UNIVERSIDADE ESTADUAL PAULISTA
“JÚLIO DE MESQUITA FILHO”
Instituto de Ciência e Tecnologia
Campus de São José dos Campos
ORIGINAL ARTICLE DOI: https://doi.org/10.4322/bds.2024.e4449
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Braz Dent Sci 2024 Oct/Dec;27 (4): e4449
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Impact of gray background on tooth color shade matching: a
comparison of visual and instrumental methods
Impacto do fundo cinza na seleção de cor dental: uma comparação entre métodos visuais e instrumentais
Walleska Feijó LIBERATO1,2 , Vinicius SALGADO3 , Marco Antonio GALLITO1 ,
André Luis FARIA-E-SILVA4 , Luis Felipe Jochims SCHNEIDER1 , Larissa Maria Assad CAVALCANTE1
1 - Laboratório de Biotecnologia Aplicada, Faculdade de Odontologia, Universidade Federal Fluminense (UFF), Niterói, Brazil.
2 - Núcleo de Pesquisa em Biomateriais Odontológicos (NPBO), Universidade Veiga de Almeida (UVA), Rio de Janeiro, Brazil.
3 - Universidade Santa Úrsula, Faculdade de Odontologia, Rio de Janeiro, Brazil
4 - Faculté de Médecine Dentaire, Université Laval, Québec, Canada.
How to cite: Liberato WF, Salgado V, Gallito MA, Faria-e-Silva AL, Schneider LFJ, Cavalcante LMA. Impact of gray background on tooth color
shade matching: a comparison of visual and instrumental methods. Braz Dent Sci. 2024;27(4):e4449. https://doi.org/10.4322/bds.2024.e4449
ABSTRACT
Objective: This study evaluates the impact of a gray background on visual tooth shade selection, focusing on
various incisal translucency patterns in upper incisors. Material and Methods: Sixty-three clinicians assessed
VITA 3D Master Shade Guide tabs representing right upper central incisors under different conditions, with or
without a gray background. Translucency patterns (A, B, C) were considered, and standard tabs were dened
using a clinical spectrophotometer. Statistical analyses, including repeated measures ANOVA and ordinal logistic
regression, compared scores and agreement levels. Results: Darker tabs were selected for Case C, while Case B
resulted in lighter tabs. A gray background increased lightness levels, enhancing agreement between visual and
instrumental shade selection. Reduced agreements were noted in cervical areas and cases with higher incisal
translucency. No signicant difference was found among tooth thirds (
p
=.097). Conclusion: Using a gray
background during tooth shade selection improved agreement between visual and instrumental shade selection.
Incorporating this method can enhance tooth shade matching when relying on visual analysis. Introducing a
cost-effective gray background can signicantly improve agreement between visual and instrumental shade
selection, addressing nancial constraints associated with advanced tools. Clinicians can now implement a more
reliable and accessible protocol, positively impacting the precision of esthetic restorations, especially in cases
involving upper incisors.
KEYWORDS
Color; Color perception; Dental shade; Operative dentistry; Shade selection.
RESUMO
Objetivo: Este estudo avalia o impacto de um fundo cinza na seleção visual da cor do dente, com foco em vários
padrões de translucidez incisal nos incisivos superiores. Material e Métodos: Sessenta e três clínicos avaliaram as
guias VITA 3D Master Shade Guide representando os incisivos centrais superiores direitos sob diferentes condições,
com ou sem um fundo cinza. Os padrões de translucidez (A, B, C) foram considerados, e as guias padrão foram
denidas usando um espectrofotômetro clínico. As análises estatísticas, incluindo ANOVA de medidas repetidas e
regressão logística ordinal, compararam os escores e os níveis de concordância. Resultados: Foram selecionadas
abas mais escuras para o Caso C, enquanto o Caso B resultou em abas mais claras. Um fundo cinza aumentou os
níveis de luminosidade, melhorando a concordância entre a seleção visual e instrumental da tonalidade. Foram
observadas concordâncias reduzidas nas áreas cervicais e nos casos com maior translucidez incisal. Nenhuma
diferença signicativa foi encontrada entre os terços dos dentes (p=.097). Conclusão: O uso de um fundo
cinza durante a seleção da cor do dente melhorou a concordância entre a seleção visual e instrumental da cor.
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Braz Dent Sci 2024 Oct/Dec;27 (4): e4449
Liberato WF et al.
Impact of gray background on tooth color shade matching: a comparison of visual and instrumental methods
Liberato WF et al. Impact of gray background on tooth color shade matching: a
comparison of visual and instrumental methods
INTRODUCTION
Tooth shade selection is a critical step in
esthetic restorative dentistry, which can be
performed either visually, by comparing the tooth
color with shade guide tabs, or instrumentally
through the use of a clinical spectrophotometer,
digital scanner, or standardized photographs [1].
While instrumental analysis tends to be more
precise, it should ideally be combined with visual
methods to ensure accuracy [2-8]. However,
many of the devices required for instrumental
shade measurement are expensive and may not
be accessible for most clinicians. As a result,
feasible clinical protocols that enhance the
accuracy of visual shade selection are needed [9].
Furthermore, successful visual shade selection
depends on several clinician-related factors,
such as professional experience and visual
acuity [10-14]. In addition, external factors
like lighting conditions, background, and the
surrounding area also inuence the accuracy of
the shade selection [15-18].
Several protocols have been proposed to
improve the reliability of visual shade analysis.
In addition to standardizing lighting conditions,
factors such as the time spent during shade
analysis and the impact of contrast effects,
such as lipstick, have been shown to inuence
shade accuracy [16,19-23]. Achieving esthetic
restorations requires the accurate reproduction
of all details observed in natural tooth
structures [24,25]. One such detail, especially
in younger patients, is incisal translucency, which
plays a crucial role in esthetic outcomes and poses
signicant challenges for clinicians [26].
The use of dark backgrounds is common
in dental photography, as it enhances the
visibility of important features, such as the
incisal borders, which can be useful during
shade selection [27]. Alternatively, backgrounds
like gray, pink, or blue have been suggested to
heighten sensitivity to the teeth’s yellowness and
reduce the need for repeated comparisons [15].
Gray backgrounds, in particular, are frequently
used to minimize background reection during
shade measurement [2]. Despite these established
practices, the specic role of incisal translucency
in shade matching—particularly in the context
of using a gray background—has not been
thoroughly investigated.
In clinical situations, background color,
translucency degree, and the surrounding area
(such as lips or adjacent teeth) can all affect
visual shade matching [16,28]. Therefore, this
study aims to evaluate the inuence of using a
gray background on dental shade selection in
upper incisors with varying patterns of incisal
translucency. We hypothesized that the use
of a gray background would enhance visual
shade matching, with its effectiveness varying
depending on the degree of incisal translucency.
MATERIAL AND METHODS
This study evaluated the independent
variables ‘background condition’ (no background
and gray background), the pattern of incisal
translucency (three cases from three different
young female adults), and the ‘tooth third’
(cervical, middle, and incisal). The dependent
variables were shade tabs (classied in scores and
lightness level) selected by the evaluators and the
agreement rate with those tabs determined by
the clinical spectrophotometer. The local ethics
committee approved the study (N.565,812/2014).
The patients who had their teeth evaluated and
all evaluators signed informed written consent.
This study followed a within-subject
design, with each subject serving as their own
control. The shade of the right maxillary central
incisors was evaluated under two conditions:
no background (control) and with an 18% gray
background. Visual shade selection was performed
by 63 evaluators, followed by instrumental analysis
A incorporação desse método pode melhorar a correspondência da cor do dente quando se depende da análise
visual. A introdução de um fundo cinza de baixo custo pode melhorar signicativamente a concordância entre a
seleção visual e instrumental da cor, abordando as restrições nanceiras associadas a ferramentas avançadas. Os
clínicos podem agora implementar um protocolo mais conável e acessível, impactando positivamente a precisão
das restaurações estéticas, especialmente em casos envolvendo incisivos superiores.
PALAVRAS-CHAVE
Cor; Percepção de cores; Cor dental; Dentística; Seleção de cor.
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Braz Dent Sci 2024 Oct/Dec;27 (4): e4449
Liberato WF et al.
Impact of gray background on tooth color shade matching: a comparison of visual and instrumental methods
Liberato WF et al. Impact of gray background on tooth color shade matching: a
comparison of visual and instrumental methods
using a spectrophotometer. The cases (A, B, and
C) were selected to represent different patterns of
incisal translucency to explore how translucency
impacts shade matching accuracy. The sequence
of evaluations was designed to minimize bias,
with evaluators assessing the shade without a
background rst, followed by a second evaluation
with the gray background after seven days.
In this study, we evaluated the shade of
the right maxillary central incisors of three
subjects. The anterior teeth of patients included
did not have carious or non-carious lesions or
restorations. The teeth were maintained in a
normal moisture state during both visual and
instrumental shade selection, and it was requested
that the patients any type of lipstick. The incisal
edges of the incisors presented different patterns
among the patients (Figure 1). The translucency
patterns of incisors evaluated were classied as
the following: Case – indeterminable; Case B -
restricted to the more incisal area; and Case C -
present in both proximal and incisal areas [29].
Two weeks before the shade measurements, each
subject received periodontal treatment and dental
prophylaxis. All three subjects presented good
oral health during the entire study.
For the instrumental analysis, an instrumental
shade selection was performed using a clinical
spectrophotometer (VITA Easyshade Advance 4.0;
VITA Zahnfabrik). The tab on the VITA 3D-Master
shade guide (VITA Easyshade Advance 4.0; VITA
Zahnfabrik) indicated by the spectrophotometer
for each crown third was recorded three times
and dened as the standard. The device tip was
placed perpendicularly to the buccal surface.
The measurements were performed with and
without an 18% gray background (Flexipalette
Color Match, Smile Line) placed behind the
upper teeth.
For the visual analysis, sixty-three trained
clinicians (31 men and 32 woman) with
normal color vision that passed color matching
competency tests (Ishihara and Farnsworth-
Munsell 100 hue) visually selected the shade
tabs corresponding to teeth color. The visual
shade selection was performed for each tooth
third using or not the gray background under
articial daylight CIE D65 standard illuminant.
After a brief adaptation period, shade selection
was completed within three minutes to avoid
visual fatigue [30]. In the rst evaluation, the
evaluators selected shade tabs without the gray
Figure 1 - Tooth color analysis cases categorized by translucency: (A) indeterminable; (B) restricted to more incisal area; and (C) present in both
proximal and incisal areas. Histograms display scores based on VITA 3D Master shade guide tabs selected by evaluators on the right side of
representative cases. Red vertical dashed lines correspond to scores attributed to tabs by the spectrophotometer (used as standard).
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Braz Dent Sci 2024 Oct/Dec;27 (4): e4449
Liberato WF et al.
Impact of gray background on tooth color shade matching: a comparison of visual and instrumental methods
Liberato WF et al. Impact of gray background on tooth color shade matching: a
comparison of visual and instrumental methods
background. The same evaluators repeated
the shade selection with the gray background
placed behind the upper teeth after a seven-day
interval. This gap was implemented to minimize
the possibility of recall bias. Evaluators were also
blinded to the specic focus of the study, ensuring
that each condition was assessed independently.
For each measurement, the agreements
between the visual and instrumental shade
analysis were calculated. Agreements were
dened when the evaluator selected the same
shade tab indicated by the spectrophotometer.
A second agreement analysis was done based on
the same lightness level, even when the shade
tab differed. Moreover, each tab selected by the
evaluators were scored according the following
rank (from the lightest to the darkest): 1 - 0M1,
2 - 0M2, 3 - 0M3, 4 - 1M1, 5 - 2M1, 6 - 1M2, 7 -
2R1.5, 8 - 2L1.5, 9 - (3M1 or, 2M2), 10 - 2R2.5,
11 - 2L2.5, 12 – [3R1.5 or, 3L1.5], 13 - 2M3,
14 - 3M2, 15 - 3L2.5, 16 -( 3M3, 3R2.5), 17 -
4L1.5, 18 -19 - 4M1, 20 - 4R1.5, 21 - 4M2, 21 -
(5M1 or, 4L2.5), 22 - 4R2.5, 23 - 4M3, 24 - 5M2,
25 - 5M3 [31].
Repeated-measures ANOVA analyzed score
data. The independent variables analyzed were
‘case’, ‘background’, and ‘tooth third’, while the
last two variables were defined as repetition
factors. Pair-wise comparisons were performed
with Tukey’s test. The lightness level (first
number) of each tab selected by the evaluators
was also evaluated. These data were analyzed
using an ordinal Logistic Regression, and the
predictors were ‘case’, ‘background’, and ‘tooth
third’.
For each experimental condition (case vs.
tooth third), the scores and lightness values from
shade tabs measured with the spectrophotometer
Easyshade were compared with those selected by
the evaluators. Data of agreements were analyzed
using binomial logistic regressions. A signicance
level of 95% was pre-set for all analyses.
RESULTS
Figure 1 shows the distribution of scores
determined for the tabs selected by evaluators
according to the case, crown third, and background
used during the evaluation. Repeated-measures
ANOVA showed that only the independent
variables ‘background’ (
P
<.001) and ‘case’
(
P
<.001) affected the scores of tabs selected.
No difference was observed among the ‘tooth
third’ (
P
=.097). All interactions were statistically
insignicant (
P
>.050). The results are presented
in Table I. The highest scores (darkest tabs) were
selected for case C, and the lowest (lightest tabs)
for case B. In general, lighter tabs were selected
using a gray background.
Results of the ordinal logistic regression
are shown in Table II. The third did not affect
the lightness level selected by the evaluators.
The lightest levels were observed using the gray
background than with the control.
Results of the binomial logistic regressions
are shown in Table III. For the tab scores, shade
selection in the incisal third presented higher
odds to agree with the spectrophotometer than
the cervical, which did not differ from the middle
third. The lowest agreements were observed for
case C, while similar values were found between
cases A and B. The gray background increased the
odds (5-fold) of obtaining agreement between the
evaluators and the spectrophotometer data. When
the lightness values were analyzed, the tooth third
did not affect the odds of agreement between
the evaluators and the spectrophotometer data.
Case B increased the odds of agreement when
compared to case A. The use of gray background
increased in 2-fold the odds of agreement.
Table I - Means (standard deviations) of scores attributed to tabs selected by evaluators in VITA 3D Master shade guide according to case,
background, and tooth third (n=20)
Backgrounds Control Gray card Pooled
average
Thirds Cervical Middle Incisal Cervical Middle Incisal
Case
A 6.5 (1.7) 6.6 (2.0) 6.8 (2.1) 6.0 (1.9) 5.3 (1.6) 5.4 (1.6) 6.1 (1.9) B
B 4.8 (0.6) 4.6 (0.7) 4.9 (1.3) 4.7 (1.1) 4.5 (1.6) 4.3 (0.6) 4.6 (0.9) C
C 14.1 (2.8) 13.6 (3.0) 13.4 (2.8) 12.6 (2.7) 11.6 (2.2) 12.9 (4.3) 13.0 (2.8) A
Pooled average 8.4 (4.4) a7.5 (4.1) b
For pooled averages, superscript distinct letters indicate statistical difference (
p
<.05). The overall agreement between the backgrounds was
32.2% (Cohen kappa coefficient: 0.228).
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Liberato WF et al.
Impact of gray background on tooth color shade matching: a comparison of visual and instrumental methods
Liberato WF et al. Impact of gray background on tooth color shade matching: a
comparison of visual and instrumental methods
Probabilities of agreements according to the
background are presented in Figures 2 (scores)
and 3 (lightness).
DISCUSSION
The study`s hypothesis was accepted.
Neutral gray 18% is a neutral color that does not
distort the other colors since it is halfway between
black and white. Therefore, it is expected that a
neutral background does not draw attention to
itself and can neutralize the possible inuence
of lips, tongue, and gums on the shade selection
process.
Different background colors have been
evaluated, seeking to improve the tooth shade
selection. It is stated that a white background
would simulate the color of an opposite tooth, a
pink would mimic the lips and oral mucosa, and
a black would increase the contrast [2,12,15,16].
The same tooth observed in a white background
and a dark background can be visualized in
different shades due to changes in absorption
and reection of specic wavelengths [25]. It is
reasonable to state that the background contrast
would affect the shade selection in the incisal
thirds of the anterior teeth due to its higher
translucency [25]. However, the lowest levels
of agreement were observed for case C, which
presented translucencies in both proximal and
incisal areas. This could be due to the more
complex optical properties of these regions,
as translucency increases light scattering and
absorption, making shade matching more
Table II - Ordinal logistic regression results estimating lightness level of tab selected by evaluators in VITA 3D Master shade guide
Predictor Estimate Standard error
P
-value
Root third
Cervical (ref.) 1.000
Middle - .416 .264 .115
Incisal -.338 .265 .201
Background
Control (ref.) 1.000
Gray -.588 .217 .010
Case
A (ref.) 1.000
B -1.326 .278 <.001
C 3.712 0.413 <.001
Table III - Binomial logistic regression results estimating odds of agreement between shade selected by evaluator and that measured using
spectrophotometer Easyshade
Predictor
Scores* Lightness
OR 95% CI
P
-value OR 95% CI
P
-value
Root third
Cervical (ref.) 1.00 1.00
Middle 2.03 .99 - 4.16 .052 1.29 .76 – 2.18 .349
Incisal 2.15 1.05 – 4.38 .036* 1.16 .68 – 1.95 .592
Background
Control (ref.) 1.00 1.00
Gray 5.01 2.71 – 9.27 <.001* 2.03 1.32 – 3.12 .001*
Case
A (ref.) 1.00 1.00
B 1.80 .97 – 3.35 .063 2.32 1.37 – 3.92 .002*
C .30 .13 – .68 .004* .868 .52 – 1.46 .595
* Scores attributed to shade tabs selected. OR: odds ratio; CI: confidence interval.
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Liberato WF et al.
Impact of gray background on tooth color shade matching: a comparison of visual and instrumental methods
Liberato WF et al. Impact of gray background on tooth color shade matching: a
comparison of visual and instrumental methods
difcult. These ndings align with prior research
that suggests highly translucent areas pose a
challenge for accurate shade matching [25].
The present study did not nd any effect of the
crown third on the level of agreement between
visual and instrumental analyses.
Inaccurate shade selection can signicantly
compromise the aesthetic outcomes of restorative
procedures [1]. A prior clinical study observed
some shade mismatch between the ceramic
restorations and surrounding teeth, ranging
from 44 to 63% [24]. Therefore, a more precise
and accurate shade matching avoids restoration
replacement for aesthetic reasons and can reduce
the cost of treatment. Still, controversial whether
gender can or not intervene in the accuracy of
tooth shade selection [6,12-14,21]. In the present
study, however, the interference of evaluator
gender on the visual tooth shade selection was not
evaluated. To avoid a possible bias of this kind,
we selected a similar number of male and female
evaluators to participate in the current study.
During dental clinical routine, tooth shade
selection is often done without any specific
background. Some contrast allowing to visualize
details in incisal edge is only achieved due to the
darkness of the oral cavity. Interposing the lower
lip between the upper and lower incisors has been
suggested to improve shade selection, but it is not
a standardized method [16]. Another approach
to improve the shade selection is using a colored
paper background [15]. In the present study,
the use of a gray background during the tooth
shade selection increased the odds of agreement
between the visual and instrumental shade tab
selection.
Using a gray background increased the odds
of obtaining agreement between the evaluators
and the spectrophotometer data. Regarding
the tabs/scores, using the gray background
increased 5-fold the odds of agreement, while a
2-fold increase was observed for agreement on
lightness. In general, darker tabs were selected
by the evaluators in the absence than using the
gray background. Considering that background
color is supposed to affect only the more incisal
area shade, these results are probably related to
the effect of the surrounding area on the color
perception [16,28]. Interestingly, the lowest
agreements were observed in the cervical third,
even though the effect of the surrounding color
is expected to be less pronounced there.
Advances in color measuring devices,
such as a spectrophotometer, may improve the
Figure 2 - Probabilities (p) and 95% confidence intervals of agreement
between scores for shade tabs selected by evaluators and those
measured using the spectrophotometer. Effect of background in
relation to case (A) or root third (B) on probabilities.
Figure 3 - Probabilities (p) and 95% confidence intervals of agreement
between lightness of shade tabs selected by evaluators and those
measured using the spectrophotometer. Effect of background in
relation to case (A) or root third (B) on probabilities.
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Liberato WF et al.
Impact of gray background on tooth color shade matching: a comparison of visual and instrumental methods
Liberato WF et al. Impact of gray background on tooth color shade matching: a
comparison of visual and instrumental methods
reliability of shade matching and communication
for reproducibility [7]. However, clinicians
commonly rely on visual shade analysis, and
practical protocols that enhance the accuracy
of shade selection can be very beneficial.
The ndings in the present study clearly showed
that simply placing a gray background behind
the teeth during the shade selection improved
the agreement of the selected tab with that
indicated by the clinical spectrophotometer.
It is important to emphasize, however, that the
chance of agreement was usually lower than
50% even when the gray background was used.
Despite the spectrophotometer data being used as
a standard, the accuracy of this device to properly
determine the correct shade was demonstrated
to be approximately 78% [9]. The present study
had a limitation in that the sequence of shade
evaluation, with or without the gray background,
was not randomized. Indeed, the rst evaluation
was always carried out without the use of the
gray background, which could have induced an
unknown bias in the study.
CONCLUSIONS
A gray background signicantly improved
the agreement between visual shade selection
and instrumental measurements using a clinical
spectrophotometer, especially in the incisal crown
third. However, this agreement decreased in
areas with incisal translucency involving proximal
and incisal regions. The use of a gray background
offers a cost-effective method to enhance the
precision of visual shade matching, making it
a more accessible alternative to advanced color
selection tools, by improving the accuracy of
esthetic restorations.
Author’s Contributions
Walleska Feijó Liberato (DDS, MS,
PhD):Conceptualization, Methodology,
Investigation, Data Curation, Formal Analysis,
Project Administration, Writing – Original
Draft Preparation. Vinicius Salgado (DDS,
MS, PhD):Conceptualization, Methodology,
Investigation, Data Curation, Writing – Original
Draft Preparation. Marco Antonio Gallito (DDS,
MS, PhD):Writing – Original Draft Preparation,
Supervision, Validation, Visualization. André Luis
Faria-e-Silva (DDS, MS, PhD):Data Curation,
Formal Analysis, Writing – Original Draft
Preparation, Validation. Luis Felipe Jochims
Schneider (DDS, MS, PhD):Conceptualization,
Methodology, Investigation, Data Curation,
Formal Analysis, Supervision, Writing – Original
Draft Preparation, Validation, Visualization.
Larissa Maria Assad Cavalcante (DDS, MS,
PhD):Conceptualization, Methodology,
Investigation, Data Curation, Formal Analysis,
Supervision, Writing – Original Draft Preparation,
Validation, Visualization.
Conict of Interest
The authors have no conicts of interest to
declare.
Funding
This research did not receive any specic
grant from funding agencies in the public,
commercial, or not-for-prot sectors.
Regulatory Statement
This study was conducted in accordance
with all the provisions of the local human
subjects oversight committee guidelines and
policies. Approval number (N.565,812/2014).
The patients who had their teeth evaluated and
all evaluators signed informed written consent.
CAAE: 24173414.0.0000.5243.
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Walleska Feijó Liberato
(Corresponding address)
Laboratório de Biotecnologia Aplicada, Faculdade de Odontologia, Universidade
Federal Fluminense (UFF), Niterói, Brazil; Professora assistente, Núcleo de Pesquisa
em Biomateriais Odontológicos (NPBO), Universidade Veiga de Almeida (UVA), Rio
de Janeiro, Brazil.
Email: walleskaliberato@id.uff.br Date submitted: 2024 Jul 16
Accept submission: 2024 Oct 23