The Clear Aligner Assessment & Fit Notes Template

BOS has explicitly warned against remote-only clear aligner provision — face-to-face assessment is mandatory. Below is a template for UK clinicians to paste into their PMS for compliant aligner therapy.

Why this clear aligner assessment & fit template wins

• Face-to-face clinical assessment documented — BOS-compliance line. Remote-only assessment is explicitly prohibited.
• IOTN scored (DHC + AC) — defines treatment need, defensible for NHS audit if applicable.
• Limitations of aligners discussed explicitly — Montgomery defence against unmet-expectations claims.
• Lifetime retention discussed and accepted — defensible against post-treatment relapse complaints.
• Written consent for elective cosmetic-functional procedures — indemnity-recommended.

The template (paste into your PMS notes field)

Paste the clear aligner assessment & fit template below into your PMS notes field. Patient demographics are left out because your PMS already holds them.

INDICATION: [Specific malocclusion — class / crowding / spacing / aesthetic specific tooth movement]

PATIENT PRESENTING COMPLAINT: [In patient's own words]
MOTIVATION + REALISTIC EXPECTATIONS DISCUSSED: [Yes — limits of aligners discussed]

PRE-TREATMENT ASSESSMENT:
- Medical history: [Bisphosphonates / pregnancy / TADS contraindications / bone disease]
- Dental history: [Previous ortho / extractions / TMD]
- Extra-oral: [Facial symmetry / lip competence / profile / smile line]
- Intra-oral: [BPE all sextants / plaque + bleeding scores / caries status / existing restorations]
- Periodontal: [STAGED + GRADED if periodontitis present — must be controlled before ortho]
- TMJ: [Click / pain / opening / parafunction]

INDEX OF ORTHODONTIC TREATMENT NEED (IOTN):
- Dental Health Component: [Grade 1-5]
- Aesthetic Component: [SCAN 1-10]

RADIOGRAPHIC ASSESSMENT:
- OPG: [Justification — root morphology, retained roots, pathology / quality / report]
- Lateral cephalogram: [Justification — skeletal pattern, cant assessment / quality / report]
- ALTERNATIVELY documented justification for deviation from standard records

TREATMENT PLAN:
- Aligner system: [Invisalign / SureSmile / 3M Clarity / specify]
- Number of aligners planned: [__]
- Attachments planned: [Teeth + types]
- IPR (interproximal reduction): [Sites + amount — typically 0.1-0.5mm per contact]
- Refinements expected: [Likely Y/N]
- Treatment duration: [__ months estimated]

LIMITATIONS DISCUSSED:
- Aligners less effective for: significant rotations >25°, severe vertical movements, large extrusions, complex skeletal corrections
- Patient understands aligners are not a universal solution

CONSENT (Montgomery, WRITTEN for elective cosmetic-functional procedures):
- Risks: root resorption, relapse without lifetime retention, periodontal risk if OH poor, possibility of refinement appointments, possibility of falling short of ideal alignment, attachment debonding
- Benefits: aesthetic improvement, alignment correction, easier hygiene
- Alternative: fixed appliances (more effective for complex cases), no treatment, lingual braces, extraction-based plan
- Lifetime retention requirement explicitly discussed and accepted
- Patient signs consent

RECORDS TAKEN: [Photographs (full face + retracted + occlusal + side) / models / digital scan / radiographs]

ALIGNER FIT (if fit visit):
- Aligner #1 (or specified) fitted
- Tracking checked: aligner seats fully on all teeth
- Patient instructed on wear (22h/day), cleaning, removal during eating
- Next aligner change schedule discussed

NEXT APPOINTMENT: [Aligner check at __ weeks]

Try the clear aligner assessment & fit note in the live demo → No account needed.

What good looks like — a worked example

The same clear aligner assessment & fit template, completed for a realistic case.

INDICATION: Anterior crowding upper arch, mild crowding lower. Increased overjet (5mm). Class II div 1 incisor relationship with mild skeletal Class II base.

PATIENT PRESENTING COMPLAINT: "I don't like my front teeth — they're crowded and sticking out."
MOTIVATION + REALISTIC EXPECTATIONS DISCUSSED: Patient understands aligners will improve alignment + reduce overjet to ~3mm. Cannot fully correct underlying skeletal Class II. Patient happy with this realistic plan.

PRE-TREATMENT ASSESSMENT:
- MHx: Fit and well. No bisphosphonates. Not pregnant.
- Dental Hx: No previous ortho. All teeth present. No TMD symptoms.
- Extra-oral: Facial symmetry good. Lip competence acceptable at rest. Convex profile (Class II skeletal).
- Intra-oral: BPE all sextants 0-1. Plaque score 15%. No bleeding. No caries. All teeth restored except UR8 + UL8 erupted, asymptomatic.
- Periodontal: Healthy.
- TMJ: No symptoms, normal MO range, no clicks.

INDEX OF ORTHODONTIC TREATMENT NEED (IOTN):
- Dental Health Component: Grade 3 (moderate need)
- Aesthetic Component: SCAN 5 (definite aesthetic need)

RADIOGRAPHIC ASSESSMENT:
- OPG: Justified for orthodontic assessment — root morphology, periodontal bone levels, presence of all teeth, pathology exclusion. Quality A. Report: All roots normal morphology, no resorption, no pathology, third molars present in early development.
- Lateral cephalogram: Justified for skeletal pattern assessment. Quality A. Report: Class II skeletal base, retrognathic mandible, normal vertical dimension, increased ANB angle (6°).

TREATMENT PLAN:
- Aligner system: Invisalign Comprehensive
- Number of aligners planned: 32 (upper) + 24 (lower) initial set
- Attachments planned: UR3, UL3, UR4, UL4, LR3, LL3 (rotation control + retention)
- IPR: 0.3mm between UL1-UR1 + UR1-UR2 (to relieve upper anterior crowding without extractions)
- Refinements expected: Likely 1 refinement set anticipated
- Treatment duration: 16 months estimated

LIMITATIONS DISCUSSED: Aligners less effective for significant skeletal Class II correction — patient understands the underlying skeletal pattern won't change, only tooth position. Outcome will be acceptable dental correction without surgical jaw correction.

CONSENT (Montgomery, WRITTEN):
- Risks discussed: root resorption (~1-2% clinically significant), relapse without lifetime retention, periodontal compromise if OH poor, possibility of refinement (~30-40% of cases), possibility of falling short of ideal, attachment debonding, gingival irritation
- Benefits: aesthetic improvement, alignment correction, easier interdental hygiene
- Alternatives: fixed appliances (slightly more effective for rotations + IPR but visible), lingual braces (more expensive), no treatment (continued aesthetic concern), surgical orthognathic (overkill for this case)
- Lifetime retention explicitly discussed: nightly bonded retainer + removable retainer; patient accepts the lifetime commitment
- Patient signed written consent today

RECORDS TAKEN: Photographs (full face smiling, retracted intra-oral, occlusal upper + lower, lateral right + left). Digital scan (TRIOS 5). OPG + lateral ceph (above).

ALIGNER FIT: First aligner (#1) fitted. Seats fully on all teeth — confirmed visually and patient verified comfortable bite into aligner. Attachments to be placed at next visit (aligners 5-10).

WEAR INSTRUCTIONS: 22h/day. Remove for eating and drinking (except water). Clean aligners daily with cool water + brush. Replace every 2 weeks (or per app schedule).

NEXT APPOINTMENT: 4-week aligner check + attachments placement.

Compliance: the medico-legal angle

• BOS Professional Standards for Orthodontic Practice (2022) — face-to-face assessment mandatory.
• BOS position on aligner claims (BDJ 2024) — direct-to-consumer / remote-only aligners not permitted.
• GDC Principle 1 (patient interests) — clinical assessment required before treatment.
• Montgomery — risks of root resorption, relapse, periodontal compromise must be discussed.
• IR(ME)R 2017 — OPG and ceph justification for orthodontic records.

Common documentation mistakes

• Remote-only consultation without face-to-face assessment — BOS breach.
• No IOTN scoring — clinical need undocumented.
• No discussion of lifetime retention — patient blames you for relapse 5 years later.
• No periodontal control before ortho — moving teeth in active periodontitis accelerates bone loss.
• No written consent for cosmetic-functional procedure — indemnity weakness.

Sources

• GDC Standards for the Dental Team, Principle 1: Put patients’ interests first (accessed 18 October 2026)
• The Ionising Radiation (Medical Exposure) Regulations 2017 (SI 2017/1322) (accessed 18 October 2026)
• Montgomery v Lanarkshire Health Board (UK Supreme Court, 2015, UKSC 11) (accessed 18 October 2026)

Frequently asked questions

Patient leaflets for this treatment

• Your Guide to Clear Aligners
• Traditional Braces vs Clear Aligners — Which Is Right for You?

Related dental note templates

Browse the full set of free dental notes templates.