Citation Nr: 1338219 Decision Date: 11/21/13 Archive Date: 12/06/13 DOCKET NO. 10-29 558 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to a rating in excess of 10 percent for prominent premaxilla with maxillary anterior segmental osteotomy with mid-line and posterior retroposition and gum disorder. REPRESENTATION Veteran represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD J. Fussell, Counsel INTRODUCTION The Veteran had active service from November 1984 to November 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2009 decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In the Veteran's June 2010 substantive appeal (VA Form 9), she requested a Board video-conference hearing before a Veterans Law Judge. However, in an August 2010 statement, the Veteran indicated that she wished to withdraw her request for a Board hearing and, instead, requested a hearing before a Decision Review Officer (DRO) at the RO. As such, in an August 2012 letter, the Veteran was informed that her DRO hearing was scheduled for November 2012. However, in a September 2012 statement, the Veteran indicated that she wished to cancel her DRO hearing. Therefore, the Board finds that there are no pending hearing requests. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claim. A review of the Virtual VA claims file does not reveal any additional documents pertinent to the present appeal. FINDINGS OF FACT 1. The service-connected prominent premaxilla with maxillary anterior segmental osteotomy with mid-line and posterior retroposition and gum disorder is manifested by no loss of all upper or lower posterior or all upper or lower anterior teeth and no more than moderate neurological impairment of the ninth cranial nerve on the right side. 2. The service-connected prominent premaxilla with maxillary anterior segmental osteotomy with mid-line and posterior retroposition and gum disorder is manifested by no loss of all upper or lower posterior or all upper or lower anterior teeth and no more than moderate neurological impairment of the ninth cranial nerve on the left side. CONCLUSIONS OF LAW 1. The criteria for a separate rating of 10 percent, but no higher, for prominent premaxilla with maxillary anterior segmental osteotomy with mid-line and posterior retroposition and gum disorder on the right side are met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.14, 4.25, 4.124a, 4.149, Diagnostic Code 9913-8309 (2012). 2. The criteria for a separate rating of 10 percent, but no higher, for prominent premaxilla with maxillary anterior segmental osteotomy with mid-line and posterior retroposition and gum disorder on the left side are met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.14, 4.25, 4.124a, 4.149, Diagnostic Code 9913-8309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). 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 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 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. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a June 2009 letter, sent prior to the initial unfavorable decision issued in July 2009, advised the Veteran of the evidence and information necessary to substantiate her increased rating claim as well as her and VA's respective responsibilities in obtaining such evidence and information. Additionally, such letter advised her of the information and evidence necessary to establish an effective date in accordance with Dingess/Hartman, supra. Relevant to the duty to assist, the Veteran's service treatment records (STRs) as well as post-service VA and private treatment records have been obtained and considered. The Board notes that, in response to the VCAA letter, the Veteran listed two physicians as having treated and examined her in June 2009. However, those two physicians are the VA examiners that evaluated her on formal VA examinations in June 2009. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. The Veteran has been afforded VA dental and neurology examinations in June 2009, February 2010, March 2010, and February 2011 in conjunction with the claim on appeal. Neither the Veteran nor her representative have alleged that such are inadequate for rating purposes. Moreover, the Board finds that the examinations are adequate in order to evaluate the Veteran's service-connected disability as they include an interview with the Veteran, a review of the record, and a full dental and physical examination, addressing the relevant rating criteria. Therefore, the Board finds that the examination report of record is adequate to adjudicate the Veteran's increased rating claim and no further examination is necessary. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, she will not be prejudiced as a result of the Board proceeding to the merits of her claim. Background On a dental and oral VA examination in June 2009, it was reported that the Veteran had popping of her right jaw for 1 year and for 3 months she had more often had shooting pains. It also caused headaches, aches and sharp pain of the neck, and ear pain. She took Ibuprofen for headaches. She had no loss of function due to limitation of motion but had some loss of masticatory function such that she had to eat softer food due to jaw pain. Her masticatory surface could not be replaced by a prosthesis. She had no missing teeth. There was no limitation of inter-incisal range of motion, mandibular bone loss or maxilla bone loss, and there was no bone loss of the hard palate. It was noted that she had had surgery 10 years earlier "to move maxilla in the anterior." The diagnoses were temporomandibular joint (TMJ) dysfunction and prominent premaxilla with maxillary anterior segmental osteotomy from mid-line and posterior retroposition and gum disorder. As to the affect on the usual occupation and daily activities, her pain caused problems in daily function with alteration of her eating pattern and fear of jaw popping and locking. She had scarring of the upper maxillary ridge, inside her mouth, which was not visible and not discernible. On a cranial nerves VA examination in June 2009, it was reported that the Veteran had pain in the left temporal area and left occipital region. She also had popping of her jaw and numbness in the maxillary and frontal teeth areas, as well as hyper-saliva production. Ibuprofen helped to some degree. Her past surgery had included trauma to the 9th cranial nerve. She had no tumor. On examination she had some sensory impairment but no motor impairment. She had numbness in the upper lip, nose and the side of the face close to the nose (the 9th cranial (terminal) nerve distribution) which affected the sensory branch of the 9th cranial nerve. Neither her sense of taste nor her sense of smell was affected. The diagnosis was prominent premaxilla with maxillary anterior segmental osteotomy from mid-line and posterior retroposition and gum disorder, with post-operative bilateral sensory deficit from neuralgia of the 9th cranial nerve. There was a moderate effect upon her usual occupation and daily activities. She had scarring of the upper maxillary ridge, inside her mouth, which was not visible, not measurable, and not discernible. VA outpatient treatment (VAOPT) records reflect that in October 2009 it was noted that the Veteran had been in a motorcycle accident 6 years earlier. Following this, she received extensive treatment for symptoms of her neck and shoulders. On VA neurology examination in February 2010 to evaluate the Veteran's complaints of neck pain, it was noted that she had, bilaterally, no sensation of lancinating or electric shock pain; involuntary painless facial twitching or spasm or weakness or paralysis of facial muscles. She did have increased salivation and moderate difficulty chewing. She had a history of mild scratching-type of throat pain. She had no symptoms of her nose. On examination, as to her 9th cranial nerve, the Veteran had a normal gag reflex, bilaterally. On evaluation of her palate, upon saying "ah" or yawning, her uvula was symmetrical and in the mid-line. Her ability to swallow and speak was normal. There was no dyspnea or stridor. There was no loss of taste of the posterior 1/3 of her tongue. It was noted that her jaw, with her mouth open, popped when closing the mouth in the TMJ area. She was currently employed on a full-time basis and had not lost any work in the last 12 months. It was commented that there was no evidence of total paralysis of the glossopharyngeal nerve. On VA dental examination in March 2010 it was noted that the Veteran had no history of dental trauma. She had a history of frequent difficulty chewing of some food. She had no swelling but had daily pain in her throat, tongue, and posterior palate which was moderate. She had no history of difficulty opening her mouth, talking or drainage. On physical examination there was no loss of bone of the maxilla and no malunion or nonunion of the maxilla. There was no nonunion of the mandible but there was malunion of the mandible with displacement and abnormal motion which were both moderate. She had moderate interference with masticatory function. As to the TMJ, she had limitation of motion at the TMJ. There was no loss of bone of the hard palate and no evidence of osteoradionecrosis or osteomyelitis. There was no loss of teeth due to loss of substance of the body of the maxilla or mandible (other than loss due to periodontal disease). She had no difficulty with speech. The examiner noted that her chief complaint was not being able to get her lips together and that her front teeth stuck out too far. Active duty records indicated that she had been counseled regarding the risks and complications of her maxillary repositioning to eliminate maxillary prominence and "overjet/bite." Records further indicated that she had tolerated the surgery well with satisfactory postoperative hearing. However, she still complained of jaw problems with trouble eating because of sharp pains, occasional numbness of her nose, and cold fluids causing her throat to hurt. X-rays revealed maxillary hardware was retained but within normal limits. Clinical evaluation to test glossopharyngeal nerves yielded mixed results. Sharp point palpation revealed decreased tactile sensitivity but not severe neuralgic response. She did not have a history of regurgitation of liquids or impairment of taste. She did not confirm having any choking or coughing episodes. Her gag reflex was present and normal. The examiner further stated that clinical testing did not confirm evidence of complete paralysis of the glossopharyngeal nerve. Her subjective history might suggest moderate functional impairment due to spontaneous moderate to high pain level scores accompanied with moderate mandibular joint dysfunction. Moderate loss of motion was noted on lateral cursive movements of the mandible only, and moderate glossopharyngeal nerve damage. On VA examination in February 2011 to evaluation TMJ dysfunction the Veteran's claim file and VA medical records were reviewed. She reported having had numbness below her eyes and into her gingiva anterior maxilla, as well as constant bilateral TMJ pain. She had a history of constant difficulty chewing but only of some foods. She had no history of difficulty opening her mouth, talking or of drainage. She reported having numbness anterior to her lips, in the skin below her nose, and in the gums in the upper anterior portion of her mouth. She also complained of tightness of the muscles of her cheeks, and constant pain behind her right eye. On physical examination there was no loss of bone, malunion or nonunion of the maxilla or mandible. She had limitation of motion at the TMJ area. There was no evidence of osteoradionecrosis or osteomyelitis. There was no loss of teeth due to loss of substance of the body of the maxilla or mandible, and no speech difficulty. She had numbness in the upper lip, bilaterally, in the area of the skin under the eyes, and the buccal gingiva from teeth's # 5 to # 12. She had clicking, bilaterally, on opening the TMJ's. She could open her mouth to 20 millimeters (mms.), incisionally, and to 10 mms. upon right and left excursion both before and after fatigue. She reported that her masseter muscles were not sore to palpation before or after fatigue. Upon opening her mouth, she had normal motion, but had limited movement before and after fatigue. She reported that her TMJ areas were tighter after fatigue. She reported that she was currently not employed and was looking for employment. The diagnoses were paresthesia, bilaterally, of the trigeminal infra-orbital nerve from orthognathic surgery in 1986, and internal derangement of both TMJ areas. On VA neurology examination later in February 2011, to evaluate complaints of headaches, it was noted that the Veteran's migraines focused on her degenerative joint disease of the cervical spine, and not problems with her jaw. On examination here cranial nerves were intact. X-rays revealed small plates and screws projecting over the ethmoid sinuses, just below the nose on each side. The TMJ articulations appeared normal and no acute problem or other abnormality was found. The examiner noted that the Veteran reported working for a school district for less than one year, having not been retained as a VA employee after her trial period. On evaluation of the Veteran's reported loss of sense of taste and smell, the Veteran's STRs and VA medical records were reviewed. She reported that this had appeared subtly and had worsened over the past 18 to 24 months. She attributed this to her maxillary surgery. On examination she could not identify the smell of coffee. Sugar tasted a little sweet and salt tasted a little sour. She was unsure what black pepper tasted like. The diagnosis was a partial loss of taste and smell with no etiology found; however, the examiner further stated that the loss of taste and smell was not due to or a result of prominent premaxilla with maxillary anterior segmental osteotomy with mid-line and posterior retroposition. It was commented that the surgery which the Veteran had had did not approach the olfactory nerve or the nerves response for sense of taste. On an unrelated VA psychiatric examination in July 2012, the Veteran reported that she was now working at Ft. Bliss, inspecting rooms for soldiers. Principles Governing Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings under Diagnostic Codes (DCs) are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7; see also 38 C.F.R. § 4.21. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007) (staged ratings during the appeal of any increased rating claim). The Board notes that a March 1988 rating decision granted service connection for the disability at issue and assigned an initial noncompensable rating. The Veteran did not enter a notice of disagreement with respect to the initially assigned rating. An increased rating was denied by an April 2005 rating decision but a June 2005 rating decision granted a 10 percent rating for the disability at issue. She did not appeal either decision. Moreover, no additional evidence referable to this disability was associated with the claims file within one year of the issuance of the June 2005 rating decision. 38 C.F.R. § 3.156(b) (when new and material evidence is received prior to the expiration of the appeal period, it will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period); Bond v. Shinseki, 659 F.3d 1362, 1367 (Fed. Cir. 2011). Thereafter, VA received the Veteran's current claim for an increased rating in May 2009. The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. See generally 38 U.S.C.A. § 5110(b)(2). An unlisted condition may be rated under a closely related disease or injury by the use of a "built-up" DC under 38 C.F.R. § 4.27, with consideration given to relevant medical history, current diagnosis, symptomatology, functions affected and anatomical localization. 38 C.F.R. § 4.20. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). The assignment of a particular diagnostic code is "dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). An unlisted condition may be rated as if it were a closely related disease or injury, when (1) the functions affected, (1) the anatomical localization, and (3) symptoms are closely analogous. 38 C.F.R. §§ 4.20, 4.27; see also Lendenmann v. Principi, 3 Vet. App. 345, 351 (1992) and Archer v. Principi, 3 Vet. App. 433 (1992). The current 10 percent rating has been assigned by the RO, citing Diagnostic Codes 9913 and 8309. Under 38 C.F.R. § 4.149, DC 9913 loss of teeth due to loss of substance of body of maxilla or mandible without loss of continuity when the loss of masticatory surface can be restored by suitable prosthesis warrants a noncompensable rating. Under 38 C.F.R. § 4.149, DC 9913 loss of teeth due to loss of substance of body of maxilla or mandible where the lost masticatory surface cannot be restored by suitable prosthesis a 10 percent rating is warranted when all upper and lower teeth on one side missing; or if all lower anterior teeth missing; or if all upper anterior teeth missing. A 20 percent rating is warranted if all upper and lower anterior teeth missing; or if all upper and lower posterior teeth missing. A 30 percent rating is warranted if all upper or if all lower teeth are missing. A maximum schedular rating of 40 percent is warranted if all teeth are missing. A note to 38 C.F.R. § 4.149, DC 9913 provides that these ratings apply only to bone loss through trauma or disease such as osteomyelitis, and not to the loss of the alveolar process as a result of periodontal disease, since such loss is not considered disabling. Under 38 C.F.R. § 4.124a, DC 8309 neuritis of the ninth (glossopharyngeal) cranial nerve is rated dependent upon relative loss of ordinary sensation in mucous membrane of the pharynx, fauces, and tonsils. With moderate neuritis, a 10 percent rating is warranted. When severe, a 20 percent rating is warranted. With complete paralysis of the ninth cranial nerve a 30 percent rating is warranted. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, an introductory paragraph in 38 C.F.R. § 4.124a, as to evaluation of diseases of the cranial nerves, provides that ratings for the cranial nerves are for unilateral involvement; when bilateral, combine the separate ratings, but without the bilateral factor. Analysis Initially, the Board notes that secondary to service-connected prominent premaxilla with maxillary anterior segmental osteotomy with mid-line and posterior retroposition, the Veteran has a separate rating of 10 percent for tinnitus, under DC 6260 and a 30 percent rating for bilateral TMJ dysfunction, assigned under 38 C.F.R. § 4.149, DC 9905 for limited motion of the TMJ articulation. She is also in receipt of a 30 percent rating for migraine and tension headaches under DC 8100 as secondary to her service-connected psychiatric disability. TMJ is temporomandibular joint syndrome and is "dysfunction of the masticatory apparatus related to spasm of the muscles of mastication precipitated by disharmony of the contact surfaces of the upper and lower teeth or alteration in vertical dimension of the jaws." Antonian v. Brown, 4 Vet. App. 179, 181 (1993). TMJ syndrome relates to the joint between the temporal bone and the mandible. Kirwin v. Brown, 8 Vet. App. 148, 154 (1995). Thus, any limitation of motion of the Veteran's jaws, such as the difficulty chewing food, is encompassed in the 30 percent rating for her TMJ dysfunction. Thus, she cannot receive compensation for the same symptomatology under a different DC. See 38 C.F.R. § 4.14; Esteban, supra. The RO has considered evaluating the service-connected disability at issue under another dental rating, i.e., DC 9913 for impairment of the maxilla or mandible. As to this, the greater weight of the clinical evidence shows no significant abnormality, including no loss of bone substance or loss of continuity. The evidence also shows that there is no loss of all upper or lower posterior or all upper or lower anterior teeth. Consequently, a rating in excess of 10 percent is not warranted on the basis of dental disability. The current 10 percent rating assigned for neurological impairment of the glossopharyngeal, i.e., the 9th cranial, nerve encompasses moderate neurological impairment. A review of the evidence shows that the involvement has repeatedly been described as no more than moderate. The 2009 VA dental examination found moderate bilateral sensory 9th cranial nerve impairment, the 2010 VA neurology examination found no total paralysis of that nerve, and the VA dental examination found decreased sensitivity of the 9th cranial nerve, but also that it was not severe. In this regard, the Board is aware that the February 2011 VA examination indicated that the involvement was of the trigeminal (5th cranial) nerve. However, the greater weight of the clinical evidence shows that it is actually the glossopharyngeal, i.e., the 9th cranial, which is affected. However, as indicated, a note to the evaluation of cranial nerves (other than those affecting organs of special sense) are for unilateral impairment. The current rating of 10 percent has been assigned on the basis of the overall impairment, on both sides of the face. That is, the VA examination in 2009 found that the sensory involvement was bilateral, as did the VA examination in February 2011 (albeit, it was incorrectly described as involving the 5th cranial nerve). Thus, under the guidelines for rating cranial nerves, two separate ratings for moderate impairment should be assigned when, as here, the neurological impairment is bilateral, i.e., affecting both sides. As to this, as discussed above, the evidence firmly establishes that the 9th cranial nerve involvement is bilateral. In other words, a separate 10 percent rating is warranted for the moderate neurological impairment of the ninth cranial nerve on the right side, and a separate 10 percent rating is warranted for the moderate neurological impairment of the ninth cranial nerve on the left side. The evidence also shows that the Veteran has some residual postoperative scarring. The schedular rating criteria pertaining to the skin were amended effective October 23, 2008, prior to the May 2009 receipt of the claim for increase. Moreover, Diagnostic Code 7805 essentially remained unchanged by the amendments. 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805 (2012); 67 Fed.Reg. 49590-49599 (July 31, 2002). Diagnostic Code 7805 (2012) provides that a scar's disabling effects not considered under Diagnostic Codes 7800 (scars on the head, face, or neck), 7801 (deep and nonlinear scars of certain sizes), 7802 (superficial and nonlinear scars of certain sizes), and 7804 (stable or painful scars) should be rated under an appropriate diagnostic code. Other Diagnostic Codes in effect both prior to and as of October 2008 provide for compensable ratings for symptomatic scars or scars of certain sizes. Here, the scarring in not visible, not measurable and not discernible. The examination reports of record do not show that the scarring is painful, unstable or in any manner productive of functional impairment. Accordingly, a separate rating for any residual scarring is not warranted. See generally Esteban, supra (under 38 C.F.R. § 4.25 disabilities are separately rated unless they constitute the "same disability" or the "same manifestation" under 38 C.F.R. § 4.14 which prohibits pyramiding (or double compensation) and the critical element is that the symptoms not be duplicative or overlap with symptoms of other disorders). In Esteban, Id., consideration was given to scarring which may have caused disfigurement, pain, and facial muscle damage resulting in mastication problems. As explained, the scarring in this case is not visible because it is not on the head, face or neck and, so, there is no disfigurement. The scarring is also not painful and does not cause problems with mastication, as opposed to the service-connected TMJ dysfunction which does. Thus, a separate compensable rating for scarring is not warranted. In making its determinations in this case, the Board has also carefully considered the Veteran's contentions with respect to the nature of her service-connected disability and notes that her lay statements are competent to describe certain associated symptoms, Layno v. Brown, 6 Vet. App. 465, 470 (1994), but are not competent to identify a specific level of disability of the service-connected disability according to the appropriate DC. Her history and symptom reports have been considered, including as presented in the medical evidence discussed above, and has been contemplated by the disability rating that is assigned. Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected disability. As such, while the Board accepts the Veteran's testimony with regard to the matters she is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected condition. The Board has considered whether staged ratings under Hart v. Mansfield, 21 Vet. App. 505, 509 (2007) are appropriate for the Veteran's service-connected dental disability; however, the Board finds that her symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for the disability is not warranted. Additionally, an extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). This requires a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the schedular evaluations are inadequate. There must be a comparison between the level of severity and symptomatology of the service-connected disability with the criteria in the rating schedule. If the rating criteria reasonably describe the disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned schedular evaluation is adequate, and no referral is required. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). If the first inquiry is met, it must be determined whether an exceptional disability picture exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. If the first two steps are met then, thirdly, the case is referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether the claimant's disability picture requires the assignment of an extra-schedular rating. Id. Here, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology for her service-connected disability. A separate rating has been assigned for other complications of her in-service dental surgery, i. e, for tinnitus and TMJ dysfunction. Moreover, the 9th cranial nerve impairment is wholly sensory. Additionally, a higher rating of 30 percent could be assigned if there was complete paralysis of the 9th cranial nerve. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability. Additionally, there are no attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. As such, the Board finds that there is no evidence of disability causing marked interference with employability. Moreover, as the Board has determined that the first factor of the Thun test is not met, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization (and in this case there are none). Id. The Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id. Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total disability rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. When evidence of unemployability is submitted at the same time that the Veteran is appealing the rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In this case, the official examinations have noted that the Veteran has been gainfully employed for many years. While there was a short period of time during which she was between jobs, she has not reported that she had any occupational impairment or had lost time from work due to her disability at issue. Additionally, the Veteran has not suggested or intimated that she is now unemployed. Therefore, the Board finds that the issue of entitlement to a TDIU is not expressly raised by the Veteran or reasonably raised by the record and, consequently, further consideration of such is not necessary. In conclusion, the Board finds that separate 10 percent ratings, but no higher, for the Veteran's prominent premaxilla with maxillary anterior segmental osteotomy with mid-line and posterior retroposition and gum disorder are warranted. In denying higher ratings or additional separate ratings, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against higher or additional separate ratings, that doctrine is not further applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER A 10 percent rating, but no higher, for prominent premaxilla with maxillary anterior segmental osteotomy with mid-line and posterior retroposition and gum disorder on the right side is granted, subject to applicable law and regulations governing the award of monetary benefits. A 10 percent, but no higher, for prominent premaxilla with maxillary anterior segmental osteotomy with mid-line and posterior retroposition and gum disorder on the left side is granted, subject to applicable law and regulations governing the award of monetary benefits. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs