Smile analysis



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SMILE ANALYSIS
Name:_________________________ Age:_____ Date:______________
Looking into a full face, close-up mirror, analyze your smile in two phases—slight smile and full smile.

I TEETH YES NO



1. Are the upper six front teeth even in length?…………………………………… _____ ____

2. Are the front teeth straight (versus being crooked, overlapped, or protruding)? _____ ____

3. Smiling more, are the teeth of one color?………………………………………. _____ ____

4. If the front teeth contain fillings, are they matched with the other teeth so they

are unnoticed?……………………………………………………………………. _____ ____

5. Are the lower six front teeth straight?………………………………………….. _____ ____

6. Are they even in appearance?…………………………………………………… _____ ____

7. In a full smile normally the back teeth show. Are these free of stains and

discolorations from unsightly restorations?……………………………………. _____ ____

8. Do your teeth appear to be dark or yellow?……………………………………. _____ ____

9. Do they contain stains? (White or brown)……………………………………… _____ ____

10. Do the necks of the teeth have erosion (a ditched-in “V” appearance that can

be seen or felt with a fingernail?………………………………………………… _____ ____

11. In a full smile does the top lip rise above the necks of the teeth so that the

gums show?….…………………………………………………………………… _____ ____

12. Do you like your smile?………………………………………………………….. _____ ____

13. Do you feel comfortable about showing your teeth when you smile?………… _____ ____

14. Do you see a need to improve the appearance of you smile via bleaching,

bonding or cosmetic dentistry?……………………………………………….… _____ ____
II GUMS
15. Have the gums receded from the necks of the teeth?……..………………...… _____ ____

16. Are the gums pink and “knife-edged?”…………………………………….….. _____ ____
III BREATH
17. Is your breath always pleasant? (controlled)………………………………… _____ ____

18. Is your mouth free of decay or gum disease that causes bad breath?…….… _____ ____
Clinical evaluation and recommendations:

Joseph A. DeLapa, DDS


363 Smith Ridge Road

South Salem, NY 10590

(914) 533-6166


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