These guides are AI-generated educational summaries — not legal or medical advice.
C&P Exam Prep: Mandible, Malunion of
DBQ Overview
Interview + Physical- Form Name
- oral-and-dental
- Form Code
- oral-and-dental
- Page Count
- 7
- Examiner Type
- Dentist or Oral Surgeon
- Estimated Duration
- 20-30 minutes
- Exam Format
- Interview + Physical
What to Expect During Your Exam
Exam Overview
To document the current severity of mandibular malunion, specifically whether the healed mandible fracture has resulted in displacement causing an open bite (anterior or posterior), and to what degree, for rating purposes under DC 9904.
What the examiner evaluates:
- Confirmation of malunion diagnosis (mandible fracture healed in a misaligned or displaced position)
- Presence and degree of anterior open bite (gap between upper and lower front teeth when biting down)
- Presence and degree of posterior open bite (gap between upper and lower back teeth when biting down)
- Occlusal alignment - how the upper and lower teeth meet when the jaw is closed
- Degree of jaw displacement visible on clinical examination
- Facial asymmetry or cosmetic deformity caused by malunion
- Functional limitations including chewing, biting, and speaking
- Pain or tenderness associated with the malunited fracture site
- Any secondary complications such as temporomandibular joint (TMJ) dysfunction, periodontal disease, or tooth loss attributable to the malunion
- Review of prior diagnostic imaging confirming malunion (X-rays, CT scans, panoramic radiographs)
- Treatment history including surgeries, orthodontics, splinting, or other therapeutic procedures
The exam typically occurs in a dental clinic or examination room equipped with a dental chair and lighting. The examiner will conduct a hands-on intraoral and extraoral examination. Bring all prior dental imaging, treatment records, and a written summary of your symptoms. You have the right to record the exam in most states - notify the examiner before beginning.
Typical duration: 20-30 minutes
Open Bite Measurement (Anterior)
The vertical gap in millimeters between the upper and lower front teeth when the jaw is in maximum intercuspation (fully closed). An anterior open bite means the front teeth do not contact when the back teeth are together.
What to expect:
The examiner will ask you to bite down as naturally as possible and will visually inspect and possibly measure the vertical gap between your upper and lower anterior teeth. They may use a periodontal probe or ruler to measure in millimeters.
Key thresholds:
- Severe anterior or posterior open bite displacement — 20% rating under DC 9904
- Moderate anterior or posterior open bite displacement — 10% rating under DC 9904
- Displacement not causing anterior or posterior open bite — 0% rating under DC 9904 - consider whether nonunion (DC 9903) is more appropriate
Tips:
- Bite down the way you naturally and comfortably close your jaw - do not force your teeth together in an unnatural position.
- If your bite feels different on a bad day versus a good day, mention this to the examiner.
- Point out exactly where your teeth do not meet - the examiner may focus only on one area.
- If you have been wearing a dental appliance that affects your bite, inform the examiner and bring it to the exam.
Pain considerations: If closing your jaw fully causes pain or discomfort, inform the examiner before and during testing. Document that pain limits your ability to achieve full occlusion, as this functional limitation is relevant to your overall assessment.
Open Bite Measurement (Posterior)
The vertical gap between the upper and lower posterior (back/molar) teeth when the jaw is fully closed, indicating lateral or posterior mandibular displacement from malunion.
What to expect:
The examiner will inspect the posterior occlusal surfaces bilaterally when you bite down. They will assess whether the molars and premolars make proper contact or whether a gap exists on one or both sides.
Key thresholds:
- Severe posterior open bite — 20% rating under DC 9904
- Moderate posterior open bite — 10% rating under DC 9904
- No posterior open bite despite displacement — 0% rating under DC 9904
Tips:
- Bite down naturally - do not compensate or shift your jaw to make teeth meet.
- Tell the examiner if you consciously shift your jaw to compensate for the malunion; this masking behavior can underestimate your true open bite.
- Describe whether the gap or malocclusion has worsened or improved over time.
- Mention any dental work (crowns, dentures, implants) that may affect occlusal contact but does not correct the underlying malunion.
Pain considerations: Note any pain when chewing hard foods due to uneven occlusal loading caused by the posterior open bite. This functional pain is directly relevant to rating severity.
Radiographic / Diagnostic Imaging Review
Confirmation of the malunion - healed mandibular fracture with anatomical displacement from normal alignment, distinct from nonunion (which involves failure of the fracture to heal/unite).
What to expect:
The examiner will review existing X-rays, panoramic radiographs (panorex), or CT scans. New imaging may be ordered if recent studies are unavailable. The imaging confirms the fracture has healed but in a displaced or maligned position.
Key thresholds:
- Imaging confirms healed fracture with displacement — Supports DC 9904 malunion diagnosis; severity determined by open bite measurement
- Imaging shows non-healed fracture fragments with mobility — May support DC 9903 (nonunion) rather than DC 9904 - potentially higher rating of 10-30%
Tips:
- Bring all dental and maxillofacial imaging from both service and post-service treatment.
- If imaging was taken in service or shortly after discharge, those films are especially important - request copies from your records.
- Ask the examiner to confirm whether the imaging shows true malunion versus nonunion, as the distinction affects your rating.
- CT scans provide more detail than panoramic X-rays for evaluating displacement - mention if a CT was performed.
Pain considerations: Not directly applicable, but note that imaging findings of malunion near the TMJ or condyle may warrant evaluation of secondary TMJ dysfunction.
Occlusal / Bite Functional Assessment
How the mandibular malunion affects your functional ability to bite, chew, and speak - including which foods you can and cannot eat, and daily activities impacted by the malocclusion.
What to expect:
The examiner may ask you to demonstrate biting, ask about your diet restrictions, and assess the functional consequence of the open bite or displacement. This is primarily a clinical and history-based assessment.
Key thresholds:
- Severe functional limitation - unable to bite or chew normally, restricted diet — Supports severe open bite finding at 20%
- Moderate functional limitation - difficulty chewing hard or tough foods — Supports moderate open bite finding at 10%
Tips:
- Be specific about which foods you cannot eat or must modify (cut into small pieces, avoid hard/crunchy textures).
- Describe your worst-day functional capacity - not your best-case day.
- Mention if the open bite causes problems with speech clarity, especially consonants that require tooth-lip or tooth-tongue contact.
- Note any weight changes or nutritional impacts from dietary restrictions caused by your bite problem.
Pain considerations: If chewing causes jaw pain, fatigue, or muscle soreness, describe the onset, duration, and intensity. This is relevant to overall functional impairment even though DC 9904 rates primarily on open bite geometry.
Rating Criteria Breakdown
| Rating % | Criteria | Key Symptoms |
|---|---|---|
| 20% | Mandibular malunion with displacement causing severe anterior or posterior open bite. The healed mandible fracture has resulted in significant misalignment where the upper and lower teeth are unable to contact in the anterior or posterior region, creating a substantial vertical gap that severely limits normal occlusal function. |
CFR: 38 CFR 4.150, DC 9904: 'Displacement, causing severe anterior or posterior open bite - 20' |
| 10% | Mandibular malunion with displacement causing moderate anterior or posterior open bite. The healed fracture has resulted in misalignment producing a moderate vertical gap between teeth, causing meaningful but not severe functional limitation in biting and chewing. |
CFR: 38 CFR 4.150, DC 9904: 'Displacement, causing moderate anterior or posterior open bite - 10' |
| 0% | Mandibular malunion with displacement that does not cause anterior or posterior open bite. The fracture has healed in a displaced position, but the occlusion (bite) is not significantly disrupted - teeth still make contact in a functional pattern despite the malunion. |
CFR: 38 CFR 4.150, DC 9904: 'Displacement, not causing anterior or posterior open bite - 0'. Note: If a 0% rating is assigned, consider whether the veteran's mandibular condition might be more accurately evaluated under DC 9903 (nonunion) if imaging reveals failure of bone union rather than healed malunion. |
20% Mandibular malunion with displacement causing severe anterio ...
Mandibular malunion with displacement causing severe anterior or posterior open bite. The healed mandible fracture has resulted in significant misalignment where the upper and lower teeth are unable to contact in the anterior or posterior region, creating a substantial vertical gap that severely limits normal occlusal function.
Key Symptoms
- Large vertical gap between upper and lower teeth when biting down (anterior or posterior)
- Severe inability to bite through foods with the front teeth (anterior open bite) or inability to chew properly on the posterior teeth (posterior open bite)
- Significant facial asymmetry or jaw deviation resulting from displaced malunion
- Marked difficulty eating a normal diet - restricted to soft or liquid foods
- Speech impairment due to inability of teeth to form proper contact for certain sounds
- Chronic jaw pain or discomfort due to compensatory muscle strain from severe malocclusion
- Compensatory jaw shifting or posturing to achieve any tooth contact
CFR: 38 CFR 4.150, DC 9904: 'Displacement, causing severe anterior or posterior open bite - 20'
10% Mandibular malunion with displacement causing moderate anter ...
Mandibular malunion with displacement causing moderate anterior or posterior open bite. The healed fracture has resulted in misalignment producing a moderate vertical gap between teeth, causing meaningful but not severe functional limitation in biting and chewing.
Key Symptoms
- Noticeable but moderate gap between upper and lower teeth when biting down
- Moderate difficulty biting through foods - must cut food or avoid hard/chewy textures
- Visible jaw displacement or facial asymmetry of moderate degree
- Periodic jaw pain or muscle fatigue associated with the malocclusion
- Some limitation in diet but still able to consume a variety of soft-to-normal foods
- Occasional difficulty with speech production
CFR: 38 CFR 4.150, DC 9904: 'Displacement, causing moderate anterior or posterior open bite - 10'
0% Mandibular malunion with displacement that does not cause an ...
Mandibular malunion with displacement that does not cause anterior or posterior open bite. The fracture has healed in a displaced position, but the occlusion (bite) is not significantly disrupted - teeth still make contact in a functional pattern despite the malunion.
Key Symptoms
- Healed mandible fracture confirmed by imaging showing displacement
- Teeth still achieve contact when biting despite the malunion
- Minimal or no open bite gap present
- Possible minor facial asymmetry
- Possibly mild occlusal irregularity without functional open bite
CFR: 38 CFR 4.150, DC 9904: 'Displacement, not causing anterior or posterior open bite - 0'. Note: If a 0% rating is assigned, consider whether the veteran's mandibular condition might be more accurately evaluated under DC 9903 (nonunion) if imaging reveals failure of bone union rather than healed malunion.
How to Describe Your Symptoms
Open Bite / Occlusal Gap
How to describe:
Describe the specific gap you notice when you bite down - whether it is in the front (anterior) or back (posterior) of your mouth, how large it feels, and whether you can close your front or back teeth together at all. Use concrete examples: 'When I bite down, my front teeth have a gap the width of my pinky finger and never touch.'
Worst-day example:
“On my worst days, when my jaw muscles are fatigued or inflamed, the gap between my front teeth widens further and I cannot bite into anything at all - not even soft bread. I have to tear food with my hands and chew only on one side of my back teeth, which causes that side to ache after eating.”
What the examiner listens for:
Specific description of whether the open bite is anterior, posterior, or both; whether it is constant or variable; the functional consequence in terms of diet and eating ability; and whether the gap has changed since the original fracture healed.
Understatements to avoid:
Do not say 'my bite is a little off' if it significantly limits your ability to eat normally. The distinction between 'moderate' and 'severe' open bite is critical to your rating - be precise and thorough in describing the gap and its functional consequences.
Functional Eating and Dietary Limitations
How to describe:
List specific foods you can no longer eat or must significantly modify. Be concrete: 'I cannot bite into an apple, sandwich, or burger. I must cut all food into small pieces. I avoid steak, crusty bread, raw vegetables, and anything chewy. I have lost weight because eating is difficult and frustrating.'
Worst-day example:
“On my worst days, jaw pain combined with my open bite means I can only tolerate soft foods like yogurt, mashed potatoes, or soup. Chewing causes the muscles on my jaw to ache and fatigue within minutes, so I stop eating before I am full. My family has noticed I avoid eating in public because of how I have to manage food.”
What the examiner listens for:
Specific food restrictions, dietary changes, weight loss or nutritional concerns, social and psychological impact of eating difficulties, and consistency between reported limitations and clinical findings.
Understatements to avoid:
Do not minimize dietary restrictions by saying 'I manage okay.' If you have permanently changed your diet or eating habits because of your jaw, that is a significant functional impairment that must be documented clearly.
Pain and Jaw Discomfort
How to describe:
Describe the location, type, frequency, and severity of pain on a 0-10 scale. Note whether pain occurs at rest, with movement, or specifically with eating. Describe how long pain lasts after a meal or jaw use, and whether it radiates to the ear, temple, or neck.
Worst-day example:
“On my worst days, my jaw aches constantly at a 7 out of 10. After trying to eat even a soft meal, the pain spikes to a 9 and lasts for one to two hours. I have to apply ice and take over-the-counter pain medication multiple times a week. The pain also radiates into my right ear and temple, making it hard to concentrate.”
What the examiner listens for:
Pain characteristics that indicate functional limitation beyond the mechanical open bite - chronic myofascial pain, referred pain patterns, and the degree to which pain limits normal activity. While DC 9904 does not independently rate pain, it provides context for severity classification.
Understatements to avoid:
Do not say 'it only hurts when I eat something hard' if you actually avoid most foods to prevent pain. The full picture of pain-driven avoidance behavior is important context even for a dental DBQ.
Speech and Communication Difficulties
How to describe:
Describe specific sounds or words that are difficult to produce due to your open bite. For example: 'I have trouble making the 's', 'f', 'v', and 'th' sounds clearly because my teeth do not come together properly. People frequently ask me to repeat myself, and I avoid phone calls or speaking in meetings at work.'
Worst-day example:
“On my worst days, the combination of jaw pain and my bite misalignment makes my speech noticeably slurred. I avoided a work presentation last month because I was embarrassed by my speech and the pain of talking for extended periods.”
What the examiner listens for:
Concrete examples of speech impairment related to dental occlusion, social and occupational impact of communication difficulties, and whether the veteran demonstrates perceptible speech changes during the exam itself.
Understatements to avoid:
Do not dismiss speech effects by saying 'people can understand me most of the time.' If you have modified your communication behavior, avoided situations, or received comments about your speech since the malunion, describe this honestly and specifically.
Facial Asymmetry and Cosmetic Impact
How to describe:
Describe any visible facial asymmetry - jaw deviation, chin displacement, or changes to your facial profile caused by the malunion. Note whether this has caused social or psychological difficulties and whether it was not present before your service-related jaw fracture.
Worst-day example:
“The displacement of my jaw is visible in photos - my chin is shifted to the right and my face looks asymmetrical. I avoid having my photo taken and feel self-conscious in social situations. Several people have asked what happened to my jaw, which is a constant reminder of my injury.”
What the examiner listens for:
Observable facial asymmetry that correlates with the malunion displacement, and any documented psychological or social impact. While cosmetic deformity alone does not affect the DC 9904 rating, it corroborates the severity of displacement.
Understatements to avoid:
Do not omit cosmetic changes if they exist - they support the overall picture of displacement severity and may be relevant to secondary claims or separate compensation.
Common Mistakes to Avoid
Demonstrating the best possible bite rather than the natural resting bite
Some veterans unconsciously shift or force their jaw to make teeth meet as closely as possible during the exam, masking the true open bite caused by the malunion.
Instead: When the examiner asks you to bite down, close your jaw naturally and comfortably without deliberate correction or shifting. If you habitually compensate, tell the examiner: 'I naturally shift my jaw to try to make my teeth meet, but my jaw doesn't actually line up this way.'
Impact: Could incorrectly reduce from 20% to 10% or 10% to 0%
Failing to bring prior imaging or treatment records
The examiner needs to confirm the malunion diagnosis and review the degree of displacement. Without imaging, they may need to order new studies, delaying the exam, or may base the assessment only on current clinical findings that may not fully reflect the history.
Instead: Gather all panoramic X-rays, CT scans, maxillofacial surgical records, and treatment notes from both service and post-service care. Bring physical copies or ensure they are in your VA records before the exam.
Impact: Could affect diagnosis confirmation and severity classification at all levels
Describing only current 'average' or 'good day' symptoms
Per M21-1 guidance, ratings should reflect the overall severity including worst-day presentations, not a best-case average. Veterans often minimize symptoms or describe a day when symptoms are managed.
Instead: When describing your condition, explicitly frame your answers around your worst days: 'On my worst days, which happen several times a month, my open bite is at its most pronounced and I cannot eat solid food at all.'
Impact: Could affect the distinction between moderate (10%) and severe (20%) classification
Not mentioning secondary conditions caused by the malunion
Mandibular malunion can cause or aggravate TMJ dysfunction, periodontal disease around teeth under abnormal occlusal stress, tooth wear, or even sleep apnea from airway changes. These secondary conditions may be separately ratable.
Instead: Tell the examiner about any conditions you believe were caused or worsened by your jaw malunion, including TMJ clicking or pain, headaches, ear pain, sleep disturbances, or accelerated tooth wear. Ask the examiner to note these associations in the DBQ.
Impact: Relevant to secondary service connection claims beyond the DC 9904 rating
Assuming the condition rates only at 0% because it 'healed'
Many veterans believe that because their fracture healed, it no longer counts as a disability. Malunion by definition means it healed incorrectly, and the resulting open bite can rate at 10% or 20%.
Instead: Understand that malunion - healing in a displaced position - is itself the disability. Focus the exam conversation on the current functional consequences of how the bone healed, not whether it healed.
Impact: Could result in failure to claim the condition at all
Not distinguishing malunion (DC 9904) from nonunion (DC 9903)
Nonunion (failure to heal) under DC 9903 can rate up to 30% if severe with false motion, while malunion tops out at 20%. If imaging actually shows nonunion, the veteran may be rated under the wrong diagnostic code.
Instead: Review your imaging reports. If the fracture fragments are still mobile or have not fully united, ask the examiner whether DC 9903 (nonunion) may apply. You can note: 'My surgeon mentioned the fracture may not have fully healed - could you evaluate whether this meets criteria for nonunion?'
Impact: Could affect eligibility for 30% rating under DC 9903 versus 20% under DC 9904
Not describing all activities of daily living affected by the jaw malunion
The DBQ includes a functional impact section, and a thorough description of how the condition affects daily life strengthens the rating decision. Omitting occupational, social, and daily functional effects results in an incomplete record.
Instead: Prepare specific examples of how your jaw condition affects work, eating, socializing, speaking, and sleep. The examiner must document functional impact - help them do so by providing detailed, concrete information.
Impact: Affects functional impact documentation across all rating levels
Prep Checklist
Before Your Exam
Day Of
During the Exam
After the Exam
Your Rights During a C&P Exam
- You have the right to record your C&P examination in most states - notify the examiner before beginning and check your state's consent laws.
- You have the right to request a copy of the completed DBQ through your VA eFolder or by asking your VSO.
- You have the right to request a new or supplemental examination if the DBQ is inadequate - for example, if the examiner did not review relevant records, did not address your primary claimed condition, or the report contains factual errors.
- You have the right to submit additional lay evidence and personal statements (VA Form 21-4138) to supplement the C&P exam findings at any time before a rating decision is issued.
- You have the right to have your worst-day symptoms considered - the rating is intended to reflect the overall disability picture, including periods of increased severity, not just your average or best-case presentation.
- You have the right to bring a support person (such as a VSO representative, family member, or caregiver) to your C&P examination. Inform the VA scheduling office in advance.
- You have the right to review your VA claims file (C-file) at any time, which includes all medical evidence, DBQs, and rating decisions. Request access through your VSO or directly from the VA.
- You have the right to appeal a rating decision you believe is incorrect using the Supplemental Claim, Higher-Level Review, or Board of Veterans' Appeals lanes under the Appeals Modernization Act (AMA).
- You have the right to request that the VA consider all potentially applicable diagnostic codes - including whether DC 9903 (nonunion) may be more appropriate than DC 9904 (malunion) based on your imaging findings.
- You have the right to a favorable interpretation of the evidence under the benefit-of-the-doubt standard (38 CFR 3.102) - when evidence is in approximate balance, it should be resolved in your favor.
Related Conditions
- Mandible, Nonunion of DC 9903 rates mandibular nonunion (failure of the fracture to fully heal/unite), confirmed by diagnostic imaging, at up to 30% (severe with false motion) or 10% (moderate without false motion). Veterans should ensure their condition is correctly classified as malunion versus nonunion, as nonunion may warrant a higher rating.
- Maxilla, Malunion or Nonunion of DC 9916 rates maxillary malunion or nonunion up to 30%. Veterans with combined maxillary and mandibular injuries may have claims under both codes. The rating criteria for maxillary malunion parallel DC 9904 but include additional severity levels.
- Temporomandibular Disorder (TMD) Mandibular malunion can cause or aggravate TMJ dysfunction through altered bite mechanics and abnormal joint loading. TMD is rated under a separate DBQ and diagnostic code. If TMJ symptoms developed after or due to the malunion, secondary service connection may be warranted.
- Limitation of Motion of the Temporomandibular Joint Malunion of the mandible, particularly involving the condyle or ramus, can result in restricted jaw opening (trismus) or lateral deviation. This may be separately evaluated under DC 9905 if limitation of temporomandibular joint motion is present.
- Loss of Teeth (Non-Periodontal) Trauma causing mandibular fracture and subsequent malunion may also result in loss of teeth due to reasons other than periodontal disease, separately ratable under applicable dental diagnostic codes. Tooth loss from the original fracture event or surgical intervention may be compensable.
- Soft Tissue Injury of the Mouth The traumatic event causing mandibular fracture may have also caused soft tissue injuries to the lips, tongue, or oral mucosa. These may be separately ratable if they resulted in residual scarring, functional limitation, or disfigurement.
- Osteomyelitis of the Mandible Mandibular fractures, particularly open or contaminated fractures, carry risk of osteomyelitis (bone infection). If osteomyelitis developed in connection with the fracture or surgical repair, it may be separately compensable under the appropriate diagnostic code.
Get Personalized C&P Exam Preparation
Upload your medical records for AI-powered prep that maps YOUR symptoms to the exact DBQ fields your examiner will evaluate.
This C&P exam preparation guide is for educational purposes only and does not constitute legal, medical, or claims advice. Always consult with a qualified Veterans Service Organization (VSO) representative or VA-accredited attorney for guidance specific to your claim. Never exaggerate, minimize, or fabricate symptoms during a C&P examination.