Citation Nr: 1334093 Decision Date: 10/28/13 Archive Date: 11/06/13 DOCKET NO. 08-30 841 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for a back disability. 2. Entitlement to service connection for residuals of chest and rib injuries. 3. Entitlement to service connection for residuals of injuries to the right hip and leg. 4. Entitlement to service connection for the right leg being shorter than the left leg. 5. Entitlement to service connection for a left hip disability. 6. Entitlement to service connection for a bilateral knee disability. 7. Entitlement to service connection for loss of teeth. 8. Entitlement to a rating in excess of 10 percent for status post fracture of the right zygomatic arch. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD Andrea Johnson, Associate Counsel INTRODUCTION The Veteran had active military service from February 1967 to December 1970. This appeal comes to the Board of Veterans' Appeals (Board) from an October 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. In April 2011, a travel board hearing was held before the undersigned and a transcript of the hearing is included in the claims file. At the hearing, the Veteran requested that the file be held in abeyance for 30 days to allow for the submission of additional evidence. He submitted duplicate treatment records and evidence regarding his in-service accident, with a waiver of RO consideration. These matters were previously before the Board in November 2011 when the claim was remanded for further development. Specifically, the Board sought additional records, including updated VA treatment records, records stemming from the Veteran's 2005 workers compensation claim involving treatment at the Yuma District Hospital, service personnel records, and hospitalization records from Fresno General Hospital and Naval Hospital at NAS Lemoore. The Board also ordered a VA examination of the Veteran's status post fracture of right zygomatic arch. Upon remand the updated VA treatment records and hospitalization records from NAS Lemoore were obtained and the VA examination was provided. The AMC also requested the Veteran submit a release for records from Yuma District and Fresno hospitals; however the Veteran did not complete the provided releases. Accordingly the Board finds the AMC at the very least substantially complied with the requested actions and the matter has been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998). It is also noted that when the Veteran's claim was remanded by the Board, several issues (back, residuals of chest and rib injuries, and residuals of injuries to the right hip and leg) were captioned as new and material claims as these issues had been previously denied by a December 1990 rating decision. However, on remand, additional service treatment records were obtained which addressed hospital treatment the Veteran received in service at the Naval Hospital at NAS Lemoore. VA regulations provide that if at any time after VA issues a decision on a claim, VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim. 38 C.F.R. § 3.157(c). Here, the records were both available and obtainable in 1990, and they are potentially material to the Veteran's claim. As such, the issues of entitlement to service connection for back, residuals of chest and rib injuries, and residuals of injuries to the right hip and leg will each be reconsidered below. The Board must note that in reviewing this case the Board has not only reviewed the Veteran's physical claims file, but also his file on the "Virtual VA" system to ensure a total review of the evidence. The issues of service connection for a dental condition, back condition, right hip/leg condition and bilateral knee condition are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The evidence does not show a diagnosed chest or rib disability at any time during the course of the Veteran's appeal. 2. The evidence does not show a diagnosed left hip disability at any time during the course of the Veteran's appeal. 3. The evidence does not establish the Veteran's current condition of his right leg being shorter than his left leg began during, or was otherwise caused by, his military service. 4. The evidence does not establish the Veteran's status post fracture of the right zygomatic arch resulted in severe paralysis of the trigeminal nerve at any point during the period on appeal. CONCLUSIONS OF LAW 1. The criteria for service connection for a chest and rib condition have not been met. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2013). 2. The criteria for service connection for a left hip condition have not been met. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2013). 3. The criteria for service connection for a condition of the right leg being shorter than the left leg have not been met. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2013). 4. Criteria for a rating in excess of 10 percent for status post fracture of the right zygomatic arch have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.27, 4.72, Diagnostic Code 5296, 4.124a, Diagnostic Code 8205 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As will be discussed the Veteran is seeking service connection for several conditions stemming from a car wreck he was involved in during his military service. During his April 2011 hearing before the undersigned the Veteran testified that around April 1970 he was in San Francisco, California when he was ordered to report to Lemoore, California in approximately six hours. The Veteran and five other men rented a car and began the drive to Lemoore. The Veteran stated during the ride he fell asleep and woke up in the hospital. When he asked the hospital staff what had happened he was informed they had been in a car accident. The Veteran stated, "I don't know whose fault it was but the car flipped over twice and then rolled once." The Veteran was then hospitalized for several weeks at the Naval Hospital at Lemoore and treated for various conditions. These treatment records establish the Veteran hit the dashboard of the car during the accident and primarily injured his chest and right side of his body, including his face. Specific treatment will be discussed below as applicable. Service Connection In seeking VA disability compensation, a Veteran generally seeks to establish that a current disability results from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110. "Service connection" basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303. Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). VA does not generally grant service connection for symptoms alone, without an identified basis for those symptoms. The VA needs to identify a disability, not symptoms of a disability. Accordingly, service connection cannot be granted for symptoms of a disability, such as pain, alone. Additionally, in the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). None of the conditions for which service connection is sought are considered to be "chronic diseases" listed under 38 C.F.R. § 3.309(a), therefore 38 C.F.R. § 3.303(b) does not apply. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Chest and Ribs As discussed the Veteran is currently seeking service connection for residuals of chest and rib injuries. Records from his hospitalization at Naval Hospital Lemoore during his military service in April 1970 reflect the Veteran was treated for injuries to his chest area. The treating care provider noted the Veteran had pain in his chest due to "contused," that is bruised, ribs from his car wreck. Another record described hemoptysis and pulmonary contusions. An x-ray from that same month shows the right chest was normal, although the left rib cage was not visible in the scan. Accordingly these records suggest the Veteran experienced some injury to his chest and ribs during his military service. At his November 1970 separation physical no chest or rib injury was noted. Instead, the Veteran's lungs and chest were noted to be in normal condition. The Board finds this evidence suggests the Veteran's chest and rib injury during military service was temporary and resolved before he was discharged, providing evidence against the Veteran's claim. Shortly after service, the Veteran sought service connection for three broken ribs. However, he wound up canceling his examination in July 1971 and his claim was denied. The Veteran did not present any evidence of any rib or chest problems for many years thereafter. Private treatment records were obtained describing treatment from 1965 through the 1980s. No chest treatment was shown following service, until August 1977 when the Veteran presented for treatment with complaints of chest pain for approximately one week. The Veteran indicated that he experienced shortness of breath for approximately 20 minutes. The Veteran reported experiencing pain down his right arm for four years following a motor vehicle accident. The Veteran was assessed with scalenus anticus syndrome, and told to return in three weeks if it was not better. No follow-up treatment is shown to have been received. In June 2004, the Veteran asserted that he had experienced broken ribs in the motor vehicle accident. However, it is important to point out that an in-service injury is but one component of service connection. As noted, an equally important component is a current disability. Post-service medical records were reviewed, but do not reflect the Veteran sought any treatment for, or otherwise complained of, any current chest or rib condition. In fact on numerous occasions, including during treatment at a VA medical facility in May 2006, November 2007, September 2008 and March 2010, either the Veteran's chest was found to be normal, or he specifically denied experiencing any chest pain, providing additional evidence against his claim. Here, the Veteran has not reported being diagnosed with a chronic rib or chest disability, and beyond filing a claim for service connection for rib and chest, he has not even described current symptoms. For example, during his April 2011 Board hearing, the Veteran was specifically asked about his rib injury/claim, which he explained was "just the normal aches and pains and stuff from everything else." The Board finds that 'aches and pains' can be symptoms of a disability, but are not themselves a disability. Again, it is not disputed that the Veteran's chest and ribs were injured by the motor vehicle accident during his military service, but an in-service injury is but one of the three elements of service connection. Here, the evidence of record does not establish the Veteran has any current chest or rib disability on which service connection could be granted, and a current disability is an equally critical component of service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Because the evidence does not establish the Veteran has a current chest or rib disability, his claim for service connection is denied. Left Hip The Veteran is also seeking service connection for a left hip disability. At his April 2011 hearing before the undersigned the Veteran reported that he injured his left hip during his in-service car accident and afterwards could not stand up without his crutches. However, the records of the Veteran's in-service hospitalization were reviewed and do not reflect the Veteran experienced pain in his left hip following his car accident. The Veteran reported difficulty walking due to pain in his right hip on several occasions during this hospitalization. However no left hip pain was noted during the Veteran's hospitalization in April 1970, providing evidence against his claim. Furthermore the Veteran's lower extremities were noted to be in normal condition during his November 1970 separation physical. Therefore, the Board finds service medical records do not establish the Veteran experienced any injury to his left hip during his military service. Similarly, post-service treatment records do not establish the Veteran has any current left hip condition. Post-service private treatment records do not describe any hip problems in the more than 20 private treatment sessions that are recorded in the two decades immediately following service. The Veteran has voiced occasional complaints of bilateral hip pain and bilateral limited range of motion of the hips has been noted, but no condition or disability of the Veteran's left hip was ever actually diagnosed. At his Board hearing, the Veteran reported he has walked with a limp ever since his car accident. As discussed above, the Veteran's uneven gait was noted by medical professionals on several occasions throughout the period on appeal, however at no point has it been suggested that this uneven gait or limp attributed to any condition or disability of the Veteran's left hip; and the Veteran's uneven gait has not been found to be service related. Here, the only suggestion that the Veteran has a left hip disability is through his own statements and by virtue of him filing a claim for service connection. However, as a lay person, the Veteran lacks the medical training and expertise to provide a complex medical opinion as diagnosing a hip disability. See Layno v. Brown, 6 Vet. App. 465 (1994), Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Additionally, while the Veteran currently asserts that he injured his left hip in service, the contemporaneous medical evidence, namely the service treatment records, show only right hip complaints. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (noting that contemporaneous evidence has greater probative value than history as reported by a veteran). The Board finds that to the extent that the Veteran now believes he injured his left hip in service, the evidence of record does not support his claim. As noted, the service treatment records do not show such problems. Moreover, the Veteran filed a claim in December 1970 in which he sought service connection for right leg and hip, but did not mention any left hip problem. This is taken as strong evidence against any in-service left hip injury, as one would have expected the Veteran to file a claim for a left hip disability along with his right hip claim in 1970 if he did in fact have a left hip disability at that time, and his failure to do so suggests that he did not actually have a left hip disability at that time, as he would now have VA believe. Therefore, the Board finds the evidence does not establish the Veteran has a current left hip disability. Moreover, even if it were accepted that the Veteran did have a current left hip disability, the evidence of record does not show a left hip injury in service, or any left hip problems for multiple decades after service, and no medical professional has even suggested that the Veteran has a left hip disability that even may be the result of his military service. As such, the criteria for service connection have not been met, and the Veteran's claim is denied. Leg length discrepancy The Veteran is also seeking service connection due to his right leg being shorter than his left. At his April 2011 hearing he testified his leg length discrepancy was also due to his car wreck from "when I had trouble walking." He reported that since service the VA had provided him lifts to put in his right shoe and he asserted that he had walked with a limp ever since service. Service treatment records were reviewed but fail to establish the Veteran had a leg length discrepancy during his military service. As noted above, records from his April 1970 hospitalization reflect the Veteran had difficulty walking and required crutches, but the records do not note his right leg was shorter than his left. Instead the Veteran's lower extremities were noted to be in normal condition at his November 1970 separation physical. Accordingly the Board finds the evidence does not establish the Veteran's right leg was shorter than his left leg during his military service. Post-service treatment records do reflect the Veteran's right leg is currently shorter than his left leg. The earliest record in the claims file noting this fact is from September 2004 when a VA physical therapist noted the Veteran had a half an inch leg length discrepancy but opined this discrepancy "did not appear to functionally affect [Veteran] in standing." In September 2007 a VA registered nurse indicated the Veteran's right leg was shorter than his left at the medial malleolus and arch. In November 2007 the Veteran's legs were measured and the care provider noted his right leg was shorter by approximately 1/4 of an inch. In December 2008 the VA determined the Veteran's shorter right leg required use of orthotics, including a lift for his right shoe. Accordingly the Board finds the medical evidence supports the Veteran's testimony that his right leg is currently shorter than his left leg. However, the claims file does not include any medical evidence which suggests the Veteran's current leg length discrepancy is due to his military service. It is true that the Veteran now reports that his leg length discrepancy is the result of his military service, but at his hearing, he stated that he had become aware of the condition less than ten years earlier. That is, multiple decades after service. The fact remains that no leg length discrepancy was noted in either the service treatment records or in the approximately 20 years of post-service private treatment records. There has similarly been no opinion by any medical professional even suggesting that the Veteran's leg length discrepancy began during service, or was otherwise caused by service. As such, the criteria for service connection have not been met, and because the evidence fails to establish the Veteran's current leg length discrepancy began during or was otherwise due to his military service his claim for service connection is denied. Increased Rating for Residuals for status post fracture of right zygomatic arch The Veteran is also seeking an increased rating for his service-connected status post right zygomatic arch fracture. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Board notes that while the regulations require review of the recorded history of a disability by the adjudicator to ensure an accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the present level of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). It is also noted that staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran is currently rated at 10 percent for his status post right zygomatic arch fracture condition under Diagnostic Code 5296-8205. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. Accordingly Diagnostic Codes 5296-8205 suggests the Veteran's loss of part of the skull resulted in impairment of the trigeminal, or fifth cranial, nerve. Diagnostic Code 8205 provides a 10 percent rating shall be assigned for moderate incomplete paralysis of the trigeminal nerve, a higher 30 percent rating shall be assigned for severe incomplete paralysis, and a maximum 50 percent rating shall be assigned for complete paralysis. 38 C.F.R. § 4.124a. The rating criteria also provides when the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. The Veteran filed the current claim in June 2004. In January 2006, he was provided with a VA examination with an otolaryngologist to evaluate his condition. The examiner noted the Veteran had experienced some numbness in the right face and cheek since his car accident. Upon examination the Veteran could discern light touch on both cheeks, but stated the sensation on the right was different than that on the left. The examiner opined the Veteran was "status post right midface fracture with injuries to the right teeth and zygomatic arch, with residual sensory neuropathy right mandibular branch of Cr Nerve V." The Board finds this examination report reflects the Veteran's condition warranted a 10 percent rating. The examiner did not opine the Veteran had any paralysis of his trigeminal nerve, but did have numbness and additional sensory involvement of the fifth cranial nerve. Accordingly the Board finds a 10 percent rating for wholly sensory involvement, analogous to a rating of moderate incomplete paralysis, was warranted. A higher 30 percent rating is not warranted because the evidence does not establish the Veteran had severe incomplete paralysis of the trigeminal nerve. As noted, light touch was discernible in both cheeks, suggesting that the paralysis was not severe. During his April 2011 hearing the Veteran testified that his zygomatic arch condition was more than moderate. The Veteran reported that when he got tired "my right eye sags and it wants to close on me and sometimes I lose vision." As discussed above, the Veteran is a lay person competent to report symptoms observable by his senses, such as experiencing sagging and occasional closing of his right eye. However, the Veteran lacks the medical expertise to determine if this occasional symptom is related to his trigeminal nerve injury. The Board finds the medical evidence of record does not reflect the Veteran made any complaint of, or sought any medical treatment for, a sagging right eye during the period on appeal. In December 2011 the Veteran was provided with an additional VA examination to evaluate his current nerve condition. The examiner noted the Veteran had a car wreck during military service which injured the trigeminal nerve, the fifth cranial nerve. However, the examiner indicated the Veteran reported "normal sensation over the entire right side of his face." Muscle strength of the fifth cranial nerve, including mastication, jaw clenching, and temporalis, were noted as normal on both sides. Sensation testing for the fifth cranial nerve was normal bilaterally on the upper face and forehead, mid face, and lower face. Accordingly the examiner opined the Veteran did not have any symptoms attributable to any cranial nerve condition. Notably, this examiner did not indicate the Veteran experienced any sagging of his right eye due to his trigeminal nerve injury. The examiner also took a facial x-ray. The examiner noted a small circular wire was seen adjacent to the superolateral aspect of the Veteran's right orbit, but no abnormal lucencies were seen adjacent to the wire. The examiner opined the x-ray revealed "no facial bone fracture" and "no acute-appearing abnormalities." The Board notes in his June 2013 written brief the Veteran's representative specifically objected to the adequacy of the December 2011 VA examination. The representative stated that the Veteran's condition was rated under Diagnostic Code 5296 for bone loss from skull and the examination report did not address this diagnostic criteria. However, the Board finds the examiner did specifically address the criteria for Diagnostic Code 5296, relating to loss of skull, when he opined there was no facial bone fracture or other acute abnormalities present on the facial x-ray. Accordingly the Board finds the examiner's report specifically addressed the Veteran's lack of facial bone loss and the examination was therefore adequate. The Board finds this report does not establish an increased rating is warranted. The examiner specifically noted the Veteran did not experience any paralysis as a result of his previous injury, and therefore he did not experience severe incomplete paralysis as contemplated by a higher 30 percent rating. Moreover, the examiner's report suggests the Veteran does not currently even experience sensory involvement due to his previous injury. However, affording all benefit of the doubt to the Veteran the Board finds a continued 10 percent rating for wholly sensory involvement is warranted. The claims file does not contain any additional medical evidence evaluating the Veteran's current trigeminal nerve condition. Accordingly the Board finds the evidence does not establish the Veteran had severe incomplete paralysis of the trigeminal nerve at any point during the period on appeal. Accordingly the Board finds an increased rating for incomplete paralysis of the trigeminal nerve is not warranted. The Board has also considered whether a separate rating is warranted under 38 C.F.R. § 4.71a, Diagnostic Code 5296. Under this Diagnostic Code, a 10 percent rating is assigned when there is a loss of part of the skull covering an area smaller than the size of a 25-cent piece or 0.716 in 2 (4.619 cm 2), without brain hernia; a 30 percent rating is assigned when there is a loss of part of the skull covering an intermediate area, without brain hernia; and a 50 percent rating is assigned when there is a loss of part of the skull covering an area larger than size of a 50-cent piece or 1.140 in 2 (7.355 cm 2), without brain hernia. An 80 percent rating is assigned when there is a loss of part of the skull that causes a brain hernia. Here, there is no indication that the Veteran has any loss of skull. X-rays were taken of the Veteran's zygomatic arch, but did not show any loss of skull. Therefore, the Veteran's claim for an increased rating is denied. In reaching this determination the Board also considered whether referral for consideration of an extraschedular rating is warranted, noting that if an exceptional case arises where ratings based on the statutory schedules are found to be inadequate, consideration of an "extra-schedular" evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities will be made. 38 C.F.R. § 3.321(b)(1). The Court has held that the determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry, the responsibility for which may be shared among the RO, the Board, and the Under Secretary for Benefits or the Director, Compensation and Pension Service. Thun v. Peake, 22 Vet. App. 111 (2008). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. This means that initially there must be a comparison between the level of severity and symptomatology of the veteran's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the veteran's disability level and symptomatology, then the veteran's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is adequate, and no referral is required. If the criteria do not reasonably describe the veteran's disability level and symptomatology, a determination must be made whether the veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). See id. However, in this case, the medical evidence fails to show anything unique or unusual about the Veteran's status post fracture of the right zygomatic arch that would render the schedular criteria inadequate. The Veteran's main symptoms were complaints of sensory involvement of his right cheek and occasional sagging of the right eye. As discussed above, these symptoms were specifically contemplated in the schedular ratings that were assigned in that the schedular rating criteria direct the Board to assess all of the Veteran's reported symptomatology in determining whether incomplete paralysis is moderate or severe. As such, the Board believes that the schedular rating criteria adequately describe the Veteran's disability picture and even if they do not, it would not be found that his disability met the "governing norms" of an extraschedular rating as the Veteran's post-fractured zygomatic arch has not resulted in any post-service hospitalizations and has not caused any impairment in employment, as multiple VA examiners found that the Veteran's cranial nerve injury did not impact his ability to work. Accordingly, referral for consideration of an extraschedular rating is not warranted. The Board has also considered whether an inferred claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) has been raised. The Board acknowledges that the Veteran is no longer employed. He has not, however, alleged that he is unemployable on account of his service connected status post fracture of right zygomatic arch. Moreover, as noted, both VA examiners from January 2006 and December 2011 specifically noted the Veteran's cranial nerve injury did not impact his ability to work. Thus, the Board finds that Rice is inapplicable since there is no evidence of unemployability due solely to the Veteran's status post fracture of the right zygomatic arch. Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to veterans. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Notice must be provided to a veteran before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits and must: (1) inform the veteran about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the veteran about the information and evidence that VA will seek to provide; and (3) inform the veteran about the information and evidence the veteran is expected to provide. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). With respect to service connection claims, a section 5103(a) notice should also advise a veteran of the criteria for establishing a disability rating and effective date of award. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). In the present case, required notice was provided by a letter dated in July 2004, which informed the Veteran of all the elements required by the Pelegrini II Court as stated above. Although this initial letter did not provide the notice required by the Dingess court, such notice was provided by an additional letter in March 2006 which informed the Veteran how disability ratings and effective dates were established. Although all required notice was not provided prior to the first adjudication of the claim, the Veteran has been provided with every opportunity to submit evidence and argument in support of his claim and ample time to respond to VA notices. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). Additionally, the Veteran's claim was readjudicated following completion of the notice requirements. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied. As to VA's duty to assist, the Board finds that all necessary development has been accomplished regarding the Veteran's claims for his left hip, leg length discrepancy, chest/ribs, and residuals of right zygomatic arch fracture claims. Therefore appellate review may proceed regarding these claims without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service treatment records and post-service VA treatment records have been obtained. The Veteran has not indicated he received any post-service private treatment regarding these claims. Additionally, the Veteran was provided with a hearing before the Board in April 2011. In Bryant v. Shinseki, the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. 3.103(c)(2) requires that the VLJ who conducts a hearing fulfill two duties to comply with the regulation. They consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. In this case, during the hearing the undersigned acting VLJ fully explained the issue on appeal. To the extent that any information about new and material evidence was not covered, there has been no prejudice, as the Veteran's service connection claims are all being considered on a de novo basis. Additionally, testimony was received regarding the Veteran's claim for service connection for the right leg and hip condition. During the hearing the Veteran was assisted at the hearing by an accredited representative from the Veteran of Foreign Wars, and the acting VLJ and the representative asked questions regarding the nature and etiology of the Veteran's claimed conditions, specifically regarding their relation to his car crash during military service. In addition, the VLJ sought to identify any pertinent evidence not currently associated with the claims file that might have been overlooked or was outstanding that might substantiate the claim, and specifically inquired as to hospital treatment the Veteran received following his car crash. The identified outstanding pertinent evidence was obtained during the previous remand, as discussed above. Furthermore, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) or identified any prejudice in the conduct of the Board hearing. As such, the Board finds that, consistent with Bryant, the acting VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2), and that any error in notice provided during the Veteran's hearing constitutes harmless error. It is noted that the RO sought to obtain VA treatment records from the Denver VAMC, but was informed by the medical center that no such records existed. The Veteran was called in September 2012 and informed that there were no VA records from Denver, to which he replied that all his records were at the VAMC in Cheyenne. These records were obtained. Regarding his claim for status post fracture of the right zygomatic arch the Veteran was provided with a VA examination, the report of which has been associated with the claims file. Notwithstanding the objection of the Veteran's representative, as discussed above, the Board finds the VA examination was thorough and adequate and provides a sound basis upon which to base a decision with regard to the Veteran's claim. The VA examiner personally interviewed and examined the Veteran, including eliciting a history from him, and provided the information necessary to evaluate his disability. The Board acknowledges the Veteran was not provided with a VA examination for several of his other claims for service connection. In McLendon v. Nicholson, 20 Vet. App. 79 (2006), the United States Court of Appeals for Veterans Claims (Court) held that an examination is required when (1) there is evidence of a current disability, (2) evidence establishing an "in-service event, injury or disease," or a disease manifested in accordance with presumptive service connection regulations occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. However, the Board finds an examination was not required under McLendon in each of those four claims. Regarding the Veteran's claim for service connection for both a chest and rib condition, the Board finds the record includes some evidence of an in-service event or injury; however the evidence did not establish the Veteran has a current chest or rib disability. Therefore both of these claims did not meet the first element of McLendon and no examination was required. Regarding the Veteran's claim for service connection for a left hip condition the Board finds the evidence did not establish any in-service injury or any current disability, and therefore no examination was required. Finally, regarding the Veteran's claim for service connection for leg length discrepancy the Board finds the evidence established a current condition, but did not include any suggestion of an in-service injury or event, or any other suggestion the current condition may be related to military service. Therefore this claim also did not meet the elements of McLendon and no examination was required. As discussed, VA has satisfied its duties to notify and assist, and additional development efforts would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. ORDER The claims for service connection for chest and rib condition, left hip condition, and the Veteran's leg length discrepancy are all denied. The claim for an increased rating for service-connected status post fracture of the right zygomatic arch is denied. REMAND Dental The Veteran is also seeking service connection for loss of teeth. As discussed above the Veteran was involved in a car wreck during military service which caused, among others, trauma and injury to his face, particularly on the right side. The Veteran has alleged that this in-service trauma lead to the loss of several teeth after his military service. In September 2008 a VA nurse opined the Veteran's current "dental problems" were at least as likely as not related to his military service, including the car crash. However, the registered nurse did not include any diagnosis of which dental problem the Veteran currently had. Other medical evidence suggests the Veteran's current dental problems, including loss of teeth, were due to poor hygiene and chronic periodontal disease. Under VA regulations only the dental conditions listed at 38 C.F.R. § 4.150 may be service connected for compensation purposes. All other dental conditions, including chronic periodontal disease, may be service connected solely for the purpose of establishing eligibility for outpatient dental treatment. 38 C.F.R. § 3.381(b). Accordingly remand is required to provide a VA examination to determine if the Veteran's current loss of teeth was due to a dental condition listed at 38 C.F.R. § 4.150 or was due to some other dental condition, including chronic periodontal disease. If only periodontal disease is found then the RO/AMC should develop a claim for service connection for treatment purposes. See Mays v. Brown, 5 Vet. App. 302 (1993) (stating a claim for service connection is also considered to be a claim for VA outpatient dental treatment). Additionally the Board notes during his April 2011 hearing the Veteran testified that he received dental treatment from a dentist in Sterling, California. These records are not yet associated with the claims file and could be highly probative to the Veteran's claim. Therefore the RO/AMC should also attempt to obtain these records upon remand. Back Throughout the period on appeal the Veteran has consistently attributed his current back pain to his car wreck during service. Accordingly there is some suggestion of an in-service injury. However, the Veteran's enlistment physical shows that prior to enlistment, he was experiencing occasional myositis and back pain. Additionally, the Veteran's back was found to be normal at his separation physical, and a private treatment record from April 1974 showed that the Veteran experienced an acute back strain, suggesting a possible post-service back injury. In a September 2008 record a VA registered nurse opined the Veteran's current back condition was as likely as not due to his military service. However the nurse did not identify what back condition the Veteran currently had, and did not provide any rationale for her conclusion. Review of the record reflects the Veteran has not been provided a VA examination regarding this condition. However, the record contains some suggestion of an in service injury, some suggestion of a current condition, and some suggestion of a military nexus. Accordingly the requirements of McLendon were met and remand is required to obtain a VA examination. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Bilateral Knees The Veteran is also seeking service connection for a bilateral knee condition. Throughout the appeal the Veteran has consistently related his current knee pain to the car crash during his military service. Similar to the Veteran's back claim, in a September 2008 record a VA registered nurse opined the Veteran's current bilateral knee pain was as likely as not due to his military service. However the nurse again did not identify any current condition in the Veteran's knees which was causing his pain. The record also includes a January 2009 x-ray which revealed degenerative changes in both knees without any acute injury. Because the record contains some suggestion of an in-service injury, some suggestion of a current condition, and some suggestion of a nexus to military service the requirements of McLendon are met and remand is required to provide an initial VA examination regarding this claim. Id. Right hip The Veteran is also seeking service connection for residuals of injuries to his right hip and leg. During his in-service hospitalization at Naval Hospital Lemoore in April 1970 the care provider noted the Veteran had pain in his right hip due to his car accident. The provider further noted that due to this pain the Veteran could not walk effectively and used crutches throughout his hospitalization. At his November 1970 separation physical no condition or injury to the Veteran's right leg or hip was noted. Instead, the Veteran's lower extremities were noted to be in normal condition. No right hip or leg problems was noted for many years after service. The Veteran currently reports that he has been diagnosed with arthritis in his right hip, although such a diagnosis does not appear to be found in the medical evidence of record. As such, an examination is found to be necessary. Accordingly, the case is REMANDED for the following actions: 1. Obtain all treatment records from the Veteran's dentist in Sterling, California and associate them with the claims file. All efforts to obtain these records should be fully documented, and a negative response must be provided if records are not available. 2. After obtaining the records from the dentist in Sterling, California and associating them with the claims file, provide the Veteran with a VA examination to evaluate the nature and etiology of his dental condition, if any. The examiner should be provided with the Veteran's complete claims file and a full rationale should be provided for any opinion expressed. All required testing and evaluation should be completed. Consistent with the factual history, including the Veteran's car crash during military service, the examiner should provide an opinion as to the following questions: a) Does the Veteran currently have a dental condition listed at 38 C.F.R. § 4.150, to include loss of teeth due to loss of substance of body of the maxilla or mandible without loss of continuity? -If so, is the Veteran's current dental condition as likely as not due to his military service, to include his car crash? b) If not, does the Veteran currently have any other dental condition, to include chronic periodontal disease, otherwise attributable to the car crash during military service? If the Veteran is not found to have a dental condition listed at 38 C.F.R. § 4.150 but instead only has an additional form of dental disease, including chronic periodontal disease, the RO/AMC is to develop a claim for service connection for dental treatment purposes, including referral to the Veterans Health Administration to determine if the Veteran meets the basic eligibility requirements under 38 C.F.R. § 17.161 as required by 38 C.F.R. § 3.381. 3. Provide the Veteran with a VA examination to evaluate the nature and etiology of his current back condition, if any. The examiner should be provided with the Veteran's claims file and a complete rationale should be provided for any opinion expressed. All required testing and evaluation should be completed. Consistent with the factual history, including the medical records of the Veteran's myositis which was noted at enlistment, the in-service treatment following his April 1960 car crash, and the post-service indication of an acute back strain in April 1974, the examiner should answer the following questions: a) Does the indication of one episode of acute myositis of the low back secondary to heavy lifting on the Veteran's medical history survey completed in conjunction with his enlistment physical clearly and unmistakably show a chronic back disability that existed prior to service? b) If yes, does the evidence clearly and unmistakably show that lumbar myositis was not aggravated (meaning permanently worsened) during the Veteran's service? c) Does the Veteran have a current back disability, other than lumbar myositis, and if so is it at least as likely as not (50 percent or greater) that a current back disability either began during or was otherwise caused by the Veteran's military service, to include as a result of his April 1970 car crash? The examiner should also consider the relevance, if any, of the fact that the Veteran experienced an acute back strain in April 1974 several years after separation. 4. Provide the Veteran with a VA examination to evaluate the nature and etiology of his current bilateral knee condition, if any. The examiner should be provided with the Veteran's claims file and a complete rationale should be provided for any opinion expressed. All required testing and evaluation should be completed. Consistent with the factual history, including the medical records of the Veteran's in-service treatment following his April 1960 car crash, the examiner should provide an opinion as to the following questions: a) Does the Veteran currently have any disability in either knee? Separately identify each condition in each knee, if applicable. b) For each identified knee condition is it as likely as not (50 percent or greater) that the Veteran's current knee condition was caused by his active military service, to include his April 1970 car crash? 5. Schedule the Veteran for a VA orthopedic examination of his right hip. The Veteran's claims file should be provided. The examiner should diagnose any current right hip/leg disability, to include arthritis, and then should provide an opinion as to whether it is at least as likely as not (50 percent or greater) that a current right leg/hip disability either began during or was otherwise caused by the Veteran's military service, to include. In doing so, the examiner should specifically address the service treatment records showing complaints of right hip pain. A complete rationale should be provided for any opinion expressed. 6. Then, readjudicate the appeal. If the claims remain denied, provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate time for response. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112. ______________________________________________ MATTHEW W. BLACKWELDER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs