Distal or Proximal Wedge Procedure

Policy No: 36F
Originally Created: 01/01/2000
Section: Periodontics
Last Reviewed: 01/01/2019
Last Revised: 01/01/2018
Approved: 01/01/2018
Effective: 01/01/2018


Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) (D4274)
This procedure is performed in an edentulous area adjacent to a periodontally involved tooth. Gingival incisions are utilized to allow removal of a tissue wedge to gain access and correct the underlying osseous defect and to permit close flap adaptation.


Procedures are in accordance with generally accepted standards of dental practice.

Procedures may be subject to review by the dental consultant.

This is a one-tooth benefit.

No benefit if done with D4210, D4240, D4260 in same quadrant.

If no evidence of bone loss, benefit D4211 or pro rated D4240.

Administrative guidelines

Process to contract benefits.


CDT - D4000-D4999 - see above


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