Citation Nr: 1336264 Decision Date: 11/07/13 Archive Date: 11/13/13 DOCKET NO. 10-35 181 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to an initial compensable rating for residuals of a hernia. 2. Entitlement to an initial compensable rating for residuals of a fractured mandible prior to November 17, 2010, and a rating in excess of 10 percent thereafter. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD R. Sauter, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1976 to August 1979. This matter comes before the Board of Veteran's Appeals (Board) from a November 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, MO, which continued separate, noncompensable ratings for service-connected residuals of a hernia, as well as residuals of a fractured mandible. In a May 2013 rating decision, the RO increased the rating for residuals of a mandible fracture to 10 percent, effective November 17, 2010. Because the Veteran was not awarded a complete grant of the benefit sought, the increased rating claim is still on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). Additionally, the Board is cognizant of the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the United States Court of Appeals for Veterans Claims held that a claim for a total rating based on unemployability due to service- connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. The Veteran has not specifically argued, and the record does not otherwise reflect, that his disabilities render him totally unemployable. Rather, a March 2013 VA examination report specifically notes that he is employed full-time as a security guard. Accordingly, a claim for TDIU has not been raised. FINDINGS OF FACT 1. The Veteran has two painful inguinal hernia scars which are not deep and nonlinear, and do not result in any other disabling manifestation not contemplated by the remaining Diagnostic Codes pertaining to scars. 2. Prior to November 17, 2010, the Veteran's residuals of a fractured mandible was manifested by complaints of clicking and popping of the mandible, inter-incisal opening greater than 40 mm. and lateral excursion greater than 4 mm., but with no loss of motion or masticatory function. Moderate displacement of the mandible has not been shown. 3. Since November 17, 2010, the Veteran's residuals of a fractured mandible are manifested by temporomandibular joint (TMJ) disorder, inter-incisal opening greater than 40 mm. and lateral excursion greater than 4 mm, with pain and occasional impairment of masticatory function. Severe displacement of the mandible has not been shown. CONCLUSIONS OF LAW 1. The criteria for an initial 10 percent rating, but no greater, for the Veteran's scars, residuals of a hernia, have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159. 3.321, 4.118, Diagnostic Code 7338 - 7804 (2013). 2. Prior to November 17, 2010, the criteria for an initial compensable rating for service-connected residuals of a fractured mandible were not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.7, 4.40, 4.45, 4.59, 4.149, Diagnostic Codes 9904, 9905 (2013). 3. Since November 17, 2010, the criteria for a rating in excess of 10 percent for residuals of a fractured mandible are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.7, 4.40, 4.45, 4.59, 4.149, Diagnostic Codes 9904, 9905 (2013). (CONTINUED ON NEXT PAGE) REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). VCAA notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). As the rating decision on appeal here granted service connection for both residuals of a hernia and residuals of a fractured mandible, and assigned disability ratings and effective dates for the awards, statutory notice has served its purpose, and its application is no longer required. See Dingess/Hartman, 19 Vet. App. at 490. A July 2010 statement of the case (SOC) provided notice on the "downstream" issues of entitlement to increased ratings; and a May 2013 supplemental SOC (SSOC) readjudicated the issues after the Veteran and his representative responded, and further development was completed. 38 U.S.C.A. § 7105; see Mayfield v. Nicholson, 20 Vet. App. 537, 542 (2006). With regard to the duty to assist, the Veteran's pertinent and available treatment records have been secured. The Veteran has been afforded VA medical examinations in connection with his claims, most recently in April 2013. 38 C.F.R. § 3.159(c)(4) (2013). The Board finds that the opinions obtained are adequate. The opinions were provided by qualified medical professionals and were predicated on a full reading of all available records. The examiners also provided detailed rationales for the opinions rendered. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Neither the Veteran nor his representative has challenged the adequacy of the examinations obtained. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159 (2013). The duty to assist has been met. Legal Criteria: Increased Rating Claims Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2013). Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2013). The Veteran has challenged the initial disability ratings separately assigned to his service-connected residuals of a hernia and residuals of a mandible fracture by seeking appellate review. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (noting distinction between claims stemming from an original rating versus increased rating). Separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged" rating. Fenderson, 12 Vet. App. at 126. VA has a duty to consider the possibility of assigning staged ratings in all claims for increase. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In Hart, the U.S. Court of Appeals for Veterans Claims (Court) extended entitlement to staged ratings to claims for increased disability ratings where "the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings." Id. at 511. Under VA regulations, separate disabilities arising from a single disease entity are to be rated separately. See 38 C.F.R. § 4.25; see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. Residuals of a Hernia Historically, the Veteran underwent a left inguinal herniorrhaphy in August of 1977, during service. On or about 1991 or 1992, the Veteran noticed a reemergence of his left inguinal hernia, and sought care at a private hospital. The Veteran underwent a second left inguinal herniorrhaphy with mesh emplacement in 1994 or 1995. The surgeries left two residual scars on the abdomen. The Veteran's service-connected residuals of a hernia are currently evaluated under 38 C.F.R. §§ 4.118 and 4.114, Diagnostic Code 7338 - 7804. 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. 38 C.F.R. § 4.27 (2013). Here, the hyphenated diagnostic code indicates inguinal hernia (Diagnostic Code 7338) which is rated under the criteria for scar(s), unstable or painful (Diagnostic Code 7804). See 38 C.F.R. § 4.20 (2013). The applicable rating criteria for skin disorders, found at 38 C.F.R. § 4.118, were most recently amended effective October 2008. The October 2008 revisions are applicable to claims for benefits received by the VA on or after October 23, 2008. See 73 Fed. Reg. 54708 (September 23, 2008). In this case the Veteran filed his increased rating claim in July 2009. Therefore, the regulations in effect after October 23, 2008 are for consideration. Diagnostic Code 7804 provides that one or two painful or unstable scars warrant a 10 percent rating, three or four scars that are unstable or painful warrant a 20 percent rating, and five or more scars that are unstable or painful warrant a 30 percent rating. The Veteran was afforded an October 2009 VA digestive examination in connection with his service connection claim. The examination report notes that the Veteran complained of pain in the area of the hernia when he turned at the waist. The report notes that, upon a thorough examination, neither scar appeared unstable or painful. The examiner concluded that it is at least as likely as not that the Veteran's residuals of the second herniorrhaphy are related to his in-service herniorrhaphy. According to a February 2010 private treatment record, the Veteran reported pain at the scar site from his second hernia repair and mesh emplacement. The Veteran was afforded a March 2013 VA hernia examination. In the questionnaire section of his report, the VA examiner responds in the negative to a question which states, "...are any of the scars painful and/or unstable...?" On examination, no hernia was detected. Two surgical scars were noted. There was minimal tenderness to touch on palpation around the first surgical scar. The examiner stated further that the Veteran experiences a mild discomfort, which appears to be related to the presence of the mesh from the second herniorrhaphy. Taking into account the relevant medical evidence and the applicable rating criteria, the Board finds that a higher initial rating of 10 percent is warranted pursuant to Diagnostic Code 7804. The record reflects that the Veteran has two residual hernia scars. In February 2010, the Veteran reported to his private physician left inguinal pain at the scar site near the mesh which was inserted during his second hernia repair. He, as a layperson, is competent to report observable symptoms of his scars, such as pain upon movement. See Layno v. Brown, 6 Vet. App. 465, 470 (1994), Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (holding that a Veteran's lay statement can be competent evidence of symptoms that are capable of lay observation). The Board finds credible the Veteran's lay statement as to pain. Additionally, the Board notes that the March 2013 VA examiner indicated that the Veteran had minimal tenderness and discomfort at the scar site due to the presence of the mesh. In a September 2013 informal hearing presentation, the Veteran, through his representative, asserted that he has not one, but two, painful scars from his hernia surgeries. This appears to be the first time during the appeal period that the Veteran reported pain in his first hernia scar. A review of the relevant medical evidence shows no complaints of pain in the first scar. Nonetheless, as noted, the Veteran is competent to report pain, and Diagnostic Code 7804 allows for a 10 percent rating for either one or two scars. As such, resolving any doubt in the Veteran's favor, the Veteran has two painful scars from his hernia repairs, a 10 percent initial rating is warranted under Diagnostic Code 7804. However, a rating higher than 10 percent under Diagnostic Code 7804 is not warranted, because the Veteran has no more than two residual hernia scars, and three or four painful or unstable scars are required to meet a higher rating under such code. The Board considered other potentially applicable codes. Diagnostic Code 7800 provides for ratings higher than 10 percent but such code contemplates burn scar(s) of the head, face, or neck; scar(s) of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck with characteristics of disfigurement. 38 C.F.R. § 4.118 (2013). As the Veteran's residual hernia scars are located on his abdomen, Diagnostic Code 7800 is not for application. Similarly, Diagnostic Code 7801 does not apply in this case, as the weight of the lay and medical evidence does not demonstrate that the Veteran's residual hernia scars are deep and nonlinear. 38 C.F.R. § 4.118, (2013). Additionally, Diagnostic Code 7802 does not provide for a rating higher than 10 percent and is therefore not applicable here. 38 C.F.R. § 4.118 (2013). Diagnostic Code 7805 rates other types and effects of scars not considered in a rating provided under the prior Diagnostic Codes. 38 C.F.R. § 4.118, Diagnostic Code 7805 (2013). This code does not apply as the evidence shows that the Veteran's hernia scars do not result in any other disabling manifestation not contemplated by the remaining Diagnostic Codes pertaining to scars. In summary, the Board concludes that an initial 10 percent rating, but no higher, is warranted for the Veteran's residual hernia scars throughout the initial appeal period. Residuals of a Fractured Mandible The RO granted service connection for residuals of a fractured mandible in a November 2009 rating decision that assigned a noncompensable (0 percent) rating pursuant to Diagnostic Code 9904, effective July 2009. As indicated above, the rating was then increased to 10 percent, effective November 17, 2010. Diagnostic Code 9904, used in rating malunion of the mandible, provides for a noncompensable disability rating where there is slight displacement of the mandible. A 10 percent disability rating is warranted for moderate displacement of the mandible, and a maximum 20 percent disability rating is warranted for severe displacement of the mandible. A Note to Diagnostic Code 9904 states that the rating is dependent upon degree of motion and relative loss of masticatory function. 38 C.F.R. §4.150, Diagnostic Code 9904. The words "slight," "moderate," and "severe," as used in the various diagnostic codes, are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Diagnostic Code 9905, which pertains to limitation of motion of temporomandibular articulation, is also applicable. It provides for a 10 percent disability rating when the range of lateral excursion is limited from 0 to 4 mm. or the inter-incisal range is limited to 31 to 40 mm. A 20 percent disability rating is applicable when the inter-incisal range is limited to 21 to 30 mm. A 30 percent rating is warranted when the inter-incisal range is limited to 11 to 20 mm., and a maximum 40 percent rating is assigned when the range is limited to 0 to 10 mm. A Note to Diagnostic Code 9905 states that ratings for limited inter-incisal movement shall not be combined with ratings for limited lateral excursion. 38 C.F.R. § 4.150, Diagnostic Code 9905. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). More recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Moreover, the provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). By way of history, the Veteran's mandible was fractured in service, in September 1977. At that time, the Veteran was diagnosed with a nondisplaced, closed, right mandibular subcondyle fracture and an open, nondisplaced, right mandibular body fracture. The Veteran was treated by closed reduction of the fractures by means of wiring his jaws closed with arch bars. Dental x-rays taken in October 1977, just prior to the removal of the arch bars, show that the fractures were healed and barely noticeable. The Veteran was afforded an October 2009 VA dental examination. The examination report notes the Veteran's current complaints of popping in the left jaw joint and tooth pain during mastication. The report notes that the Veteran is missing 15 teeth, which are replaceable by prosthesis. The report also indicates that the Veteran has a full range of inter-incisal motion. The VA examiner diagnosed the Veteran with well-healed mandible fractures without residual effects, very poor oral hygiene, and an abscess on tooth number 19. The report concludes that the Veteran has no functional impairment due to loss of motion and masticatory function loss, and that neither the abscess on tooth number 19, nor the popping he experiences in his left jaw, result from his fractured mandible. The Veteran saw a private physician in February 2010. The private physician's treatment record states that the Veteran's left jaw clicks and pops out of place with pain. The record also notes that the Veteran has difficulty opening his jaw at times. The Veteran submitted a statement, received on November 17, 2010, from his private dentist, reporting the Veteran's diagnosis with TMJ disorder. The dentist stated that TMJ disorder was diagnosed through intra and extra oral exams and radiographs. In April 2013, the Veteran was afforded an additional VA dental examination. He reported experiencing a painful locking of his jaw on occasion. He reportedly has to massage and manipulate his jaw in order to open his mouth. After taking the Veteran's statements, the VA examiner conducted a series of range of motion tests. The Veteran's range of motion for lateral excursion was greater than 4 mm., with no objective evidence of painful motion. Range of motion for opening mouth, measured by inter-incisal distance, was greater than 40 mm., with pain. The Veteran was able to perform repetitive-use testing with three repetitions. Post-test range of motion for lateral excursion was 0 to 4 mm. Post-test range of motion for opening mouth remained the same, at greater than 40 mm. After repetitive use testing, the examiner noted that the Veteran had less movement than normal, weakened movement, incoordination, impaired ability to execute skilled movements smoothly, pain on movement, and deformity in his left TMJ. The Veteran did not have localized tenderness or pain on palpation of the joints or soft tissues of either TMJ. Clicking or crepitation of joints of soft tissues of his left TMJ was present. The Veteran had no scars (surgical or otherwise) related to his fractured mandible. The examiner also noted that the Veteran had an obvious deformity when he opened or moved the jaw, and obvious popping and clicking on the left jaw that was sometimes accompanied by pain. The Veteran had significant pain when trying to protrude his jaw straight forward, as well as difficulty initiating that movement. The Veteran also had difficulty initiating lateral excursive movements to his left. The VA examiner compared the Veteran's old x-rays to the new x-rays, and determined that the Veteran has a different presentation to the angle and inclination of the left condyle. While the Veteran's right condyle was shaped within normal limits, the left condyle was abnormal in shape. The examination report noted that degenerative or traumatic arthritis of the TMJ was not seen on x-rays. Finally, the examiner indicated that the Veteran's TMJ disorder did not affect his ability to work. The Veteran's residuals of a fractured mandible are currently evaluated at 10 percent disabling under the criteria found at 38 C.F.R. § 4.150, Diagnostic Code 9904, for malunion of the mandible. Prior to November 17, 2010, the disability was evaluated at a noncompensable (0 percent) rating. The evidence of record shows that, prior to November 17, 2010, the weight of the lay and medical evidence demonstrates that the Veteran's residuals of a fractured mandible were primarily manifested by no more than complaints of popping of the mandible. During the October 2009 VA examination, the Veteran had no functional loss due to masticatory function loss. The examiner described his condition as well-healed mandible fractures without residual effects. Therefore, as moderate displacement of the mandible has not been demonstrated, an initial compensable rating under Diagnostic Code 9904 is not warranted prior to November 17, 2010. Similarly, during this prior time period, an initial compensable rating is not warranted under Diagnostic Code 9905. During the October 2009 VA examination, range of inter-incisal motion was greater than 40 mm. and lateral excursion was greater than 4 mm. Consequently, the Board concludes that an initial compensable rating is not warranted prior to November 17, 2010 under Diagnostic Code 9905. Since November 17, 2010, the evidence reflects that the Veteran continues to experience obvious popping and clicking of the left TMJ. His left condyle is abnormal in shape. He reported pain in the left TMJ region and on some days the jaw was stuck in a closed position which requires massage to open. There was no report of impairment of masticatory function. These findings however do not demonstrate that there is malunion of the mandible with severe displacement. Accordingly, a rating higher than 10 percent for residuals of fractured mandible is not warranted under Diagnostic Code 9904 since November 17, 2010. Additionally, a rating higher than 10 percent is not currently warranted under Diagnostic Code 9905. During the April 2013 VA examination, the Veteran's inter-incisal range was greater than 40 mm., and his lateral excursion was greater than 4 mm. The Board recognizes the Veteran's current pain when opening his mouth and protruding his jaw forward. Upon repetitive motion testing during the April 2013 VA examination, there was evidence of additional functional loss on the left TMJ in terms of less movement than normal, weakened movement, and deformity. As noted, post-test range of motion for lateral excursion was 0 to 4 mm. However, even with consideration of this additional functional loss, the criteria for a higher rating have not been met under Diagnostic Code 9905. The weight of the competent and probative lay and medical evidence establishes that the Veteran does not have actual inter-incisal range of motion limited to 30 mm. or less or the functional equivalent of inter-incisal motion limited to 30 mm. or less. DeLuca; 38 C.F.R. §§ 4.3, 4.59, 4.150. The Board notes that the 10 percent disability rating assigned contemplates flare ups to include loss of time from exacerbations, if any. 38 C.F.R. § 4.1; Mitchell, 25 Vet. App. 32; Burton, 25 Vet. App. 1. In considering the applicability of other regulatory criteria, the Board finds that there is no evidence that the Veteran's residuals of a fractured mandible, left side, is manifested by chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible, nonunion of the mandible, loss of any part of the maxilla, mandible, ramus, condyloid process, hard palate, or teeth, or malunion or nonunion of the maxilla. Thus Diagnostic Codes 9900-9903 and 9906-9916, contemplating the above-listed disorders, are not applicable in the present appeal and may not serve as bases for an increased rating. 38 C.F.R. § 4.150, Diagnostic Codes 9900-9903, 9906-9916 (2013). Although the Veteran's left condyle is abnormally shaped, loss of the condyloid process is not present. Moreover, the Veteran has missing teeth, but only tooth number 29 was affected by the mandible fracture. Additionally, the October 2009 VA examiner related the Veteran's missing teeth to poor hygiene as opposed to the mandible fracture. At any rate, the evidence shows that the mandible fracture involved the area around tooth number 29 only, and there is no indication that such tooth is missing. The Board also considered whether a separate rating for a residual scar is warranted; however, according to the April 2013 VA examination report, the Veteran's fractured mandible did not result in any scars. The Veteran, as a layperson, is competent to report any observable symptoms of his fractured mandible, such as popping and clicking of the jaw, and he has done so in conjunction with his VA examinations. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, without the appropriate medical training and expertise, he is not competent to provide an opinion on a medical matter, such as the nature and severity of his fractured mandible. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The medical evidence of record are highly probative as to the nature and severity of the Veteran's fractured mandible residuals. The VA examination reports were based on physical examinations and provided sufficient information to allow the Board to apply the schedular criteria. Thus, although the Veteran's competent and credible reports of symptoms have been considered and are probative, the Board attaches greater probative weight to the clinical findings of medical professionals. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). Based on the foregoing, the Board concludes that the preponderance of the evidence is against an initial compensable rating prior to November 17, 2010, and a rating higher than 10 percent thereafter for the Veteran's service-connected residuals of a fractured mandible. The rating schedule represents as far as is practicable, the average impairment of earning capacity. Ratings will generally be based on average impairment. See 38 C.F.R. § 3.321(a), (b) (2013). In exceptional cases an extra-schedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of this VA regulation, for determining whether a Veteran is entitled to an extra-schedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of his disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extra-schedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The schedular rating criteria contemplate the extent and severity of the Veteran's residuals of a hernia, which, as noted, are manifested by no more than two painful scars. Additionally, the schedular rating criteria contemplate the extent and severity of the Veteran's residuals of a fractured mandible, which includes malunion of the mandible and symptoms such as popping, clicking, pain on movement and some limited motion. The Board, then, is not obligated to refer this claim to the Under Secretary for Benefits or to the Director of Compensation and Pension (C&P) Service for extra-schedular consideration. Bagwell v. Brown, 9 Vet. App. 237, 238-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); and VAOPGCPREC 6-96 (August 16, 1996). (CONTINUED ON NEXT PAGE) ORDER A 10 percent rating, but no greater, for the Veteran's residual hernia scars is granted, subject to the applicable regulations concerning the payment of VA monetary benefits. Prior to November 17, 2010, entitlement to an initial compensable rating for residuals of a fractured mandible is denied. Since November 17, 2010, entitlement to a rating in excess of 10 percent for residuals of a fractured mandible is denied. ____________________________________________ K. J. Alibrando Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs