How doctors review a digital treatment setup

The review is the moment where a proposed plan becomes a clinical decision. It deserves a routine. This is the one we suggest to doctors who review setups in a browser, whether the plan came from our team or from anywhere else.

The reason a routine matters is that a rendered plan is persuasive. It is symmetrical, it is well lit, and the final stage always looks better than the initial one. Reviewing in a fixed order stops the presentation from doing your thinking for you, and it means the same checks happen on the case you are keen about and the case you are tired of.

Start with the instructions

Re-read what you asked for before you look at what you received. A plan is judged against its prescription. If your instructions were vague, the plan will reveal that, and the first comment should clarify the intent rather than correct the geometry.

Have the prescription visible while you review rather than remembered. Reviews go wrong less often because a doctor missed something in the model than because they forgot which of their own constraints applied to this patient.

Compare initial and final

Switch between the initial scan and the final setup from the front, from each side and from the occlusal view of each arch. Look at the arch form, the midlines, the incisal edges and the buccal corridors. Ask whether the result is the one the patient wanted and the one you would be comfortable delivering.

Watch particularly for the arch that has been quietly widened. Expansion is the easiest way for a setup to make crowding disappear, and a few tenths of a millimetre per tooth across a full arch adds up to a change in arch form that may not be supported by the buccal bone or stable once retention ends. If the final arch is wider than the initial one and you did not ask for that, ask where the space came from.

Read the movement table

Every tooth has figures for translation, rotation, tipping, torque, intrusion and extrusion. Scan for large values. A big rotation on a premolar, a large extrusion on an incisor, or intrusion across several teeth are the movements most likely to fall short or to need attachments and anchorage. Decide whether each is realistic for this patient.

Then check the small values for the teeth you said should not move. A molar carrying a millimetre of unrequested distal movement is usually not a decision anyone made; it is the reciprocal force of something else in the plan, and it is the kind of thing that only shows up in the table.

Check the occlusion

View the arches together at the final stage and at a few intermediate stages. Look for premature contacts, open contacts and canine guidance. A setup can produce a beautiful arch that does not meet the opposing arch; the review is where that is caught.

Remember what the digital articulation is. It positions the two meshes in the recorded bite; it is not a functional analysis and it does not know how the patient's mandible moves. Use it to find obvious interferences and vertical discrepancies, and use the patient's examination for everything else.

Attachments and IPR

Look at each attachment and ask whether the movement it serves needs it and whether the patient will accept it there. Read the IPR schedule contact by contact and judge the amounts against the enamel you can see in the photographs. Both can be changed by a comment.

Comment on the thing, not the impression

Attach comments to a tooth number or a stage. "Reduce the rotation on 23 and add an attachment" can be actioned. "The left side looks wrong" cannot. Ask for what you want changed. Expect the planner to reply on the same comment and to deliver the change as a new version, with the earlier one kept.

Where you are unsure, say what you are worried about rather than issuing an instruction you are not confident in. "I am concerned the intrusion on 41 and 31 is more than the periodontal support will take — what does the plan look like with half of it?" gets you an alternative to compare. A planner can build two versions far more easily than they can read your mind.

Approve deliberately

Approve the version you would defend to a colleague. Once approved, the plan is used to make the aligners, and changes after that point mean a refinement. The approval is yours; that is the point of the workflow.

Approve only as the treating clinician, and only when you have actually opened the case. An approval clicked by a coordinator to keep a case moving removes the one control the whole workflow is built around, and it is the approval, not the plan, that carries the clinical responsibility.

A short checklist

1. Re-read the prescription.
2. Compare initial and final from five views.
3. Scan the movement table for large values and for movement on teeth that should be still.
4. Step through the stages and watch for jumps and collisions.
5. Check occlusion at the end and at two intermediate stages.
6. Read the attachment list and the IPR schedule against the photographs.
7. Comment by tooth or stage, or approve.

A routine like this takes minutes for a simple case and repays the time on every case that follows. The plan can be revised without limit; the appliances cannot.