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C&P Exam Prep: Mandible, Nonunion 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 nonunion, confirm diagnosis via diagnostic imaging, and determine whether false motion is present, which directly determines the assigned disability rating under DC 9903.
What the examiner evaluates:
- Presence and confirmation of mandibular nonunion via diagnostic imaging (X-ray, CT scan, MRI, panoramic/intraoral imaging)
- Presence or absence of false motion (abnormal mobility between mandibular fracture fragments)
- History and onset of the mandibular fracture or condition and its course since service
- Current functional limitations including chewing, speech, swallowing, and mouth opening
- Presence of associated conditions such as osteomyelitis, osteoradionecrosis, or osteonecrosis of the jaw
- Any prior surgical or non-surgical treatments including open reduction, internal fixation, bone grafting, or radiation therapy
- Pain levels at rest and with use, including worst-day presentation
- Impact on daily activities, employment, and nutrition
- Dental complications such as malocclusion, tooth loss, or periodontal disease attributable to the nonunion
- Concomitant TMJ limitation of motion secondary to mandibular nonunion
The exam is typically conducted in a dental or oral surgery clinic setting. The examiner will review imaging and perform a direct clinical assessment of the mandible. If conducted via telehealth, note that some physical assessments may be limited; you have the right to request an in-person examination if you believe a records-only or telehealth review is inadequate for capturing your functional deficits.
Typical duration: 20-30 minutes
Assessment for False Motion
Abnormal mobility or movement between the separated fragments of the mandible, which is the single most critical determinant under DC 9903. False motion = 30%; absence of false motion = 10%.
What to expect:
The examiner will manually palpate the mandible along the fracture site and may ask you to open and close your mouth slowly while they apply gentle pressure to assess whether the bone segments move independently. This may cause discomfort or pain.
Key thresholds:
- False motion present — 30% rating under DC 9903 - Severe
- No false motion present — 10% rating under DC 9903 - Moderate
Tips:
- Tell the examiner immediately if palpation causes pain - pain during the false-motion assessment is clinically relevant.
- Do not clench your jaw or resist the examiner's assessment; allow natural movement so an accurate evaluation can occur.
- If you feel clicking, grinding, or abnormal shifting at the fracture site during daily activities, describe this clearly to the examiner.
- Bring imaging reports that already document nonunion, as the diagnosis must be confirmed by diagnostic imaging for rating purposes.
Pain considerations: Pain at the fracture site with mandibular movement is a symptom that supports the severity of the nonunion. Clearly communicate any pain experienced during the examination itself, as well as pain during eating, speaking, yawning, or other daily jaw movements.
Diagnostic Imaging Review
Radiographic or imaging confirmation of mandibular nonunion - a required element of DC 9903 rating. Without imaging confirmation, the condition cannot be rated under this code.
What to expect:
The examiner will review existing imaging (panoramic X-rays, CT scans, MRI, cone-beam CT) or may order new imaging during or around the exam. You should bring all relevant imaging records, reports, and dates.
Key thresholds:
- Imaging confirms nonunion — Rating under DC 9903 becomes applicable - 10% or 30% depending on false motion
- No imaging confirmation available — Rating under DC 9903 may not apply; examiner must note the absence or order imaging
Tips:
- Ensure your imaging records are in your VA Claims File (C-File) before the exam by submitting them with your claim or at the exam.
- If you have private dental or oral surgery imaging, bring physical copies or a CD/USB to the exam.
- Ask the examiner to document the date and type of imaging reviewed in the DBQ.
- A CT scan provides more detailed cross-sectional views than a panoramic X-ray and may better demonstrate the fracture gap.
Pain considerations: N/A - imaging is a passive diagnostic test, but notify staff if positioning for imaging (e.g., biting on an intraoral sensor) causes jaw pain.
Mandibular Range of Motion and Functional Assessment
The functional capacity of the mandible, including mouth opening, lateral excursion, protrusion, and impact on mastication and speech. While not the primary rating criterion under DC 9903, functional limitations support the overall severity narrative and may trigger additional rating considerations (e.g., TMJ limitation of motion under DC 9905).
What to expect:
The examiner may measure maximum interincisal opening (mouth opening in millimeters) and assess lateral jaw movement. Normal mouth opening is approximately 40-50mm. You may be asked to bite, chew, or speak.
Key thresholds:
- Maximum interincisal opening less than 10mm — May support additional rating under DC 9905 for TMJ limitation of motion
- Maximum interincisal opening 10-20mm — May support additional rating under DC 9905 at moderate level
- Maximum interincisal opening 20-40mm — May support rating under DC 9905 at mild level
Tips:
- Perform your mouth opening slowly and only to your comfortable maximum - do not force beyond your pain limit.
- Inform the examiner if your jaw locks, catches, deviates to one side, or produces clicking or crepitus during opening.
- Describe how eating specific foods (hard, chewy, crunchy) aggravates your jaw or causes pain.
- Note whether you have modified your diet (e.g., soft foods only) because of your mandibular condition - this is a key functional impact.
Pain considerations: Report pain with jaw movement accurately, including at what point in the range of motion pain begins and its severity on a 0-10 scale. This helps establish the functional impact beyond what the physical measurement alone shows.
Rating Criteria Breakdown
| Rating % | Criteria | Key Symptoms |
|---|---|---|
| 30% | Mandibular nonunion confirmed by diagnostic imaging studies - Severe, with false motion. False motion means the separated bone fragments of the mandible move abnormally and independently relative to each other, demonstrating failure of bony union. |
CFR: 38 CFR 4.150, DC 9903: 'Severe, with false motion - 30%' |
| 10% | Mandibular nonunion confirmed by diagnostic imaging studies - Moderate, without false motion. The fracture fragments have not united but do not exhibit abnormal independent mobility. |
CFR: 38 CFR 4.150, DC 9903: 'Moderate, without false motion - 10%' |
30% Mandibular nonunion confirmed by diagnostic imaging studies ...
Mandibular nonunion confirmed by diagnostic imaging studies - Severe, with false motion. False motion means the separated bone fragments of the mandible move abnormally and independently relative to each other, demonstrating failure of bony union.
Key Symptoms
- Palpable or observable movement between mandibular fracture fragments
- Pain with mandibular movement at the fracture site
- Difficulty chewing, biting, or speaking due to mandibular instability
- History of failed fracture healing despite treatment
- Abnormal mandibular mechanics causing malocclusion or jaw deviation
- Chronic pain at the fracture site
- Possible associated osteomyelitis or infection at the nonunion site
CFR: 38 CFR 4.150, DC 9903: 'Severe, with false motion - 30%'
10% Mandibular nonunion confirmed by diagnostic imaging studies ...
Mandibular nonunion confirmed by diagnostic imaging studies - Moderate, without false motion. The fracture fragments have not united but do not exhibit abnormal independent mobility.
Key Symptoms
- Imaging-confirmed fracture gap with no bony bridging
- Pain at the fracture site with jaw use
- Mild to moderate difficulty chewing firm or hard foods
- Possible malocclusion or bite asymmetry
- Jaw fatigue with prolonged talking or eating
- Localized tenderness to palpation at the fracture site
- No palpable independent movement of bone fragments
CFR: 38 CFR 4.150, DC 9903: 'Moderate, without false motion - 10%'
How to Describe Your Symptoms
False Motion and Mandibular Instability
How to describe:
Describe any sensation of movement, shifting, clicking, or instability at the fracture site during jaw use. Use specific language: 'I can feel the bone shift when I open my mouth wide,' or 'When I bite down, I feel movement at the break site, not just pain.' Explain when this occurs and what activities trigger it.
Worst-day example:
“On my worst days, any attempt to chew causes the fracture site to shift noticeably. I cannot bite into anything without my jaw feeling like it is going to give way. I can physically feel one side of my jaw moving differently from the other side. I have to hold my jaw steady with my hand when I try to eat.”
What the examiner listens for:
The examiner is specifically listening for patient-reported descriptions of fragment mobility that correlate with the clinical palpation findings. Spontaneous descriptions of false motion from the veteran strongly support the 30% rating level.
Understatements to avoid:
Do not say 'my jaw is just a little loose sometimes' if you are actually experiencing significant fragment movement. The difference between false motion and no false motion is the entire difference between a 30% and a 10% rating - describe this accurately and completely.
Pain During Jaw Function
How to describe:
Describe pain at the fracture site specifically - not just general jaw pain. Indicate the pain location (e.g., left body of mandible, angle, symphysis), intensity on a 0-10 scale, what triggers it (chewing, speaking, yawning, laughing, clenching), and how long it lasts after the triggering activity.
Worst-day example:
“On my worst days, even speaking for more than a few minutes causes sharp pain rated 8 out of 10 at the fracture site. I cannot eat anything other than liquid or very soft foods. After attempting to eat a soft sandwich, the pain at the nonunion site lasted three to four hours. I took over-the-counter pain medication twice that day and it only partially helped.”
What the examiner listens for:
Specific, located pain that is associated with mandibular function and correlates anatomically with the nonunion site. The examiner needs to distinguish fracture-site pain from general dental pain or TMJ pain.
Understatements to avoid:
Do not minimize pain by saying 'it is not that bad' or 'I manage okay.' Describe your worst days and the specific functional limitations pain creates. The examiner rates based on the full spectrum of your condition.
Functional Limitations - Chewing and Diet
How to describe:
Be specific about dietary modifications you have been forced to make because of the mandibular nonunion. Name specific foods you can no longer eat. Quantify the impact: 'I used to eat a regular diet but now I can only eat foods that require no chewing.' Explain the nutritional and quality-of-life consequences.
Worst-day example:
“On my worst days I subsist entirely on protein shakes, yogurt, and soup because any chewing triggers immediate pain and shifting at the fracture site. I have lost weight because of this dietary restriction. I cannot eat at restaurants or social gatherings without embarrassment because I cannot eat what is served.”
What the examiner listens for:
Evidence that the nonunion has materially altered the veteran's ability to maintain adequate nutrition and normal social participation through meals. Diet modification is a recognized functional impact that reinforces severity.
Understatements to avoid:
Do not say 'I can eat most things if I am careful.' If you have meaningfully changed what you eat because of your jaw, state that clearly and specifically.
Impact on Speech and Communication
How to describe:
Describe any difficulty with speech articulation, slurring, pain during prolonged speaking, or social/occupational avoidance caused by jaw pain or instability. Quantify how long you can speak before pain begins.
Worst-day example:
“On my worst days, I can only speak in short sentences before the pain and fatigue at the fracture site become unbearable. I have stopped participating in long phone calls or meetings. My speech is sometimes slurred when the jaw shifts during talking, which causes me significant embarrassment.”
What the examiner listens for:
Functional communication deficits that go beyond subjective discomfort and affect the veteran's daily life, employment, and social engagement.
Understatements to avoid:
Do not omit speech limitations simply because the primary complaint is pain. Communication impact is a meaningful functional dimension of mandibular nonunion that should be documented.
History of Injury and Treatment
How to describe:
Provide a clear chronological account: the in-service event that caused the mandibular fracture (combat injury, training accident, vehicle accident, assault), all treatments received (closed reduction, ORIF, bone grafting, external fixation, hyperbaric oxygen), and why healing failed. Include dates of surgeries, hospitalizations, and follow-up imaging.
Worst-day example:
“N/A - this is historical factual information, not a worst-day description. Be thorough and accurate.”
What the examiner listens for:
A coherent nexus between a service event and the fracture, documentation of failed healing attempts, and evidence that the nonunion is a chronic, persistent condition rather than an acute healing issue.
Understatements to avoid:
Do not assume the examiner has read your service records. Verbally narrate the in-service injury and its treatment history clearly and completely, even if it is documented elsewhere.
Common Mistakes to Avoid
Failing to clarify whether false motion is present
The single most consequential rating distinction under DC 9903 is whether false motion is present (30%) or absent (10%). Veterans who do not clearly describe or demonstrate fragment mobility may be rated at 10% even when false motion exists.
Instead: Before the exam, reflect carefully on whether you have ever felt, heard, or been told that the fracture fragments move independently. If you have experienced this, describe it in detail using your own words during the exam. Bring any prior clinical notes or imaging reports that document false motion.
Impact: 30% vs. 10%
Not bringing diagnostic imaging to the exam
DC 9903 explicitly requires that nonunion be 'confirmed by diagnostic imaging studies.' Without imaging, the examiner cannot rate under this code, and the claim may be deferred or denied.
Instead: Gather all available imaging (panoramic X-rays, CT scans, MRI, CBCT) from VA facilities, military treatment facilities, and private providers. Submit copies to VA before the exam and bring originals or digital copies on the day of the exam.
Impact: 10% and 30% - both levels require imaging confirmation
Describing average days rather than worst days
VA rating instructions and M21-1 guidance direct examiners to consider the full range of a veteran's disability, including worst-day presentations. Veterans who only describe their best or average days systematically underrepresent their condition.
Instead: Prepare specific, concrete worst-day examples before the exam. Think about the most symptomatic episode in the past month or the past year. Describe that episode in detail - what happened, what you could not do, how long it lasted, and what relief, if any, you obtained.
Impact: Both rating levels
Omitting dietary modifications and nutritional impact
Diet modification is a key functional indicator of mandibular nonunion severity. Examiners recording functional impact on DBQ fields need concrete examples. Vague statements like 'I watch what I eat' do not convey the severity of restriction.
Instead: Name specific foods you can no longer eat. State whether you have lost weight or suffered nutritional deficiency. Describe whether you use a liquid or pureed diet regularly and under what circumstances.
Impact: Functional impact documentation supports both 10% and 30% levels
Not mentioning associated conditions that could receive separate ratings
Mandibular nonunion can cause or coexist with TMJ limitation of motion (DC 9905), malunion (DC 9904), osteomyelitis of the jaw (DC 9904), dental loss (DC 9913), and malocclusion. If these are not mentioned, they may not be evaluated or separately rated.
Instead: Proactively mention all related symptoms and conditions to the examiner: jaw clicking or locking, bite asymmetry, tooth loss attributable to the fracture, open bite, and any history of jaw infection. Ask the examiner to document all conditions noted.
Impact: Separate ratings for related conditions
Underreporting pain because the condition is oral/dental in nature
Veterans sometimes assume dental pain is less significant or less ratable than musculoskeletal pain. All pain that affects function, sleep, nutrition, speech, and quality of life is relevant and should be fully reported.
Instead: Rate your pain on a 0-10 scale. Describe its character (sharp, aching, throbbing, burning), frequency, duration, and triggers. Describe what you cannot do because of pain and how it affects sleep, work, and social activities.
Impact: Both 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 a thorough, adequate C&P examination. If the examiner does not review your imaging, fails to assess for false motion, or conducts an unreasonably brief examination, the resulting opinion may be challenged as inadequate under Barr v. Nicholson, 21 Vet. App. 303 (2007).
- You have the right to know the diagnosis being evaluated. The examiner must confirm the diagnosis in the DBQ. Under DC 9903, nonunion must be confirmed by diagnostic imaging, and you should ensure the examiner documents the specific imaging reviewed.
- You have the right to request an in-person examination. If you are scheduled for a telehealth or records-only review and believe a physical examination is necessary to accurately document false motion and functional limitations, you may request that the exam be conducted in person.
- You have the right to record your C&P examination in most states. Single-party consent recording is permitted in the majority of U.S. states. Research your state's law and, if permitted, you may record the exam using a smartphone or recording device.
- You have the right to be accompanied by a representative or support person. You may bring a VSO representative, accredited claims agent, VA-accredited attorney, or a trusted support person to your C&P examination.
- You have the right to submit buddy statements and personal statements. Evidence submitted by the veteran, family members, friends, and coworkers describing the functional impact of the condition will be considered by the rater and should be submitted before the exam date.
- You have the right to submit a private independent medical opinion (IMO). A private dentist or oral surgeon can examine you and provide a nexus opinion or severity opinion that VA must consider under Walters v. Principi, 15 Vet. App. 522 (2002).
- You have the right to the benefit of the doubt. Under 38 U.S.C. 5107(b), when there is an approximate balance of positive and negative evidence, VA must resolve the doubt in the veteran's favor. This applies to questions such as whether false motion is present.
- You have the right to challenge a rating decision based on an inadequate examination. If the C&P examiner failed to address false motion, failed to review imaging, or provided a conclusory opinion without explanation, you can argue the examination was inadequate and request a new one.
Related Conditions
- Mandible, Malunion of Related jaw bone healing complication under 38 CFR 4.150. Malunion (DC 9904) involves healed but misaligned bone, while nonunion (DC 9903) involves failure to heal. Both can coexist if partial union occurred with displacement and remaining nonunion fragments. Rated separately if applicable.
- Temporomandibular Disorder (TMD) Mandibular nonunion at or near the ramus or condyle can cause or exacerbate temporomandibular joint dysfunction, resulting in limited jaw opening, clicking, locking, and pain. Evaluated separately under the TMD DBQ if present.
- Maxilla, Malunion or Nonunion of DC 9916 covers maxillary nonunion and malunion. When both mandibular and maxillary fractures occurred from the same in service event (e.g., blast injury or facial trauma), both may be ratable as separate disabilities.
- Limitation of Motion of Temporomandibular Joint Mandibular nonunion can restrict jaw opening and movement, potentially supporting a separate or combined rating under DC 9905 for temporomandibular joint limitation of motion if documented by measurement.
- Osteomyelitis of the Jaw Nonunion sites are susceptible to chronic infection. Osteomyelitis, osteoradionecrosis, or osteonecrosis of the jaw at or near the nonunion site may be separately ratable and should be documented during the C&P exam.
- Loss of Teeth (Traumatic or Non-Periodontal) Mandibular fractures in service frequently result in traumatic tooth loss. If teeth were lost due to the fracture rather than periodontal disease, they may be ratable under DC 9913 for service connected dental treatment purposes.
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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.