PRACTICAL APPLICATIONS

Decisions Before Incisions: Technique Selection for the Distal Wedge

Procedure
Thomas M. Johnson,∗ Robert W. Herold,∗ Joshua A. Akers,∗ Daniel A. DiPirro,∗ Joshua P. Berridge† and Ryan T. McGary‡

Focused Clinical Question: What factors identify the optimal surgical technique when a distal wedge procedure
is indicated at a terminal maxillary or mandibular molar site?
Summary: Incision design for the distal wedge procedure is based primarily on the dental arch (maxilla or mandible),
the distance from the terminal molar to the hamular notch or ascending ramus, and the dimensions of the attached gingiva.
Conclusions: In most situations, favorable clinical results are achievable irrespective of the chosen distal wedge
method, and technique selection is based more on operator preference than evidence. However, anatomic limitations
can render distal wedge procedures challenging in some cases, and procedural advantages of specific techniques can
simplify treatment. One systematic approach to distal wedge technique selection is presented in this report. Additionally, a
laser-assisted distal wedge protocol is presented for cases in which unfavorable tooth-to-ramus distance or presence of a
prominent external oblique ridge contraindicates conventional distal wedge techniques. Clin Adv Periodontics 2020;10:94–
102.
Key Words: Clinical protocols; crown lengthening; gingiva; mandible; maxilla; treatment outcome.

Background tors can exaggerate periodontal probing depth.1,9 Caries

Many individuals exhibit, on the distal aspect of terminal
molars, thick attached gingiva level with or coronal to
the occlusal plane.1 A combination of anatomic factors
contribute to this condition.1-8 Relative to other areas
of the oral cavity, attached gingiva has been found to
be thickest at the distal aspect of terminal molars (mean
thickness greater than four millimeters in each arch).4
Additionally, in the mandibular arch, terminal molars
are often positioned in close proximity to the ascending
ramus, and, accordingly, supporting bone on the distal
aspect of these teeth lies near the cementoenamel junction
(CEJ).1,5 This supporting bone, and the mandibular ramus
itself, tend to maintain soft tissue in a coronal position.
Palatal exostoses6,7 and thick buccal ledges8 commonly
contribute to excessive tissue dimensions around terminal
maxillary molars.
Bulbous and movable soft tissue in the retromolar
pad and maxillary tuberosity areas can frustrate proper
oral hygiene.1 When periodontitis is present on the distal
aspect of terminal molars, the described anatomic fac-
∗ Department
of Periodontics, Army Postgraduate Dental School,
Uniformed Services University of the Health Sciences, Fort Gordon,
GA
† Department of Periodontics, United States Army Dental Health
Activity, Fort Bragg, NC
‡ Department of Periodontics, United States Army Dental Health
Activity, Fort Jackson, SC
Received October 18, 2019; accepted December 20, 2019
doi: 10.1002/cap.10091
removal and restorative treatment on the distal aspect of
terminal molars can challenge even experienced practi-
tioners when excessive soft tissue and unfavorable local
anatomy are present.
Decision Process
The distal wedge procedure is indicated on the distal
aspect of terminal molars or on other proximal tooth sur-
faces bordering edentulous spaces (1) to treat periodonti-
tis, (2) to enable effective oral hygiene measures, and (3)
to facilitate restorative treatment. The distal wedge can
be applied as a stand-alone procedure or in conjunction
with flap access for crown lengthening, apically positioned
flap, osseous surgery, or regenerative periodontal therapy.
Distal wedge is contraindicated when proximity to the
ascending ramus or a prominent external oblique ridge
severely limits the benefit of the procedure or necessitates
extensive, overly traumatic removal of bone.1
Three classic distal wedge incision designs have been
defined: square, triangular, and linear.1 Since the 1960s,
a few authors have offered incremental modifications to
these approaches.10-13 Positive treatment outcomes are
achievable irrespective of the selected distal wedge tech-
nique in most cases, and evidence supporting superiority
of any particular method is lacking. Relatively little has
been written about the distal wedge since the introduction
of the procedure, and criteria for technique selection have
not been validated through controlled clinical study. The
purpose of this report is to describe one approach to
distal wedge incision design (Fig. 1), primarily considering
the dental arch (maxillary or mandibular), proximity to

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FIGURE 1 Proposed decision tree for distal wedge technique selection.

the ascending ramus or hamular notch, and the zone of

attached gingiva present. Distal wedge procedures can
be indicated at any site adjacent to an edentulous space.
However, these procedures are very commonly applied
on the distal aspect of terminal second molars. When
severe gingival excess, periodontitis, or repeated abscesses
occur on the distal aspect of third molars, tooth extraction
may represent the safest and most appropriate treatment
option in many cases.

Clinical Scenarios
All patients in this report presented to the Periodon-
tics Department, Army Postgraduate Dental School, Uni-
formed Services University of the Health Sciences, Fort
Gordon, Georgia. Each patient completed an informed
consent process involving verbal and written components,
and treatment options were discussed in detail.
FIGURE 2 Square distal wedge technique. Baseline appear-
Outcomes ance. Tooth #3 required crown lengthening to facilitate pros-
Expected outcomes are similar for all variations of the thetic treatment. Excessive bone and soft tissue was appar-
ent adjacent to tooth #2. A 6-mm pseudopocket was noted
technique. Each distal wedge type efficiently removes a at the distopalatal line angle of tooth #2, with clefting in the
large volume of excess tissue when appropriate, yet several retromolar area.
incision designs afford approximation of wound margins
for primary intention healing. The techniques can increase
clinical crown height to facilitate restorative treatment, Terminal Maxillary Molar, Favorable
reduce probing depths when periodontitis is present, and Tooth-to-hamular-notch Distance
improve oral hygiene effectiveness. For patients experienc- Clinical management. When adequate space is avail-
ing abscesses of the periodontium related to tissue excess able between a terminal maxillary molar and the hamular
on the distal aspect of terminal molars, the distal wedge notch, the square distal wedge1 offers several advan-
procedure represents a reliable therapeutic approach. tages (Figs. 2 through 7). This incision design allows the

Johnson et al. Clinical Advances in Periodontics, Vol. 10, No. 2, June 2020 95
P R A C T I C A L A P P L I C A T I O N S
FIGURE 3 Square distal wedge technique. A square incision
design was selected based primarily on the favorable distance
between the tooth and the hamular notch. Incisions were
carried to bone, and the soft tissue was reflected and removed
using a periosteal elevator.
FIGURE 4 Square distal wedge technique. Excised tissue.
practitioner to control the volume of tissue removed and
easily adjust the excision before closure if additional tissue
removal is needed. The horizontal (buccopalatal) incision
is typically made with a Kirkland knife, while taking
care to place the incision within the masticatory mucosa.
The depth of the incision should reach the osseous crest.
The horizontal incision extends beyond the buccal and
palatal surfaces of the terminal molar. The amount of
tissue removed is primarily determined by the distance
between the two parallel anteroposterior incisions, which
96 Clinical Advances in Periodontics, Vol. 10, No. 2, June 2020
FIGURE 5 Square distal wedge technique. Full thickness gingi-
val flaps were reflected, allowing excellent access for osseous
recontouring. The flaps were thinned before closure.
FIGURE 6 Square distal wedge technique. Independent sling
sutures were used around tooth #3. The area distal to tooth
#2 was closed using two simple interrupted sutures. Wound
closure for primary intention healing was achieved. The patient
reported virtually no postoperative discomfort during healing
and did not require an opioid analgesic.
are placed using a #12 scalpel blade. Next, an Orban
knife is used to make an intrasulcular incision on the
distal surface of the terminal molar. Finally, a periosteal
elevator is used to reflect the delineated tissue segment
and remove it from the tuberosity. The buccal and palatal
flaps can be thinned, and if necessary, osteoplasty and
ostectomy can be performed. Because of the extension of
the Kirkland incision, the thinned buccal and palatal flaps
can be approximated.
Distal Wedge Technique Selection

FIGURE 7 Square distal wedge technique. Five weeks follow-
ing the procedure, the gingiva appeared healthy with favorable
contours.
FIGURE 8 Gingivectomy/gingivoplasty. 8a Baseline appearance. Tooth #2 exhibited a 6-mm pseu-
dopocket with bleeding on probing. 8b and 8c Gingivectomy and gingivoplasty were performed
to reduce probing depths and facilitate effective oral hygiene. The procedure enhanced access to
the root surface, which was thoroughly debrided. 8d The patient healed as expected, and 3-mm
probing depths were noted at postoperative month six.
Terminal Maxillary Molar, Minimal
Tooth-to-hamular-notch Distance
Clinical management. When the distal aspect of a
terminal maxillary molar is near the hamular notch, the
square distal wedge can be technically challenging and
inefficient. Alternatively, simple gingivectomy (Fig. 8) or a
triangular distal wedge may be performed. Gingivectomy
in this area is commonly accomplished by selecting the
Johnson et al.
P R A C T I C A L A P P L I C A T I O N S
desired gingival level on the distal aspect of the terminal
molar. A Kirkland knife or #12 scalpel blade, held hor-
izontally, is then advanced from posterior to anterior to
excise the excess gingiva at the selected vertical level. Gin-
givoplasty may then be performed to establish physiologic
gingival morphology.
Terminal Mandibular Molar, Favorable
Tooth-to-ramus Distance, Favorable or
Excessive Keratinized Tissue Volume
Clinical management. The triangular distal wedge
is useful for terminal mandibular molars when tooth-
to-ramus distance is adequate, and the keratinized tis-
sue volume is favorable or excessive. Keratinized tissue
on the distal/distolingual aspect of terminal mandibu-
lar molars is often lacking,5 and the triangular distal
wedge may not be the optimal approach under such
circumstances. Assuming appropriate case selection, the
triangular distal wedge can eliminate excessive soft tissue
while retaining an adequate zone of attached gingiva.
Gingival flap reflection in conjunction
with a triangular distal wedge affords
access for osteoplasty and ostectomy, if
needed (Fig. 9).
Terminal Mandibular Molar,
Favorable Tooth-to-ramus
Distance, Minimal Zone of
Keratinized Tissue
Clinical management. The width of
lingual mandibular attached gingiva
exhibits a consistent pattern of variation
in humans.14 The widest zone of lingual
mandibular attached gingiva typically
occurs in the first and second molar
areas.14 However, the zone of attached
gingiva narrows posteriorly, in the area
adjacent to the third molar.14 Some
patients exhibit minimal keratinized
tissue on the distal and distolingual
aspects of terminal mandibular second
molars.5,14 Periodontal health is possible
in the absence of keratinized tissue.15
However, lack of keratinized tissue is
a predisposing factor for development
of inflammation, discomfort during
toothbrushing, and gingival recession,
particularly in patients with suboptimal
plaque control.15,16 Thus, in many cases,
selecting a distal wedge technique which does not
eliminate the zone of attached gingiva is prudent.
The linear distal wedge (Figs. 10 through 12) is a tech-
nique which preserves a maximum amount of attached
gingiva bordering the terminal mandibular molar. To pro-
tect the lingual nerve, the distolingual line angle of the
tooth is a key landmark for this incision. An oblique
incision is placed from the distolingual line angle of the
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aspect of the molar is removed using

a traditional triangular distal wedge
approach. A small corticotomy is
established in the exposed bone using
a #6 round bur. The tissue adjacent to
the distal wedge site is neither freed nor
pulled in a coronal direction during
suturing. The periosteum remains
bound to the alveolar bone and tethers
adjacent tissue in place. A neodymium–
doped: yttrium, aluminum, garnet
(Nd:YAG) laser is used to stabilize
a blood clot over the exposed bone
(Table 1). The laser-generated clot is
intended to protect the alveolar bone
and minimize patient discomfort.

Discussion
Keratinized tissue dimensions represent
an important consideration in most
periodontal procedures, including the
distal wedge. Practitioners may hesitate
to perform a distal wedge procedure
at a mandibular terminal molar site
with minimal keratinized gingiva bor-
dering the distal surface. Whether or
not the proposed laser-assisted distal
wedge technique can reliably produce
FIGURE 9 Triangular distal wedge technique. 9a The patient exhibited favorable tooth-to-ramus
or enhance a zone of attached gingiva
distance distal to tooth #31. Irregular osseous contours and excessively thick masticatory mucosa is unknown. However, indirect evidence
contributed to 7-mm probing depths on the distal aspect of tooth #31. Triangular distal wedge suggests that this procedure—or sim-
incisions were placed. 9b The distal wedge was carefully reflected and removed using a periosteal
elevator. 9c Full thickness gingival flaps offered access for osteoplasty and minimal ostectomy.
ply denuding the alveolar bone—may
9d Six months following the procedure, clinical signs of inflammation were absent, and probing result in increased keratinized gingiva
depths were <3 mm. in some individuals. Granulation tissue
originating from gingival connective
tissue or the periodontal ligament appears capable
tooth toward the buccal, and a full thickness gingival flap of inducing formation of a keratinized gingival
is reflected. Reduction in tissue volume occurs by thinning epithelium.19 In the 1960s, this concept formed the
and replacing the gingival flap. Chan and coworkers stud- basis for increasing the zone of attached gingiva using
ied 18 fresh cadaver heads and reported a mean vertical denudation20 and periosteal retention techniques.21
distance of 9.6 mm between the mid-lingual mandibular Lundberg and Wennström reported development of
second molar CEJ and the lingual nerve.17 However, in gingiva (apicocoronal width of 2.5 mm) following surgical
the third molar area, the lingual nerve can contact the exposure of a facially positioned unerupted incisor
mandibular cortical plate in the horizontal dimension and surrounded entirely by alveolar mucosa.22 Granulation
may lie superior to the lingual osseous crest in ≈10% of tissue originating from the periodontal ligament
individuals.18 An oblique incision that terminates distal presumptively induced formation of a keratinizing oral
and medial to the distolingual line angle of the mandibular epithelium in this case.22 Alveolar bone denudation and
second molar may risk damage to the lingual nerve in wounding of the periodontal ligament at a distal wedge
some individuals. site may similarly influence the zone of attached gingiva
established. Presence of native gingiva adjacent to the
Terminal Mandibular Molar, Unfavorable distal wedge site may increase the zone of attached gingiva
Tooth-to-ramus Distance achieved, owing to granulation tissue contributions from
Clinical management. A laser-assisted distal wedge wounded gingival connective tissue.19
protocol (Fig. 13) is proposed for mandibular molars The distal wedge procedure has long been a useful
positioned close to the mandibular ramus. Flap reflection method for treating periodontitis at teeth adjacent to
is avoided in this technique. Redundant tissue on the distal edentulous sites, particularly on the distal of second

98 Clinical Advances in Periodontics, Vol. 10, No. 2, June 2020 Distal Wedge Technique Selection
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molars.1 Additionally, restora-

tive dentists depend on
periodontists to remove redun-
dant tissue distal to second
molars to facilitate restorative
treatment and enhance
oral hygiene effectiveness.
Fortunately, in many cases,
practitioners can achieve
excellent treatment outcomes
irrespective of the selected distal
wedge technique. Patients and
referring dentists expect distal
wedge procedures to accomplish
therapeutic goals without undue
morbidity; however, anatomic
limitations are sometimes
underappreciated. Despite lack
of evidence supporting a rigid
treatment algorithm, thoughtful
application of specific distal
wedge techniques may help
practitioners optimize treatment
outcomes.

FIGURE 10 Linear distal wedge technique. 10a Tooth #31 required an onlay to replace a defective composite
restoration, and the treating prosthodontist referred the patient for a distal wedge procedure prior to the
restorative phase. The tooth-to-ramus distance was minimal, and the zone of attached gingiva was ≈2 mm Conclusions
at the distobuccal aspect of the tooth. 10b On the distolingual aspect of tooth #31, moveable soft tissue
Although positive treatment
was at the level of the distal marginal ridge. 10c An oblique linear incision was planned (dotted line) from the
distolingual line angle of the tooth toward the buccal. 10d A minimal buccal flap was reflected and thinned. outcomes are achievable with
10e Gingival connective tissue was removed from the deep aspect of the flap without reducing the zone of a variety of distal wedge
attached gingiva. Minimal gingivectomy was also performed on the lingual aspect of tooth #31. 10f A sling
suture and a simple interrupted suture were used to close the wound. techniques, the various available
methods are associated with
subtle advantages and disadvantages, as reviewed in this
report. The present report offers a framework for distal
wedge technique selection based on the clinical situation.
A novel laser-assisted distal wedge protocol is proposed
for mandibular molars positioned in close proximity with
the ascending ramus.

FIGURE 11 Linear distal wedge technique. Occlusal view. FIGURE 12 Linear distal wedge technique. Lingual view. Definitive
Definitive restoration three months following linear distal restoration three months following linear distal wedge. Minor clefting
wedge. The gingiva appeared clinically healthy and probing was noted at the distolingual line angle of tooth #18. The restorative
depths were ≤3 mm. margin was supragingival.

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FIGURE 13 Laser-assisted distal wedge technique. 13a Baseline clinical appearance. The soft
tissue distal to tooth #18 partially covered the distal marginal ridge. A 7-mm probing depth was
noted on the distal of tooth #18. 13b Triangular distal wedge removed and corticotomy with
a #6 round bur. 13c Clot established with a Nd:YAG laser. Following hemostasis, laser energy
was applied in noncontact mode to dry the clot and improve wound stability. 13d Six months
following the procedure, probing depths on the distal of tooth #18 were <3 mm. The zone of
attached gingiva on the distal of tooth #18 was ≈3.5 mm in width.

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TABLE 1 Recommended Nd:YAG Laser-Assisted Distal Wedge Technique

Step Description Technique

1 Deep insertion of optical
fiber
2 Superficial insertion of
optical fiber
3 Photobiomodulation
4 Gauze and pressure
5 Additional
photobiomodulation
Following removal of the distal wedge and completion of the corticotomy, the optical fiber is
pressed firmly against the alveolar bone in the distal wedge site. The laser is activated in contact
with alveolar bone, and the fiber is withdrawn over a period of approximately one second
(3.6 watts, 650 microseconds, 20 hertz). Laser activation is terminated once the optical fiber
rises above the pooled blood surface. This process is repeated at approximately four to eight
locations within the site.
The optical fiber is inserted one millimeter below the pooled blood surface and activated for
approximately one second. This process is repeated at approximately four to eight locations
within the site. The blood begins to attain a crimson color. The total energy applied during steps
1 and 2 is limited to <200 joules.
The optical fiber is maintained approximately two to three centimeters away from the site, and the
laser is activated continuously (3.0 watts, 100 microseconds, 20 hertz). The fiber is slowly
moved in overlapping circles at the distal wedge site. The total energy applied during the
photobiomodulation step is limited to ≈200 joules. Step 3 typically dries the distal wedge site
and enhances clot stability. The clot becomes darker in color. Although the superficial surface of
the clot may appear dry, deeper portions of the clot remain less stable initially.
If blood flow is observed from beneath the dried clot surface, a gauze compress is applied, and
the patient is asked to gently bite for five minutes.
Clot stability is reassessed following five minutes of pressure. If necessary, the practitioner may
apply an additional 100 joules of laser energy using the described photobiomodulation
technique (step 3).

Acknowledgments
The views expressed in this manuscript are those of the
authors and do not necessarily reflect the official pol-
icy of the United States Government, the Department
of Defense, the Department of the Army, the United
States Army Medical Department, or the Uniformed Ser-
vices University of the Health Sciences. The authors
gratefully acknowledge the following practitioners in the
Department of Prosthodontics, Army Postgraduate Den-
tal School, Fort Gordon, Georgia, for the restorative treat-
ment presented: Dr. Rebecca H. Brim (Resident; square
distal wedge case), Dr. Patricia M. Walworth (Assistant
Professor; linear distal wedge case).
CORRESPONDENCE
Dr. Thomas M. Johnson, Department of Periodontics, Army Post-
graduate Dental School, Uniformed Services University of the Health
Sciences, 320 East Hospital Road, Fort Gordon, GA 30905. E-mail:
thomas.m.johnson34.mil@mail.mil
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