Free Clear Aligner (Invisalign) Start Note Template (D8080/D8090)
The aligner start visit sets the record every later check is measured against. This clear aligner template documents the consent, the system and case, the attachments you bonded, interproximal reduction by contact and amount, the aligners delivered, and the wear and change instructions you gave.
By Yasmin Byott, DDS, MS · Founder, ButterNote · Updated
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Pick each contact, then the amount removed.
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Replace each [bracketed field] with your specific clinical detail. Brackets are placeholders. They don't get saved into the chart.
Clear aligner treatment start with [Invisalign]. Case: [comprehensive, adult dentition (D8090)] / [limited treatment]. Digital treatment plan reviewed and approved [date]: [22] upper and [22] lower aligners. Records on file: [intraoral scan, photos, panoramic radiograph]. Informed consent reviewed and signed, including [wear-time compliance, attachments, IPR, possible refinement aligners, root resorption, and long-term retention]. Oral hygiene: [good; no active caries or periodontal disease]. Attachments bonded [#5-12, #21-28]: enamel cleaned, etched, and bonded; composite placed with the attachment template and light cured; excess removed. Interproximal reduction (IPR) performed: [22/23 0.2 mm, 23/24 0.2 mm, 25/26 0.2 mm, 26/27 0.2 mm], checked with [an IPR gauge]; contacts smoothed and polished. Aligners [1-3] delivered. Fit verified; insertion and removal demonstrated and practiced. Instructed to wear aligners [20 to 22] hours per day, removing them only to eat, drink anything other than water, and brush; change to the next aligner every [7] days. Chewies (aligner seaters) given and use demonstrated. Oral hygiene and aligner care instructions given, including [cleaning the aligners, storing them in the case, and wearing the previous aligner and calling the office if one is lost]. Next visit: [aligner check in [6 to 8] weeks].
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When to use this template
Use this clear aligner start note template at the appointment where aligner treatment begins: attachments bonded, interproximal reduction (IPR) if the plan stages it this early, and the first aligners delivered. Invisalign, a trademark of Align Technology, is the system most patients know by name, and others include Spark and ClearCorrect. The note is the same whichever you use, so name yours. Before this visit the chart should already hold the records (scan, photos, radiographs), the diagnosis, the digital treatment plan you approved, and informed consent that covers wear-time compliance, attachments, IPR, possible refinement aligners, root resorption, and retention afterwards. The FDA describes clear aligners as prescription devices for use under the supervision of a dentist or orthodontist, after an in-person evaluation.
The CDT codes describe the scope of orthodontic treatment and the stage of the dentition, not the appliance. A comprehensive aligner case is reported with the comprehensive code for the dentition: D8070 (transitional), D8080 (adolescent), or D8090 (adult). A case with a limited objective uses the limited treatment codes, D8010 to D8040. CDT defines the adolescent dentition as the dentition present after the normal loss of primary teeth and before the cessation of growth that would affect orthodontic treatment, and the adult dentition as the one present after that growth has stopped. So it is growth that decides between D8080 and D8090, not a birthday. Many payers pay orthodontic benefits in installments and tie them to the date the appliances were placed, which is this visit, so the date and the code matter.
Record the specifics so the first check has something to compare with: attachments by tooth number, IPR by contact and amount in mm (for example 22/23 0.2 mm) and how it was measured, the aligner numbers delivered, fit, insertion and removal practice, and the wear and change instructions you actually gave. The FDA patient information says aligners should be worn at least 20 hours per day, or as the dentist or orthodontist directs, and are typically changed every one to two weeks.
Step by step: how to document this clear aligner start
- 1
Confirm the plan and consent
Record the system, case scope, approved digital plan, aligner count, records on file, and signed consent.
- 2
Check the baseline
Record oral hygiene, caries and periodontal status, and existing restorations.
- 3
Bond attachments
Record the teeth, the enamel preparation, and the attachment template and composite.
- 4
Perform IPR
Record each contact and the amount removed in mm, how it was measured, and that contacts were smoothed.
- 5
Deliver aligners
Record the aligner numbers delivered, fit, and insertion and removal practice.
- 6
Instruct and schedule
Record wear hours, change interval, chewies, care instructions, what to do if an aligner is lost, and the first check.
Tips for using this template
- check_circleName the system and the scope of the case: comprehensive or limited, and the stage of the dentition. That, not the appliance, is what the code describes.
- check_circleDo not hard-code D8080 or D8090 into your office template. Pick by dentition stage: CDT ties adolescent and adult to whether growth that would affect treatment has stopped.
- check_circleRecord consent explicitly, including that results depend on wear time and that retention continues after treatment ends.
- check_circleList attachments by tooth number. When one comes off at a check, you will know where it was.
- check_circleRecord IPR by contact and amount in mm, as performed, not just "IPR per plan". If you did less than the plan staged, say so.
- check_circleRecord the aligner numbers delivered. It makes the first check, and any lost-aligner call, simple.
- check_circleWrite the wear and change instructions you actually gave, in hours per day and days per aligner.
- check_circleNote the baseline: caries, periodontal status, and existing restorations, before aligners and attachments go on.
Standards & references
- ADA Code on Dental Procedures (CDT): Limited (D8010 to D8040) and comprehensive (D8070, D8080, D8090) orthodontic treatment codes and the dentition stage definitions.
- U.S. FDA: Clear Dental Aligners: Prescription status, in-person evaluation and supervision, wear time of at least 20 hours per day or as directed, and risks.
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