, Delahunt et al30 report-

Gokce et al

ed that human color matching consistency depends on the color direction

of the illuminant change. Paramei et
al25 indicated that an illuminant with
low temperature improves the color
discrimination ability of color visiondeficient subjects.
The purpose of this study was to
evaluate the shade matching performance of NCV and RGCVD subjects
with high (D65) and low (T) illuminants. The hypothesis of the present
study was that (1) the subjects with
RGCVD would have lower shade
matching performance than the subjects with NCV by D65 illuminant,
and (2) a low color temperature,
tungsten (T) illuminant (artificial,
yellow-white, room light) should improve the shade matching ability of
the subjects with RGCVD, while decreasing the shade matching ability of
subjects with NCV.

MATERIAL AND METHODS

The study was approved by the
Ethics Committee of Gulhane Military Medical Academy, Ankara, Turkey, and informed consent was obtained from all subjects. To compare
the difference between normal and
color vision-deficient dental professionals using 2 different illuminants,
it was calculated that 12 subjects for
each group should be included in this
study, according to the effect size of
0.65, estimated power of the study
of 0.80, and error level of _=.05 and
`=.20. Observers (n=24) were men
between the ages of 22 and 41 years
(mean age, 26.6 years) and had at
least 2 years of dental practice experience. Only male dental professionals were selected as subjects, since
achromatopsia is an X-linked hereditary disorder that generally affects
the male population.3,26 All subjects
had normal (or corrected) visual acuity with no visual field deficiency and
were examined at the Gulhane Military Medical Academy, Department
of Ophthalmology, via the Ishihara
test (24 plate, 1993 edition)24,26 to
confirm normal color vision (NCV)

and red-green color vision deficiency

(RGCVD) (n=12). Eighty dental professionals, including prosthodontists, dentists, and dental technicians
(qualified in the area of shade matching) were asked to identify the standard pseudo-isochromatic Ishihara
test plates. When the number of redgreen color vision-deficient subjects
reached 12, the RGCVD group was
confirmed, and 12 out of 68 NCV
dental professionals were selected using a random number generator to
determine the subjects of the NCV
group. RGCVD subjects were classified as having deuteranomaly or
deuteranopia (M-cone defect or Mcone absence, green weakness) (11
observers), and protanopia (L-cone
absence, red weakness) (1 observer).
A porcelain guide system (VITA Lumin Shade Guide; VITA Zahnfabrik)
was used for shade matching in this
study. Disc-shaped porcelain specimens were fabricated, 13 mm in diameter and 2.4 mm thick, to fit the
barrel size of the optic detector of the
colorimeter (Gardner XL-20 colorimeter; Paul N. Gardner Co, Inc, Pompano Beach, Fla). A stainless steel metal
mold with a 13.8-mm inner diameter
(considering shrinkage of the porcelain discs after porcelain firings) was
used to standardize the dimensions of
the specimens. The mold was cleaned
with 80% ethyl alcohol (Ethyl Alcohol;
Military Medicine Factory, Ankara,
Turkey), then washed with distilled
water in a cleaner. This procedure was
repeated prior to the fabrication of
each shade tab (32 porcelain discs).
Two sets of porcelain discs (Omega 900 classical kit; VITA Zahnfabrik), representing the 16 shades of
the VITA Lumin Shade guide system,
were fabricated. Porcelain slurry was
prepared according to the manufacturers instructions. Dentin porcelain was applied and poured into
the stainless steel mold on a vibrator
(Degussa R2; Evonik Industries AG,
Essen, Germany). Then the porcelain
discs were removed from the mold
and fired (920C), according to the
directions of the porcelain manufac-

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Volume 103 Issue 3

turer, on a platinum sheet (Platinum
sheet; Heraeus Kulzer GmbH, Hanau,
Germany) in a porcelain furnace
(Heramat C; Heraeus Kulzer GmbH).
Fired porcelain discs were polished
with 150, 320, and 360 P silicone
carbide emery (Carborundum Silicon
Carbide; Greenhill Supply LLC, Phila-

delphia, Pa) for smoothness before

the glaze firing, which was performed
without vacuum at 915C. Since the
dimensions of the specimens could
potentially affect the L*a*b* values
and the fit to the barrel size of the
optic detector of the colorimeter, the
diameter (13 mm) and thickness (2.4

mm) of the discs were confirmed with

a caliper (150 x 0.05 mm/6 x 1/128
Manual Vernier caliper; Vernier Software and Technology, Beaverton,
Ore) by 2 independent investigators.
Nonconforming specimens were discarded and remade.
The colored calibration plate

Table I. L*a*b* values of 16 twin porcelain discs representing shades of VITA Lumin Shade Guide
Twin Porcelain Discs Representing
VITA Lumin Shade Tabs with
Same L*a*b* Values

L*

a*

b*

A1

+58.2

3.4

1.2

A2

+51.9

06.4

+07.0

A3

+48.6

09.3

+0.2

A3, 5

+44.6

05.3

+0.05

A4

+42.9

09.2

+00.5

B1

+53.1

01.8

B2

+51.8

04.8

B3

+48.8

01.6

+3.3

B4

+36.5

01.6

+8.1

C1

+50.8

01.8

001.8

C2

+41.6

06.7

+00.3

C3

+43.5

012.6

+01.5

C4

+38.8

09.5

+2.2

D2

+41.7

01.8

0.5

D3

+43.8

07.1

+3.3

D4

+31.1

013.6

Table II. Mean correct shade match scores of dental professionals by illuminants (n=12)

Color
Vision Illuminant

Mean Values
of Correct
Shade Match
(among
16 Matches)

RGCVD - D65

95% CI

SD

Standard
Error

Lower

Upper

4.92

1.73

0.50

3.82

6.02

RGCVD - T

9.00

1.76

0.51

7.88

10.12

NCV - D65

10.08

1.88

0.54

8.89

11.28

NCV - T

3.33

2.77

0.80

1.57

5.10

Total

6.83

3.47

0.50

5.83

7.84

Mean Values
of Total
Correct
Shade Match
for Both
Illuminants
(among
32 Matches)

4.132

.054

13.92

13.41

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March 2010
(cream color) most similar to the natural tooth shade was selected from
the 6 original calibration plates of
the colorimeter (XL-20 Colorimeter;
BYK-Gardner USA, Columbia, Md)
to calibrate the colorimeter prior to
the verification procedure. Calibration was completed when the L*a*b*
values of the calibration plate were
perceived directly by the colorimeter.

Then the colorimetric measurements

of the twin discs were made. L*a*b*
values were obtained from 5 different
points on the disc surface. Any twin
shade tab with a mismatched L*a*b*
value within its own colorimetric
measurements was discarded and remade. This procedure was repeated
for each twin porcelain disc that represented the 16 shades of VITA Lumin

Shade Guide. The results were recorded. Then the twin porcelain disc pairs
with the exact same L*a*b* values
were set aside for the observer evaluations (Table I).
Color matching tests were performed in a light booth/color matching cabinet (VeriVide CAC 60; VeriVide
Ltd, Leicester, UK) to mimic different
lighting conditions and to standardize

Table III. Correct match scores according to shade numbers for NCV and RGCVD groups with D65 and
T illuminants

Shade Number
(VITA)
(16 Twin Discs)

NCV

RGCVD

Correct Shade
Match Score

Correct Shade
Match Score

D65

D65

1 (A1)

2 (A2)

3 (A3)

4 (A3, 5)

10

10

5 (A4)

11

11

6 (B1)

7 (B2)

8 (B3)

9 (B4)

10 (C1)

11 (C2)

12 (C3)

13 (C4)

11

11

14 (D2)

10

15 (D3)

16 (D4)

121

40

59

108

(63.02%)

(20.83%)

(30.73%)

(56.25%)

192

192

192

192

Number of correct matches

(percentage)
Number of matches
Number of correct matches
(percentage)
Number of total matches

Gokce et al

161

167

(42%)

(43.5%)

384

384

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Volume 103 Issue 3

the illumination (DIN 6173-2, ASTM
D 1729).34 Two reference illuminants
by the Commission Internationale de
lEclairage (CIE), artificial daylight
D65 and tungsten filament lamp illuminant, were selected to achieve
optimum results. Daylight D65 (CIE,
1986) has a spectrum corresponding
to a typical mixture of direct sunlight
and scattered skylight, with a color
temperature of 6504 K. T illuminant
is an artificial illuminant that simulates typical home/accent lighting
with a mixture of yellow-white and
has a low (2850 to 3200 K) color temperature.13
All observers were asked to match
the 2 mixed sets (32 disc-shaped
specimens) of porcelain discs by 2
different illuminants. When an observer completed the matching of
all 16 pairs, an investigator counted
the correct matches (the shade tab
codes were written on the back of
each disc) (Table II). Sixteen correct
matches were considered as 100%
success. Each observer worked on the
matching test with 1 light source only,
on a single day, in a maximum time
period of 10 minutes. Subjects were
positioned approximately 50 cm from
the light cabinet apparatus, and their
viewing angle was 45 degrees. Also,
shade matching data were recorded
for each observer. The mean values
of correct match scores of each shade
tab with D65 and T illuminants are
given in Table III.
Recorded data were analyzed
graphically and with the Shapiro-Wilk
test for the relevance of normal distribution. Repeated-measures ANOVA
was used for statistical analysis of the
dental professionals shade match
scores with different illuminants.

Then, paired and independent samples t tests were used to investigate

the significant differences between
the dental professional groups using
the 2 different illuminants. Additionally, the interaction effect of the differences between groups and illuminants were analyzed with ANOVA and
post hoc multiple comparisons test
with Bonferroni correction. Statistical software (SPSS 15.0 for Windows;
SPSS, Inc, Chicago, Ill) was used for
the analysis, and _=.05 values were
considered statistically significant.
The actual power of the study was 81.

RESULTS
Correct shade match mean scores
of dental professionals with respect to
their color vision status versus different illuminants and 95% confidence
levels are given in Table II. The distribution and the percentages of correct
match scores of the NCV and RGCVD
groups with both illuminants are given in Table III. Regarding total observations, mean correct match scores
of the groups (13.92 for RGCVD and
13.41 for NCV among 32 matches)
with both D65 and T illuminants were
not statistically significant (F=4.132;
P=.054) (Table II). Similarly, color vision deficiency of the dental professionals was not statistically significant
when both illuminants were considered together (F=.215; P=.648). However, the mean correct shade match
score differences for each illuminant
within NCV and RGCVD groups were
statistically significant (F=68.195;
P<.001). The differences between observer groups were analyzed with the
paired samples t test (Table IV). Additionally, the interaction effects of the

differences between groups and differences between illuminants were analyzed with ANOVA post hoc multiple
comparisons with Bonferroni correction, and the differences were found
statistically significant (F=28.807;
P<.001) (Table V).
The correct shade match score
for NCV dental professionals was approximately 6.75 pairs more with the
D65 illuminant when compared with
the T illuminant, and this difference
was significant (t=6.204; P<.001).
The correct shade match score for
RGCVD dental professionals was approximately 4 pairs more with the T
illuminant when compared with the
D65 illuminant, and this difference
was also significant (t=5.571; P<.001)
(Table IV).
When the correct shade match
scores were analyzed according to
D65 and T illuminants, there was
a significant difference between
RGCVD and NCV dental professionals. The correct shade matching score
was approximately 5 more pairs with
D65, and this difference was statistically significant (t=7.004; P<.001).
NCV dental professionals were more
successful than RGCVD dental professionals in shade matching with
D65 illuminant. In contrast, RGCVD
dental professionals were more successful than NCV dental professionals
with T illuminant. Their mean correct
shade match score was approximately
5.7 more pairs than the NCV group,
and the difference was statistically
significant (t=5.977; P<.001).
According to the statistical analyses of the interaction effect between
groups and the illuminants: except
RGCVD with T versus NCV with D65,
and RGCVD with D65 versus NCV

Table IV. Paired samples test values

Color Vision
Groups

95% CI

Mean

Standard
Error

Lower

Upper

(RGCVD-D65) - (RGCVD-T)

4.083

0.733

5.697

2.470

5.571

.001

(NCV-D65) - (NCV-T)

6.750

1.088

4.355

9.145

6.204

.001

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March 2010

Table V. Interaction effect of differences between groups and illuminants (ANOVA post
hoc multiple comparisons with Bonferroni correction) (F=28.807; P<.001)

Groups

Groups

RGCVD - D65

RGCVD - T

4.08

.001

6.43

1.74

NCV - D65

5.17

.001

7.51

2.82

NCV - T

1.58

.414

0.76

3.93

NCV D65

1.08

1.000

3.43

1.26

NCV - T

5.67

.001

3.32

8.01

NCV - T

6.75

.001

4.40

9.10

RGCVD - T

NCV - D65

with T, the differences were statistically significant (F=28.807; P<.001)

(Table V).

DISCUSSION
The results supported acceptance
of both of the research hypotheses of
the study. The correct shade matching percentage of the RGCVD group
(30.73%) was significantly lower
than the NCV group (63.02%) with
the standard daylight D65 (t=7.004;
P<.001). Although the correct shade
matching score of NCV dental professionals was 121 out of 192 matches
(63.02%), even under the optimum
lighting condition D65, it was still
more than double compared to
the RGCVD subjects correct shade
matching score (59 out of 192 matches, 30.73%). Correct shade matching performance (63.02%) of the
NCV group with D65 illuminant was
within the range (35% to 74%) indicated in the literature.8,9,13,23 However,
the correct shade match score of the
NCV group decreased dramatically
(20.83%) with the T illuminant. Furthermore, a significant increase was
observed for correct shade matching
in the RGCVD group (56.25%) with
this lower color temperature illuminant (t=5.977; P<.001). The correct
match score (108 matches) of the
RGCVD group was more than double
compared to the correct match score

Gokce et al

95% CI

Mean Difference
of Correct Scores

Lower

Upper

(40 matches) of the NCV group with

T illuminant.
Color shade tabs were reported to
be nonreliable by some authors.4,5,8
Particular shade tabs were analyzed
and reported to include E (color
change) and different L*a*b* values
for some of the same tabs.7 Barrett et
al8 reported the overall disc-matching score was better than the tabmatching score by 5%. On the basis
of these factors, the original shade
tabs in the VITA Lumin Shade Guide
were not used in the present study. Instead, twin porcelain disc specimens
were manufactured for each shade
tab, and a colorimeter was used to reproduce the exact L*a*b* values and
verify them.
Geary and Knirons2 investigated
the color perception of laboratory
specimens of body-colored ceramic
with a similar observer group and
indicated a poor level of agreement
between expected and observed color
of the ceramic specimens examined.
Klemetti et al5 tested interobserver
variability in shade selection for porcelain restorations and reported that
there was no statistical difference in
shade selection between dental and
dental technician students. Barna et
al27 stated that neither the specialty
of the dentist nor the amount of time
in practice appeared to be a factor
in making color discriminations. The
subjects of the present study con-

sisted of male prosthodontists, general dentists, and dental technicians

who were experienced with shade tab
matching. Citirik et al16 investigated a
healthy population of men from different regions of Turkey for the presence of congenital red-green color
blindness using the Ishihara test and
found that the prevalence of red-green
color blindness was 7.33 0.98%.
In the present study, 80 dental
professionals were screened to identify at least 12 RGCVD male subjects.
The investigators were confronted
with some difficulties while inviting
the dental professional subjects for
participation in the matching tests,
because of the time committment.
Increasing the number of the subjects would help to clarify the effects
of RGCVD classifications (deuteranomaly, deuteranopia, protanopia)
on color perception and increase the
actual power of the study. Also, one
of the studys limitations is that there
were 11 deuteranopia and only 1 protanopia RGCVD subject. The results
of this study might be more relevant
for deuteranopia subjects, those with
green weakness or an absent M-cone.
To generalize, it would be best to have
6 subjects of each type.
In this study, some of the shade
tabs were matched more correctly or
incorrectly with each illuminant. A4
and C4 shade tabs were the most correctly matched pairs for both groups,

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Volume 103 Issue 3

but with different illuminants (D65
for NCV, T for RGCVD groups). The
A3 and D3 shade tabs were the most
incorrectly matched pairs for the NCV
group with D65 illuminant and for
the RGCVD group with the T illuminant (Table III). The same shade tabs
(A4, C4, and A3, D3) were matched
more correctly or incorrectly in each
group with different illuminants. It is
possible that the color distribution
of these shade tabs or their specific
L*a*b* values might have affected
their perceptibility beyond the other
shade tabs in normal and red-green
color vision-deficient subjects with
different illuminants.
The incidence of color vision deficiency is reported to be approximately 2.8% to 9.99%, as it varies depending on the population studied.1,16-19
Due to the high ratio of RGCVD and
its implications for certain professions,17,18,26 dental clinicians should
be aware of their RGCVD, as intraoral
shade matching is dependent upon
each clinicians visual discrimination
and matching abilities.8
Individuals with abnormal color
vision, even those with a mild deficiency, have a diminished ability
to search for objects in natural surroundings when those objects are
marked by their color.19,24,27,33 Joiner1
noted that an individual may not be
able to perceive colors (that is, may
have achromatopsia), yet that same
individual may be able to perceive differences.3 Davison and Myslinski,22
in a similar study, found that dental
personnel with color vision deficiency
made significantly greater errors in
hue and chroma selection than normal-vision dental personnel. Barna
et al27 reported that color visiondeficient dentists serving as subjects
have lower color discrimination abilities than those of normal dentists and
suggested that color vision-deficient
dentists should obtain assistance
when matching tooth shades. These
results are in agreement with the
RGCVD groups D65 illuminant shade
matching results (correct match percentage: 30.73%). However, Ethell et

al23 reported that there were no significant differences between colorvision-defective and unimpaired subjects with respect to shade matching
abilities. This discrepancy in study
results could be due to differences
in the lighting conditions of the test
environments; in fact, standardization of illumination without a color
matching cabinet is difficult. The color viewing booth is extensively used
by the textile and painting industries
for standardization and certification
tests such as CIE color stabilization.34
Light cabinets are painted using Munsell N7 paint, which has a matte,
nonreflective finish to minimize glare,
and light sources can be controlled,
sequenced, and programmed independently of each other for accurate
color comparison as well as for easy
detection of metamerism.14
Some authors13,21,25,33 investigated
color matching accuracy with different illuminants such as CIE standard
illuminant A and daylight illuminants
D15, D55, D65, D75, artificial illuminants, C illuminant, F2 fluorescent
light, and tungsten filament lights,
which have different color temperatures varying between 2856 K (A) and
7000 K. Dagg et al15 used a special
lamp to achieve ideal light conditions
and the natural light from the window
for adverse light conditions. Curd et
al12 compared the shade matching
ability of dental students using 2 light
sources and declared that dental students shade matching abilities were
better with a light-correcting source
than under natural light. Park et al31
studied the influence of different illuminants (D65, A, and F2) on the color
distribution of 2 shade guides. Color
distribution of shade guides varied by
the illuminant, and the range of color
difference was found to be clinically
unacceptable. The authors indicated
that the 3 color parameters of value,
chroma, and hue varied significantly
based on the illuminant. Also, Delahunt et al30 revealed that human color
matching consistency depends on
the color direction of the illuminant
change. Dagg et al15 reported that light

The Journal of Prosthetic Dentistry

quality was the most critical influencing factor in the selection of correct
shades, and changes in lighting conditions can cause changes in the perceived color. Dain21 investigated the
influence of the illuminating source
on a color vision examination test and
indicated that the 4 fluorescent tubes
that simulate daylight with similar
color temperatures were found essentially equivalent. In an in vitro study,
Mann et al29 stated that color-blind
observers preferred lighting with a
low color temperature to distinguish
and differentiate dental hard tissues,
while subjects with NCV preferred
the higher color temperature illuminant. RGCVD individuals have been
reported to be better than normal individuals at determining certain types
of color camouflage.18 These studies
findings support the matching scores
of the observer groups with both illuminants. The shade matching performance of the NCV and the RGCVD
groups were significantly influenced
by the high (D65) and low (T) color
temperature illuminants. The RGCVD
subjects correctly matched approximately 5.7 more twin discs than the
NCV subjects with T illuminant and 4
more twin discs than with D65.
Further studies are required to enhance the accuracy of shade matching of individuals with color vision
deficiency. The use of supplementary
methods such as digital cameras,
spectrophotometers, colorimeters,
electronic shade matching devices,
and color mapping techniques could
prove to be advantageous in overcoming the problems with visual shade
matching in the dental profession.

CONCLUSIONS
Within the limitations of this
study, the lighting conditions of the
environment and color vision deficiency affected the shade matching
performance of the dental professionals. The correct shade match ratio of NCV dental professionals was
63.02%, even under the optimum
lighting condition D65. Furthermore,

Gokce et al

147

March 2010
color vision-deficient subjects were
found less successful (20.83%) in performing visual color determination
with D65 illuminant. In addition, color perception decreased significantly
with lower color temperature illuminant in professionals with normal color vision and increased significantly
in professionals with red-green color
vision deficiency.

REFERENCES
1. Joiner A. Tooth colour: a review of the
literature. J Dent 2004;32:3-12.
2. Geary JL, Kinirons MJ. Colour perception of
laboratory-fired samples of body-coloured
ceramic. J Dent 1999;27:145-8.
3. Hammad IA. Intrarater repeatability of
shade selections with two shade guides. J
Prosthet Dent 2003;89:50-3.
4. Cal E, Sonugelen M, Guneri P, Kesercioglu
A, Kose T. Application of a digital technique in evaluating the reliability of shade
guides. J Oral Rehabil 2004;31:483-91.
5. Klemetti E, Matela AM, Haag P, Kononen
M. Shade selection performed by novice
dental professionals and colorimeter. J Oral
Rehabil 2006;33:31-5.
6. Paravina RD, Powers JM, Fay RM. Color
comparison of two shade guides. Int J
Proshodont 2002;15:73-8.
7. Hassel AJ, Koke U, Schmitter M, Beck J,
Rammelsberg P. Clinical effect of different
shade guide systems on the tooth shades
of ceramic-veneered restorations. Int J
Prosthodont 2005;18:422-6.
8. Barret AA, Grimaudo NJ, Anusavice KJ,
Yang MC. Influence of tab and disk design
on shade matching of dental porcelain. J
Prosthet Dent 2002;88:591-7.
9. Okubo SR, Kanawati A, Richards MW,
Childress S. Evaluation of visual and instrument shade matching. J Prosthet Dent
1998;80:642-8.

Gokce et al

10.Wozniak WT, Moser JB. How to improve

shade matching in the dental operatory.
Council on Dental Materials, Instruments, and Equipment. J Am Dent Assoc
1981;102:209-10.
11.Ishikawa-Nagai S, Ishibashi K, Tsuruta O,
Weber HP. Reproducibility of tooth color
gradation using a computer color-matching
technique applied to ceramic restorations. J
Prosthet Dent 2005;93:129-37.
12.Curd FM, Jasinevicius TR, Graves A, Cox V,
Sadan A. Comparison of the shade matching ability of dental students using two light
sources. J Prosthet Dent 2006;96:391-6.
13.Wee AG, Monaghan P, Johnston WM. Variation in color between intended matched
shade and fabricated shade of dental porcelain. J Prosthet Dent 2002;87:657-66.
14.Leow ME, Ng WK, Pereira BP, Kour AK,
Pho RW. Metamerism in aesthetic prostheses under three standard illuminantsTL84, D65 and F. Prosthet Orthot Int
1999;23:174-80.
15.Dagg H, OConnell B, Claffey N, Byrne D,
Gorman C. The influence of some different
factors on the accuracy of shade selection. J
Oral Rehabil 2004;31:900-4.
16.Citirik M, Acaroglu G, Batman C, Zilelioglu
O. Congenital color blindness in young
Turkish men. Ophthalmic Epidemiol
2005;12:133-7.
17.Cole BL. The handicap of abnormal colour
vision. Clin Exp Optom 2004;87:258-75.
18.Sharpe LT, de Luca E, Hansen T, Jgle
H, Gegenfurtner KR. Advantages and
disadvantages of human dichromacy. J Vis
2006;6:213-23.
19.Amano K, Foster DH. Colour constancy
under simultaneous changes in surface
position and illuminant. Proc Biol Soc
2004;271:2319-26.
20.Chu SJ, Devigus A, Mieleszko AJ. Fundamentals of color: shade matching and communication in esthetic dentistry. Chicago:
Quintessence; 2004. p. 39.
21.Dain SJ. Daylight simulators and colour
vision tests. Ophthalmic Physiol Opt
1998;18:540-4.
22.Davison SP, Myslinski NR. Shade selection
by color vision-defective dental personnel. J
Prosthet Dent 1990;63:97-101.
23.Ethell J, Jarad FD, Youngson CC. The effect
of colour defective vision on shade matching accuracy. Eur J Prosthodont Restor
Dent 2006;14:131-6.

24.Cole BL, Lian KL. Search for coloured objects in natural surroundings by people with
abnormal colour vision. Clin Exp Optom
2006;89:144-9.
25.Paramei GV, Bimler DL, Cavonius CR.
Effect of luminance on color perception of
protanopes. Vision Res 1998;38:3397-401.
26.Cumberland P, Rahi JS, Peckham CS. Impact of congenital colour vision defects on
occupation. Arch Dis Child 2005;90:906-8.
27.Barna GJ, Taylor JW, King GE, Pelleu GB Jr.
The influence of selected light intensities on
color perception within the color range of
natural teeth. J Prosthet Dent 1981;46:450-3.
28.Moser JB, Wozniak WT, Naleway CK, Ayer
WA. Color vision in dentistry: a survey. J
Am Dent Assoc 1985;110:509-10.
29.Mann DS, Makinson OF, Pietrobon RA.
Operating illumination to differentiate
dental hard tissues. Quintessence Int
1990;21:741-7.
30.Delahunt PB, Brainard DH. Does human
color constancy incorporate the statistical regularity of natural daylight? J Vis
2004;4:57-81.
31.Park JH, Lee YK, Lim BS. Influence of illuminants on the color distribution of shade
guides. J Prosthet Dent 2006;96:402-11.
32.Saleski CG. Color, light, and shade matching. J Prosthet Dent 1972;27:263-8.
33.Loop MS, Shows JF, Mangel SC, Kuyk TK.
Colour thresholds in dichromats and normals. Vision Res 2003;43:983-92.
34.International Organization for Standardization. ISO 3668:1998 - Paint and varnishes-visual comparison of the colour of paints.
Geneva: ISO; 1998. Available at http://
www.iso.ch/iso/en/prods-services/ISOstore/store.html
Corresponding author:
Dr Hasan Suat Gokce
Department of Prosthodontics
Dental Sciences Center
Gulhane Military Medical Academy
Etlik, 06018
Ankara
TURKEY
Fax: 0090 312 3046020
E-mail: suatgokce@yahoo.com
Copyright 2010 by the Editorial Council for
The Journal of Prosthetic Dentistry.