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C&P Exam Prep: Maxilla, Loss of More Than Half
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 extent of maxillary bone loss, determine whether the loss exceeds 50% of the maxilla, and assess whether the defect is or is not replaceable by a prosthetic appliance. These two factors - extent of loss and prosthetic replaceability - directly drive the rating percentage under DC 9914.
What the examiner evaluates:
- Confirmation of diagnosis: loss of more than half of the maxilla
- Anatomical extent of maxillary bone loss (percentage lost and anatomical regions affected)
- Whether the defect is replaceable by a suitable prosthesis or not
- Current prosthetic status: obturator, palatal prosthesis, implant-supported restorations, or none
- Functional impact on mastication, swallowing, and speech
- Presence of oronasal or oroantral communication/fistula
- Associated soft tissue defects, scarring, or contracture
- Secondary diagnoses such as malunion/nonunion of maxilla, osteomyelitis, osteoradionecrosis, osteonecrosis, or oral neoplasm that may have caused or accompanied the loss
- History of radiation therapy, chemotherapy, or surgical treatment
- Residuals and complications of maxillary loss including nasal regurgitation, difficulty breathing through nose, speech intelligibility changes
- Impact on daily occupational and social functioning
Exam is conducted in a dental operatory or clinical setting. The examiner will visually inspect the oral cavity, may probe or palpate residual bone and soft tissue margins, and review all available imaging (panoramic radiograph, CT scan, MRI if available). Bring all current prosthetic appliances to the exam to demonstrate fit and function - or lack thereof. The examiner will note whether you arrived with or without your prosthesis and test its adequacy in restoring oral function.
Typical duration: 20-30 minutes
Anatomical Assessment of Maxillary Bone Loss
The examiner visually inspects and documents what percentage and which anatomical portions of the maxilla are absent. The maxilla includes the hard palate, alveolar ridge, anterior maxilla, and posterior maxilla bilaterally. Loss of more than half means greater than 50% of the total maxillary structure is absent.
What to expect:
The examiner will look directly into your mouth and nasal cavity if an oronasal defect exists. They may use a dental mirror and probe to assess borders of remaining bone. Any prior operative reports or imaging should confirm extent of surgical resection or bone loss.
Key thresholds:
- Loss of more than 50% of maxilla - Not replaceable by prosthesis — 100% rating under DC 9914
- Loss of more than 50% of maxilla - Replaceable by prosthesis — 50% rating under DC 9914
Tips:
- Bring all surgical operative reports, pathology reports, or trauma records that document the extent of maxillary resection or loss.
- If you have had a maxillectomy, the operative report will usually specify the class of resection (e.g., total, subtotal, infrastructure, superstructure) - bring this documentation.
- CT scan or panoramic radiograph imaging is the gold standard for confirming extent of bone loss; ensure prior imaging is available for review.
- If bone loss occurred gradually through osteomyelitis, osteoradionecrosis, or osteonecrosis, treatment records documenting the progression are essential.
Pain considerations: While maxillary bone loss itself is a structural finding, accurately describe any chronic pain, pressure, or discomfort associated with the defect site, prosthetic wear, or oronasal communication.
Prosthetic Replaceability Assessment
Whether a suitable prosthesis - such as an obturator, palatal plate, or implant-supported maxillary prosthesis - can adequately restore oral function and close the defect. The examiner must distinguish between a defect that is anatomically amenable to prosthetic rehabilitation and one that is not.
What to expect:
The examiner will assess whether you currently have a prosthesis, how well it fits, whether it restores adequate oral separation from the nasal cavity, and whether it permits intelligible speech and functional mastication. If you do not have a prosthesis, the examiner should note whether the defect anatomy would permit one.
Key thresholds:
- Defect NOT replaceable by prosthesis — 100% rating - the higher rating tier under DC 9914
- Defect IS replaceable by prosthesis — 50% rating - the lower rating tier under DC 9914
Tips:
- Bring your obturator, palatal prosthesis, or maxillary denture to the exam so the examiner can assess it directly.
- If your prosthesis is ill-fitting, causes pain, falls out, does not seal the defect, or fails to restore speech and chewing, clearly communicate this to the examiner.
- If you have been told by treating dental providers that prosthetic rehabilitation is not possible due to inadequate residual bone, soft tissue deficiency, radiation damage, or other factors, bring documentation of that assessment.
- A prosthesis that exists but does not functionally restore oral separation or mastication should be described as inadequate, not as a successful replacement.
- If you cannot afford or access a prosthesis but one is theoretically feasible, the examiner should still note this - but also document the functional deficits you currently experience without adequate prosthetic coverage.
Pain considerations: If wearing the prosthesis causes significant pain, ulceration, or tissue irritation that limits its use, accurately describe the frequency and severity of these episodes so the examiner understands your actual functional prosthetic use.
Functional Assessment - Speech, Mastication, and Deglutition
The degree of functional impairment caused by the maxillary loss in terms of ability to speak intelligibly, chew food, and swallow without nasal regurgitation. These functional deficits directly inform whether the condition creates additional ratable residuals.
What to expect:
The examiner may ask you to speak, swallow, or demonstrate chewing. They will listen for hypernasal speech, nasal air escape, and intelligibility. They will ask about dietary restrictions and whether you experience nasal regurgitation of food or liquids.
Key thresholds:
- Severe speech unintelligibility, inability to masticate any solid food, or recurrent nasal regurgitation — Supports non-replaceable by prosthesis finding; may also generate separate ratings for speech impairment
- Mild to moderate functional limitation with prosthesis in place — Supports replaceable by prosthesis finding at 50%; functional residuals may be separately rated
Tips:
- Describe your actual diet on a typical day - if you can only eat soft or pureed foods, state this clearly with specific examples.
- If you experience nasal regurgitation, describe how frequently it occurs and what triggers it (liquids, certain foods, position).
- If your speech is affected, describe how others react - do they frequently ask you to repeat yourself? Have you been told your speech is difficult to understand?
- Describe how long you can tolerate wearing your prosthesis before discomfort forces you to remove it.
Pain considerations: Accurately describe any pain associated with eating, speaking, or wearing a prosthetic device. Chronic pain can limit prosthetic use and is relevant to the examiner's assessment of functional replaceability.
Rating Criteria Breakdown
| Rating % | Criteria | Key Symptoms |
|---|---|---|
| 100% | Loss of more than half of the maxilla that is NOT replaceable by a suitable prosthesis. This is the highest rating available under DC 9914 and reflects the most severe functional and anatomical impairment - a major structural defect of the upper jaw that cannot be adequately restored through prosthetic intervention. |
CFR: 38 CFR 4.150, DC 9914: 'Maxilla, loss of more than half: Not replaceable by prosthesis - 100' |
| 50% | Loss of more than half of the maxilla that IS replaceable by a suitable prosthesis. Despite the significant extent of maxillary bone loss, a prosthetic appliance (such as an obturator or palatal prosthesis) can adequately restore oral function, separate the oral and nasal cavities, and permit reasonably intelligible speech and functional mastication. |
CFR: 38 CFR 4.150, DC 9914: 'Maxilla, loss of more than half: Replaceable by prosthesis - 50' |
100% Loss of more than half of the maxilla that is NOT replaceabl ...
Loss of more than half of the maxilla that is NOT replaceable by a suitable prosthesis. This is the highest rating available under DC 9914 and reflects the most severe functional and anatomical impairment - a major structural defect of the upper jaw that cannot be adequately restored through prosthetic intervention.
Key Symptoms
- Absence of more than 50% of the maxillary bone structure (confirmed by examination and imaging)
- Oronasal communication that cannot be surgically closed or prosthetically sealed
- No adequate prosthetic option exists due to insufficient residual bone, soft tissue deficiency, radiation-damaged tissue, or anatomical extent of loss
- Severe hypernasal speech or near-unintelligible speech
- Inability to chew solid foods; restricted to liquid or pureed diet
- Chronic nasal regurgitation of food and liquids
- Significant facial disfigurement and structural collapse of mid-face
- Recurrent infections, oroantral fistula, or chronic sinusitis related to defect
- Failed prosthetic attempts or documented contraindication to prosthetic rehabilitation
CFR: 38 CFR 4.150, DC 9914: 'Maxilla, loss of more than half: Not replaceable by prosthesis - 100'
50% Loss of more than half of the maxilla that IS replaceable by ...
Loss of more than half of the maxilla that IS replaceable by a suitable prosthesis. Despite the significant extent of maxillary bone loss, a prosthetic appliance (such as an obturator or palatal prosthesis) can adequately restore oral function, separate the oral and nasal cavities, and permit reasonably intelligible speech and functional mastication.
Key Symptoms
- Absence of more than 50% of the maxillary bone structure (confirmed by examination and imaging)
- Oronasal communication that is successfully or potentially closed by obturator or prosthesis
- A functioning prosthetic appliance exists and provides adequate oral function
- Speech is intelligible or near-normal with prosthesis in place
- Patient can eat a reasonably varied diet with prosthesis
- Nasal regurgitation is controlled or minimal with prosthesis in use
- Ongoing need for prosthetic maintenance and replacement
- Residual functional limitations even with prosthesis (e.g., cannot eat all foods, some speech difficulty)
CFR: 38 CFR 4.150, DC 9914: 'Maxilla, loss of more than half: Replaceable by prosthesis - 50'
How to Describe Your Symptoms
Prosthetic Status and Adequacy
How to describe:
Clearly state whether you have a prosthesis (obturator, palatal plate, maxillary denture), how well it functions, and how long you can actually wear it before discomfort forces removal. If your prosthesis is ill-fitting, does not seal the defect, or does not restore speech and chewing, say so explicitly using specific examples. If you have no prosthesis, explain why - including any provider statements that one is not feasible.
Worst-day example:
“On my worst days, my obturator causes severe ulceration on the residual soft tissue edges within two hours of insertion. I cannot wear it for more than a few hours before the pain becomes intolerable and I must remove it, leaving me unable to eat anything except liquids and experiencing significant nasal speech that makes telephone communication nearly impossible.”
What the examiner listens for:
The examiner needs to determine whether the maxillary defect is 'replaceable by prosthesis' - meaning the prosthesis actually and adequately restores function, not merely that one exists. Statements about prosthesis failure, pain, poor fit, and inadequate seal directly inform this critical binary determination.
Understatements to avoid:
Do not say 'I have a prosthesis' without describing how well it actually works. Many veterans have a prosthesis that technically exists but provides minimal functional benefit - if yours falls short, accurately describe the limitations. Avoid saying 'it's okay' when in reality it does not seal the nasal cavity, causes pain, or restricts your diet significantly.
Speech Impairment
How to describe:
Describe the quality of your speech without the prosthesis in place and with it in place. Use concrete examples: do strangers understand you on the first attempt? Do you avoid phone calls because of speech difficulty? Has your speech changed your professional or social interactions? Describe hypernasal quality, nasal air escape, and any articulation problems.
Worst-day example:
“Without my prosthesis, my speech is nearly unintelligible due to severe hypernasality and nasal air escape. Even with my prosthesis in, I have noticeable nasal speech quality and I frequently have to repeat myself in conversations. I have stopped making phone calls to people who do not know me because they cannot understand me, and I have declined social engagements as a result.”
What the examiner listens for:
The examiner is listening for the degree to which speech is functionally impaired and whether the prosthesis meaningfully corrects the impairment. Significant persistent speech impairment even with prosthesis supports a finding that the defect is not adequately replaced by the prosthesis.
Understatements to avoid:
Do not minimize speech changes. Veterans often adapt to abnormal speech and no longer notice their own impairment. Ask a family member or close friend whether your speech has changed and relay what they have told you. Avoid framing speech difficulty as merely 'a little different' when it substantively affects communication.
Mastication and Dietary Restriction
How to describe:
Describe exactly what you can and cannot eat. List the specific foods you have eliminated from your diet due to the maxillary defect. State whether these restrictions apply with or without your prosthesis. Note how long meals take compared to before the injury or surgery, and whether eating causes pain, fatigue, or nasal regurgitation.
Worst-day example:
“On my worst days I can only tolerate liquids and soft foods like yogurt and mashed potatoes. I cannot chew meats, raw vegetables, hard bread, or anything requiring significant bite force. Meals take me over an hour because I must eat in very small pieces and avoid anything that might enter the nasal cavity. I have lost significant weight since the surgery because eating is so difficult and uncomfortable.”
What the examiner listens for:
Specific food restrictions, unintentional weight loss, meal duration, nasal regurgitation events, and pain with eating. These details substantiate both the extent of functional impairment and the adequacy - or inadequacy - of prosthetic restoration.
Understatements to avoid:
Do not say 'I eat normally' if you have significantly modified your diet. Veterans often normalize major dietary changes over time. Think about what you ate before the injury and compare it honestly to what you eat now. If you avoid restaurants, social meals, or certain food groups because of the defect, say so.
Nasal Regurgitation and Oronasal Communication
How to describe:
Describe whether food or liquid passes into your nasal cavity when eating or drinking. Note the frequency, which foods or liquids trigger it, whether it occurs with or without your prosthesis, and any associated complications such as chronic sinusitis, nasal infections, or aspiration.
Worst-day example:
“Without my prosthesis or when it becomes dislodged during eating, liquids immediately escape through my nose. Even with the prosthesis, thin liquids sometimes pass around the margins into the nasal cavity. I have had three sinus infections in the past year that my doctor attributed to this chronic contamination. I must eat with my head tilted forward and I cannot drink from a glass without a straw.”
What the examiner listens for:
The presence and frequency of nasal regurgitation, whether it occurs with or without the prosthesis, and associated complications such as recurrent rhinosinusitis. Ongoing nasal regurgitation despite a prosthesis suggests inadequate prosthetic seal.
Understatements to avoid:
Do not dismiss nasal regurgitation as minor or occasional if it occurs regularly. Even intermittent episodes significantly affect quality of life and dietary choices and must be fully described. If you have changed how you eat or drink to prevent it, that behavioral adaptation itself reflects the severity of the impairment.
Pain, Discomfort, and Secondary Complications
How to describe:
Describe any chronic pain at the defect site, pain from prosthetic use, recurrent infections, headaches related to sinusitis, facial pain, or psychological distress from disfigurement. Use a consistent pain scale (0-10) and describe pain on typical days and on your worst days. Note how pain affects sleep, work, and daily activities.
Worst-day example:
“On my worst days, the soft tissue around the defect edges is so irritated and inflamed from prosthetic use that I experience a constant 7 out of 10 burning pain that radiates into my cheek and eye socket. I take prescription pain medication on those days and am unable to work or concentrate. The pain prevents any prosthetic use, leaving me with a fully open oronasal defect for days at a time.”
What the examiner listens for:
The impact of pain on the veteran's ability to wear and benefit from a prosthesis, and the overall functional burden of the condition including its psychosocial impact. Pain that prevents prosthetic use directly informs the replaceability determination.
Understatements to avoid:
Veterans with maxillary loss often underreport pain because they view it as something they must endure. Do not say 'the pain is manageable' without clarifying what 'manageable' means in terms of medication use, activity limitations, and impact on daily life.
Common Mistakes to Avoid
Bringing and wearing a well-fitting prosthesis to the exam without disclosing its limitations
The examiner may observe the prosthesis in place, note adequate oral closure, and conclude the defect is 'replaceable by prosthesis,' resulting in a 50% rather than 100% rating, even if the prosthesis only works under ideal exam conditions and fails in daily use.
Instead: Bring your prosthesis but proactively describe its daily limitations - how long you can wear it, under what conditions it fails, how often you must go without it, and what your function is like without it. If you can, demonstrate the poor fit or seal to the examiner directly.
Impact: 100% vs. 50%
Failing to bring surgical operative reports documenting the extent of maxillary resection
The examiner must confirm that loss exceeds 50% of the maxilla to apply DC 9914. Without operative or imaging documentation, the examiner may be unable to confirm the extent of loss, potentially resulting in a lower diagnostic code (DC 9915 for loss of half or less) or an inadequate exam.
Instead: Obtain and bring all operative reports from the surgery or trauma that caused the maxillary loss, along with any CT scan, panoramic radiograph, or pathology reports that document the extent of the defect.
Impact: 100% or 50% under DC 9914 vs. lower rating under DC 9915
Describing diet and speech as 'fine' or 'okay' out of habit or social minimization
Veterans adapt to functional limitations over time and often underestimate how significantly their daily function differs from normal. Underreporting functional deficits fails to give the examiner the complete clinical picture needed to accurately assess prosthetic adequacy.
Instead: Before the exam, write down specifically what foods you can no longer eat, how your speech has changed, whether others comment on your speech, and what activities you avoid because of the defect. Bring these written notes to ensure you communicate the full impact.
Impact: 100% vs. 50%
Not reporting secondary complications such as chronic sinusitis, osteonecrosis, or recurrent infections
Secondary conditions related to maxillary loss may be separately ratable or may inform the overall functional picture. Failing to report them means they cannot be captured in the DBQ or considered by the rater.
Instead: Disclose all conditions you believe are related to the maxillary loss, including sinus infections, oroantral fistulas, skin or mucosal breakdown, facial pain, or psychological effects. Ask the examiner to note each one in the DBQ.
Impact: May affect separate ratings for sinusitis, speech, or other residuals
Assuming the examiner knows the full history from the file alone
C&P exams are often conducted by contractors or examiners unfamiliar with the veteran's specific history. The examiner may not have reviewed all records or may not understand the full context of how the maxillary loss occurred and its current functional impact.
Instead: Prepare a concise written summary of your condition history, current functional limitations, prosthetic status, and most significant daily impacts. Offer it to the examiner at the start of the appointment to ensure nothing is missed in a 20-30 minute exam.
Impact: 100% vs. 50%
Not requesting that the examiner document the nexus between the maxillary loss and the service-connected event if service connection is not yet established
For initial claims, the examiner must provide a nexus opinion. Veterans sometimes assume this is automatic, but if the examiner focuses only on current severity without addressing etiology, the claim may be denied for lack of nexus.
Instead: If this is an initial claim, clearly describe to the examiner the in-service event, injury, disease, or treatment that caused or contributed to the maxillary loss. Bring service treatment records and any medical records linking the loss to the service event.
Impact: Service connection determination
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 request that your C&P examination be recorded (audio or video) in most states. Inform the examiner at the start of the appointment if you intend to record.
- You have the right to receive a copy of the completed C&P examination report (DBQ). Request it through the VA or your VSO and review it for accuracy.
- You have the right to bring a VSO representative, accredited claims agent, or attorney to your C&P examination. They may accompany you but typically do not participate in the clinical assessment.
- You have the right to submit a written statement describing your symptoms and functional limitations before or after the C&P exam. Use VA Form 21-4138 or a buddy statement to supplement the examiner's findings.
- You have the right to request a new or additional C&P examination if you believe the original exam was inadequate, incomplete, or based on an inaccurate review of the evidence.
- Under the benefit of the doubt standard (38 CFR 3.102), when there is an approximate balance of positive and negative evidence, the VA must resolve the question in your favor.
- You have the right to obtain a private independent medical opinion from your own treating provider (such as your oral surgeon or prosthodontist) and submit it as evidence in support of your claim.
- You have the right to appeal a rating decision you believe is incorrect through the Supplemental Claim, Higher-Level Review, or Board of Veterans' Appeals pathways.
- You are not required to accept the examiner's conclusions without question. If the report mischaracterizes what you said or omits important findings, you may challenge it through the appeals process.
- The VA has a duty to assist you in developing evidence for your claim, including ordering imaging studies, obtaining service records, and scheduling appropriate examinations.
Related Conditions
- Maxilla, Loss of Half or Less Adjacent diagnostic code (DC 9915) covering smaller maxillary bone loss (50% or less). If loss is confirmed to exceed 50%, DC 9914 applies; if it does not exceed 50%, DC 9915 governs with lower rating percentages based on extent and prosthetic replaceability.
- Teeth Loss Due to Loss of Substance of Body of Maxilla or Mandible DC 9913 covers tooth loss due to maxillary or mandibular bone loss without loss of continuity. Veterans with maxillary loss under DC 9914 may also have ratable tooth loss under DC 9913 where the lost masticatory surface cannot be restored by suitable prosthesis.
- Malunion or Nonunion of Maxilla Malunion or nonunion of the maxilla (DC for maxilla malunion/nonunion under 38 CFR 4.150) may be a co existing or causal condition. Trauma or surgery causing maxillary loss may also result in malunion or nonunion of residual bone fragments, which is separately ratable and should be documented on the same DBQ.
- Osteomyelitis, Osteoradionecrosis, or Osteonecrosis of the Maxilla These conditions are frequent causes of maxillary bone loss. If osteomyelitis, osteoradionecrosis (radiation induced), or medication related osteonecrosis (e.g., from bisphosphonates) caused or contributed to the maxillary loss, it should be documented as a diagnosis on the DBQ and may be separately ratable.
- Oral Neoplasm (Benign or Malignant) Oral cancer (e.g., squamous cell carcinoma of the hard palate or maxillary sinus) is a leading cause of maxillary resection resulting in loss of more than half of the maxilla. If a malignant neoplasm caused the loss and is service connected, both the neoplasm and the resulting maxillary loss are ratable. Active malignancy may entitle the veteran to a 100% rating independently.
- Temporomandibular Disorder (TMD) Loss of maxillary structure and resultant occlusal disharmony can stress the temporomandibular joint, contributing to or aggravating TMD. If the veteran also has TMD symptoms, a separate TMD DBQ examination may be warranted. The dental oral DBQ notes that TMD should be referred to a separate DBQ if present.
- Limitation of Motion of the Temporomandibular Joint Secondary to maxillary loss, scarring, or surgical treatment, the veteran may develop limitation of mouth opening (trismus) or TMJ restriction. This is separately ratable under the TMD/jaw limitation diagnostic codes and should be mentioned to the examiner if present.
- Soft Tissue Injury of the Mouth Trauma or surgery causing maxillary loss often also causes soft tissue injuries, scarring, or contracture of the oral mucosa, lips, cheek, or palate. These may be separately ratable under DC 9916 or related soft tissue codes and should be disclosed at the C&P exam.
- Chronic Sinusitis / Rhinosinusitis Oronasal communication resulting from maxillary loss frequently causes chronic contamination of the paranasal sinuses, leading to recurrent or chronic sinusitis. This condition is separately ratable under the respiratory diagnostic codes and should be claimed as a secondary condition if present.
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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.