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Policy No:  36B

Originally Created: 01/01/2011

Section: Periodontics

Last Reviewed:  01/01/2019

Last Revised:  01/01/2018

Approved: 01/01/2018

Effective:  01/01/2018


Surgical revision procedure, per tooth (D4268)

This procedure is to refine the results of a previously provided surgical procedure. This may require a surgical procedure to modify the irregular contours of hard or soft tissue. A mucoperiosteal flap may be elevated to allow access to reshape alveolar bone. The flaps are replaced or repositioned and sutured.


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

Must be over 3 years since the first procedure by the same dentist.

Procedure may be subject to review by the dental consultant.

Administrative guidelines

Process to contract benefits, by report.


CDT - D4000-D4999 - see above


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