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VA Rating Assistant

DC 9903 · 38 CFR 4.150

Mandible, Nonunion of C&P Exam Prep

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.

Format:
Interview + Physical
Typical duration:
20-30 minutes
DBQ form:
oral-and-dental (oral-and-dental)
Examiner:
Dentist or Oral Surgeon

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.

Measurements and tests

Assessment for False Motion

What it measures: 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.

Critical 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

What it measures: 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.

Critical 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

What it measures: 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.

Critical 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 by percentage

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.

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

From 38 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.

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

From 38 CFR: 38 CFR 4.150, DC 9903: 'Moderate, without false motion - 10%'

Describing your symptoms accurately

False Motion and Mandibular Instability

How to describe it: 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.

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.

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.

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 it: 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.

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.

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.

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 it: 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.

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.

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.

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 it: 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.

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.

Examiner listens for: Functional communication deficits that go beyond subjective discomfort and affect the veteran's daily life, employment, and social engagement.

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 it: 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.

Example: N/A - this is historical factual information, not a worst-day description. Be thorough and accurate.

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.

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

Why: 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.

Do this 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

Why: 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.

Do this 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

Why: 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.

Do this 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

Why: 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.

Do this 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

Why: 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.

Do this 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

Why: 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.

Do this 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

  • critical

    Gather all diagnostic imaging records

    Collect panoramic X-rays, CT scans, cone-beam CT (CBCT), MRI, and any intraoral imaging related to the mandibular fracture and nonunion. Include reports from service-era treatment, VA care, and private providers. Submit to VA before the exam date and bring copies to the appointment.

    before exam

  • critical

    Obtain all treatment records for the mandibular fracture

    Gather operative reports from open reduction internal fixation (ORIF), bone grafting, external fixation, or other surgeries. Include records of follow-up appointments where healing was assessed. These establish the chronology of nonunion and failed healing.

    before exam

  • critical

    Write a detailed personal statement

    Document the in-service event that caused the fracture, the full treatment history, current symptoms on worst days, dietary modifications, speech difficulties, pain levels, and the impact on daily life and employment. Submit this as a buddy statement or personal statement (VA Form 21-4138) with your claim prior to the exam.

    before exam

  • critical

    Identify and document false motion occurrences

    Recall specific instances when you felt, heard, or observed the fracture fragments moving independently. Write these down. Note what activity caused the movement and what the sensation was like. If a prior clinician documented false motion, locate those records.

    before exam

  • recommended

    List all medications for jaw pain and related conditions

    Prepare a written list of all prescription and over-the-counter medications you use for jaw pain, inflammation, or related conditions (e.g., NSAIDs, opioids, muscle relaxants, antibiotics for recurrent infection). Include dosages and how frequently you use them.

    before exam

  • critical

    Review your nexus theory for service connection

    Be prepared to clearly explain how your mandibular nonunion is connected to your military service. Identify the specific in-service event (date, location, nature of injury) or the in-service treatment that caused or contributed to the fracture.

    before exam

  • optional

    Research whether your state permits exam recording

    Most states permit single-party consent recording. If your state allows it, you have the right to record your C&P examination. Research your state's laws and bring appropriate recording equipment if you choose to exercise this right.

    before exam

  • recommended

    Eat before the exam in a way that reflects your actual limitations

    Do not eat a normal meal right before the exam if you typically cannot do so. If you ate a modified or liquid diet this morning because of your jaw, that is accurate and relevant. Do not perform activities before the exam that you normally avoid.

    day of

  • critical

    Bring all imaging and records in physical or digital format

    Carry printed imaging reports, CDs or USBs with imaging files, and any clinical notes in a folder. Do not rely solely on VA having received them in advance.

    day of

  • optional

    Arrive early and request to review examiner credentials

    Confirm the examiner is a licensed dentist or oral surgeon with appropriate credentials for this evaluation. If you have concerns about the examiner's qualifications, note them for potential later challenge.

    day of

  • critical

    Describe worst-day symptoms, not average or best days

    When asked how you are doing or how your jaw feels, describe your worst-day experience explicitly. State: 'I want to describe my symptoms on my worst days, which is what the VA asks veterans to report.' Then give specific worst-day examples.

    during exam

  • critical

    Clearly describe false motion if you experience it

    If you have experienced fragment movement, describe it in plain language. Say: 'I feel the bone segments move separately when I open my mouth wide' or 'I can feel a shift at the fracture site when I bite down.' This directly supports the 30% rating level.

    during exam

  • critical

    Report pain in real time during the physical examination

    If the examiner's palpation or range-of-motion assessment causes pain, say so immediately and rate it on a 0-10 scale. State where the pain is located. Do not remain silent about pain out of stoicism - pain documentation is medically and legally important.

    during exam

  • recommended

    Mention all related symptoms and conditions

    Proactively mention TMJ symptoms, malocclusion, tooth loss, open bite, difficulty speaking, dietary restrictions, infection history, and any other oral/jaw conditions you experience. Ask whether the examiner is documenting these.

    during exam

  • critical

    Do not minimize symptoms under any circumstances

    Veterans often downplay symptoms out of habit or military culture. The C&P exam is the formal record of your disability. Accurate, complete reporting of all symptoms - including embarrassing or difficult ones - is essential. You are not exaggerating; you are accurately communicating.

    during exam

  • recommended

    Write down everything that happened during the exam

    As soon as possible after the exam, write a detailed account of what was asked, what you said, what the examiner did, and whether you felt anything was missed or misrepresented. Include the examiner's name, credentials, and the date. This record may be vital if you need to challenge an inadequate examination.

    after exam

  • recommended

    Request a copy of the completed DBQ

    You have the right to request the DBQ completed during your C&P exam. File a Freedom of Information Act (FOIA) or Privacy Act request to obtain it. Review the DBQ for accuracy - particularly whether false motion was documented correctly and whether imaging was noted.

    after exam

  • recommended

    Challenge an inadequate examination if necessary

    If the DBQ does not accurately reflect your symptoms, if the examiner did not review your imaging, if false motion was not assessed, or if the exam was unreasonably brief, you can request a new C&P examination by filing a Notice of Disagreement (NOD) or submitting a written challenge through your VSO or accredited VA attorney.

    after 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

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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.