What D4264 means

D4264 covers a bone replacement graft, retained natural tooth, each additional site in a quadrant. "D" is dental, "42" is the surgical periodontal group, and "64" is this additional-site bone graft. It's the companion to D4263: when periodontal bone grafting is done at more than one site within the same quadrant of the mouth, the first site is coded D4263 and each additional site in that quadrant is coded D4264. So if, for example, three teeth in one quadrant need grafting for periodontal defects, the coding would be one D4263 plus two D4264.

Like D4263, it's specifically for grafting around retained natural teeth to regenerate bone lost to periodontal (gum) disease — placing graft material into bony defects around the teeth. The same critical restriction applies: these codes are only for natural-tooth sites, not extraction sites, edentulous spaces, or implant sites.

The per-site coding (D4263 for the first, D4264 for each additional in the quadrant) reflects that each defect treated involves its own grafting work. Additional sites (D4264) typically have a somewhat lower fee than the first. Barrier membranes (D4266/D4267) are billed separately. Coverage is under periodontal benefits with documentation of each defect. The clinical concepts (how gum disease destroys bone, how grafting regenerates it) are the same as for D4263.

When it's typically used

D4264 is reported for each additional site (beyond the first) in the same quadrant where a bone graft is placed around a natural tooth for periodontal regeneration — used together with D4263 (the first site) when multiple teeth in a quadrant need grafting for gum-disease bone loss.

How much does D4264 cost?

A periodontal bone graft additional site is a moderate fee, often roughly 250 to 600 USD per additional site depending on region — typically somewhat less than the first site (D4263), since it's done in the same surgical area. Any barrier membrane is billed separately. Multiple sites add up for extensive periodontal regeneration.

Is D4264 covered by insurance?

Covered under periodontal benefits like D4263, when documented as necessary for periodontal bony defects around natural teeth, with pocket depths, defect types, and radiographs for each site. Only valid for natural-tooth sites (not extraction or edentulous sites). Barrier membranes (D4266/D4267) are billed separately. The per-site documentation supports the additional-site claims.

Why bone grafts are coded per site

Periodontal bone grafts are coded per site (D4263 for the first, D4264 for each additional in a quadrant), and understanding why clarifies this coding structure.

Periodontal bone grafting treats specific bony defects around individual teeth. Each defect is a distinct area requiring its own assessment, access, cleaning, and graft placement — so each site treated represents separate clinical work. The coding reflects this by charging per site: the first site grafted in a quadrant is D4263, and each additional site in that same quadrant is D4264. This per-site structure means the total coding (and cost) for periodontal grafting scales with the number of sites treated — someone with one defect has one graft site, while someone with multiple affected teeth in a quadrant has several. The 'per quadrant' organization groups the sites by the mouth's quadrants (the four sections of the dentition).

This per-site coding is logical because the extent of periodontal bone grafting varies greatly between patients depending on how many teeth have grafting-amenable defects. Charging per site captures the actual work done. The additional-site code (D4264) typically has a somewhat lower fee than the first site (D4263) in the same quadrant, partly because the additional sites are treated in the same surgical session and area (some of the access and setup is shared). Understanding that grafting is coded and charged per defect site helps patients make sense of their treatment plan and cost when multiple teeth need grafting — each contributes to the total. The dentist or periodontist documents each site (with its defect and pocket measurements) to support the coding. For extensive periodontal disease affecting several teeth, the per-site grafting can add up, which is part of why advanced periodontal treatment can be a significant investment, reflecting the work to treat each affected tooth's bony defect.

Treating multiple sites of gum-disease bone loss

When periodontal disease has caused bone loss around several teeth, multiple grafting sites may be needed, and understanding this clarifies extensive periodontal treatment.

Periodontal disease often affects multiple teeth, not just one — it can be widespread, with bony defects and pockets around several teeth in an area or throughout the mouth. When the disease has created grafting-amenable defects around multiple teeth, treating them comprehensively may involve grafting several sites. Within a single quadrant, this means one D4263 (first site) plus D4264 for each additional site, and the treatment may span multiple quadrants in extensive cases. The periodontist assesses all the affected teeth, identifies which defects are suitable for regenerative grafting (some defects regenerate better than others based on their shape and remaining bony walls), and plans the grafting accordingly.

Treating multiple sites is often done in surgical sessions organized by area (for example, treating one quadrant or sextant at a time), allowing efficient access to multiple adjacent defects. This comprehensive approach aims to regenerate bone around the multiple affected teeth to improve their collective prognosis and save them. It's a more involved undertaking than treating a single site, reflecting the extent of the disease. Importantly, treating multiple sites of bone loss is done in the context of overall periodontal therapy — the disease must be controlled first, and diligent maintenance must follow, for the multiple grafts to succeed. For patients with widespread periodontal bone loss, understanding that multiple grafting sites may be needed (and coded per site) helps them grasp the scope and cost of comprehensive regenerative treatment aimed at saving multiple teeth. The periodontist develops a plan tailored to the extent of the disease and the defects amenable to regeneration.

What makes a defect suitable for grafting

Not every area of periodontal bone loss can be successfully grafted, so understanding what makes a defect suitable clarifies why grafting is done at some sites and not others.

The success of regenerative bone grafting depends significantly on the shape and characteristics of the bony defect. Defects that are more 'contained' — meaning they have more remaining bony walls surrounding the defect — tend to regenerate better, because the surrounding walls help contain the graft material and provide a framework and blood supply for new bone formation. A classic favorable example is a narrow, deep 'three-walled' defect (surrounded by bone on three sides), which holds the graft well and has good regenerative potential. Defects with fewer remaining walls (such as broad, shallow defects or those open on multiple sides) are less contained and generally regenerate less predictably, because the graft is harder to contain and the regeneration is less supported. The overall amount and pattern of bone loss, the tooth's condition, and the control of the gum disease also matter.

So the periodontist evaluates each bony defect to determine whether regenerative grafting is likely to succeed there. Suitable defects (well-contained ones) are good candidates for grafting (D4263/D4264), often with a membrane (guided tissue regeneration). Less suitable defects might be managed differently (for example, with pocket-reduction surgery to make the area cleanable, rather than attempting regeneration). This is why grafting is selectively applied to the defects amenable to it, rather than to all areas of bone loss. Understanding that defect shape determines suitability for grafting helps patients see why their periodontist recommends grafting at certain sites and other approaches elsewhere — matching the treatment to what each specific defect can support. The goal is to use regenerative grafting where it's likely to work, maximizing the benefit of rebuilding bone around teeth where the defect characteristics favor success.

Maintaining results after periodontal grafting

After periodontal bone grafting (whether one site or several), maintaining the results through ongoing care is essential, and understanding this clarifies the long-term commitment.

Periodontal bone grafting aims to regenerate lost bone and improve the affected teeth's support, but the results must be maintained to last. The key is keeping the underlying gum disease controlled, because periodontal disease is a chronic condition that can recur if not managed — and recurrence would undermine the regenerated bone and the teeth. So after grafting, diligent ongoing care is essential: excellent home oral hygiene (thorough brushing and flossing to control the plaque that drives gum disease), and regular professional periodontal maintenance visits (more frequent than routine cleanings, often every three to four months for periodontal patients) where the hygienist or periodontist cleans below the gumline, monitors the periodontal health, and catches any recurrence early. This ongoing maintenance is what preserves the results of the grafting and the overall periodontal treatment.

Without this maintenance, the gum disease can return, the inflammation and bone loss can resume, and the benefits of the grafting can be lost — potentially leading back toward losing the teeth that the treatment aimed to save. So periodontal grafting (and periodontal treatment generally) is not a one-time cure but the start of an ongoing management of a chronic condition. For patients, understanding that maintaining good home care and keeping up with regular periodontal maintenance is essential to preserve the results helps them commit to the long-term care needed. The investment in regenerative grafting to save teeth pays off only if the results are protected through ongoing periodontal health maintenance. The periodontist guides the patient on the recommended maintenance schedule and home care. With this commitment, the regenerated bone and the teeth it supports can be maintained for the long term, fulfilling the goal of the treatment to keep the natural teeth healthy and functional despite the history of gum disease.

Frequently asked questions

What is the D4264 dental code?

It's a bone graft around a retained natural tooth for each additional site in the same quadrant (after the first). It's used with D4263 (the first site) when multiple teeth in a quadrant need periodontal bone grafting for gum-disease bone loss.

How are D4263 and D4264 used together?

The first grafting site in a quadrant is D4263, and each additional site in that same quadrant is D4264. So three sites in one quadrant would be one D4263 plus two D4264.

Why are bone grafts coded per site?

Each bony defect around a tooth is a distinct area requiring its own access, cleaning, and graft placement — separate clinical work. Per-site coding captures the actual work, so the total scales with the number of sites treated.

How much does an additional graft site cost?

Often around 250 to 600 USD per additional site, typically somewhat less than the first site since it's in the same surgical area. Any barrier membrane is billed separately. Multiple sites add up.

What makes a defect suitable for grafting?

More 'contained' defects (with more remaining bony walls, like a deep three-walled defect) regenerate better, since the walls contain the graft and support new bone. Less contained defects regenerate less predictably and may be managed differently.

How do I maintain the results after grafting?

Keep the gum disease controlled with excellent home hygiene and regular periodontal maintenance visits (often every 3-4 months). Periodontal disease is chronic and can recur, undermining the results, so ongoing care is essential.

This page is an independent, plain-language explanation for general information only. It is not billing, coding, or clinical advice. For the official CDT descriptor and current-year wording, refer to the American Dental Association.