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VA Rating Assistant

DC 9904 · 38 CFR 4.150

Mandible, Malunion of C&P Exam Prep

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.

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

  • 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.

Measurements and tests

Open Bite Measurement (Anterior)

What it measures: 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.

Critical 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)

What it measures: 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.

Critical 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

What it measures: 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.

Critical 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

What it measures: 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.

Critical 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 by percentage

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.

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

From 38 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.

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

From 38 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.

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

From 38 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.

Describing your symptoms accurately

Open Bite / Occlusal Gap

How to describe it: 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.'

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.

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.

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 it: 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.'

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.

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.

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 it: 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.

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.

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.

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 it: 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.'

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.

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.

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 it: 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.

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.

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.

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

Why: 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.

Do this 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

Why: 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.

Do this 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

Why: 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.

Do this 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

Why: 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.

Do this 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'

Why: 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%.

Do this 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)

Why: 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.

Do this 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

Why: 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.

Do this 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

  • critical

    Gather all relevant dental and maxillofacial imaging

    Collect panoramic X-rays (panorex), CT scans, and any maxillofacial or oral surgery imaging from service, post-service treatment, and VA care. Organize by date. Confirm these are in your VA claims file or bring physical copies.

    before exam

  • critical

    Obtain and review all treatment records for the mandible fracture

    Request military service treatment records (STRs) documenting the original fracture event, surgical repair, and any follow-up. Also gather post-service oral surgery, orthodontic, or dental records. Submit through VA MyHealtheVet or bring to the exam.

    before exam

  • critical

    Write a detailed symptom summary to bring to the exam

    Write a one-to-two page summary describing: how the malunion occurred (service incident), current bite problems (anterior/posterior open bite), functional limitations (diet restrictions, eating pain, speech issues), worst-day versus average presentations, and all secondary effects. Give this to the examiner at the start of the appointment.

    before exam

  • recommended

    Document your dietary restrictions and changes

    Make a list of foods you can no longer eat or must modify due to your jaw malunion. Include any weight changes, nutritional concerns, or social avoidance of eating situations. This directly supports functional impact documentation.

    before exam

  • recommended

    Research DC 9904 rating criteria so you understand how severity is classified

    Know that the rating hinges on whether your open bite is classified as severe (20%), moderate (10%), or absent (0%). Understand the difference between malunion (DC 9904) and nonunion (DC 9903) so you can ask informed questions if the examiner's assessment seems inconsistent with your records.

    before exam

  • recommended

    Check your state's laws on recording C&P examinations

    Most states permit recording with notice. If your state allows it, bring a recording device (phone) and notify the examiner at the start: 'I would like to record this examination for my personal records.' This protects your right to an accurate record of what was discussed.

    before exam

  • recommended

    Identify and note any secondary conditions possibly caused by the malunion

    Consider whether you have TMJ dysfunction, chronic jaw/facial pain, headaches, periodontal problems, tooth wear, or sleep disturbances that developed after or because of your mandible malunion. List these to mention to the examiner as potential secondary conditions.

    before exam

  • critical

    Do not take pain medication that artificially reduces your symptoms before the exam

    The exam should reflect your actual functional state. If you routinely take pain medication and it is part of your normal management, that is fine - but do not take extra doses to make the exam more comfortable if your natural state involves significant discomfort.

    day of

  • critical

    Bring all imaging and records in physical form if possible

    Even if records are in your VA file, having physical copies ensures the examiner reviews them. Organize them in a folder labeled with your name and claim number.

    day of

  • recommended

    Arrive early and bring your written symptom summary

    Arriving 15 minutes early allows you to present your symptom summary to the examiner before the clinical portion begins. This ensures key information is on the record even if the exam is brief.

    day of

  • recommended

    Bring any dental appliances, splints, or occlusal guards associated with your condition

    If you wear a night guard, dental splint, or other appliance related to your jaw condition, bring it to show the examiner. This documents that treatment has been necessary and ongoing.

    day of

  • critical

    Bite down naturally without compensating or correcting your jaw position

    When asked to bite down or demonstrate your occlusion, close your jaw naturally. Do not shift your jaw or force teeth together. If you habitually compensate, verbally inform the examiner.

    during exam

  • critical

    Describe your worst-day presentation, not your average or best day

    When answering questions about your symptoms and function, explicitly describe your worst-day experiences. Use the phrase 'on my worst days' to frame answers. Per VA M21-1 guidance, the overall disability picture includes the full range of severity.

    during exam

  • recommended

    Ask the examiner to address functional impact in the DBQ

    If the examiner appears focused only on the clinical bite measurement, politely note: 'I'd also like to make sure my functional limitations - eating, speaking, and daily activities - are documented in the DBQ.' The functional impact section is a required component.

    during exam

  • recommended

    Mention secondary conditions and ask the examiner to note the relationship

    If you have TMJ dysfunction, chronic pain, or other conditions you believe are related to your mandible malunion, mention them during the exam and ask: 'Could you note in the DBQ whether these conditions may be related to the malunion?' The examiner is not obligated to agree but should document the question.

    during exam

  • recommended

    Ask for clarification if the examiner says your bite appears 'normal' or 'not significantly displaced'

    If the examiner's clinical impression seems inconsistent with your documented history of fracture and symptoms, calmly point to your imaging or surgical records and ask: 'Could you explain how the imaging showing displaced healing is consistent with a normal bite finding?'

    during exam

  • critical

    Document everything you remember from the exam immediately afterward

    As soon as possible after the exam, write down what was discussed, what the examiner found, what imaging was reviewed, and whether all your symptoms were addressed. This record is valuable if you need to challenge an inadequate exam.

    after exam

  • critical

    Request a copy of the completed DBQ through your VA eFolder

    You can request your DBQ through the VA's Blue Button or your VSO. Review the DBQ for accuracy - specifically that the open bite severity, functional impact, and diagnosis sections reflect what was actually discussed and found.

    after exam

  • recommended

    Contact your VSO or accredited claims agent if the DBQ appears incomplete or inaccurate

    If the completed DBQ understates your open bite severity, omits functional limitations, or fails to address all claimed conditions, you can request a new examination or submit a buddy statement and lay evidence to supplement the record.

    after exam

  • optional

    Consider submitting a lay statement (21-4138) to supplement the DBQ

    A personal statement describing your daily experience with the mandible malunion - including worst-day examples, dietary restrictions, speech problems, and social/occupational impact - becomes part of your claims file and can support the rating decision.

    after 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

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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.