For bounded domains \(\Omega \) with Lipschitz boundary \(\Gamma \) , we investigate boundary value problems for elliptic operators with variable coefficients of fourth-order subject to Wentzell (or dynamic) boundary conditions. Using form methods, we begin by showing general results for an even wider class of operators of type \(\begin{aligned} {\mathcal {A}}=\begin{pmatrix} B^*B & 0 \\ -{\mathscr {N}}^{\mathfrak {b}}B & \gamma \end{pmatrix}, \end{aligned}\) where B is associated to a quadratic form \({\mathfrak {b}}\) and \({\mathscr {N}}^{{\mathfrak {b}}}\) an abstractly defined co-normal Neumann trace. Even in this general setting, we prove generation of an analytic semigroup on the product space \({\mathcal {H}}:=L^2(\Omega ) \times L^2(\Gamma )\) . Using recent results concerning weak co-normal traces, we apply our abstract theory to the elliptic fourth-order case and are able to fully characterize the domain in terms of Sobolev regularity for operators in divergence form \(B=-\mathop {{div} }Q \nabla \) with \(Q \in C^{1,1}({\overline{\Omega }},{\mathbb {R}}^{d\times d}),\) also obtaining Hölder-regularity of solutions. Finally, we also discuss asymptotic behavior and (eventual) positivity.