C&P Exam for Maxilla, malunion or nonunion of (DC 9916)

Read the C&P exam preparation guideWhat happens at the exam, what 38 CFR Part 4 requires the examiner to record, and what to bring.
Diagnostic code: 9916Condition: Maxilla, malunion or nonunion ofRegulation: 38 CFR § 4.150DBQ: DBQ DENTAL Oral and Dental

Which form the examiner uses

For maxilla, malunion or nonunion of (DC 9916), the C&P examiner completes the following Disability Benefits Questionnaire (DBQ):

DBQs are Department of Veterans Affairs Form 21-0960 series documents. Public DBQs are hosted on benefits.va.gov. A handful are examiner-only and are not posted publicly.

What the examiner records

The fields below are reproduced from the DBQ form the examiner completes for this diagnostic code. This is the structural map of the form, showing what the examiner is asked to measure, observe, and record. It is a factual reproduction of the public DBQ, not advice on how to answer.

This DBQ evaluates oral and dental conditions including bony injury, anatomical loss of teeth, mandible/maxilla impairment, osteomyelitis of the jaw, and oral/lip injuries.

How DC 9916 maps to this DBQ: for this diagnostic code specifically, the examiner typically completes sections I-III and IX-XII of this form. Section III is the condition-specific section for this code. Sections IV-VIII cover unrelated conditions on this DBQ and are skipped.

7 of 12 sections apply to DC 9916 on this DBQ
DIAGNOSIS (Section I) MEDICAL HISTORY (Section II) MANDIBLE, INCLUDING ANATOMICAL LOSS OR BONY INJURY (Section III) OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS, AND SCARS (Section IX) DIAGNOSTIC TESTING (Section X) FUNCTIONAL IMPACT (Section XI) REMARKS (Section XII)
DIAGNOSIS (Section I)
  • 1A. List the claimed condition(s) that pertain to this questionnaire: Note: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed above. If there is no diagnosis, if the diagnosis is different from a previous diagnosis for this condition, or if there is a diagnosis of a complication due to the claimed condition(s), explain your findings and reasons…
  • 1B. Select diagnoses associated with the claimed condition(s) (check all that apply): The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above. Explain your findings and reasons in the remarks section. Loss of any portion of mandible (for reasons other than periodontal disease or edentulous atrophy) ICD code: Date of diagnosis: Loss of any portion of…
  • 1C. If there are additional diagnoses that pertain to oral and dental conditions, list using above format:
MEDICAL HISTORY (Section II)
  • 2A. Describe the history (including onset and course) of the Veteran's oral and/or dental condition(s) (brief summary): Oral and Dental Conditions Including Mouth, Lips, and Tongue (Other Than Temporomandibular Disorder Conditions)
MANDIBLE, INCLUDING ANATOMICAL LOSS OR BONY INJURY (Section III)
  • 3A. Has the Veteran lost any part of the mandible to include the ramus (not due to edentulous atrophy or periodontal disease)? Yes No If yes, indicate if unilateral or bilateral, and indicate severity. Unilateral Bilateral Loss of less than one-half of the mandible including the ramus, not involving the temporomandibular articulation Loss of less than one-half of the mandible including the ramus,…
  • 3B. If the Veteran has lost any part of the mandible, is the loss replaceable by prosthesis? Yes No Not Applicable
  • 3C. Has the Veteran lost either condyle (condyloid process) of the mandible? Yes No If yes, indicate side: Right Left Both
  • 3D. Has the Veteran lost either coronoid process of the mandible? Yes No If yes, indicate side: Right Left Both
  • 3E. Has the Veteran had an injury resulting in malunion or nonunion of the mandible? Yes No If yes, indicate severity: Malunion, displacement, causing only mild or no anterior or posterior open bite Malunion, displacement, causing moderate open bite anterior posterior Malunion, displacement, causing severe open bite anterior posterior Nonunion, confirmed by diagnostic imaging, moderate without…
MAXILLA, INCLUDING ANATOMICAL LOSS OR BONY INJURY (Section IV)
  • 4A. Has the Veteran lost any part of the maxilla? (Not due to endentulous atrophy or periodontal disease) Yes No If yes, indicate severity: Loss of less than 25% Loss of 25% - 50% Loss of more than half
  • 4B. If the Veteran has lost any part of the maxilla, is the loss replaceable by prosthesis? Yes No Not applicable
  • 4C. Has the Veteran lost any part of the hard palate? Yes No If yes, indicate severity: Loss of less than half Loss of half or more
  • 4D. If the Veteran has lost any part of the hard palate, is the loss replaceable by prosthesis? Yes No Not Applicable
  • 4E. Has the Veteran had an injury resulting in malunion or nonunion of the maxilla? Yes No If yes, indicate severity: Malunion, displacement, causing only mild or no open bite anterior posterior Malunion, displacement, causing moderate open bite anterior posterior Malunion, displacement, causing severe open bite anterior posterior Nonunion, confirmed by diagnostic imaging, moderate without false…
TEETH, INCLUDING ANATOMICAL LOSS OR BONY INJURY LEADING TO LOSS OF ANY TEETH (Section V)
  • 5A. Is the loss of teeth due to loss of substance of body of maxilla or mandible without loss of continuity? Yes No
  • 5B. Is the loss of teeth due to trauma or disease (such as osteomyelitis)? Yes No If yes, describe:
  • 5C. Can the masticatory surfaces be restored by suitable prosthesis? Yes No If yes, describe. If no, explain why not.
  • 5D. List missing teeth by number: Right Upper 1 2 3 4 5 6 7 8 Left Upper 9 10 11 12 13 14 15 16 Left Lower 17 18 19 20 21 22 23 24
INJURY OF MOUTH, LIPS, TONGUE AND DISFIGURING SCARS TO THE MOUTH OR LIPS (Section VI)
  • 6A. Does the Veteran have any scars or other disfigurement to the mouth or lips? Yes No If yes, also complete the appropriate dermatological questionnaire.
  • 6B. Does the Veteran have a soft tissue injury of the mouth, other than the tongue or lips, that results in impairment of mastication? Yes No If yes, describe:
  • 6C. Does the Veteran have partial or complete loss of the tongue? Yes No If yes, select one of the following: Asymptomatic Intact oral nutritional intake with permanently impaired swallowing function without prescribed dietary modification. Intact oral nutritional intake with permanently impaired swallowing function that requires prescribed dietary modification. Absent oral nutritional intake.
  • 6D. Does the Veteran have complete or incomplete aphonia due to loss of whole or part of the tongue? Yes No If yes, also complete the aphonia questions on the appropriate Ear, Nose, and Throat questionnaire. Oral and Dental Conditions Including Mouth, Lips, and Tongue (Other Than Temporomandibular Disorder Conditions)
OSTEOMYELITIS/OSTEORADIONECROSIS/OSTEONECROSIS OF THE JAW (Section VII)
  • 7A. Does the Veteran now have or has he or she ever been diagnosed with osteomyelitis or osteoradionecrosis of the mandible? Yes No If yes, also complete the Osteomyelitis questionnaire.
  • 7B. Does the Veteran now have or has he or she ever been diagnosed with osteonecrosis of the jaw? Yes No If yes, describe
TUMORS AND NEOPLASMS (Section VIII)
  • 8A. Does the Veteran currently have, or has had, a benign or malignant neoplasm or metastases related to any condition in the diagnosis section? Yes No If yes, complete the following section.
  • 8B. Is the neoplasm: Benign Malignant (if malignant complete the following): Active In remission Primary Secondary (metastatic) (if secondary, indicate the primary site, if known):
  • 8C. Has the Veteran completed treatment or is the Veteran currently undergoing treatment for a benign or malignant neoplasm or metastases? Yes No; watchful waiting If yes, indicate type of treatment the Veteran is currently undergoing or has completed (check all that apply): Treatment completed Surgery If checked, describe: Date(s) of surgery:
  • 8D. Does the Veteran currently have any residuals or complications due to the neoplasm (including metastases) or its treatment, other than those already documented in the report above? Yes No If yes, list residuals or complications (brief summary), and also complete the appropriate questionnaire: Oral and Dental Conditions Including Mouth, Lips, and Tongue (Other Than Temporomandibular Disorder…
  • 8E. If there are additional benign or malignant neoplasms or metastases related to any of the diagnoses in the diagnosis section, describe using the above format:
OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS, AND SCARS (Section IX)
  • 9A. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the diagnosis section above? Yes No If yes, describe (brief summary)
  • 9B. Does the Veteran have any scars or other disfigurement (of the skin) related to any conditions or to the treatment of any conditions listed in the diagnosis section other than those identified in Section VI? Yes No If yes, also complete the appropriate dermatological questionnaire.
DIAGNOSTIC TESTING (Section X)
  • 10A. Have clinically relevant diagnostic imaging studies or other diagnostic procedures been performed or reviewed in conjunction with this examination? Yes No If yes, check all that apply. Panographic/intraoral imaging to demonstrate loss of teeth, mandible or maxilla Date: Results: X-ray Date: Results: CT scan Date: Results:
  • 10B. Are there any other clinically relevant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es), that were reviewed in conjunction with this examination? Yes No If yes, provide type of test or procedure, date and result (brief summary):
  • 10C. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: Oral and Dental Conditions Including Mouth, Lips, and Tongue (Other Than Temporomandibular Disorder Conditions)
FUNCTIONAL IMPACT (Section XI)
  • 11A. Regardless of the Veteran's current employment status, do the conditions listed in the diagnosis section impact his/her ability to perform any type of occupational task? Yes No If yes, describe the functional impact of each condition, providing one or more examples:
REMARKS (Section XII)
  • 12A. Remarks (if any – please identify the section to which the remark pertains when appropriate).

Rating Levels for DC 9916

The following tiers are reproduced from 38 CFR Part 4, the VA Schedule for Rating Disabilities. Toggle between the official VA criteria and a Plain English explanation.

Plain-English summaries are AI-generated to explain the official criteria. The official 38 CFR language is the binding legal standard. When in doubt, ask a VSO.

View the full DC 9916 pageSearch BVA decisions for this codeAbout DBQ forms

Disclaimer: This page reproduces public Department of Veterans Affairs forms (DBQs) and verbatim text from 38 CFR Part 4 (the VA Schedule for Rating Disabilities). It is informational only and is not legal or medical advice. For guidance on a specific claim, contact a VA-accredited representative.