Smile Evaluation

Tell Us How You Would Like To Change Your Smile

SMILE ANALYSIS (click here for a printable PDF)

Hold a full face mirror 12" - 14" from your face. Smile to show your teeth; take the time to observe your teeth
carefully. Then answer the following questions:

Name: Date:

1. Please describe the concern(s) you have about the appearance of your smile.


2. How would you like your teeth to look?


3. Is there anything else we should know?


If you feel the need for more specific guidance, read through the following list of frequent problems. Please indicate
any that may apply to you by checking the item.

Do you wish your teeth were whiter?
Are the teeth of different colors?
Do your teeth have white, brown, or gray stains?
Do the front teeth contain fillings that are discolored?
In a full smile, normally the back teeth show. Are these teeth stained or discolored from existing fillings?
Do you wish that your silver fillings or gold crowns could be tooth colored?
Do you feel you show too few or too many teeth when you smile?
Do you wish you had longer or shorter teeth?
Would you prefer wider or narrower teeth?
Are your teeth too square or round?
Do you wish your teeth were shaped differently?
Do you have gaps or spaces between your teeth?
Are the front teeth crooked, overlapped, protruding or chipped?
Do the teeth have grooves or notches at the gum line?
Are you dissatisfied with the way your gums look?
Do you think you show too much or too little gum tissue when you smile?
Are your gums receded or bulky?
Is the color of your gums a concern?
Does your upper or lower jaw seem too far forward or recessed?
Do you wish your teeth came together differently?