I. Disclaimer

This document is intended to be used as a reference for VA and non-VA providers. It is not intended to replace clinical judgment when determining care pathways. These guidelines do not guarantee benefits or constitute medical advice.

Eligibility for VA dental care is defined by statute and is to be provided in accordance with the provisions of existing law and VA regulations, specifically 38 U.S.C. §§1710(c) and 1712, and 38 CFR §§17.160 through 17.166.

II. Dental Clinical Determinations and Indications

1. Indications for Periodontal and Alveolar Bone Grafting Procedures
   Periodontal and alveolar bone grafting procedures may be considered clinically necessary when ANY of the following criteria are met:
   • Periodontal intrabony defects: Treatment of 1-, 2-, or 3-wall intrabony defects to regenerate periodontal ligament, cementum, and alveolar bone, confirmed by radiographic evidence of bone loss
   • Grade II furcation defects: Management of Grade II furcation involvement to improve clinical attachment levels and promote defect fill
   • Alveolar ridge preservation: Placement of barrier membranes following tooth extraction to minimize horizontal and vertical ridge resorption and facilitate future prosthetic or implant placement
   • Ridge augmentation or reconstruction: Augmentation or reconstruction of deficient alveolar ridges to achieve adequate bone volume for prosthetic or implant-supported restorations
   • Defect morphology: Evidence of favorable defect morphology such as three-wall defect
   • Peri-implant defects or alveolar ridge augmentation: Peri-implant defects or alveolar ridge augmentation in preparation or in conjunction with dental implant

2. Limitations/Exclusions
   Periodontal and alveolar bone grafting procedures are not indicated and therefore considered not clinically necessary if any of the following conditions are present:
   • Hopeless prognosis teeth: Teeth with severe periodontal attachment loss or non-restorable defects that cannot be maintained
   • Non-contained horizontal bone loss: Bone loss without a vertical component and lacking evidence of regenerative potential
   • Poor oral hygiene: Documented inability or willingness to maintain adequate oral hygiene
   • Non-compliance: Documented inability or willingness to adhere to prior periodontal therapies
   • Uncontrolled systemic conditions: Conditions that impair wound healing, including but not limited to uncontrolled diabetes, autoimmune disorders, chronic corticosteroid use, or immunosuppressive medication use
   • Active tobacco use: Current smoking or tobacco use, which reduces regenerative outcomes
   • Cosmetic or aesthetic use: Procedures aimed solely at improving gingival contour without functional necessity
   • Bone grafting with periradicular surgery: Grafting performed with endodontic periradicular surgery, unless clinically necessary due to periapical bone loss

   For all other conditions or indications not listed in section II.a. of this document, bone grafting procedures are considered not clinically necessary due to insufficient evidence of efficacy and safety.

3. Description of Treatment
4. Periodontal and alveolar bone grafting procedures help repair bone loss around teeth or in the jaw to support healthier gums, stronger teeth, or dental implants. The process may involve local anesthesia or in some cases, general anesthesia or intravenous (IV) sedation depending on the complexity of the procedure. The surgeon carefully accesses the area of bone loss and places a graft material—such as the patient’s own bone, donor bone, animal-derived bone, or synthetic material—into the defect to encourage new bone growth. Sometimes, a special membrane or growth-enhancing substances are added to improve healing. For ridge preservation after a tooth extraction, the graft is placed in the empty socket to maintain the jaw’s shape for future implants or dentures. These procedures aim to rebuild bone strength, support dental implants, or improve the fit of dental restorations, helping the patient maintain better oral health and function. They are all performed using trusted dental techniques.

III. Background and Supporting Information

The following information is for reference purposes only in accordance with dental eligibility as defined by statute (law). Each subsection supports VA’s determinations for clinical necessity and alignment with generally accepted standards of dental practice.

1. Background Information
   Periodontal and alveolar bone grafting procedures are critical in modern periodontal and implant dentistry, addressing bone loss due to periodontal disease, tooth extraction, or implant-related deficiencies. These procedures promote bone regeneration, preserve alveolar ridge dimensions, and ensure adequate bone volume for dental implants or prosthetics. By using biocompatible graft materials and advanced techniques like guided tissue regeneration, bone grafting enhances periodontal support, implant stability, and long-term oral health outcomes, improving patient function and quality of life.

2. Research, Clinical Trials, and Evidence Summaries
   The efficacy and safety of bone grafting procedures are supported by robust clinical literature. Reynolds et al. (2003) in Annals of Periodontology confirm improved clinical and radiographic outcomes for bone grafts in intrabony and furcation defects. Avila-Ortiz et al. (2020) in Journal of Dental Research show that alveolar ridge preservation (ARP) reduces volumetric bone loss and minimizes the need for additional augmentation prior to implant placement. Jambhekar et al. (2015) in Journal of Prosthetic Dentistry report that alloplasts exhibit high vital bone content, while allografts and xenografts reduce ridge loss compared to extraction alone. Miron (2024) in Periodontology 2000 highlights autogenous bone as the gold standard for its osteoinductive and osteogenic properties, with xenografts improving handling and volume stability. These studies provide a multifaceted evidence base, combining clinical expertise, systematic reviews, and primary research to justify bone grafting indications.

3. U.S. Food & Drug Administration Information
4. VA generally only approves use of medical devices that have received at least Food & Drug Administration (FDA) clearance for 510(k) Premarket Notification. The FDA has determined these Class II devices are substantially equivalent (SE) to legally marketed predicate devices, in terms of safety and effectiveness, and may be marketed in the U.S. Manufacturers must adhere to FDA regulations on labeling, manufacturing practices, and post-market surveillance. The FDA monitors adverse event reports and can mandate recalls. Manufacturer’s Instructions for Use (MIFU) must be followed.

   Grafting materials and biologics used in periodontal and alveolar bone grafting, such as autogenous, allogenic, xenogenic, and alloplastic grafts, are regulated by the FDA’s Center for Devices and Radiological Health (CDRH) or Center for Biologics Evaluation and Research (CBER), these are typically classified as Class II medical devices or biologics. Materials must comply with FDA standards for biocompatibility, safety, and efficacy under functional loads.

   To search for devices that have received FDA 510(k) clearance or Premarket Approval (PMA), please visit the FDA Devices database.

4. American Dental Association Current Dental Terminology Coding Information
5. The following CDT codes listed in this section are provided for informational purposes only. Inclusion or exclusion of a code does not constitute or imply VA coverage or provider reimbursement. The list of codes may not be all-inclusive since the American Dental Association (ADA) code updates may occur more frequently than dental CDI updates. Please refer to section II.a. in this document to review indications and clinical criteria for clinical necessity.

6. CDT Code	Description
   D4263	Bone replacement graft – retained natural tooth – first site in quadrant
   D4264	Bone replacement graft – retained natural tooth – each additional site in quadrant
   D4265	Biologic materials to aid in soft and osseous tissue regeneration, per site
   D6104	Bone graft at time of implant placement
   D7950	Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla – autogenous or nonautogenous, by report
   D7953	Bone replacement graft for ridge preservation – per site

   Current Dental Terminology (CDT), Copyright © 2026 American Dental Association. All rights reserved.

IV. Definitions

Term	Definition
Allogenic	A tissue taken from different individuals of the same species
Alloplastic grafts	A synthetic tissue used to replace or support a human tissue
Alveolar ridge preservation	A procedure to place graft material in an extraction socket to minimize ridge resorption and preserve bone volume for future prosthetics or implants
Autogenous graft	Tissue taken from a patient and used to support another area of the body in the same patient
Bone grafting	A surgical procedure involving the placement of bone or bone substitute materials into osseous defects to stimulate new bone growth and restore structural support
Guided tissue regeneration	A regenerative surgical technique using a barrier membrane to direct the growth of new bone and periodontal ligament at sites with insufficient hard or soft tissue
Intrabony defect	A periodontal defect with bone loss below the alveolar crest, classified by the number of remaining bony walls (1-, 2-, or 3-wall)
Periodontal osseous defect	Bone loss around a tooth due to periodontal disease, such as intrabony defects or furcation defects, requiring regenerative treatment
Xenogenic graft	Tissue taken from one species and used in another species to help rebuild human bone

V. References

Avila-Ortiz, G., Gubler, M., Romero-Bustillos, M., Nicholas, C. L., Zimmerman, M. B., & Barwacz, C. A. (2020). Efficacy of Alveolar Ridge Preservation: A Randomized Controlled Trial. Journal of dental research, 99(4), 402–409.

Canellas, J. V. D. S., Medeiros, P. J. D., Figueredo, C. M. D. S., Fischer, R. G., & Ritto, F. G. (2019). Which is the best choice after tooth extraction, immediate implant placement or delayed placement with alveolar ridge preservation? A systematic review and meta-analysis. Journal of cranio-maxillo-facial surgery : official publication of the European Association for Cranio-Maxillo-Facial Surgery, 47(11), 1793–1802

Centers for Medicare & Medicaid Services. (2025). Dental and oral health summary. Medicare Physician Fee Schedule Final Rule. CMS.

Defense Health Agency. (2024). TRICARE Dental Program Reference Document. Defense Health Agency.

Jambhekar, S., Kernen, F., & Bidra, A. S. (2015). Clinical and histological outcomes of socket grafting after flapless extraction: A systematic review of randomized controlled clinical trials. Journal of Prosthetic Dentistry, 113(5), 371–382.

Miron, R. J. (2024). Optimized bone grafting. Periodontology 2000, 94(1), 143–160.

Reynolds, M. A., Aichelmann-Reidy, M. E., Branch-Mays, G. L., & Gunsolley, J. C. (2003). The efficacy of bone replacement grafts in the treatment of periodontal osseous defects: A systematic review. Annals of Periodontology, 8(1), 227–265.

Reynolds, M. A., Kao, R. T., Nares, S., Camargo, P. M., Caton, J. G., Clem, D. S., Fiorellini, J. P., Geisinger, M. L., Mills, M. P., Nevins, M. L., & Rosen, P. S. (2015). Periodontal Regeneration – Intrabony Defects: Practical Applications From the AAP Regeneration Workshop. Clinical advances in periodontics, 5(1), 21–29

United Concordia. (2025). TRICARE Dental Reference Guide 2025. United Concordia Companies, Inc.

UnitedHealthcare. (2024). Dental Clinical Policy: Bone Replacement Grafts. Policy Number: DCP048.03. UnitedHealthcare Services, Inc.

U.S. Food and Drug Administration. (2005). Class II Special Controls Guidance Document: Dental Bone Grafting Material Devices

VI. CDI History/Revision Information

Date	Summary of Updates
08/01/2026	New dental CDI created describing clinically necessary indications / not clinically necessary indications

---