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THE JOURNAL

OF

PROSTHETIC
DENTISTRY
AUGUST 1987

FIXED PROSTHODONTICS

VOLUME

58

NUMBER 2

OPERATIVE DENTISTRY

SECTION EDITORS

WILLIAM LEFKOWITZ
SAMUEL E. GUYER
JOHN E. RHOADS
WILLIAM F. MALONE

ROBERT C. SPROULL

Improved color matching of metal-ceramic


restorations. Part I: A systematic method for shade
determination
John A. Sorensen,

D.M.D.,*

and Tony J. Tomes**

University of California, Los Angeles, School of Dentistry, Los Angeles, Calif.

election of the proper porcelain shade and colormatching ceramic restorations to the natural dentition
continues to be one of the most perplexing and frustrating problems in fixed prosthodontics. Inadequate technology to aid the ceramist and dentist in the appropriate
selection of porcelain shades has rendered this part of
dentistry more of an art form than a science. Unlike
science, art form is subordinate to the individual abilities
of the dentist that influence the predictability
and
reproducibility
of the finished restoration.
Traditionally,
communication
between dentist and
ceramist on color and shade matching has been poor.
Lack of clarity, errors of omission, and variability in the
amount of information conveyed are just a few reasons
for this communication
gap. As a consequence, frustration can be anticipated when the dentist subjectively
determines the shade and communicates shade information in an inconsistent manner. A ceramic restoration
drastically different from that originally prescribed often
results.
This series of articles presents a simplified systematic
approach for shade selection, improved methods of
communication,
and porcelain application
procedure.
This information will assist the dentist-ceramist
team in
its goal of consistently producing inconspicuous life-like
ceramic restorations. The techniques presented in this
series are aimed toward dentists who are willing to exert
extra effort and time to achieve the greatest esthetic
potential for their patients. Some dentists may find these
procedures too time-consuming
to justify their use.

*Assistant Professor,Assistant Director, Graduate Prosthodontics.


**ResearchAssistant, Certified Dental Technician.
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OF PROSTHETIC

DENTISTRY

THE PROBLEM
The observer. In general, dentists have little or no
training in vision physiology or color science.lV3 A survey
in 1967 revealed that only 23 of 112 dental schools had
color education in their curriculum.* More recent surveys are not available but inadequate training in color
science is still prevalent.
Although color perception is subjective and varies
between individuals,4-8 Bergen9 demonstrated that color
discrimination,
perception,
and description
can be
improved with training in dental procedures.
Culpepper
found disagreement between dentists in
shade matching the same tooth, and individual dentists
could not duplicate their shade selections on different
days. The problem of determining and communicating
shade selections from dentist to ceramist becomes readily
apparent.
These factors, in addition to the easily fatigued nature
of the cones responsible for color perception, would seem
to make accurate color matching nearly impossible.
Viewing conditions. Color and shade selection is
highly affected by viewing conditions. The light sources
in the operatory and laboratory, color of the walls,
amount of sunlight, the patients clothing and make-up,
and the viewing angle of the tooth can all affect the
selection of a shade.
Light is composed of different wavelengths dependent
on the source. Fluorescent light tends to accentuate the
blue range of the color spectrum whereas incandescent
light accentuates the yellow-red range. To reduce the
effects of metamerism, the dentist should evaluate and
compare shade determinations
under several light
sources. To standardize lighting conditions, both dentist
and ceramist should use color-corrected lights with a
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color-rendering index of 90 or greater for selecting


shades and evaluating completed ceramic restorations., I2
Shade guides. Commercially available shade guides
add another weak link in the shade matching process.
Several studies have evaluated a large number of natural
teeth by using the Munsell color system115and CIE
LAB system.16Several texts are available to explain the
CIE Lab System.7-20When comparing the range of color
space for available shade guides and natural teeth,
Sproull15 found that (1) available guides did not cover the
volume of color space required; (2) there was no logical
or systematic arrangement of the tabs; and (3) clustering
and duplication of colors existed in some areas of the
color space and voids in other regions. More elaborate
shade matching systems that attempt to adequately cover
the color space occupied by natural teeth have been
presented, but have not been widely used.6~2~22*
Another inadequacy of commercial shade guides is in
their unrealistic method of fabrication. A typical shade
tab measures 4 mm buccolingually and is made with
high-fusing denture tooth porcelain, giving an unrealistic representation of the metal-ceramic porcelain shade.
Application of internal and external characterization to
the shade tabs by the manufacturer further misrepresents the actual porcelain shade. The lack of a metal
backing may also mislead the observer. Miller** reported variation among shade guides produced by the same
manufacturer.
The inherent weakenessesof commercial shade guides
motivated individuals such as Muiaz3 to develop custom
shade determination techniques. Using custom-fired
shade tabs, Muia determined the Four Dimensional
Tooth Color System. Excellent results can be achieved
with this method but few laboratories are willing to
expend the time and expense necessary to fire new shade
tabs for each new bottle of porcelain and each patient.
Inadequate technology. Ideally the dentist would
have a spectrophotometer linked to a computer. A fiber
optic head held against a tooth would give the formulation of porcelain powders for reproducing the natural
tooth color being viewed. Presently we lack the technology to perform this function.11~24~25
Clarkz5 listed the
properties of teeth that contribute error to measurement
with calorimeters and spectrophotometers. These are:
fluorescence, metamerism, nonuniformity across the surface, inhomogeneous internal structure in layers, translucency, small size, irregular shape, and conditions
preventing close approximation of the measuring port.
Colorgen, Inc. (Billerica, Mass.) has made advances in
*&swell CW. Personal communication. Lecture before the American
College of Prosthodontists, October 1986.
**Miller
L. Personal communication. Lecture before the American
Academy of Restorative Dentistry, February 1985.

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the development of a dental spectrophotometer with a


fiber optic probe. A workable prototype is several years
away. *
In summary, the development of these devices show
merit but they are an aid and cannot replace the human
eye. Even if the technology were perfected, the general
availability and use of these devices by dentist and
ceramist could be many years away.
Communication. It is interesting to note how little
information is often given the ceramist and how much is
expected of him. Vague orders on the laboratory prescription form such as a little darker than an A-3, are
indicative of the lack of clarity and the absence of a
common language for communicating color. This makes
the possibility of matching a natural tooth shade difficult, but a language is available. The use and understanding of the three dimensions of color can greatly
improve communication between the dentist-ceramist
team.
Considering these five problems, for the dentist to
observe the natural tooth color, select a porcelain shade
under variable lighting conditions, communicate the
shade to the ceramist, have the ceramist apply the
appropriate porcelain, and produce a crown that
matches the natural dentition would indeed seem a
Herculean feat. With the following guidelines and
procedures, the dentist-ceramist team can achieve
improved successand greater unity in the color matching
of ceramic restorations.
COLOR TERMINOLOGY
The three dimensions of color offer a universal
language to communicate shades. In the same way that
objects can be spatially described in terms of length,
width and height, color is described with the Munsell
terms of Hue, Value, and Chroma.
Hue (color) is the description or name of a color, the
quality by which we distinguish one color family from
another (for example, blue, red, green).
vualue(lightness/darkness) is achromatic. The Value
of a color refers only to its lightness and darkness as
related to a scale from black to white.
Chroma (saturation) is the purity or strength of a
given Hue, the quality that describes the extent to which
a color differs from a gray of the same Value.
The proper Value is the most important dimension to
match in ceramic restorations.5s26-28
Several physical properties of an object can modify
color perception. The matching of surface texture in
ceramic restorations can be as important as matching the
shade and shape.29 Surface texture affects the Value
perception of a restoration. Obregon et a1.30reported that

*OBrien J. Personal communication, October 1986.


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a smooth surface texture increased the Value of porcelain samples and suggested the use of a textured surface
on opaque to keep the Value level down.
AND SHADE
COLOR MATCHIN
SELECTION GUIDE E INES
1. Create a neutral-colored environment for shade selection.
2. Have the patient remove lipstick or bright makeup.
3. Drape the patient with a neutral-colored cover if the
patient is wearing bright-colored clothing.
4. Have the patients mouth at the dentists eye level.
5. Make the shade selection at the beginning of the
appointment before the eyes are fatigued from dental
procedures.
6. Make rapid shade comparisons for no more than 5
seconds to avoid fatigue of cones in the retina.
Prolonged viewing strains the cones and results in
perception of decreased Chroma and Value of the
sample. First impressions are more accurate.
7. Gaze at a blue card or patient napkin between each
shade evaluation. Prolonged viewing results in a
negative afterimage that is the complimentary color of
the originally observed color. Blue fatigue accentuates
yellow-orange sensitivity, which is the dominate Hue
of teeth.
8. Assess Value levels by squinting. Half-closed eyes
decrease the amount of light entering the eye to
inactivate the cones and allow peripherally located
rods of the retina to discriminate lightness and
darkness.
9. Grind off the necks of shade tabs, which have heavy
extrinsic coloring and may distract shade determination.
10. Rapidly scan the shade guide and, by the process of
elimination, determine several tabs that match the
closest.
11. Compare shade selection under varying conditions
(for example, wet versus dry, lip retracted versus lip
down, and light sources at different angles).
12. Check for metamerism by evaluating shade selection
under different light sources (for example, colorcorrected, incandescent, fluorescent, and daylight).
13. Use the canines for a reference in selecting a shade
because they have the highest Chroma of the dominant Hue of the teeth.31
14. To create natural appearing restorations, be aware
of variation in shade among teeth in the arch.
Maxillary incisors are similar in Chroma to premolars. Mandibular incisors are usually one Chroma
level lower than maxillary incisors. Canines are two
Chroma levels higher than maxillary incisors.z9
15. Select a shade that is of lower Chroma and higher
Value if unable to precisely match a shade. It is
difficult to extrinsically color a restoration to decrease
THE JOURNAL

OF PROSTHETIC

DENTISTRY

Chroma and increase Value (lighten) without creating opacity.27,31


A SYSTEMATIC
MATCHING

APPROACH

TO SHADE

The following method for assessmentof natural tooth


color and selection of matching dental porcelains greatly
improves the predictability of shade matching with
dental porcelain. Clarity of communication between
dentist and ceramist is enhanced, facilitating the ceramists ability to replicate the shades recorded by the
dentist.
The method uses the Vita (Vita Zahnfabrik, Sackingen, West Germany) VMK shade indicator chart (Fig. 1)
and ring of tabs (Fig. 2), both of which have individually
fired buttons of opaque, body, and incisal porcelains.
These tabs are made of porcelain the same as that used
for metal-ceramic crowns, and are 1 to 2 mm thick. By
using the individual tabs, the dentist can systematically
determine which shade number of opaque, body, and
incisal porcelains are to be used in fabricating the
ceramic restoration. A shade prescription listing the
porcelain shade numbers, combined with a detailed
diagram illustrating enamel translucency patterns and
other characteristics,, clearly and concisely communicates
to the ceramist the information needed. This specific
information closes the communication gap, greatly
decreasing the need for interpretation of previously
unclear laboratory prescriptions.
The use of this shade indicator chart combines the
advantages of the commercial shade guide and custom
shade-determination techniques. A greater range of
flexibility and latitude is offered because each shade can
be selected and evaluated individually. Through spectrophotometry, Miller and Hemmendinger* demonstrated
that opaque and body porcelain shades typically do not
match. This problem can be rectified by interchanging
alternative opaque and body shades to achieve the
desired shade and avoiding the predetermined relationship demanded by the standard commercial shade guide.
Other porcelain manufacturers either have (Shofu Dental Corporation, Menlo Park, Calif.) or will soon market
(Will-Ceram, Williams Gold Refining Co., Buffalo,
N.Y.) similar shade indicator charts.
SHADE

SELECTION

PROCEDURE

Teeth Nos. 6 through 11 were crowned as part of an


extensive fixed prosthodontic treatment. These teeth had
severe lingual erosion and attrition resulting in near
pulp exposure. In addition, the severe erosion and
attrition of the posterior teeth, with resulting decreased
vertical dimension of occlusion, necessitated an increased
*Miller L. Personal communication.
Lecture before American Academy of Restorative Dentistry, February 1985.

135

SORENSEN

AND

TORRES

Fig. 1. VMK shade indicator chart, with permission.


Fig. 2. VMK shade indicator tab ring, with permission.
Fig. 3. Identification of B Hue group with standard shade guide.
Fig. 4. Colored paper backgrounds for shade comparison, with permission.
Fig. 5. Yellow background for evaluation of opaque shade.

vertical dimension through posterior restorations (Fig.


3).
The shade selection procedure began with a standard
Vita Lumin shade guide. According to the shadedetermination guidelines listed, the shade guide was
rapidly scanned to assesswhich basic Hue group most
nearly matched the natural teeth. The canine was used
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for initial shade comparisons, because it has the highest


Chroma for the dominant Hue of the natural dentition
(Fig. 3).
We found the use of a colored paper background of the
dominant Hue useful in shade determination and comparison (Table I) (Fig. 4). (Use of the complimentary
colored background may also be helpful.) Paper with a
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Fig. 6. B shade group opaque, bond, and incisal shade tabs from VMK shade indicator
chart, with permission.
Fig. 7. Evaluation of canine opaque shade No. 514. (Value is too high.)

yellow Hue for the B shade group (Fig. 5) for opaque


shade evaluation was used for standard shade tab,
dentin, or incisal porcelain comparison.
After the selection of a Hue group, the individual
shade that most nearly matched was chosen and recorded. The selection of a shade tab on the standard guide
provided a starting point for matching the opaque, body,
and incisal shades on the shade indicator chart (Fig. 6).
The corresponding opaque shade was then evaluated for
the canine (Fig. 7) and central incisor (Fig. 8). If the
opaque shade is inappropriate, the dentist can compare
and select a more appropriate opaque shade. The
opaque is the primary determinant of the Value of the
metal-ceramic restoration. Therefore, squinting to facilitate Value discrimination may be helpful.
The corresponding body shade was evaluated and
recorded (Figs. 9 and 10). For this patient, two shades of
body porcelain were selected, No. 545 for the incisal half
and No. 544 for the gingival half of the tooth. Occasionally a body shade that falls within another dominant
Hue group may be the most suitable selection.
Finally, the corresponding incisal shade was evaluated
and the most appropriate shade recorded (Fig. 11).
Areas of high translucency requiring translucent porcelain application were also recorded.
Shade tabs for opaque and body porcelain modifiers to
decrease Value or increase Chroma are also available as
shade tabs (Figs. 1 and 2).
To complete the communication process, a detailed
diagram of the teeth to be matched included dental
THE JOURNAL

OF PROSTHETIC

DENTISTRY

Table I. Dominant
Vita shade group

A
B
C
D

Hue of Vita shade group


Dominant

Hue

Orange-brown
Yellow
Grey-brown
Red

characteristics such as enamel translucency patterns,


locations of high Chroma, stains, hypocalcification patterns, craze lines, or stained cracks that were to be
reproduced in the restoration (Fig. 12). A more detailed
discussion will follow in Part II of this series.
The restorations were evaluated for shade fidelity
before delivery (Fig. 13). Figs. 14 and 15 show the
cemented metal-ceramic restorations.
SUMMARY
The inherent problems in present shade matching
procedures and communication between dentist and
ceramist have been discussed. These five areas of weakness include (1) the observer, (2) variable viewing
conditions, (3) commercially available shade guides, (4)
inadequate technology, and (5) poor communication.
A systematic procedure that breaks down shade selection to the elements of opaque, body, and incisal
porcelain shades was presented. This method simplifies
and adds clarity in the registration of shades, improving
the communication chain between dentist and ceramist.
The system is suggested as a means to overcome many of
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SORENSEN AND TORRES

See opposite page for legends.


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the inherent problems in shade selection and communication. This approach enhances the dentist-ceramist
teams ability to esthetically match metal-ceramic restorations to the natural dentition.
Future parts of this series will present procedures for
improved communication
and a system for porcelain
application.
We thank the Word Processing Center of the University
California, Los Angeles, in the preparation of this manuscript,

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Reprint requests to:


DR. JOHN A. SORENSEN
UNIVERSITYOF CALIFORNIA, Los ANGELES
SCHOOLOF DENTISTRY
CHS-33-041
Los ANGELES,CA 90024

Fig. 8. Evaluation of incisor opaque shade No. 516.


Fig. 9. Selection of body shade No. 546 for canine.
Fig. 10. Selection of body shade No. 545 for incisal half and No. 544 for gingival
incisors.
Fig. 11. Selection of incisal shade No. 559.
Fig. 12. Recording of shades and esthetic prescription.
Fig. 13. Evaluation of shade fidelity before delivery.
Figs. 14 and 15. Cemented metal-ceramic restorations.
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